AJR 2004; 182:467-469
© American Roentgen Ray Society
Successful Interventional Treatment of Acute Internal Jugular Vein Thrombosis
Hiroyuki Tajima1,
Satoru Murata1,
Tatsuo Kumazaki1,
Kazuo Ichikawa1,
Takashi Tajiri2 and
Yasuhiro Yamamoto3
1 Department of Radiology, Center for Advanced Medical Technology, Nippon
Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo 113-8602, Japan.
2 Department of Surgery 1, Nippon Medical School, Tokyo 113-8602, Japan.
3 Department of Advanced Emergency Critical Care Medicine, Nippon Medical
School, Tokyo 113-8602, Japan.
Received April 25, 2003;
accepted after revision August 19, 2003.
Address correspondence to H. Tajima
(h-tajima{at}nms.ac.jp).
Introduction
Percutaneous thrombectomy was introduced more than 10 years ago and
involves the removal of acute thrombi using nonsurgical methods
[1]. It has been used to remove
thrombi from arteries, veins, and vascular grafts. However, there have been no
reports, to our knowledge, of percutaneous thrombectomy for the management of
internal jugular vein thrombosis, a commonly encountered problem. The purpose
of this study was to evaluate the feasibility, efficacy, and safety of
mechanical thrombectomy, manual aspiration thrombectomy, and standard balloon
dilatation for the treatment of acute internal jugular vein thrombosis.
Subjects and Methods
Approval was obtained from the local university ethics committee, and
written informed consent was obtained from the patients.
Patients
Between May 2000 and December 2000, three consecutive patients with severe
neck pain and swelling due to internal jugular vein thrombosis were
prospectively selected for interventional treatment. One woman and two men,
ages 43, 66, and 71 years, were selected. The patients had a postsurgical
condition that began after clipping a cerebral aneurysm, coronary artery
bypass graft for myocardial infarction, or hemicolectomy for colon cancer. Two
patients developed thrombosis as a result of trauma to the internal jugular
vein from catheterization, and one developed a spontaneous case. The affected
side was the right in one patient and the left in two patients. Before
treatment, the extent of thrombus formation was evaluated using
contrast-enhanced CT. Follow-up CT was performed 3–7 days after the
procedures. Sonography and MR venography were not used because they are not
available to emergency patients at our hospital.
Percutaneous Interventional Procedures
A temporary filter (Antheor, Boston Scientific, Watertown, MA) was inserted
into the superior vena cava via the left femoral vein for protection against
large emboli. A 6-French short sheath was inserted in the right femoral vein,
and a 5-French catheter for cerebral angiography (Headhunter catheter,
Medikit, Tokyo, Japan) was advanced into the thrombosed internal jugular vein
using a guidewire (Radifocus, Terumo, Tokyo, Japan).
Through the catheter, a 260-cm extrastiff guidewire (Amplatz, Cook,
Bloomington, IN) was guided into the central thrombosed internal jugular vein.
The Headhunter catheter was then withdrawn, leaving the guidewire in the
central internal jugular vein. The short 6-French sheath was exchanged with a
10-French sheath, and a mechanical thrombectomy system (Oasis [10-French],
Medi-Tech/Boston Scientific, Watertown, MA) was used. The thrombectomy system
was advanced repeatedly for mechanical thrombectomy.
An 8-French long sheath with a hemostatic valve was advanced into the
internal jugular vein. Then a modified pigtail catheter was advanced into the
thrombus. Emboli were fragmented by the mechanical action of the rotating
pigtail catheter. The catheter was rotated manually and advanced or withdrawn
over the guidewire.
An 8-French aspiration catheter (Judkins Right 3.5 Percutaneous
Transluminal Coronary Angioplasty Guider, Boston Scientific Scimed, Maple
Grove, MN) was advanced into the thrombus. A 10-mL syringe with a connector
was used to apply suction while the catheter was moved slowly back and forth
across an area of several centimeters in the thrombus. During advancement with
this technique, it is important to be aware of any resistance because
resistance may indicate subintimal passage of the catheter. When blood readily
entered the syringe, the thrombus was assumed to have cleared the catheter.
The syringe was removed and its contents were expressed over a gauze-draped
basin. Multiple aspirations can be performed if necessary
[1].
Local infusion of urokinase (24–36 x 104 U) was
administered over 24–36 min. After complete clot removal, final
dilatation of the stenotic orifice of the internal jugular vein was performed
with a standard balloon (Ultra-Thin Diamond [10-mm-diameter], Medi-Tech/Boston
Scientific). We used these techniques as needed for each patient.
During the aspiration thrombectomy, all patients received heparin sodium
treatment to reach an activated partial thromboplastin time ratio of 2.
Additional systemic urokinase infusion was administered at an ICU, depending
on the patient's condition.
Results
The interventional procedures were as follows: mechanical thrombectomy
using the Oasis system, four times; mechanical thrombectomy using a rotatable
pigtail catheter, one time; thromboaspiration, three times; balloon
percutaneous transluminal angioplasty, four times; and catheter-directed
thrombolysis, two times.
All patients survived, and their clinical status improved. In two patients,
angiography performed soon after treatment showed complete resolution of
venous perfusion, and the procedure was finished the same day. In the third
patient (Fig. 1A,
1B,
1C,
1D,
1E,
1F,
1G), a small thrombus remained,
so we recommended systemic thrombolysis (urokinase, 360,000 U/day for 6 days)
and tried a second intervention 6 days later; the second intervention was
successful. A prophylactic temporary superior vena cava filter was used in all
patients, and no symptomatic pulmonary thromboembolism was encountered.
