A patient with an internal jugular central venous catheter develops neck swelling, pain, erythema, limited neck movement, and catheter malfunction. What is the most likely diagnosis and how should it be evaluated and managed?

Diagnosis and Management of Internal Jugular Catheter-Related Thrombosis

Most Likely Diagnosis

The clinical presentation of neck swelling, pain, erythema, limited neck movement, and catheter malfunction in a patient with an internal jugular central venous catheter is most consistent with catheter-related internal jugular vein thrombosis, potentially complicated by local infection or abscess formation. 1, 2

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Clinical Presentation and Differential Diagnosis

Catheter-Related IJV Thrombosis

• Neck pain and swelling are the most common presenting symptoms, often accompanied by a palpable cord beneath the sternocleidomastoid muscle 3
• Catheter malfunction (inability to aspirate blood or infuse solutions) occurs in up to 25% of cases and strongly suggests thrombotic occlusion 1, 4
• Limited neck movement results from local inflammation and venous distension 2
• Thrombosis typically develops days to weeks after catheter placement, with prolonged dwell time being a major risk factor 2

Infectious Complications

• Erythema, warmth, and tenderness at the insertion site indicate local exit-site infection or abscess formation 2
• Infection typically develops 48–72 hours after catheter insertion, though earlier onset can occur 2
• The combination of thrombosis and infection is common, as catheter-related thrombi provide a nidus for bacterial colonization 1

Hematoma (Less Likely Given Timeline)

• Arterial puncture with hematoma formation occurs in approximately 1.8–6.2% of IJ catheterizations but typically presents immediately or within hours of insertion, not days later 2
• An expanding hematoma would cause rapid airway compromise rather than the subacute presentation described 2

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Diagnostic Approach

First-Line Imaging: Bedside Ultrasound with Doppler

Perform bedside duplex Doppler ultrasound immediately to differentiate thrombosis, hematoma, abscess, and arterial injury 1, 2

Ultrasound findings for thrombosis:

• Lack of vein compression with manual probe pressure (seen in both acute and chronic thrombus) 1
• Echogenic material visualizing directly within the vein lumen 1
• Dampened or absent respiratory variation and cardiac pulsatility on Doppler waveforms, indicating central venous obstruction 1
• Impaired venous collapse with rapid inspiration ("sniffing maneuver") suggests obstructive thrombus 1
• Ultrasound has sensitivity and specificity above 80% for detecting upper extremity DVT 1

Additional ultrasound assessments:

• Identify fluid collections to distinguish hematoma from abscess 2
• Confirm catheter tip location within the superior vena cava 2
• Rule out arterial injury or pseudoaneurysm 2

Mandatory Chest Radiography

• Obtain chest X-ray to verify catheter tip position in the lower SVC and exclude pneumothorax or hemothorax 1, 2
• This is required even when ultrasound guidance was used during insertion 2

Advanced Imaging When Needed

• Contrast-enhanced CT of the neck is indicated when ultrasound is inconclusive or when deep/complex collections are suspected 2
• CT better delineates the extent of thrombosis and can identify complications such as abscess or pseudoaneurysm 2

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Immediate Management

For Suspected Thrombosis

1. Do not remove the catheter immediately unless there is clear evidence of infection requiring removal 1
2. Initiate anticoagulation with unfractionated heparin (weight-adjusted bolus followed by continuous infusion) unless contraindicated 3
3. Assess for pulmonary embolism risk, which occurs in 5–14% of upper extremity DVT cases 1, 4
4. Consider catheter removal or repositioning after anticoagulation is established, particularly if the catheter is no longer essential 1

For Suspected Infection

• Obtain blood cultures from both the catheter and a peripheral site 2
• Obtain local wound cultures if purulent drainage is present 2
• Complete blood count with differential to assess for leukocytosis 2
• Initiate empiric antibiotics covering coagulase-negative staphylococci and Staphylococcus aureus (the primary pathogens in catheter-related infections) 1, 4
• Remove the catheter if there is evidence of exit-site infection, abscess, or catheter-related bloodstream infection 1

For Expanding Hematoma with Airway Compromise

• Secure the airway immediately before any imaging studies 2
• This is a life-threatening emergency requiring immediate intervention 2

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Risk Factors Present in This Case

• Prolonged catheter dwell time is the strongest risk factor for IJV thrombosis 2
• Catheter malposition (tip not in lower SVC) increases thrombosis risk 1, 4
• Left-sided IJ catheters have higher thrombosis rates than right-sided 2, 4
• High (mid-neck) insertion site increases both infection and thrombosis risk 2, 4

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Complications to Monitor

Thrombotic Sequelae

• Pulmonary embolism (5–14% incidence) 1, 4
• DVT recurrence (2–5% incidence) 1, 4
• Post-phlebitic syndrome (10–28% incidence) 1, 4

Infectious Sequelae

• Catheter-related bloodstream infection with potential for sepsis 1
• Deep neck abscess requiring surgical drainage 2

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Key Clinical Pitfalls

• Do not delay ultrasound based on clinical suspicion alone; thrombosis can be asymptomatic or present with subtle findings 1, 3
• Do not assume isolated jugular vein thrombosis is benign; it carries significant PE risk despite older literature suggesting otherwise 1, 3
• Do not use DVT prophylaxis doses to prevent catheter-related thrombosis; standard prophylactic anticoagulation is ineffective for this indication 5
• Do not overlook malignancy as an underlying cause in spontaneous or catheter-related IJV thrombosis 6