Right atrium thrombosis in patients on hemodialysis

Catheter-related right atrial thrombosis

INTRODUCTION

Catheter-related right atrial thrombosis is an under-recognized complication of central venous catheter placement. We performed a retrospective review, characterizing clinical aspects of catheter-related right atrial thrombosis (CRAT).

METHODS

To identify cases, a literature search was conducted in PubMed and additional items selected by review of related items and bibliography review. Key clinical data were extracted and analyzed both in total and as stratified by hemodialysis versus non-hemodialysis groups.

RESULTS

A total of 68 catheter-related right atrial thrombosis events were reported in 63 patients (five recurrences, of which 4 involved catheter left in place following primary treatment). Median (interquartile range) time to CRAT diagnosis was longer among hemodialysis patients - 12 (4.0-24.0) weeks compared to 5.5 (1.8-16.1) weeks among non-hemodialysis patients. The most common presentations were asymptomatic in 16/68 (23.5%), fever/sepsis in 21/68 (30.9%), pulmonary embolism in 11/68 (16.2%), catheter dysfunction in 8/68 (11.8%), dyspnea in 8/68 (11.8%), and new murmur or valvular dysfunction in 8/68 (11.8%) patients. Primary treatment selection was anticoagulation in 33/68 (48.5%), surgical thrombectomy in 17/68 (25.0%), thrombolysis in 12/68 (17.6%), or no active therapy in 6/68 (8.8%) patients. Primary treatment failure for anticoagulation and thrombolysis was 27.3% and 33.3%, respectively. The most common rescue therapy was surgical thrombectomy, ultimately resulting in an overall rate of 26/62 (41.9%). Overall, per-patient mortality was 13/63 (20.6%). Intracardiac tip position - 27/34 (79.4%) - overshadowed thrombophilia - 16/63 (25.4%) - as a risk factor for CRAT.

CONCLUSION

Catheter-related right atrial thrombosis is an underdiagnosed complication of central venous catheter placement. For the hemodialysis population, a fistula-first approach is advocated. While many instances were asymptomatic, the development of unexplained fever, dyspnea, catheter dysfunction, or new murmur should trigger a search for this complication.

Internal Jugular Vein Thrombosis after Positioning CVC in Dialysis Patients: The Most Common Ultrasound Patterns

Frequently patients are started on hemodialysis after the placement of a central venous catheter (temporary or tunneled) in the internal jugular vein (IJV). Currenty this procedure is facilitated by ultrasound probes that improve the rate of success of catheter placement in vessels and diminishes the possible complications, minimizing the gap between nephrologists with wide surgical expertise and those with limited surgical experience. Stenosis and thrombosis of the subclavia vein are well documented complications derived from the placement of the venous catheter. Internal jugular vein thrombosis is not seen very often due to scarce clinical evidence. In our paper we have been able to systematically document various extrinsic thrombotic complications outside the central venous catheter, by use of ultrasound (periluminar or related to the vessel).

Right Atrial Thrombi Complicating use of Central venous Catheters in Hemodialysis

Background

There has been an increase in the use of central venous catheters for temporary hemodialysis access. In this report, we describe a case series of 12 patients on hemodialysis who developed intracardiac clots associated with the use of central venous catheters, their outcomes and review the literature on this syndrome.

Methods

Retrospective, single-center case series of 12 patients with right atrial thrombi associated with central venous catheter use for dialysis vascular access. These patients were treated between June 1, 2001 and June 30th 2002 at the three University of Rochester affiliated dialysis clinics. The medical records of these patients were reviewed to obtain information concerning demographics, dialysis history, dates of catheter insertion, catheter complications, identification and dimensions of intracardiac thrombi, echocardiographic data, and outcome of anticoagulant therapy.

Results

Right heart thrombi were identified in 12 patients in our hemodialysis population over the study interval. Anticoagulation for 6 months led to clot resolution in more than 50% of our patients. Bacteremia recurred in 6 patients (50%), in spite of catheter replacement. There was zero mortality related to presence of clots in the short term. One patient with non-bacteremic right atrial thrombus suffered sudden cardiac arrest, but was successfully resuscitated.

