Internal Jugular Vein Size and Thrombosis Risk in Central Venous Catheterization

Introduction

Central venous catheterization (CVC) is a technique administered extensively to adult patients for many indications, including establishing a secure stable route for drug administration, volume resuscitation, hemodialysis, nutritional support, central venous pressure measurement, and facilitation of complex interventions such as oncologic treatments [1,2]. Therefore, central venous port (CVP) catheters have become the preferred tool to administer intravenous drugs to patients who may require extended treatment periods [3]. As malignancies have become more prevalent, the number of patients requiring intravenous medical therapies via CVP catheters in outpatient settings has also increased [3].

The first use of a totally implantable venous access port (TIVAP) was reported by Niederhuber in 1982 [4,5]. TIVAPs can reduce the incidence of infectious complications during long-term CVC treatment [4]. TIVAPs generally facilitate simple implantation of a subcutaneous reservoir port, which is attached to a catheter in a vein that drains into the vena cava [4].

Despite their advantages, TIVAPs, like normal central venous catheters, are associated with venous thromboembolism as a complication [6,7]. In the literature, the incidence of symptomatic TIVAP-related thromboembolic complications is 0–13.6% [8–10]. Catheter-related thrombosis (CRT) is a significant indication for TIVAP removal and treatment interruption and can increase patient morbidity and mortality [11,12]. The causes of CRT are serious problems for clinicians to overcome.

In the literature, there is no evidence of a relationship between central venous lumen diameter and CRT. Therefore, this study aimed to evaluate the association between the diameter of the internal jugular vein (IJV) and the risk of catheter thrombosis in 467 patients undergoing CVC.

Material and Methods

ETHICS STATEMENT:

This prospective, cross-sectional, descriptive study was conducted at a tertiary care hospital’s Anesthesiology Department between April 1, 2023, and February 28, 2024. The study commenced following approval by the Local Clinical Research Ethics Committee (decision number 77, dated March 24, 2023). Written informed consent was obtained from all patients prior to the procedure, in accordance with the Declaration of Helsinki.

RESEARCH METHODS:

We prospectively enrolled 467 patients who received a CVC inserted under ultrasound (US) guidance and were found to have CRT from April 2023 to February 2024. We recorded patient age, sex, height, weight, body mass index (BMI), diagnosis, IJV diameter (vertical or transverse), anticoagulant use, and history of surgery for oncological diseases. Complete blood count tests and coagulometric values were obtained before the procedure.

Inclusion criteria were: a CVP catheter was inserted due to malignancy and who were followed up at our department for 1 year, and patients aged >18 years with CVP catheter inserted via the IJV.

Exclusion criteria were: underwent CVP catheter insertion via the femoral or subclavian veins, catheters did not function correctly, a BMI >40 kg/m², blood coagulation disorder, and infection at the puncture site.

TECHNICAL PARAMETERS:

The patients began chemotherapy sessions after the CVP catheter was inserted. If a catheter-associated error was detected by the oncologist, the patients were assessed by an anesthesiologist who was participating in the study. We checked to be sure the CVP catheters were functioning properly and if the placement of the CVP catheter was correct assessed using US. All patients were checked on the 7^th day and every month until the end of the oncologic treatment. Patients whose catheters functioned incorrectly were excluded.

CVP CATHETER INSERTION TECHNIQUE:

All patients were prepared according to the American Society of Anesthesiologists (ASA) guidelines and taken to the operating room. Noninvasive blood pressure, electrocardiogram, and oxygen saturation (SpO2) were monitored in the supine position. Patient measurements were performed after ensuring that they were neither hypotensive nor dehydrated. The vein selected for CVP catheter insertion was examined using the linear probe of the US device (Esaote My Lab Five), and all necessary calculations were performed. A peripheral vascular access device was inserted in the appropriate hand, and 2 mg of midazolam was administered intravenously. The planned insertion area was wiped with an antiseptic solution, and the patient was covered with sterile dressings. The Secure PORT 8fr Plan/Health Total Implantable Access System was used as the CVP catheter. Local anesthesia of the insertion area was induced with 2% prilocaine. The IJV is located anterolateral to the common carotid artery, typically in the superior portion of the triangle created by the 2 heads of the sternocleidomastoid muscle (SCM) and the clavicle [2]. For the IJV puncture, a guidewire, accompanied by a linear US probe, was placed in the triangle formed by the clavicle of the 2 arms of the right SCM lateral to the jugular notch. A pocket for the reservoir was prepared using a 2-cm skin incision in the pectoral region. The circumference of the guidewire was then expanded. A tunnel was drilled with a metal rod from the guidewire inlet through the reservoir pocket. The catheter was attached to the metal rod and passed through the tunnel. The distal end was cut, inserted into the reservoir, and locked using a connector. Isotonic fluid was passed through the reservoir to remove air and blood clots. The guidewire and the dilator were removed by passing the dilator/sheath over the guidewire. The catheter was passed through a sheath. Reservoir checks were performed using a fluoroscope. The reservoir and catheter were washed with 100 μg of heparin in 5 cc normal saline after blood was confirmed to flow freely from the reservoir. After bleeding was controlled, the subcutaneous and skin sutures were closed. The patient was kept in the recovery room for 30 minutes and then discharged with care recommendations.

