Recommended Citation
Rashid M, Khorasani A. Overcoming perioperative challenges: Aspirated blood clots during internal jugular line placement in a factor v leiden patient. Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Presentation Notes
Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Abstract
Introduction: Hypercoagulable coagulopathy is a serious condition associated with increased morbidity and higher complication rates. In this case, we highlight the devastating consequences of a hypercoagulable state in a young female patient and emphasize the critical role of the anesthesia team in perioperative management. Case Presentation: A 33-year-old female with a history of diabetes mellitus, hypertension, and heterozygous Factor V Leiden mutation presented with extensive right lower extremity deep vein thrombosis (DVT) and an acute non-occlusive pulmonary embolism (PE) in the right lower lobe, along with a stable chronic PE. Her medical history was significant for multiple thrombotic events, including a left femoral vein DVT requiring inferior vena cava (IVC) filter placement in 2016 and a pulmonary embolism in 2023. Given the severity of her condition, the vascular surgery team performed suction thrombectomy for extensive right iliac vein thrombosis. Venography revealed IVC filter erosion into the vein wall, necessitating an open IVC filter explantation with iliac vein reconstruction and partial explantation of the left common iliac vein stent on January 13, 2025. Despite these interventions, she developed recurrent thrombosis due to her hypercoagulable state, requiring mechanical thrombectomy of the IVC and iliac veins on January 21, 2025. During preoperative evaluation, Doppler ultrasound revealed left upper extremity arterial occlusion with no detectable flow. A right radial artery catheter was successfully placed. Given the critical nature of the surgery, ultrasound assessment of bilateral upper extremity veins showed thrombosed, non-compressible veins, necessitating left internal jugular (IJ) vein catheter placement. Under ultrasound guidance, the needle was correctly positioned in the left IJ vein, but blood return was scant. Despite this, guidewire insertion was attempted but met resistance at 5 cm. Ultrasound confirmed longitudinal guidewire passage, so the angiocatheter was advanced, revealing four medium-sized blood clots on aspiration. A second guidewire attempt at 10 cm also met resistance, but a triple-lumen catheter was successfully threaded, yielding additional blood clots upon aspiration. To maintain patency, heparinized saline flushes were performed until fresh blood aspiration was achieved. The vascular surgery team utilized the catheter due to extensive right IJ vein thrombosis, using it for heparin administration and venography. This facilitated successful mechanical thrombectomy, improving venous patency and perfusion. Conclusion: Factor V Leiden is a genetic mutation that increases the risk of thrombosis by making factor V resistant to inactivation by activated protein C, with varying prevalence across populations[1,2]. This case highlights the challenges of managing hypercoagulable patients, particularly when thrombosis complicates central venous access, necessitating innovative anesthesia approaches. Despite significant clot burden, successful ultrasound-guided cannulation provided critical vascular access, functioning as a mini suction thrombectomy and facilitating the vascular surgery team’s intervention. 1. Thorelli E, et al. (1999) V. Blood. 93(8):2552-8. 2. National Library of Medicine. Factor V Leiden thrombophilia. MedlinePlus Genetics. Available at: https://medlineplus.gov/genetics/condition/factor-v-leiden-thrombophilia. Accessed February 10, 2025.
Type
Oral/Podium Presentation
Affiliations
Advocate Illinois Masonic Medical Center