1. Incidence and risk factors for internal jugular vein thrombosis associated with introducer sheaths for pulmonary catheter after cardiac surgery
Atsuko Shono, Toru Mihara, Yurika Murakami, Junichi Ota, Fumiko Kono, Yoji Saito. 　
Department of Anesthesiology, Shimane University Faculty of Medicine, Japan

2. Background and aims
Pulmonary catheter is widely placed for cardiac surgery. Complications of indwelling pulmonary catheter, such as perforation pulmonary artery perforation and pulmonary embolism, are well known. However, thrombosis associated with introducer sheaths has received much less attention.
We evaluated the incidence and possible risk factors for internal jugular vein thrombosis (IJVT) associated with introducer sheaths for pulmonary catheter after cardiac surgery.

3. Methods ◆ Observational study
◆ Patients who underwent cardiac surgery were included (n=61)
◆ PA catheter and introducer sheath were inserted immediately before start of operation.
introducer sheaths : 8.5Fr, 10cm, arrow®
Site : right internal jugular vein (IJV)
◆ Ultrasonographic evaluations of IJVT were performed prior to insertion and daily until removal of introducer sheaths.

4. Measurements Demographic data Operation factors♦
Demographic data
age, gender, height, weight, BMI, presence of underlying disease and cancer, duration of catheterization, complications during cannulation ♦
Operation　factors
length of surgery, use of CPB and IABP, emergency or not ♦
Coagulation status and Cardiac Index
(before and after operation)
Platelet count , %PT, APTT, D-dimer, CI
These parameters were compared between patients who developed IJVT (IJVT group) and those who did not (Non-IJVT group).
The Student’s t test, χ2 test, and Mann-Whitney test were used for statistics and P value of < 0.05 was considered significant.

5. Result (1) ❖ Total number of patients who developed thrombosis
20 /61 (32.8%)
No clinical symptoms related to IJVT were found. ❖
❖ Type of thrombosis ♦
fibrin sheath (n=12) ♦
wall thrombosis (n=8)
IJV
IJV
✦visualization of echogenic intravascular mass
　　血管内のechogenicなmassがある
✦ non-compressibility
　　 プローべにて血管壁に圧をかけてもつぶれない
✦ absence of respiratory variation
　呼吸性の変動がない
✦ No spontaneous Doppler flow (intra luminal defect at color Doppler imaging)
　　　ドプラー法にて血管内の血流が欠損する
catheter
thrombosis

6. fibrin sheath ♦
wall thrombosis ♦

7. ❖
Number of patients who developed thrombosis and postoperative date thrombosis was found
Number of patients (n)
Postoperative day 7 5 4 3 1
❖ Mean duration from insertion to development of thrombosis was 2.8 ±1.5 day.

8. Result (2) : Demographic data IJVT group Non-IJVT group (n=20) (n=41)
Age(yr) 　　 ± ±12
Gender : M/F (n) / /18
BMI (kg/m2)　　　　　　 　　 22.1±3.4 　 ±3.2
5± ±2　
duration of catheterization (day) *
1.5± ±1.7　　　　　　　　　　　
attempts of insertion (n)
18 (90.0%) (51.2%) 　
presence of underlying disease (n) *
presence of Cancer (n) 　　
2 (10%) (2.4%)
P<0.05 VS Non-IJVT group *
(mean±S.D.)

9. Result (3) : 結果(3): 穿刺および手術に関わる因子 Operation factors
IJVT group Non-IJVT group
(n=20)
(n=41)
operation time (min)　　 ±130 　 ±119
use of CPB (n) (40.0%) 　　 (53.7%)
use of IABP (n)　 (45%)　 (22%)
emergency (n)　 (40.0%)　 (24.4%)
P<0.05 VS Non-IJVT group *
(mean±S.D.)

10. Result (4) : Coagulation status IJVT group Non-IJVT group (n=20)*
platlet
(104/μl)
Pre operation ± ±5.3
Post operative day ± ±4.4
Post operative day ± ±3.5
D-dimer (mg/dl)
Pre operation ±4.0 　　　　 　 ±2.4
Post operative day ± ±2.8
Post operative day ±2.1 　　　　 　 　　　2.6±3.3
Pre operation ±7.0 　　　　 ±7.9
Post operative day ± ±8.3
Post operative day ± ±10.8
APTT (sec)
PT (%)
Pre operation ±24.7 　 　　 　 ±17.0
Post operative day ± ±13.1
Post operative day ± ±13.7 * * *
P<0.05 VS Non-IJVT group *
(mean±S.D.)

11. Cardiac index (l/min/m2)
Result (4) :
IJVT group Non-IJVT group
(n=20)
(n=41)
Cardiac index　(l/min/m2)
Pre operation　　　 ± ±0.7
Post operative day ± ±0.5
Post operative day ± ±0.5
Post operative day ± ±0.4 *
P<0.05 VS Non-IJVT group
(mean±S.D.)

12. Result (5) : Risk Factors Odds Ratio ( 95% Confidence interval )
Male (gender) ( )
( )
presence of underlying disease
emergency ( )
use of IABP ( )
use of CPB ( )

13. Discussion ♦ ♦ ♦ We should reconsider the necessity of PA cathether.
IJVT associated with introducer sheaths was frequent (32.8%). ♦
In the IJVT group, cardiac index was lower, D-dimer was higher significantly on the postoperative day 1, and duration of cathetherization was longer than Non-IJVT group. ♦
IJVT can develope even on day 1 after surgery, but were usually found to be asymptomatic.
We should reconsider the necessity of PA cathether.
If inserted, daily ultrasonographic assessment of IJVT and D-dimer testing are needed, and we should consider early decannulation of PA cathether and introducer sheath.

14. Conclusions
1. IJVT associated with introducer sheaths was a frequent complication.
2. Male and underlying disease were identified as risk factors for IJVT.
3. This risk should be carefully considered if insertion of pulmonary catheter is chosen for cardiac surgery.