Triad

INTRODUCTION: Pulmonary venous thromboembolism (PVTE) is commonly encountered in hospitalized patients. Risk increases following trauma, surgery, immobilization and malignancy. Most often, the origins of the emboli are from the deep veins of the lower extremities. We present an unusual case of recurrent PVTE originating from the Right Internal Jugular Vein (RIJV) in a patient following self-strangulation.

CASE PRESENTATION: A 21 year-old male with no prior medical history presented to the emergency department following a suicide attempt by self-strangulation. The patient was found hanging from his neck, apneic, obtunded, hypotensive and bradycardic. Despite successful resuscitation efforts, the patient developed ARDS requiring mechanical ventilation. Physical examination revealed coarse breath sounds and a distinctive circumferential excoriation on his neck. On the 5th day the patient demonstrated improved neurological function and good weaning parameters. A trial of extubation resulted in hypoxia and reintubation. A chest radiograph revealed only resolving bilateral infiltrates. ACT pulmonary angiogram revealed bilateral subsegmental PVTEs. Simultaneously preformed doppler ultrasounds of the lower and upper extremities were normal. Intravenous anticoagulation was started and maintained at therapeutic levels. Three days later appropriate spontaneous breathing parameters prompted extubation. Within 24 hours of extubation the patient once again became hypoxic. On this occasion, hypoxemia was further complicated by hypotension. An arterial blood gas demonstrated respiratory alkalosis and an Arterial-alveolar oxygen gradient of 426 while breathing 100% oxygen. Following reintubation and fluid resuscitation, a second CT pulmonary angiogram was performed. New, bilateral central and segmental PVTE were demonstrated (Figure 1). Once more, doppler ultrasonography of the extremities remained normal. Interestingly, doppler ultrasonograpby of the neck discovered the presence of a near occlusive thrombus of the RIJV. Echocardiogram demonstrated mild right ventricular dilatation with an estimated right ventricular systolic pressure of 60mm of Hg. Apart from strangulation injury to the neck, the RIJV remained naive to central lines and intravenous canulations. The combination of high oxygen requirements, hemodynamic instability and extensive clot burden prompted thrombolysis with alteplase. A post-thrombolysis doppler ultrasound study of the patient's neck revealed persistent clot in the RIJV (Figure 2). In an attempt to prevent further thromboembolic events the RIJV was surgically ligated. Two days after the RIJV ligation the patient was successfully extubated after a 30 minute T-piece trial. In the days following the patient's oxygen requirement was brought down to room air.

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DISCUSSIONS: In 1856 Rodolf Virchow described a triad of predisposing factors necessary for the formation of thrombus--abnormal flow, vessel injury, and hypercoagulability. We report a unique case of PVTE originating form the RIJV following trauma to the neck. It is postulated that the injury sustained by strangulation predisposed our patient to endothelial injury in the RIJV, creating a nidus for persistent thromboses and recurrent PVTE. In addition, the strangulation effect caused by the ligatures around our patient's neck likely prevented venous return for an unknown amount of time, thus causing blood stasis. The injury that occurred before the patient was hospitalized predisposed him to eventual thrombosis, with ensuing recurrent PVTE. Our patient did not have a known genetic hypercoagulable state or malignancy, according to our work up. This is the only known reported case of PVTE originating from a RIJV thrombus as a result of self-strangulation. Anticoagulation likely plays a role in the therapy of these patients, however, there is no literature to support the use of upper extremity, or superior vena cava filters to prevent clot propagation.

CONCLUSION: Embolic events originating from the upper extremity and neck veins are phenomena that must always be considered in patients with PVTE and injury to the neck.

DISCLOSURE: Justin Sebastian, None.

Avelino Verceles MD Justin Sebastian MD * Siva Ramachandran MD Drexel University College of Medicine, Philadelphia, PA

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group