Comments on “Prevalence of Subclinical Internal Jugular Vein Thrombosis After Microvascular Head and Neck Reconstruction”

We read with great interest the article by Kurita and colleagues evaluating the prevalence of subclinical internal jugular vein thrombosis after microvascular head and neck reconstruction using contrast enhanced computed tomography (Kurita et al. 2026). The authors should be acknowledged for adopting explicit radiologic definitions of complete and partial occlusion and for correlating thrombus location with the venous anastomotic site during the early postoperative period. Their report of a 4.7% incidence, with preserved flap survival even in cases of complete obstruction on the anastomotic side, directly challenges prevailing assumptions regarding venous vulnerability. The principal interpretive implication of these findings is that internal jugular vein thrombosis detected in the first postoperative week may not equate to functional venous failure. However, the study frames flap survival as the dominant outcome, which may oversimplify venous pathophysiology. Venous hypertension can impair microcirculatory outflow without progressing to overt necrosis, particularly in jejunal and musculocutaneous transfers where monitoring relies on pin prick assessment or an externalized segment (Cuthbert et al. 2018). A flap that survives may still experience subclinical congestion influencing edema, fistula formation, or delayed healing (Bilancini et al. 2021). For reconstructive surgeons, the relevant clinical question is whether early thrombosis alters postoperative monitoring intensity or thresholds for re exploration rather than merely whether the flap is lost. The absence of statistically significant predictors for internal jugular vein thrombosis may also induce a perception of uniform procedural safety. With five events among 103 imaged patients, a lack of detectable associations does not necessarily indicate absence of clinically meaningful gradients in risk. Variables such as bilateral neck dissection, prior radiotherapy, pedicle orientation, or recipient vein dominance may exert directional effects that are not apparent within limited event counts (Chang et al. 2022). In practice, surgeons must still stratify thrombosis risk when selecting recipient vessels, particularly in irradiated or previously dissected necks. The reported case of concomitant pulmonary embolism further complicates the notion of benign subclinical thrombosis. Even when the venous anastomosis remains patent and flap perfusion intact, systemic thromboembolic consequences may occur (Mishra et al. 2025). This introduces a decision point regarding anticoagulation, balancing propagation risk against postoperative bleeding in freshly dissected cervical fields. The study documents the safe use of heparin and direct oral anticoagulants, yet criteria for initiating therapy remain empiric and could benefit from standardized algorithms based on thrombus location relative to the anastomosis. We commend the authors for providing anatomically detailed analysis of thrombus position in relation to end to side anastomosis and for advancing discussion beyond crude incidence reporting. Prospective integration of standardized imaging timelines, hemodynamic assessment of venous outflow, and protocolized anticoagulation strategies may refine postoperative care pathways and clarify which internal jugular vein thromboses represent adaptive collateralization rather than impending compromise. Kishankumar Mahida: conceptualization, methodology, writing – original draft, writing – review and editing. Snehal Rajendra Jagtap: validation, supervision, project administration, writing – original draft, writing – review and editing. Grammarly and ChatGPT tools were used solely to assist with language refinement and formatting. All scientific content, interpretations, and critical analyses were developed by the authors, who take full responsibility for the integrity and accuracy of the manuscript. The authors have nothing to report. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report.