Perioperative Internal Jugular Vein Catheter Placement in Neonates and the Very Real Risk of Vessel Thrombosis
James DiNardo, Viviane Nasr, Susan Nicolson, Lindsey Loveland
Original article
Xiong L, Tan Y, Yang X, Wang H, Ding M, Sessler DI, Zhong J, Zhu L, Tang L, Xu Y. Catheter-related Internal Jugular Vein Thrombosis in Neonates and Long-term Consequences: A Prospective Cohort Study. Anesthesiology. 2025 Feb 1;142(2):298-307. doi: 10.1097/ALN.0000000000005250. Epub 2024 Oct 4. PMID: 39365956.
This is a meticulously conducted investigation from China that asks and, in part, answers a question of significant clinical importance.1 That is: what is the incidence of short and long-term internal jugular vein (IJV) thrombosis following perioperative placement of a catheter in the internal jugular vein of a neonate? This issue is of particular concern in children with congenital heart disease where loss of patency of the IJV may actually preclude, in the absence of procedures to reestablish patency, performance of certain necessary palliative procedures the most recognized being the superior cavopulmonary anastomosis (SCPA) more commonly known as the bidirectional Glen shunt (BDG). In fact, in many institutions, placement of any catheter in the IJV of a neonate deemed likely to undergo a SCPA is absolutely verboten.
The study enrolled 188 neonates aged less than 28 days scheduled for major intestinal (171 patients, 91%) or cardiac surgery (17 patients, 9%) who were expected to require central venous catheters for at least 48 hours. Catheter size (4-French double lumen, 5-French double lumen, or 5.5-French triple lumen), insertion method, and puncture site were determined by the attending anesthesiologist. The duration of catheterization was also determined by clinical need. Central venous thrombi were diagnosed by color Doppler ultrasound (US) imaging within 48 h after catheter removal. The definition of central venous catheter–related thrombosis was the presence of occlusive or nonocclusive thrombi in at least one vessel and thrombi were considered asymptomatic when there were no clinical signs or symptoms of thrombosis in the affected area. US examinations were repeated 1, 3, and 6 months after discharge, and importantly these results were not shared with clinicians. The study enrolled 188 neonates during a period of 2 years. The catheters in the study were “flushed routinely with heparin-containing solutions”. However, it is entirely unclear how often this was done, and the volume of the flush solution and its heparin concentration are not specified.
The median duration of catheter insertion was 12 days. A total of 128 (68%) of the neonates had central venous thrombi at the catheter site, all of which were asymptomatic. Among patients with thrombi, 29 (23%) had complete vessel occlusion and 5 (4%) had venous stenosis at 6 months after discharge. Central venous stenosis was defined by a diameter at least 30% narrower than that of the contralateral vein with or without collateral circulation. Central venous catheter to vein diameter ratio ≥ 33.3%, time that the catheter remained indwelling, and catheter dysfunction were independent risk factors for vessel thrombus. Complete vessel occlusion was most common in patients whose thrombus occupied more than 58% of the vessel at the initial assessment.
It is interesting that difficulty of insertion, defined as two or more attempts at the same site, did not prove to be a risk factor for development of thrombus. However, the number of neonates who experienced difficult insertion was small; as difficulty was only identified in 9 of 188 insertions. That said, these neonates suffered a disproportionately large number of thrombotic complications with 7 who developed thrombosis; 3 who developed complete occlusion, and 2 who developed central vein stenosis. The authors speculate that difficult insertion increases the risk of intimal damage and leads to both short-term and long-term complications. One of this PAAD’s authors (JAD) strongly believes this is true. Furthermore, hematoma formation around a vein with a diameter of 4.0 mm and a cross-sectional area of 12.6 mm2 will lead to vessel compression which increases in the central venous catheter to vein diameter ratio and the likelihood of thrombus formation and subsequent vessel occlusion. These findings strongly support the policy that IJV catheter insertion in neonates be performed, utilizing ultrasound, by experienced operators and by less experienced operators only under meticulous supervision.
Several factors make the information provided here less than optimally generalizable. Half of the neonates in the cohort were premature, and 88 were of low birth weight. Forty -two neonates weighed less than 2 kg, and 78 weighed less than 2.5 kg. The authors acknowledge, and most practitioners would agree, that a placing a 4-French double lumen, 5-French double lumen, or 5.5-French triple lumen in a baby this small, given the size of the IJV, is likely to be associated with a significant obstruction to vessel blood flow and an enhanced risk of thrombus formation. In addition, most of the neonates were diagnosed with necrotizing enterocolitis requiring surgery, and were likely in an inflammatory, prothrombotic state. Consequently, this study likely significantly over-estimates the risk of IJV thrombus formation in neonates who are not acutely inflamed and are managed with a smaller catheter.
Because the IJV thrombi were asymptomatic and because the results of US examination of the IJV were not shared with clinicians this study provides a reasonable assessment of the natural history of catheter induced IJV thrombus in neonates. Remarkably, thrombi spontaneously resolved by 6 months in 73% of the neonates without intervention. This is consistent with a previous investigation wherein US of 146 children at 72 hours post central venous catheter placement determined a 21.9% incidence of acute catheter-related thrombosis. Two children were symptomatic. No radiological thrombosis extension or clinical embolization occurred in the 126 children assessed at 2-year follow-up.2
Should asymptomatic IJV thrombi associated with central venous catheter placement be detected, the American Society of Hematology guidelines are explicit and recommend no removal, rather than removal, of a functioning central venous access device (CVAD) in pediatric patients with symptomatic CVAD-related thrombosis who continue to require venous access (conditional recommendation based on very low certainty in the evidence of effects).3 The expert panel also places a high value on avoiding the insertion of another CVAD in children who may have limited availability of access sites due to the thrombogenic effect of placing another line and new endothelial injury. The panel considered that treatment of symptomatic CVAD-related thrombus with anticoagulation likely leads to minimal complications.3
In summary, while asymptomatic IJV thrombosis that occurs as a consequence of central venous catheter placement is highly likely to resolve spontaneously it is nonetheless prudent to have an experienced operator or a well supervised trainee place a catheter where the ratio of catheter to vessel diameter < 33%. In very small neonates this will require use of catheters smaller than 4-French.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Xiong L, Tan Y, Yang X, et al. Catheter-related Internal Jugular Vein Thrombosis in Neonates and Long-term Consequences: A Prospective Cohort Study. Anesthesiology 2025;142(2):298-307. (In eng). DOI: 10.1097/aln.0000000000005250.
2. Jones S, Butt W, Monagle P, Cain T, Newall F. The natural history of asymptomatic central venous catheter-related thrombosis in critically ill children. Blood 2019;133(8):857-866. (In eng). DOI: 10.1182/blood-2018-05-849737.
3. Monagle P, Cuello CA, Augustine C, et al. American Society of Hematology 2018 Guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism. Blood Adv 2018;2(22):3292-3316. (In eng). DOI: 10.1182/bloodadvances.2018024786.