The internal jugular vein (IJV) originates at the jugular foramen, tracks down to the lateral neck and ends at the brachiocephalic vein. The IJV is one of the four components of the carotid sheath, along with the common carotid artery, internal carotid artery, the vagus nerve, and the deep cervical lymph nodes. It courses medially to the sternocleidomastoid muscle at the carotid triangle. Studies have suggested significant variations in individuals, such as the IJV is anterior, lateral or anterior and lateral to the common carotid artery in the majority of the general population; whereas, for the remaining population, the IJV is medial to the common carotid artery. IJV thrombosis is the formation of thrombus located intraluminally in the IJV. Hereditary and acquired risk factors for thrombosis include intravenous drug use, factor V Leiden mutation, malignancies, hormone replacement therapy, immobilization, trauma, and pregnancy. These factors contribute to either one or more of the three components of Virchow triad: increased blood coagulation, altered blood flow (stasis) or endothelial dysfunction which lead to thrombosis. The internal jugular vein is a common route used by clinicians to access the central circulation for hemodynamical monitoring and stabilization due to its accessibility and anatomic location. Intravenous catheters cause injuries to the endothelium and vein wall inflammation. The most frequently encountered site of deep vein thrombosis for centrally placed catheters is the IJV.
A German physician, Rudolf Virchow is the first ever to coin the term of thrombosis and pulmonary embolism in 1855. The Virchow Triad refers to hypercoagulability, stasis or turbulence in blood flow and endothelial dysfunction. Despite being flushed with anticoagulants such as heparin, catheter placement in the internal jugular vein not only causes changes in the blood flow but also causes injury to the endothelium of the vein. In a retrospective review by Major KM et al. showed that the presence of a central venous catheter was a significant factor for IJV thrombosis. However, there are various causes of the IJV such as Inherited hypercoagulable states, including Factor V Leiden mutation, Protein S deficiency, Protein C deficiency, Antithrombin deficiency, acquired risk factors including previous thromboembolism, malignancy, pregnancy, oral contraceptives, an intravenous drug, trauma, immobilization. Additionally, jugular vein suppurative thrombophlebitis, also known as Lemierre syndrome is suspected in patients with persistent bacteremia preceded by pharyngitis, dental infections or infectious mononucleosis. There have also been reports of surgical complications to the neck, necrotizing fasciitis, antiphospholipid syndrome, nephrotic syndrome, and severe burns.
A cross-section study suggested that the most common causes of internal jugular vein thrombosis are cancer and central venous catheter. A systematic review and meta-analysis revealed 7.5 percent of patients out of 5636 cancer patients developed catheter-related venous thrombosis. In examining catheter-related venous thrombosis, researchers weighed many factors such as the previous history of deep vein thrombosis, insertion site, and positioning of the catheter tip. Patients with factor V Leiden or other hypercoagulopathy were found to have a threefold increased risk of developing upper extremities thrombosis.
The pathogenesis of venous thromboembolism (VTE) is Virchow triad. Three components of Virchow triad as below,
Internal jugular vein thrombosis is most commonly due to prolonged central venous catheterization, trauma to the neck, infection, ovarian hyperstimulation syndrome (OHSS) and intravenous drug abuse.
Internal jugular vein thrombosis is asymptomatic in the majority of patients. Due to its subtle manifestation, it is difficult to diagnose for clinicians. However, patients may present with typical signs for deep vein thrombosis such as erythema, tenderness, and warmth. On physical examination, swelling at the left sided neck, mandible angle or the anterior border of the sternocleidomastoid muscle can be found. Internal jugular vein thrombosis in the setting of infection as known as Lemierre syndrome (necrobacillosis), fever, headache, swelling of the neck and angle of the jaw along with trismus is another possible presentation.
Laboratory studies may show an increased level of D-dimer, a degradation product of fibrin that is highly sensitive and nonspecific for venous thrombosis. Elevated levels of D-dimer present in malignancy, sepsis, recent surgery or trauma, pregnancy which often coexist with internal jugular vein thrombosis. Compression ultrasonography with Doppler is the test of choice for diagnosis with a sensitivity of 96% and a specificity of 93%. While venography is the gold standard for diagnosing the IJV thrombosis, bedside ultrasound is noninvasive and rapid which may show hyperechoic thrombus within the IJV. CT scan may indicate an intraluminal filling defect in the jugular venous wall. CT scan may be superior to ultrasound due to a better assessment of veins located under soft tissues.
The risk of bleeding requires careful assessment. Anticoagulation therapy is individualized for each patient; tools such as HAS-BLED help assess the bleeding risk in adults However, no definitive index or tool can reliably predict bleeding risk in patients with internal jugular vein thrombosis. In patients with an indwelling catheter, it is crucial to remove the catheter; however, if the catheter cannot be removed for any reason, then anticoagulants should be initiated. Patients without bleeding risks should receive dual therapy with low molecular weight (LMW) heparin and warfarin, dual therapy with LMW heparin followed by direct thrombin inhibitor or factor Xa inhibitor, or monotherapy with factor Xa inhibitor. For high-risk patients like thrombophilia, some studies have suggested an INR maintained between 2.5 and 3.0; long-term warfarin therapy can also be a consideration. However, clinical studies in anticoagulation therapy for IJV thrombosis are lacking. Internal jugular vein thrombosis is often found incidentally in the majority of the patients. Hence, many patients were left untreated. Intravenous thrombolytic infusion regimens such as alteplase have been reported to be effective in IJV thrombosis. For patients diagnosed with catheter-induced IJV thrombosis, thrombolysis is not recommended as first-line therapy, as there is sparse evidence to suggest that thrombolysis leads to better outcomes than anticoagulation. Rarely do patients need surgical interventions.
