Correct!
2. Right femoral vein
A large echogenic mass was seen occluding approximately 90 percent of the right internal jugular vein, extending cranially and caudally throughout the neck (Figure 2).
Figure 2. Transverse ultrasound image of the right neck labeled demonstrating the internal jugular vein (V), thrombus (T), and carotid artery (A).
This echogenic mass represented a thrombus which formed in an internal jugular vein naive to previous central line placement or cannulation. The decision was made to place the hemodialysis catheter in the right femoral vein, which occurred successfully without complication. The contralateral internal jugular vein should be avoided in the setting of an internal jugular thrombosis so as to avoid bilateral impairment of venous return. Subclavian dialysis catheters are often avoided due to the risk of stenosis. The patient was started on hemodialysis which corrected her electrolyte abnormalities and her kidney function began to trend back to baseline. Unfortunately, renal ultrasound demonstrated that the patient’s acute kidney injury was found to be secondary to obstruction by large abdominal masses from her gastrointestinal carcinoma. The patient opted not to have a nephrostomy tube placed, instead deciding to stop hemodialysis and return home on hospice care.
Discussion
Internal jugular venous thrombosis in a vessel without previous cannulation or central line placement is an uncommon occurrence with the potential for serious complications such as pulmonary embolus, sepsis or cerebral edema. Several studies have looked at characteristics that predispose patients to internal jugular vein thrombosis, demonstrating that older patients, female gender and ovarian hyperstimulation syndrome are significantly associated risk factors (1). Internal jugular thrombosis resulting from hypercoagulability secondary to distant malignancies has also been described in the literature (2-7). This case study adds to the body of evidence demonstrating an association between internal venous thrombosis and distant underlying malignancy. Such an association has implications to both potentially aid in the detection of undiagnosed occult malignancies in patients found to have spontaneous internal jugular thrombosis, as well as for vigilant surveillance for complications resulting from predisposition to internal jugular vein thrombosis in patients with known malignancy. The above case also demonstrates the importance of routine ultrasound examination of the proposed site of central venous catheterization.
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