Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 4  |  Page : 497-499

Usefulness of preoperative color Doppler study in chronic renal failure patients undergoing renal transplantation having internal jugular vein thrombosis: anesthesiologist's perspective


1 Department of Anaesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre & Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital campus, Asarwa, Ahmedabad, Gujarat, India
2 Department of Urology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre & Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital campus, Asarwa, Ahmedabad, Gujarat, India

Date of Submission05-Apr-2014
Date of Acceptance03-May-2014
Date of Web Publication28-Nov-2014

Correspondence Address:
Manisha P Modi
Professor, Department of Anaesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre & Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital campus, Asarwa, Ahmedabad, 380016, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.145676

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  Abstract 

Aim
The aim of the study was to identify the prevalence of internal jugular vein (IJV) thrombosis and usefulness of preoperative color Doppler study in chronic renal failure patients undergoing live related renal transplant surgery.
Materials and methods
Two hundred and fifty adult patients of either sex having history of prolonged IJV cannulation were enrolled in this study. They were advised to undergo Doppler neck vessels study. Normal IJV was used to measure central venous pressure during renal transplantation surgery.
Results
Results are shown as mean±SD. Two hundred and fifty adult patients were included in the study, aged 36 ± 12 years. All patients were cannulated with Mahorkar 16 Fr double-lumen catheter. Duration of catheterization was 52.38 ± 18.91 days. Of the 250 patients, 50 were female patients. The cause of removal was infection, blockage, or maturation of arteriovenous fistula. All patients were clinically asymptomatic. Color Doppler study showed chronic thrombosis either complete/partial in 93 (37.2%) patients. Five (2%) patients had bilateral thrombosis, 80 (86%) patients had partial thrombosis, and 13 (14%) patients had complete thrombosis. The incidence and prevalence were 0.62 and 37.2%, respectively. Right IJV was the common site for insertion [right: 70 (75.2%) and left: 23 (24.7%)].
Conclusion
To prevent inadvertent catheter placement and embolism, all patients having history of prolonged IJV cannulation should undergo preoperative color Doppler study.

Keywords: chronic renal failure, color Doppler study, internal jugular vein thrombosis


How to cite this article:
Modi MP, Vora KS, Parikh GP, Modi PR, Shah VR. Usefulness of preoperative color Doppler study in chronic renal failure patients undergoing renal transplantation having internal jugular vein thrombosis: anesthesiologist's perspective. Ain-Shams J Anaesthesiol 2014;7:497-9

How to cite this URL:
Modi MP, Vora KS, Parikh GP, Modi PR, Shah VR. Usefulness of preoperative color Doppler study in chronic renal failure patients undergoing renal transplantation having internal jugular vein thrombosis: anesthesiologist's perspective. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2021 Apr 19];7:497-9. Available from: http://www.asja.eg.net/text.asp?2014/7/4/497/145676


  Introduction Top


Central venous pressure (CVP) monitoring is an essential part of fluid management during renal transplantation surgery. Central venous catheterization is a common transient access for hemodialysis in chronic renal failure patients before maturation or creation of arteriovenous fistula. The internal jugular vein (IJV) is the preferred central vein to indwell a catheter. Catheter-related central vein thrombosis is a known complication in hemodialysis patients, which could be due to increased use of this access site, larger catheter size, or possibly due to prolonged catheterization. Although IJV thrombosis is often clinically occult, it results in loss of the preferred access site for CVP measurement during renal transplantation. When bilateral, jugular thrombosis may lead to the use of far less desirable access sites for catheterization.

The purpose of our study was to determine the prevalence of IJV thrombosis at our center and usefulness of preoperative color Doppler study for anesthetists and selection of cannulation site, thereby avoiding adverse event such as pulmonary embolism and inadvertent catheter placement or failure to pass a guidewire or catheter in chronic renal failure patients scheduled for live related renal transplantation who are having history of IJV catheter placement for 1 month or more. All of them were advised to undergo preoperative color Doppler study of the IJV.


  Materials and methods Top


This study was approved by our Institutional Review Board. The study was designed as a prevalence study to determine the prevalence of IJV thrombosis in chronic renal failure patients by preoperative color Doppler study. Between June 2011 and January 2012, 250 adult patients of either sex undergoing live renal transplantation surgery with history of IJV cannulation for 1 month or more were enrolled in the study. The study was limited to the IJV because it is our preferred access site for CVP monitoring during renal transplantation. Pediatric patients and patients having short history of IJV cannulation were excluded from our study.


  Evaluation and imaging of patients Top


All patients were evaluated preoperatively when they were scheduled for renal transplantation surgery. Detailed information regarding catheterization was obtained from patients regarding the type of catheter and cause of removal and duration of cannulation, and patients were advised to undergo color Doppler study. All patients had surgical fistula for dialysis. Either right/left IJV cannulation was used for temporary hemodialysis before maturation or creation of arteriovenous fistula. Color Doppler study of cannulated IJV site was performed by radiologist. Results of the ultrasonography examination were recorded, and accordingly we planned for IJV cannulation for CVP measurement.


  Patients and methods Top


Statistical analysis was performed by SPSS version 12 (Statistical Package for Social Sciences; SAS Institute Inc., Cary, North Carolina, USA). Data were analyzed by mean ± SD. The incidence and prevalence were calculated as percentage.