Conclusion

Right atrial thrombi may occur in hemodialysis patients who use central venous catheters for dialysis access. These clots are frequently found in the right atrium or right atrial-superior vena caval junction. Ten of 12 patients (83%), had catheter-associated bacteremia, but the precise relationship between bacteremia and intracardiac clots is unclear. Chronic anticoagulation for 6 months lead to resolution of these clots in more than 50% of patients in our series.

Deviations of Placement / Function of Permanent Central Vein Catheters for Hemodialysis

Fourteen cases of malposition of a permanent central vein catheter for hemodialysis or poor blood flow associated with thrombosed central veins but correct catheter positioning, in 13 patients suffering from end stage renal disease, presented from September 1991 to December 2003 among 385 permanent central vein catheters for hemodialysis (3.6%). There were 8 episodes of catheter tip malplacement in the azygos vein (1 case), hemiazygos vein (1), left internal thoracic (mammalian) vein (1), contralateral innominate vein (5) and 6 cases with correct anatomical catheter tip placement but with blood inflow from the catheter through the collateral vein system because of thrombosis of a major vein trunk (hemiazygos vein system (2), azygos vein (2), ascending lumbar veins (1), or portal vein system (1)). The malposition was diagnosed using roentgenography, with or without contrast, and computer tomography. In 3 cases the catheter was removed, in 5 cases the position was corrected. In the remaining 6 cases its function was maintained using anticoagulation or/and thrombolytic therapy. In conclusion, the placement of a permanent central vein catheter for hemodialysis must be followed by simple or contrast medium x-ray evaluation of its correct position or function. The malposition must be corrected whereas in the case where there is no alternative solution the function of the catheter may be maintained in the incorrect position using a combination of anticoagulation or/and thrombolytic therapy.

Early Results of Brachial Arterio-Arterial Prosthetic Loop (AAPL) for Hemodialysis

BACKGROUND

Vascular access has always been the Achilles heel of hemodialysis. Advances in health care have brought forward patients requiring treatment who have no veins suitable for creation of arteriovenous fistula (AVF) or insertion of central venous catheters. Use of an artery as permanent vascular access has been reported by many authors. This study reports brachial AAPL as an efficient and safe access for hemodialysis patients with central venous occlusion.

METHODS

Between January 2011 and December 2014, 35 brachial arterio-arterial prosthetic loops (AAPL) were created. The age of patients ranged between 27 and 72 years, with a mean age of 52.8 years.

RESULTS

The primary patency rates were 87.9%, 70.4%, and 38.8% at 12, 24, and 36 months, respectively. The secondary patency was 90.7%, 80.3%, and 67.6% at 12, 24, and 36 months, respectively, after successful thrombectomy in seven cases.

CONCLUSION

Mid-term follow-up results demonstrate patency rates comparable with those of the synthetic AVF. The rate of complications, although slightly higher than that with traditional synthetic AVF, is still acceptable in this population with no option for access.

Surgical Management of a Hemodialysis Catheter-Induced Right Atrial Thrombus

The placement of hemodialysis catheters are widely performed by vascular surgeons and surgical residents for use in both the hospital and the outpatient setting. Although long-term complications of this type of vascular access are relatively uncommon, an appreciation is warranted for the life-threatening complication of right atrial thrombus (RAT). Once recognized, medical or surgical management is mandatory to prevent further consequences from RAT. The optimal treatment for catheter-induced RAT is still controversial. Our case and review illustrates how the routine placement of a malpositioned hemodialysis catheter in a young man can lead to the serious complication of RAT that necessitated cardiac surgery after thrombolysis failed. We describe the successful surgical management of a hemodialysis catheter-induced RAT and suggest that in cases of large, mobile RATs with adherence to both atrial wall and catheter, suspicion or evidence of pulmonary embolus (PE), and low-risk surgical candidates, open thrombectomy may be an optimal and definitive treatment.

