• Users Online: 292
  • Print this page
  • Email this page

LETTER TO EDITOR Table of Contents  
Ahead of print publication
Incidental intraoperative detection of central venous catheter-related internal jugular vein thrombus in an infant with d-transposition of great arteries


1 Division of Cardiac Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2 Division of Cardiac Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

Click here for correspondence address and email

Date of Submission02-Sep-2020
Date of Decision17-Sep-2020
Date of Acceptance21-Oct-2020
Date of Web Publication23-Apr-2021
 


How to cite this URL:
Chennakeshavallu G N, Sankar S, Ponnaboyina S. Incidental intraoperative detection of central venous catheter-related internal jugular vein thrombus in an infant with d-transposition of great arteries. J Med Ultrasound [Epub ahead of print] [cited 2021 Oct 20]. Available from: http://www.jmuonline.org/preprintarticle.asp?id=314168




Dear Editor,

A 25-day-old male' baby weighing 3.1 kg presented with bluish discoloration of lips and tachypnea. On examination, the pulse rate was 140/min with palpable peripheral pulses, SpO2 of 65% at room air in all four limbs, and there was no audible cardiac murmur. Complete blood picture showed hemoglobin of 16 g/dl and hematocrit of 50%. Transthoracic echocardiography (TTE) showed features of d-transposition of great arteries (d-TGA) with intact ventricular septum and small PDA. A continuous infusion of alprostadil was planned. Since peripheral venous access was difficult, a 4.5 F triple-lumen central venous catheter (CVC) was inserted into the right internal jugular vein (IJV) under ultrasound guidance. Intravenous fluid and alprostadil infusion were commenced after confirmation of correct placement by free aspiration of the blood from all three ports and with chest X-ray. Due to poor response to alprostadil infusion, the child was posted for balloon atrial septostomy under general anesthesia. After septostomy, the SpO2 improved to 88% on room air, and the child was extubated. Two days later, the child was posted for arterial switch operation (ASO). In the operation room, there was the absence of free aspiration of venous blood from the distal port of CVC. After anesthesia induction and endotracheal intubation, ultrasound imaging of the right IJV revealed the presence of thrombus with CVC in situ [Figure 1]. A TTE examination was prompted to look for any extension of thrombus into cardiac chamber. The latter disclosed the absence of thrombus in the right atrium [Figure 2]. Due to possible risk of systemic embolization associated with CVC removal, it was left in situ and another CVC was inserted into the right femoral vein. Cardiopulmonary bypass (CPB) was instituted with a single inferior vena cava (IVC) drainage cannula and aortic cannulation after systemic heparinization. The right atrium was opened after administration of cardioplegia, and thrombectomy of superior vena cava (SVC)/IJV was performed using Fogarty catheter. A SVC drainage was then placed, and ASO with atrial septal defect closure was performed. The CPB time was 150 min and aortic cross-clamp time (ACT) was 100 min. The child was weaned off CPB with milrinone 0.5 μg/kg/min and adrenaline 0.05 μg/kg/min. Anticoagulation was reversed with protamine, and ACT was 140 s. The child was shifted to the intensive care unit (ICU) with open sternum as per the institutional protocol. In the ICU, ultrasound of the right IJV revealed the absence of thrombus and the CVC was removed. The child underwent delayed sternal closure the following day and was extubated on postoperative day 3 without any neurological deficits. The workup for hypercoagulable conditions was negative. The rest of the hospital stay was uneventful, and the child was discharged on postoperative day 12.
Figure 1: Ultrasound image showing the presence of thrombus in the right IJV with CVC in situ. (a) Short-axis view and (b) long-axis view of IJV. IJV: Internal jugular vein, CVC: Central venous catheter

Click here to view
Figure 2: Subcoastal transthoracic echocardiography 4-chamber view showing the absence of thrombus in the right atrium and atrial septal defect post-BAS (white arrow). BAS: Balloon atrial septostomy

Click here to view


CVC line occlusion is a common problem in infants and often occurs secondary to thrombosis.[1] The incidence of neonatal jugular vein thrombosis as an early complication has been reported to an amount between 6% and 23%.[2] The common sites of CVC-related thrombus formation are CVC lumen (intraluminal), site where CVC enters the vein, CVC tip and along the external surface of the CVC. Several risk factors for neonatal CVC thrombosis are small for gestational age, indwelling time, catheter type (silastic vs. polyurethane) and size, addition of blood products to infusate, malpositioned CVC, and polycythemia.[1],[3] In the present case, the high hematocrit associated with cyanotic congenital heart disease would have contributed to CVC-related IJV thrombosis. IJV thrombosis is asymptomatic in most patients. Complications such as cerebral edema and acute pulmonary thromboembolism although rare can occur.[4] However, in d-TGA, as in our case, due to ventricloarterial discordance, there is a possibility of systemic embolization as the right ventricle ejects the blood into aorta.

Ultrasonography has been shown to be an adequate method for the evaluation of clinically asymptomatic jugular vein thrombosis.[2] In the present case, detection of IJV thrombosis by ultrasound led to change in the surgical management wherein the SVC cannulation was not attempted until CPB with cardiac standstill was established due to possible risk of systemic embolization.

To conclude, CVC-related thrombosis should be suspected in infants with malfunctioning CVC and should be evaluated with ultrasound. Appropriate measures should be instituted to avert the consequences of CVC-related IJV thrombosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the parents have given the consent for the baby's images and other clinical information to be reported in the journal. The parents understand that the baby's name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Park CK, Bosco AP, Nagel K, Chan AK, Murthy P, Thrombosis, Hemostasis in Newborn (THiN) Group. Neonatal central venous catheter thrombosis: Diagnosis, management and outcome. Blood Coagul Fibrinolysis 2016;25:97-106.  Back to cited text no. 1
    
2.
Rand T, Kohlhauser C, Popow C, Rokitansky A, Kainberger F, Jakl RJ, et al. Sonographic detection of internal jugular vein thrombosis after central venous catheterization in the newborn period. Pediatr Radiol 1994;24:577-80.  Back to cited text no. 2
    
3.
Veldman A, Nold MF, Michel-Behnke I. Thrombosis in the critically ill neonate: Incidence, diagnosis, and management. Vasc Health Risk Manag 2008;4:1337-48.  Back to cited text no. 3
    
4.
Major KM, Bulic S, Rowe VL, Patel K, Weaver FA. Internal jugular, subclavian, and axillary deep venous thrombosis and the risk of pulmonary embolism. Vascular 2008;16:73-9.  Back to cited text no. 4
    

Top
Correspondence Address:
GN Chennakeshavallu,
Division of Cardiac Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum . 695 011, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None



    Figures

  [Figure 1], [Figure 2]



 

Top
 
  Search
 
   Ahead Of Print
  
 Download PDF Version
     Search Pubmed for
 
    -  Chennakeshavallu G N
    -  Sankar S
    -  Ponnaboyina S


References
Article Figures

 Article Access Statistics
    Viewed327    
    PDF Downloaded3    

Recommend this journal