Follow-up contrast-enhanced CT in each patient revealed no residual thrombosis
of the internal jugular vein. No patient experienced any significant
complications during or after the procedures, and no recurrence of symptoms
had occurred in any of the patients.
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Fig. 1C. —66-year-old woman with severe neck swelling and pain.
Radiograph shows mechanical thrombectomy system (Oasis [10-French],
Medi-Tech/Boston Scientific, Watertown, MA) and temporary vena caval filter
(Antheor, Boston Scientific, Watertown, MA). After recanalization of left
internal jugular vein, systemic urokinase (360,000 U/day for 6 days) was
administered.
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Fig. 1E. —66-year-old woman with severe neck swelling and pain.
Radiograph obtained during second interventional treatment, which occurred 6
days after first intervention, shows rotatable pigtail catheter system.
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Fig. 1F. —66-year-old woman with severe neck swelling and pain.
Angiogram obtained after second procedure shows complete recanalization and no
stenosis of left lower part of internal jugular vein.
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Discussion
Nonspontaneous internal jugular vein thrombosis is an uncommon condition
that historically has been associated with deep neck infections, such as
Lemierre syndrome, during the preantibiotic era
[2]. Today, trauma to the
internal jugular vein from catheterization and repeated IV injections by drug
users are the leading causes of thrombosis, and direct extension of a tumor is
a rare cause [3]. Data relating
to the natural history of internal jugular vein thrombosis are lacking
[4]. In one study, seven
(17.5%) of 40 patients who underwent serial imaging had thrombus propagation.
Outcomes similar to those seen in patients with lower extremity deep vein
thrombosis were observed [4].
Management of thrombosis of the internal jugular vein typically involves the
administration of anticoagulation antibiotics, and there are few indications
for surgical intervention. Mechanical interventional procedures are therefore
the ideal approach for the treatment of the internal jugular vein.
Catheter-directed thrombolysis of internal jugular vein thrombosis has been
reported [5]. However, before
the cases detailed here, there have been no reports of percutaneous
thrombectomy for internal jugular vein thrombosis.
Prophylactic Temporary Filter
Clinical and experimental researchers have reported observing numerous
thrombi in the inferior vena cava filter after placing it to treat deep vein
thrombosis of the lower extremities. Therefore, in this study, to avoid the
risk of any embolic event, we deemed it essential to use a temporary superior
vena caval filter to avoid the possibility of this complication.
Mechanical Embolectomy
Although effective, conventional thrombolysis is associated with a high
risk of bleeding; mechanical thrombectomy is therefore a novel approach to the
treatment of internal jugular vein thrombosis. Several small studies have
shown that mechanical thrombectomy devices can be used to remove venous
thrombi quickly and effectively in the treatment of deep venous thrombosis and
pulmonary thromboembolism. We used a 10-French Oasis device, which allowed
efficient thrombus removal.
The technique of fragmentation with a special pigtail catheter system has
been described [6,
7]. The rotational movement of
the pigtail portion of the catheter acts directly on the clots in the internal
jugular vein, causing fragmentation and distal migration of the smaller
fragments. In this study, we undertook this additional procedure in one
patient for the management of residual clots.
Thromboaspiration
Percutaneous aspiration thrombectomy evolved from a simple technique
previously used in many fields
[1]. The thin wall of the
aspiration catheter ensures the maximum internal luminal diameter for
aspiration of the thrombus [1].
Aspiration of a pulmonary clot using a large-lumen percutaneous transluminal
coronary angioplasty guiding catheter has been reported
[8]. This technique is less
invasive for the vessels and is convenient to perform with the use of a small
8-French introducer sheath and a conventional percutaneous transluminal
coronary angioplasty guiding catheter in a standard angiography laboratory. It
is also inexpensive.
Thrombectomy and thromboaspiration have a possible synergistic effect with
concurrent thrombolytic therapy because a large surface area of the resulting
clot fragments is exposed to the thrombolytic agent, thus improving the
results of lytic activity and allowing a reduction of dose and infusion time.
In one patient, we used low-dose urokinase, which is less dangerous, with
success. In the other two patients, we did not have to use thrombolytic
therapy because of the excellent results of thrombectomy and
thromboaspiration.
After complete clot removal, performing a final dilatation of the stenotic
orifice of the internal jugular vein is necessary. The main purpose of this
procedure is to maintain an efficient central channel in the orifice of the
vessel. Because the dilatation was effective in all patients in this study, we
did not have to use metal stents. Because creating septic emboli with the
percutaneous interventional therapy is a risk, prophylactic antibiotic therapy
is needed.
The major limitation of this study is the relatively small number of
patients included. Future studies are required to establish the role of
interventional treatment in the management of acute and chronic internal
jugular vein thrombosis, to determine whether thrombectomy and percutaneous
transluminal balloon angioplasty may play a role in the prevention of
pulmonary thromboembolism in selected patients, and to identify the optimal
adjunct pharmacologic, mechanical, and dilatational therapies.
In conclusion, the percutaneous interventional procedures reported here
achieved a rapid and safe improvement in the venous circulation of patients
with acute internal jugular vein thrombosis.
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Introduction
Subjects and Methods
