BACKGROUND
The causes of internal jugular vein (IJV) thrombosis include: malignancy, thrombophilic abnormalities, central venous catheter (CVC), etc1. The complications vary from sepsis, pulmonary embolism and airway edema1. Two-dimensional imaging ultrasound guidance (US-G) is recommended, by the main societies, as the preferred method for insertion of a CVC into the IJV in elective situations, for its higher first insertion attempt success rate, fewer number of attempts and reduced mechanical complications2,3. This case reports a clinical situation in which the US-G was of high clinical relevance compared with landmark guided technique (LGT).
CASE REPORT
Female, 30 years old, ASA 3, presenting with controlled asthma, end-stage renal disease on hemodialysis, atrophic right kidney, mechanical aortic, mitral and tricuspid valve, under anticoagulant therapy, pacemaker and controlled hyperprolactinemia. She was proposed for retroperitoneal laparoscopic nephrectomy due to right kidney cancer.
Preoperative evaluation had no significant findings. Before induction of anesthesia it was attempted placement of CVC in the right IJV by LGT, with multiple unsuccessful attempts. It was tried again on the left using an US-G technique, which showed an intraluminal thrombus in the left IJV. It was then decided not to put CVC and keep only two broad gauge peripheral accesses. It was performed a balanced general anesthesia. The patient remained hemodynamically stable throughout the procedure, which lasts about 2 hours. It was extubated and taken to the post-anesthesia care unit where she recovers for 24h, uneventful.
DISCUSION
The identification and management of complications related to CVC placement is essential to a safe anesthetic practice. The US-G CVC insertion allow the identification of the precise position of the target vein, the surrounding anatomic structures and the detection of anatomical variants or thrombosis within the vessel2. This case highlights the great importance of US-G in the CVC insertion to improve patient outcome based on the available literature.
LEARNIG POINTS
Despite the obvious advantages of US-G technique, many hospitals do not have easy access to such technology. Since it´s an operator-dependent method, experience has an influence on the results, therefore there´s a need for investment on operator’s training to acquire the necessary manual skills2.
REFERENCES
1 - Internal jugular vein thrombosis: outcome and risk factors. Q J Med 2011; 104:209–219.
2 - Guidelines for Performing Ultrasound Guided Vascular Cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocard. 2011; 24:1291-318
3 - Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012 Mar; 116:539.

Intraluminal thrombus during placement of a central venous catheter: is the ultrasound a thing of the present or from the future?