(1046) Rapid Thrombus Formation and Massive Pulmonary Embolism Following Central Venous Catheter Placement

Introduction: Central venous catheters (CVCs) are often used for monitoring hemodynamic status and rapidly delivering fluids and vasoactive medications during the peri- and postoperative periods. The incidence of thrombosis after CVC insertion depends upon the site, duration, and underlying patient risk factors like malignancy. Isolated internal jugular vein (IJV) thrombosis is a rare entity, with a low incidence (0.5%) of pulmonary embolism (PE) cases. We present a case of rapid thrombus formation following CVC placement resulting in a massive PE.

Description: A 58-year-old female with retroperitoneal leiomyosarcoma underwent elective surgical resection. For the procedure, a left IJV CVC was inserted for vascular access and medication administration. On postoperative day 1, the patient experienced a syncopal episode. She was alert and oriented but hypotensive (BP 76/45 mm Hg), tachycardic (HR 130/min), and with oxygen saturation of 88% on room air, necessitating 2L oxygen via nasal cannula. POCUS revealed a left IJV thrombus within the CVC, with RV dysfunction and hyperdynamic apex. The CVC was promptly removed, and the patient was started on a heparin infusion and admitted to the ICU. Computed tomography pulmonary angiography (CTPE) confirmed the presence of emboli in the right inter-lobar and left lower lobar distal segmental branches, with possible evidence of right heart strain. Interventional Radiology was consulted but the patient was not suitable for catheter thrombolysis and mechanical thrombectomy due to her recent surgical procedure. Anticoagulation therapy with heparin was continued with gradual improvement on oxygen saturation. On Day 4, she was transitioned to enoxaparin. Follow-up CTPE on Day 8 revealed no evidence of right ventricular strain, suggesting PE resolution. The patient was discharged home on an oral factor Xa inhibitor.

Discussion: Our case highlights the rare instance of rapid thrombus development in the IJV following CVC placement and its potential to lead to massive PE in the perioperative setting. POCUS plays a crucial role in early diagnosis, enabling rapid removal of the CVC and initiation of anticoagulation therapy.