  Results Top


Two hundred and fifty adult patients were included in the study, aged 36 ± 12 years. All patients were cannulated with Mahorkar 16 Fr double-lumen catheter. Duration of catheterization was 52.38 ± 18.91 days. Of the 250 patients, 50 were female patients. The cause of removal was infection, blockage, or maturation of arteriovenous fistula. All patients were clinically asymptomatic. Color Doppler study showed chronic thrombosis either complete/partial in 93 (37.2%) patients. Five (2%) patients had bilateral thrombosis, 80 (86%) patients had partial thrombosis ([Figure 1], [Figure 2], [Figure 3]), and 13 (14%) patients had complete thrombosis ([Figure 4] and [Figure 5]). The incidence and prevalence were 0.62 and 37.2%, respectively. Right IJV was the common site for insertion [right: 70 (75.2%) and left: 23 (24.7%)].
Figure 1: Right IJV partial thrombosis. IJV, internal jugular vein.

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Figure 2: Left IJV partial thrombosis. IJV, internal jugular vein.

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Figure 3: Left IJV partial thrombosis. IJV, internal jugular vein.

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Figure 4: Left IJV complete thrombosis. IJV, internal jugular vein.

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Figure 5: Left IJV complete thrombosis. IJV, internal jugular vein.

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  Discussion Top


CVP monitoring is an essential monitoring during renal transplantation surgery for guidance of fluid therapy. In recent years, hemodialysis catheters have come to play an increasingly important role in the delivery of hemodialysis. The use of both temporary as well as cuffed hemodialysis catheters has emerged as a significant boon for patients. The National Kidney Foundation Dialysis Outcomes recommended that 'less than 10% of chronic maintenance hemodialysis patients should be maintained on catheters as their permanent chronic dialysis access' [1]. However, the complications associated with each of these hemodialysis catheters, in terms of anatomic, thrombotic, and infectious issues, have emerged as a major problem with their continued use. There are some studies on catheter-related thrombosis in patients having hemodialysis catheter in situ. Apart from patients with hematological and other malignancies as well as those having hemodialysis cannula, the incidence of central venous catheter-related thrombosis and its clinical impact have not been studied well. Terrece and colleagues found the evidence of right IJV thrombosis in 25.9% of the patients [2,3]. In our study, 70 patients had right IJV thrombosis; therefore, left IJV was used to measure CVP. In contrast to thrombosis of the subclavian or innominate vein, IJV thrombosis or stenosis is often clinically occult. This is due to the development of extensive venous collaterals and the isolation of IJV thrombosis from the high outflow drainage from the upper extremities.

Despite being clinically occult, IJV thrombosis results in loss of the preferred access site for CVP measurement. We observed bilateral thrombosis in five patients. In these patients, we used peripheral venous catheters for CVP measurement intraoperatively. Femoral vein cannulation is not the preferred site for cannulation because these vessels are being used for anastomosis during renal transplantation surgery. Furthermore, femoral vein cannulation is known to have a higher rate of infection and have been reported to have a 25% frequency of lower extremity deep venous thrombosis [4]. This will further add risk in chronic renal failure patients. Epidemiologic studies have reported an increased risk for venous thromboembolism in dialysis and in renal transplant patients [5,6]. The overall diagnostic value of color Doppler ultrasound, with a sensitivity of 94% and specificity of 96% in the detection of central venous thrombosis, is regarded as satisfactory [7]. Color Doppler duplex sonography is a noninvasive, safe, and convenient means of diagnosing central venous catheter-related thrombosis [8]. A major problem with color Doppler ultrasound is the difficulty in direct visualization of the superior vena cava and brachiocephalic vein because of the sternum.


  Conclusion Top


To prevent inadvertent catheter placement and embolism, all patients having history of prolonged IJV cannulation should undergo preoperative color Doppler study.


  Acknowledgements Top


 
  References Top

1.
NKF-DOQI clinical practice guidelines for vascular access. National Kidney Foundation-Dialysis Outcomes Quality Initiative. Am J Kidney Dis 1997; 30:S150-S191.  Back to cited text no. 1
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2.
Kujur R, Rao SM, Badwaik G, Paraswani R. Thrombosis associated with right internal jugular central venous catheters: a prospective observational study. Ind J Crit Care Med 2012; 16: 17-21.  Back to cited text no. 2
    
3.
Wilkin TD, Kraus MA, Lane KA, Treotola SO. Internal jugular vein thrombosis associated with hemodialysis catheters. Radiology 2003; 228:697-700.  Back to cited text no. 3
    
4.
Trottier SJ, Veremakis C, O'Brien J, Auer AI. Femoral deep vein thrombosis associated with central venous catheterization: results from a prospective, randomized trial. Crit Care Med 1995; 23:52-59.  Back to cited text no. 4
    
5.
Tvei DP, Hypolite IO, Hshieh P, Cruess D, Agoda LY, Welch PG, Abbot KC. Chronic dialysis patients have high risk for pulmonary embolism. Am J Kidney Dis 2002; 39:1011-1017.  Back to cited text no. 5
    
6.
Abbott KC, Cruess DF, Agodoa LY, Sawyers ES, Tveit DP. Early renal insufficiency and late venous thromboembolism after renal transplantation in the United States. Am J Kidney Dis 2004; 43:120-130.  Back to cited text no. 6
    
7.
Koksoy C, Kuzu A, Kutlay J, Erden I, Ozcan H. The diagnostic value of color doppler ultrasound in central venous catheters related thrombosis. Clin Radiol 1995; 50:687-689.  Back to cited text no. 7
    
8.
Mustafa BO, Rathbun SW, Whiteett TL, Raskob GE. Sensitivity and specificity of ultrasonography in the diagnosis of upper extremity deep vein thrombosis: a systemic review. Arch Intern Med 2002; 162:401-404.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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