Internal jugular vein thrombosis is rare. It is often secondary to prolonged central venous cannulation and associated with local or distant malignancy. The authors present a case of intra-operative thrombosis of the internal jugular vein which complicated subsequent microvascular anastomosis of a radial forearm free flap. The management of the intra-operatively thrombosed internal jugular vein and alternative anastamotic options for the free flap are discussed.
A 67-year-old male presented with a T2N0 squamous cell carcinoma of the right floor of mouth. A staging contrast enhanced computed tomography (CT) scan revealed no obvious neck nodes and bilateral patent internal jugular veins (IJVs). The tumour encroached on the midline and a plan was made for tumour resection in continuity with bilateral supraomohyoid neck dissections and radial forearm free flap repair. The right side of the neck was planned for flap anastomosis as the tumour was predominantly right sided in the floor of the mouth.
The right external jugular vein had been preserved without sectioning and there were no surgical breaches in the wall of the right IJV. The radial forearm flap was raised with both separate cephalic vein and venae comitantes outflow. When a venotomy was performed on the right IJV, the vessel was found to be full of fresh clot. Intra-luminal suctioning and heparinised saline irrigation of the vessel failed to establish any reliable flow.
The venotomy was closed and a single venae comitans anastamosed end-to-side to the right external jugular vein, good venous outflow being established. As an additional measure, the authors found the cephalic vein was sufficiently long to allow anastamosis end-to-end with the contralateral anterior jugular vein, again with good outflow.
A postoperative, contrast enhanced CT scan was obtained which confirmed total occlusion of the right IJV ( Fig. 1 ). There was no clot propagation beyond the IJV. A thrombophilia screen was normal. In view of the risk of postoperative bleeding the patient was not fully anti-coagulated but maintained on prophylactic subcutaneous heparin until uneventful discharge with a healthy free flap on day 10 post surgery ( Fig. 2 ).