UNRESOLVED ISSUES IN DIALYSIS: Long-Term Management of the Tunneled Venous Catheter

Despite their propensity for significant complications, tunneled central venous catheters have become a common means of vascular access in the United States for patients requiring maintenance hemodialysis for end-stage renal disease (ESRD). Reasons for their use include advanced patient age, peripheral vascular disease (arterial and venous), late referral for creation of vascular access, and more importantly, the lack of an interdisciplinary service line on vascular access among vascular surgeons, radiologists, and nephrologists. This review article summarizes complications commonly encountered in dialysis patients who use tunneled central venous catheters for vascular access-mainly thrombosis, stenosis, and infection. Special attention is given to novel approaches for the prevention of catheter-associated infections. Effective prevention and timely treatment of common catheter-associated complications can reduce the substantial morbidity associated with the use of these devices. However, these measures should not detract from the goal of avoiding or limiting the long-term use of catheters, thereby optimizing vascular access management by ensuring the timely availability of functioning arteriovenous fistulas.

Chemical-induced atrial thrombosis in NTP rodent studies

Cardiac thrombosis, one of the causes of sudden death throughout the world, plays a principal role in several cardiovascular diseases, such as myocardial infarction and stroke in humans. Data from studies of induction of chemical thrombosis in rodents help to identify substances in our environment that may contribute to cardiac thrombosis. Results for more than 500 chemicals tested in rodents in 2-year bioassays have been published as Technical Reports of the National Toxicology Program (NTP) http://ntp-server.niehs.nih.gov/index. We evaluated atrial thrombosis induced by these chemical exposures and compared it to similarly induced lesions reported in the literature. Spontaneous rates of cardiac thrombosis were determined for control Fischer 344 rats and B6C3F1 mice: 0% in rats and mice in 90-day studies and, in 2-year studies, 0.7% in both genders of mice, 4% in male rats, and 1% in female rats. Incidences of atrial thrombosis were increased in high-dosed groups involving 13 compounds (incidence rate: 20-100%): 2-butoxyethanol, C.I. Direct Blue 15, bis(2-chloroethoxy)methane, diazoaminobenzene, diethanolamine, 3,3'-dimethoxybenzidine dihydrochloride, hexachloroethane, isobutene, methyleugenol, oxazepam, C.I. Pigment Red 23, C.I. Acid Red 114, and 4,4'-thiobis(6-t-butyl-m-cresol). The main localization of spontaneously occurring and chemically induced thromboses occurred in the left atrium. The literature survey suggested that chemical-induced atrial thrombosis might be closely related to myocardial injury, endothelial injury, circulatory stasis, hypercoagulability, and impaired atrial mechanical activity, such as atrial fibrillation, which could cause stasis of blood within the left atrial appendage, contributing to left atrial thrombosis. Supplementary data referenced in this paper are not printed in this issue of Toxicologic Pathology. They are available as downloadable files at http://taylorandfrancis.metapress.com/openurl.asp?genre=journal&issn=0192-6233. To access them, click on the issue link for 33(5), then select this article. A download option appears at the bottom of this abstract. In order to access the full article online, you must either have an individual subscription or a member subscription accessed through www.toxpath.org.

Right atrial thrombus in an asymptomatic hemodialysis patient with malfunctioning catheter and patent foramen ovale

The creation of an accurate functioning arteriovenous fistula has been a long-lasting problem in the hemodialysis setting. In spite of recent guidelines and largely because of the old age of the current dialysis population and a high incidence of diabetes mellitus, atherosclerosis, and related vascular problems, it is not always possible to create an adequate fistula. In that case, long-term tunneled indwelling central vein catheters are a frequently used alternative. Of the many possible complications related to venous access in hemodialysis patients, catheter dysfunction is the most prevalent. We report a 23-year-old female hemodialysis patient in whom such malfunctioning was followed by echocardiography that revealed a large right atrial thrombus (RAT) in close contact to the tip of a long-term indwelling catheter in the presence of a patent foramen ovale. Although RAT is a rare complication in hemodialysis patients, it has very specific therapeutic implications. The present patient underwent a successful surgical atrial thrombectomy. Our experience underscores that in cases of malfunctioning catheter, echocardiographic screening is mandatory.