CVP CATHETER FOLLOW-UP:

Seven days after the CVP catheter inserted, patients returned for a follow-up. Each patient continued their treatment under the routine chemotherapy algorithm recommended by the oncologist after the type of malignancy was identified. Thus, since the same chemotherapy drug scheme was applied to each malignancy subtype, treatment continued without changing chemotherapy drugs. At the end of the 1-month follow-up, all patients were evaluated with US for CRT. If any hypoechoic thrombus was observed in the IJV, the patient was diagnosed with CRT (Figure 1).

STATISTICAL ANALYSIS:

Power analysis was conducted using the G*Power 3.1.9.7 program and the t test with difference between 2 independent means were analyzed. Power analysis was conducted using the G*Power 3.1.9.7 program and the t test was used to test differences between the means of 2 groups Input parameters included 2-tailed analysis, and large effect size effect, showing that the number of patients in the CRT group should be at least 12 patients, with an alpha margin of error of 5% and an 80% confidence interval.

SPSS software version 27.0 was used for the analysis. The descriptive statistics of the data are reported as the mean and standard deviation, median (minimum, maximum), or frequency with percentage. The distribution of the variables was measured using the Kolmogorov-Smirnov test. The Mann-Whitney U test was used to analyze quantitative independent data. The chi-square test was used to analyze qualitative independent data, and Fisher’s exact test was used when chi-square test conditions were not met. Statistical significance was set at p < 0.05.

Results

PATIENT GENERAL INFORMATION:

A total of 467 patients were included in the study, of which 226 (48.4%) were female, with a mean age of 59.5±12.4 years. The demographic data are summarized in Table 1. There were no statistically significant differences in age, height, weight, BMI, or insertion side between the thrombus and non-thrombus groups (p>0.05, Table 2). A significant association was observed between male sex and the development of thrombus (p=0.005).

THE DIAMETER OF THE IJV AND RISK OF CRT RESULTS:

The mean axial diameter of the IJV was 12.9±4.1 mm. The CRT was detected 12 patients (2.6%). Additionally, no statistically significant difference (p>0.05) was detected in the axial diameter of the central vein between the thrombus and non-thrombus groups. Furthermore, there was no significant difference (p>0.05) in the rate of anticoagulant use between the thrombus and non-thrombus groups, as detailed in Table 2.

Discussion

We investigated the association between the incidence of thrombosis between use of CVP catheters and the axial diameter of IJV, but we did not find any significant association. Although the axial diameter of the thrombus group was higher than that of the non-thrombus group (14.3±3.2 mm vs 12.8±4.1 mm, p=0.104), the difference was not statistically significant.

CRT develops as a result of the interaction between anatomical features of the patient and the CVC. Several features of the CVC may be related to thrombosis, such as its material or number of lumens [13–18]. Hence, in our study, we used a monotype TIVAP. A catheter-to-vein ratio >45% may lead to peripherally-placed central catheter thrombosis. However, in our study, we discovered that the diameter of the jugular vein, which is one of the central veins, had no effect on the development of CRT.

Taxbro et al evaluated the incidence of catheter-related deep vein thrombosis (DVT) in a randomized controlled trial of patients who received chemotherapy through either a peripherally inserted central catheter (PICC) or a centrally inserted totally implanted vascular access port (PORT) catheter [19]. They concluded that PICCs were associated with a higher risk of DVT than PORTs [19].

In a recent study, Taglialatela et al investigated the complications and outcomes of CVC placement in oncology patients by employing risk scores [19]. They concluded that the potential risk for CRT was increased, as measured by the Khoranakloi Risk Score, Protecht Risk Score, and COMPASS Risk score. However, they did not find any association with sex, which differed from our results. We believe that this difference was due to the small number of patients included in that study [20].

We found a positive association between male sex and CRT occurrence (p=0.005). A recent review investigated the prevention and treatment of CRT during long-term parenteral treatment [21]. The authors stated that risk factors for CRT development are a catheter larger than 33% of the vein diameter, cancer occurrence, inflammatory conditions, thrombophilia, endothelial damage, and local inflammation [21].

Our study has several limitations. First, it was conducted at a single center, and a multicenter study is necessary for generalization of the results. Second, we could not explore the presence of microthrombi. Some serological methods, such as D-dimer, can be used in further studies to investigate the relationship. Finally, the success of IJV access depends on operator experience. In this study, an attempt was made to minimize the risk by performance of the procedure by a single experienced operator, but human errors could not be completely eliminated.

Conclusions

We discovered that the diameter of the jugular vein, which is one of the central veins, had no effect on the development of thrombosis.