Significance of Echocardiographically Detected Central Venous Catheter Tip-Associated Thrombi

Malposition of a Femoral Tunneled Dialysis Catheter through a Patent Foramen Ovale

Patent foramen ovale (PFO) is a common congenital abnormality of high prevalence in adults. Its clinical significance is magnified in a right-to-left shunt, where paradoxical embolism can have catastrophic outcomes involving the brain, heart, mesenteric circulation, or extremities. Right-to-left shunting through a PFO is caused by increased right atrial pressure, as seen in the setting of pulmonary artery hypertension or pulmonary embolism. This case highlights the relevance of central venous catheter placement in the setting of a PFO. While the patient did not experience clinical sequelae from line placement, she was at high risk for paradoxical embolus. Recognizing the possibility of a PFO during central venous catheter placement, especially in the setting of increased right pressures, should be a consideration of all interventional radiologists.

Catheter-related atrial thrombosis: prevalence and risk factors in the pediatric age group—a retrospective study

Background

Catheter-related right atrial thrombosis (CRAT) is an under-studied complication of a long-term implantable venous access devices (IVAD), particularly in children with incidence rates extrapolated from the adult literature ranging between 2 and 29%. This is a single-center retrospective review of electronic medical records of children who underwent insertion of IVADs and had at least one echocardiogram performed prior to catheter removal between 2008 and 2018. Data collection included demographic information, development of CRAT, systemic infection, and administration of thrombogenic chemotherapeutic agents. We identified six patients who developed CRAT and compared them to 120 control patients. We also performed a detailed chart review for the patients who developed CRAT. Data was entered and analyzed using SPSS.

Results

A total of 764 patients underwent IVAD placement between 2008 and 2018. Six (0.79%) patients developed CRAT, and 120 patients were identified as controls that match the CRAT patients based on definitive criteria that include age, gender, chemotherapy type, steroid therapy, reason of line insertion, site of catheter insertion, tip-location at insertion, and history of systemic infections. In the CRAT group, 3 (50%) patients had their catheter tips placed in the superior vena cava-right atrial junction and 3 (50%) in the right atrium, whereas in the control group, all patients had their catheter tips placed in the superior vena cava-right atrial junction (p=0.000). Five (83.3%) patients in the CRAT group received L-asparaginase as compared to 75 (62.5%) patients in the control group (p=0.301). In the CRAT group, all patients had a history of systemic infection compared to 47 (39.2%) in the control group (p=0.180).

Conclusion

We identified 6 (0.79%) children with CRAT. Catheter-tip location within the right atrium is a potential risk factor for CRAT development in children.

Right Heart Clot-in-Transit: Endovascular Therapies

Right heart thrombus is a challenging high mortality disease typically seen in the setting of pulmonary embolism. Traditional treatments have included anticoagulation, thrombolysis, and surgical embolectomy. Advances in recognition and treatment of clot-in-transit have led to the development of endovascular therapies increasingly becoming the preferred method of treatment due to rapid debulking and lower morbidity. Novel endovascular devices are large bore aspiration thrombectomy systems which mitigate the use of concomitant thrombolytics. The article reviews the disease process, relevant literature, and current endovascular devices and strategies for the treatment of right heart thrombus and clot-in-transit.

Prevention of Paradoxical Cerebral Embolus with Protection System during Combination Right Atrial Clot Aspiration Thrombectomy and Closure of Patent Foramen Ovale

In this technical case report, we describe a 41-year-old female with a history of breast cancer who was found to have a right atrial clot attached to the tip of her Port-A-Cath. During transthoracic echocardiography to evaluate her clot, she was also noted to also have a patent foramen ovale. The decision was made to perform a simultaneous right atrial endovascular aspiration thrombectomy and patent foramen ovale closure. To minimize the risk for paradoxical embolus during clot manipulation, an intravascular embolic neuroprotection device was deployed. After the procedure, it was noted on visual inspection that the device filter contained several embolic fragments. The presence of macroscopic embolic fragments in the filter baskets highlights the role of prophylactic embolic protection when performing cardiac interventions in the setting of a patent foramen ovale, particularly in the presence of a right atrial thrombus or mass.

Management of Central Venous Access in Children With Intestinal Failure: A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group

ABSTRACT

Intestinal failure requires the placement and maintenance of a long-term central venous catheter for the provision of fluids and/or nutrients. Complications associated with this access contribute to significant morbidity and mortality, while the loss of access is an increasingly common reason for intestinal transplant referral. As more emphasis has been placed on the prevention of central line-associated bloodstream infections and new technologies have developed, care for central lines has improved; however, because care has evolved independently in local centers, care of central venous access varies significantly in this vulnerable population. The present position paper from the Intestinal Failure Special Interest Group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) reviews current evidence and provides recommendations for central line management in children with intestinal failure.

