Right atrial thrombi complicating haemodialysis catheters. A meta-analysis of reported cases and a proposal of a management algorithm

Suction thrombectomy of catheter-associated right atrial thrombus in two patients

Catheter associated right atrial thrombus (CRAT) is an uncommon but potentially life-threatening condition. There are no established guidelines for management, and treatment ranges from systemic anticoagulation and thrombolysis to open surgery. While there have been reports on use of suction thrombectomy for right atrial thrombi, the feasibility and outcomes of suction thrombectomy in CRAT have not been described. These two cases describe a successful off-label use of two devices (Triever 20, Inari Medical, Irvine, CA, and AlphaVac, AngioDynamics, Latham, NY) for thrombectomy in CRAT. Both patients had near complete extraction of chronic appearing thrombus, with follow up imaging demonstrating complete resolution. Suction thrombectomy may have a unique role in management in CRAT, especially in cases of infected thrombi. A formal exemption from the institutional review board was obtained for publication.

Hemodialysis catheter-related right atrial thrombus treated with the FlowTriever system

Tunneled catheters are frequently used in patients with end-stage renal disease who require hemodialysis access. Catheter-related atrial thrombus is a documented complication of prolonged catheter use. The incidence of catheter-related atrial thrombus is 2% to 29%, with a high mortality rate approaching 20%, raising concerns for serious complications and death in the absence of an established universal management plan. This case series demonstrates the successful use of a minimally invasive approach to treat patients with intracardiac thrombus and high perioperative risk factors using mechanical and aspiration thrombectomy with the FlowTriever system (Inari Medical).

Management of a Right Heart Intracavitary Thrombus in Transit in a Patient With Gastric Cancer in a Resource-Limited Setting: A Case Report

A right atrial thrombus is an unusual source of imminent massive saddle pulmonary embolism (PE) . A hypercoagulable state secondary to gastric cancer (GC) can result in deep vein thrombosis (DVT) with a resultant right-sided heart thrombus in transit. Here, we present a case of a young male patient from Honduras with DVT and multiple venous thrombi extending from the external iliac veins to the suprahepatic left vein, inferior vena cava, and right atrium of the heart, secondary to a hypercoagulable state from GC, adenocarcinoma type. We describe the approach of treating a right heart intracavitary thrombus with imminent risk for saddle PE and sudden cardiac death with thrombolysis through a central venous catheter (CVC) in a resource-limited setting.

Catheter related atrial thrombus caused by Abiotrophia defectiva: A case series and review of literature

Catheter related atrial thrombus (CRAT) is a devastating complication associated with tunneled hemodialysis catheter. Abiotrophia defectiva is a rare fastidious pathogen implicated predominantly in culture negative infective endocarditis. Here we report three cases of CRAT in maintenance hemodialysis patients with variable clinical presentation caused by Abiotrophia defectiva. Video assisted thoracoscopic retrieval of atrial thrombus is a novel technique which is scarcely reported in medical literature for surgical management of large atrial thrombus. Our cases were managed by timely administration of antibiotics and anticoagulants followed by surgical retrieval of atrial thrombus with removal of tunneled dialysis catheter. This case series illustrates the importance of prompt diagnosis, appropriate anticoagulation with antibiotics, and mini-invasive surgical removal of atrial thrombus for the management of CRAT.

Right heart thrombus in transit and peripherally inserted central catheters

Right heart thrombus in transit or "free-floating right heart thrombus" is defined as thrombus(i) arising from the deep veins that embolises to the right atrium or right ventricle before reaching the pulmonary vasculature. It is almost always associated with pulmonary thromboembolism and is a medical emergency with reported mortality rates of over 40%. We present two cases of right heart thrombus in transit with pulmonary thromboembolism resulting from venous thrombosis associated with peripherally inserted central catheters that were managed with different approaches. The cases highlight that clinicians should have a low threshold to utilise imaging modalities such as computerised tomography and transthoracic echocardiography when there is an untoward change in physiological parameters among patients with peripherally inserted central catheters, particularly those with risk factors for peripherally inserted central catheter associated venous thrombosis. Furthermore, procedural optimisation surrounding peripherally inserted central catheters, such as insertion technique and choice of lumen size, is underscored.