The clinical manifestations that accompany internal jugular vein thrombosis include erythema, swelling, and warmth along the sternocleidomastoid muscle resemble neck infections such as cellulitis. Facial pain, neck edema, a palpable cord, and neck fullness can present in some patients and may be similar to superior vena cava syndrome. A mechanical obstruction such as a lung tumor should be ruled out.
In a prospective study, the mortality rate of internal jugular vein thrombosis was reported to be 44%. The mortality rate is significantly higher in patients over 75 years old, patients not treated with anticoagulation and patients with an indwelling central venous line. In patients with underlying comorbidities such as malignancy, chronic kidney diseases, infections, and multiorgan failure, mortality is significantly higher.
Pulmonary embolism is the most common complications in upper extremity thrombosis, followed by post-thrombotic syndrome and death. Complications of IJV thrombosis are pulmonary embolism (10.3%) and post-thrombotic syndrome (41.4%). In Lemierre's syndrome, without proper antibiotic management, 97 percent of cases developed septic emboli to the lung.
Internal jugular vein thrombosis is asymptomatic in most patients. Clinicians should carefully evaluate swelling, erythema, or tenderness in the angle of the jaw or the side of the neck. Complications such as pulmonary embolism although rare but can occur. Further investigations on malignancy, hypercoagulopathy or infections are necessary for recurrence prevention. Anticoagulation therapy is the treatment of choice for patients without contraindications.
Internal jugular vein thrombosis has been reported to be more common due to the widespread use of the internal jugular vein for venous access, central venous catheters. Of note, an increased number of IV drug abuses present with IJV thrombosis, nevertheless anticoagulation still is the mainstay of treatment comparing to thrombolysis or surgical intervention.
Anticoagulation is the treatment of choice for patients with internal jugular vein thrombosis. [Level l] Anticoagulant therapy following a diagnosis of IJV thrombosis prevents severe complications such as pulmonary embolism. The pharmacist, nurse practitioner, internist or the primary care provider can monitor the patient's anticoagulation status. These professionals need to work together in an interprofessional team approach to managing IJV thrombosis to ensure optimal clinical results for patients.
In patients with asymptomatic IJV thrombosis, anticoagulation is the recommendation, as a delay in therapy increases the risk of potentially life-threatening embolization. Anticoagulants include subcutaneous low molecular weight (LMW) heparin, subcutaneous fondaparinux, the oral factor Xa inhibitors (rivaroxaban or apixaban), or unfractionated heparin (UFH) (Level III). Anticoagulation management requires individualized customization along with clinician experience.
The duration of anticoagulation ranges from 4 to 12 weeks. It is standard to obtain an imaging study before discontinuing anticoagulation.
We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.
This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.
Click Your Answer Below
Would you like to access teaching points and more information on this topic?
Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.
Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.
|Karakitsos D,Labropoulos N,De Groot E,Patrianakos AP,Kouraklis G,Poularas J,Samonis G,Tsoutsos DA,Konstadoulakis MM,Karabinis A, Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Critical care (London, England). 2006; [PubMed]|
|Wolberg AS,Rosendaal FR,Weitz JI,Jaffer IH,Agnelli G,Baglin T,Mackman N, Venous thrombosis. Nature reviews. Disease primers. 2015 May 7; [PubMed]|
|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 Mar-Apr; [PubMed]|
|Gbaguidi X,Janvresse A,Benichou J,Cailleux N,Levesque H,Marie I, Internal jugular vein thrombosis: outcome and risk factors. QJM : monthly journal of the Association of Physicians. 2011 Mar; [PubMed]|
|Saber W,Moua T,Williams EC,Verso M,Agnelli G,Couban S,Young A,De Cicco M,Biffi R,van Rooden CJ,Huisman MV,Fagnani D,Cimminiello C,Moia M,Magagnoli M,Povoski SP,Malak SF,Lee AY, Risk factors for catheter-related thrombosis (CRT) in cancer patients: a patient-level data (IPD) meta-analysis of clinical trials and prospective studies. Journal of thrombosis and haemostasis : JTH. 2011 Feb; [PubMed]|
|Kommareddy A,Zaroukian MH,Hassouna HI, Upper extremity deep venous thrombosis. Seminars in thrombosis and hemostasis. 2002 Feb; [PubMed]|
|Lip GY, Implications of the CHA(2)DS(2)-VASc and HAS-BLED Scores for thromboprophylaxis in atrial fibrillation. The American journal of medicine. 2011 Feb; [PubMed]|
|Flinterman LE,Van Der Meer FJ,Rosendaal FR,Doggen CJ, Current perspective of venous thrombosis in the upper extremity. Journal of thrombosis and haemostasis : JTH. 2008 Aug; [PubMed]|
|Golpe R,Marín B,Alonso M, Lemierre's syndrome (necrobacillosis). Postgraduate medical journal. 1999 Mar; [PubMed]|
|Kearon C,Akl EA,Ornelas J,Blaivas A,Jimenez D,Bounameaux H,Huisman M,King CS,Morris TA,Sood N,Stevens SM,Vintch JRE,Wells P,Woller SC,Moores L, Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb; [PubMed]|
The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Anesthesiology. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.
StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Anesthesiology, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Anesthesiology, you will already be prepared.
Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Anesthesiology. When it is time for the Anesthesiology board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Anesthesiology.