Paradoxical embolism through a patent foramen ovale from central venous catheter thrombosis: A potential cause of stroke

Paradoxical embolism refers to a potential condition in which an embolus arising from a venous source crosses into the systemic circulation through a right-to-left cardiac shunt causing an arterial embolism. A 39-year-old woman carrier of a central venous catheter (CVC) without evident risk factors for stroke, developed an acute right homonymous hemianopia during hemodialysis. On neuroimaging, an infarct in the territory of the left posterior cerebral artery was demonstrated. Transesophageal echocardiography revealed a patent foramen ovale (PFO) and a large fluctuating thrombus in the right atrium on the tip of the CVC, thus allowing a diagnosis of ischemic stroke from paradoxical embolism. Oral anticoagulation therapy was started and the PFO was closed. This case emphasizes the potential risk of paradoxical embolism in patients with CVCs and PFO. This condition should be prevented and identified in patients with specific risk factors, such as long-term catheterization and hemodialysis.

How to manage catheter-related right atrial thrombosis: Our conservative approach

BACKGROUND

Catheter-related right atrial thrombosis is an underestimated, severe, and life-threatening complication of any type of central venous catheters. No clear-cut epidemiological data are available. Catheter-related right atrial thrombosis is often asymptomatic; however, it can lead to serious complications and death.

CASE SERIES

We report seven catheter-related right atrial thrombosis events occurred in five hemodialysis patients; two recurrences following primary treatment are included in the report, all of them managed with a conservative approach without catheter removal. Systemic anticoagulation (vitamin K antagonists), having a well-defined target of International Normalized Ratio of 2.5-3.0, combined with urokinase as a locking solution at the end of each hemodialysis session were the therapeutic strategy used in all patients. After the first month, the anticoagulation target was reduced to an International Normalized Ratio value of 1.5-2.0 and urokinase to a weekly administration. After sixth months, when no thrombus was identified at transthoracic echocardiographic examinations, the treatment was stopped. No bleeding complications were reported.

CONCLUSION

The combination therapy here described is safe, quick, and effective, achieving the goal of not removing catheters.

Role of Imaging for Suspected Cardiac Thrombus

PURPOSE OF REVIEW

Cardiac thrombus formation is a frequent complication of a variety of prevalent diseases. Embolism of cardiac thrombus has the potential to result in significant morbidity and mortality from cerebrovascular and peripheral vascular events.

RECENT FINDINGS

Echocardiography is the most commonly used imaging modality for diagnosing intracardiac thrombus. However, technological advances in computed tomography and magnetic resonance imaging have allowed newer noninvasive modalities to evolve into robust tools for the clinical evaluation of patients suspected of disease. Complimentary use of these imaging techniques is crucial in the diagnosis of cardiac thrombus and initiation of anticoagulation therapy.

Comparison of Ultrasound-Guided Right Brachiocephalic and Right Subclavian Vein Cannulation in Adult Patients

OBJECTIVES

To compare ultrasound-guided right brachiocephalic vein (BCV) central venous catheter (CVC) placement to right subclavian vein (SCV) CVC insertion in terms of the puncture success rate and complications.

METHODS

A retrospective review was performed for all adult patients who received an ultrasound-guided CVC via the right BCV or right SCV access route between January 2016 and March 2018. The puncture success rates and procedure-related complications were analyzed.

RESULTS

Data were analyzed from 755 adult patients who underwent 915 CVC insertions. The overall success rate was higher in the BCV group compared to that in the SCV group (98.99% versus 96.87%; P = .019). The first-attempt success rate was higher in the BCV group compared to that in the SCV group (96.64% versus 89.34%; P < .001). Intraoperative complications were observed in 16 cases in the BCV group (2.68%) and in 12 cases in the SCV group (3.76%). The incidence rates of postprocedure complications were 5.20% in the BCV group and 6.58% in the SCV group and included catheter-related infections and thrombosis.

CONCLUSIONS

Ultrasound-guided cannulation of the right BCV is an effective and safe method for CVC placement in adult patients and provides an additional option for catheter access.

Vascular access considerations for extracorporeal photopheresis

Extracorporeal photopheresis is an immunomodulatory therapy indicated for patients with cutaneous T-cell lymphoma, graft-versus-host disease, and heart or lung allograft rejection. Whole blood from the patient is drawn into the photopheresis instrument where it is separated into its components. Plasma, red blood cells, and the treated buffy coat are subsequently returned to the patient. Consistent, adequate blood flow is necessary to successfully complete the procedure. Vascular access options for photopheresis include peripheral vein cannulation, tunneled central venous catheters, and subcutaneous ports. Photopheresis is a very safe procedure; however, the complications and impact on the patient's quality of life associated with vascular access devices can be significant.