Right atrial thrombi complicating use of central venous catheters in hemodialysis

BACKGROUND

There has been an increase in the use of central venous catheters for temporary hemodialysis access. In this report, we describe a case series of 12 patients on hemodialysis who developed intracardiac clots associated with the use of central venous catheters, their outcomes and review the literature on this syndrome.

METHODS

Retrospective, single-center case series of 12 patients with right atrial thrombi associated with central venous catheter use for dialysis vascular access. These patients were treated between June 1, 2001 and June 30th 2002 at the three University of Rochester affiliated dialysis clinics. The medical records of these patients were reviewed to obtain information concerning demographics, dialysis history, dates of catheter insertion, catheter complications, identification and dimensions of intracardiac thrombi, echocardiographic data, and outcome of anticoagulant therapy.

RESULTS

Right heart thrombi were identified in 12 patients in our hemodialysis population over the study interval. Anticoagulation for 6 months led to clot resolution in more than 50% of our patients. Bacteremia recurred in 6 patients (50%), in spite of catheter replacement. There was zero mortality related to presence of clots in the short term. One patient with non-bacteremic right atrial thrombus suffered sudden cardiac arrest, but was successfully resuscitated.

CONCLUSION

Right atrial thrombi may occur in hemodialysis patients who use central venous catheters for dialysis access. These clots are frequently found in the right atrium or right atrial-superior vena caval junction. Ten of 12 patients (83%), had catheter-associated bacteremia, but the precise relationship between bacteremia and intracardiac clots is unclear. Chronic anticoagulation for 6 months lead to resolution of these clots in more than 50% of patients in our series.

Unusual Clot Formation following Insertion of Central Double Lumen Catheter for Hemodialysis

Background

We report a case of a patient with chronic renal failure (CRF) due to fibrillary glomerulonephritis, who was admitted to our Hospital with fever accompanied by chills, of two days duration. Due to aggravation of his CRF, accompanied by severe metabolic acidosis, an internal jugular double lumen central vein catheter was inserted, through which he was hemodialyzed.

Methods

Blood cultures were negative. The catheter was removed and the tip was cultured; it revealed colonization with hemolytic Staphylococcus sensitive to vancomycin and metilmycin. They were both given to the patient with excellent results. Trans-thoracic and trans-esophageal echocardiography revealed a clot in the right atrium with an abnormal circumference, connected to the tip of the second catheter. Anticoagulants were administered (calsium nadroparin, converted seven days later to acenocoumarol) and the size of the clot was significantly reduced.

Results

The case is presented in order to prove the significant contribution of trans-esophageal echocardiography as a non-invasive imaging technique for the detection of a clot in the right atrium and the impressive influence of appropriate therapeutic management in saving the patient's life and reducing the clot size.

Conclusions

The trans-esophageal echocardiogram provides invaluable information concerning the evolution, development and regression of right atrium clots formed at the tip of jugular catheters.

Catheter thrombosis

Catheter malfunction due to poor flow is a common problem. When it occurs early, the cause is generally technical. Late occurrences are most often related to thrombus formation. Several types of thrombus may be seen, differing by location and supposed mechanism of formation. The most common offender, however, is the fibrin sheath thrombus. Prevention of catheter malfunction is an endeavor that continues to beg many questions. Catheter malfunction should be treated early to avoid inadequate dialysis. In the past, urokinase was a highly valuable aid to the nephrologist in managing this problem. Since this agent became unavailable a suitable alternative has not emerged. Recombinant tissue plasminogen activator (tPA) seems to be the most likely candidate for this role; however, it is not currently available in a packaging form that is optimal for this purpose. Currently, catheter exchange appears to be the best available alternative for this problem, which cannot yet be resolved by simpler means.

Atrial thrombus and central venous dialysis catheters

A native arteriovenous fistula is the first choice for hemodialysis access. Despite improved catheter designs and the use of internal jugular veins, thrombotic complications still occur when tunneled central venous catheters are used as an alternative. Although right atrial thrombus (RAT) is a well-characterized complication of long-term central venous cannulation, particularly when used for parenteral nutrition and chemotherapy in pediatric practice, only 9 reported cases previously have been associated with the long-term use of central venous catheters for hemodialysis. We report five cases of RAT seen at our unit between 1994 and 1998 in patients who had been dialyzed using tunneled catheters. In four of five cases, the diagnosis was made during the investigation of hemoptysis or dyspnea. In the fifth case, a screening transthoracic echocardiogram revealed the thrombus. Three of five of the patients suffered pulmonary emboli, and a fourth patient had an unexplained electromechanical dissociation cardiac arrest without definite evidence of pulmonary embolus. Our experience suggests that anticoagulated patients with RAT remain at risk of pulmonary embolism. One of our patients successfully underwent atrial thrombectomy. In four of five of our cases and four of nine cases in the literature, the central venous catheter tip was within the right atrium. Positioning of the central venous catheter tip low down in the superior vena cava or in the right atrium has been advocated to improve dialysis adequacy and to reduce the incidence of catheter thrombosis. However, placement of the catheter tip within the right atrium may be associated with an increased risk of RAT.

The hemodialysis catheter conundrum: hate living with them, but can't live without them

BACKGROUND

Hemodialysis requires reliable recurrent access to the circulation. On a chronic basis, this has been best provided by the use of arteriovenous fistulae and arteriovenous grafts. In recent years, hemodialysis catheters have come to play an increasingly important role in the delivery of hemodialysis. The use of both temporary as well as cuffed hemodialysis catheters has emerged as a significant boon for both patients and practicing nephrologists. The complications, however, associated with each of these hemodialysis catheters, both in terms of anatomic, thrombotic, and infectious issues, have emerged as a major problem with their continued use. This significant morbidity and complication rate has forced many nephrologists to face a basic conundrum: they have come to hate having to deal with the problems inherent in catheter usage, but the enormous utility of these devices have forced physicians to accept the fact they cannot live without them in their current practice.

METHODS

We used a comprehensive literature review to describe the types, use and dilemmas of hemodialysis catheters.

RESULTS

This article provides a comprehensive review of both the benefits inherent with the use of these hemodialysis catheters while cataloging their complications and offering some possible solutions.

CONCLUSION

Hemodialysis vascular access catheters are essential in the maintenance of hemodialysis vascular access. However, they have a significant infectious, thrombotic, anatomic complication rate that are detailed with proposed problem-solving guidelines.

Bilateral ophthalmoplegia and exophthalmos complicating central hemodialysis catheter placement

We describe a 58-year-old woman who presented with bilateral ophthalmoplegia, exophthalmos, and headache and was found to have retrograde internal jugular vein flow secondary to a high-grade obstruction of the ipsilateral brachiocephalic vein from a previous hemodialysis catheter placement. The patient had also a high-flow dialysis graft in the ipsilateral arm. The cranial and extracranial venous system congestion resolved, and the signs disappeared soon after a balloon angioplasty and stent placement at the level of the obstruction.

Replacement of accidentally removed tunneled venous catheters through existing subcutaneous tracts

PURPOSE

The authors describe their experience with reinsertion of accidentally removed tunneled venous catheters using existing subcutaneous tracts.

MATERIALS AND METHODS

Replacement of 13 dislodged tunneled venous catheters was attempted a median of 12 hours (range, 3 hours to 5 days) after accidental removal. The catheters were needed for hemodialysis (n = 11), plasmapheresis (n = 1), or antibiotic therapy (n = 1). The tunnel exit was probed in the same fashion as for a dislodged nephrostomy tube, and new catheters were reinserted once a guide wire was advanced into the central veins. The medical record was reviewed to determine materials used and occurrence of complications, if any.

RESULTS

Replacement was successful in 12 of 13 patients. The remaining patient had a new catheter placed through a fresh puncture during the same visit. There were no infections associated with re-use of existing tunnels. In five patients, after probing the tract with a guide wire, new catheters were simply advanced into the desired position. Seven other successes required additional manipulations with use of dilators and peel-away sheaths.

CONCLUSIONS

Tunneled catheters that "fall out" can be readily replace even when reinsertion is attempted up to 5 days later. This represents an important contribution that radiologists can offer in the management of venous access cases.