Case report: Central venous catheter thrombosis complicated by chronic thromboembolic disease/pulmonary hypertension in two children requiring parenteral nutrition

Chronic thromboembolic pulmonary hypertension is a rare but life-threatening complication of long-term central venous catheters (CVC) in children. However, evidence in terms of potential treatment strategies and outcome data remains scarce. We describe two cases of CVC-related thrombosis (Hickman-catheter) complicated by recurrent pulmonary emboli. One patient experienced a complete thromboembolic obstruction of the right pulmonary artery with normal pulmonary pressures and the second patient suffered from a central thromboembolic obstruction of both pulmonary arteries associated with severe pulmonary hypertension. Both patients successfully underwent surgical thromboendarterectomy with deep hypothermic circulatory arrest.

Asymptomatic pulmonary thromboembolism due to hemodialisys catheter thrombosis: case series and literature review

Right atrial thrombus is commonly associated to catheters. Catheter-related right atrial thrombus (CRAT) in hemodialysis patients frequently presents as pulmonary embolism. Although CRAT is sometimes asymptomatic, even in these cases it is associated with worse prognosis. The management strategy for CRAT is not well established, however, along with catheter removal, anticoagulation, thrombolysis, and surgical thrombectomy may be performed. Suspicion of asymptomatic pulmonary embolism associated to CRAT is important in order to perform proper treatment. The authors of this article report two cases of asymptomatic pulmonary thromboembolism due to CRAT in hemodialysis patients and perform a review of the literature.

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.

The evolving panorama of vascular access in the 21st century

There are three major types of hemodialysis vascular access: hemodialysis catheters, arteriovenous grafts, and arteriovenous fistulas. Arteriovenous fistulas provide the best access due to their reliability and long-term patency. They are recommended by the current Kidney Disease Outcomes Quality Initiatives (K-DOQI) guidelines; however, not all patients benefit from arteriovenous fistulas due to poor maturation or a lack of adequate vasculature. Currently, hemodialysis is initiated via catheters in the majority of patients. Catheters are associated with high morbidity and mortality due to infection, lower quality of dialysis, and the development of central vein stenosis. The varied responses of patients to the different access types exemplify the need to choose the "right access for the right patient" based on scores that can predict death risk and progression of chronic kidney disease. Additionally, vascular access, often referred to as the "Achilles' heel" of hemodialysis patients, represents a significant percentage of the Medicare budget that continues to increase yearly. The purpose of this paper is to review the current literature on the management of vascular access complications and infection treatment and prevention. The paper also explores emerging research regarding the devices and methods to improve access outcomes such as early cannulation arteriovenous grafts, endovascular arteriovenous fistula creation, and regenerative grafts with resorbable scaffolds, among others. The data were collected through literature searches via PubMed, Athens and web search engines.

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.

Application of Aspiration-Assisted Percutaneous Venous Removal of Right Atrial Thrombus in a Critically Ill Patient: A Case Study and Clinical Management Overview

We herein present a complex case of a 50-year-old female with catheter-related atrial thrombus (CRAT). This patient with end-stage renal disease on hemodialysis presented with angioedema leading to respiratory failure. She was subsequently intubated, and the pre-procedural course was complicated by a cardio-respiratory arrest, and anoxic brain injury. The patient’s hemodialysis catheter placement in the superior vena cava (SVC) potentially correlated with the development of the right atrial thrombus. The patient was treated percutaneously as she presented with complex morbidities. The mass was successfully removed via aspiration-assisted percutaneous right heart bypass, a procedure that utilizes a vacuum system to remove thrombi. Post-procedure, the patient remained stable and continued supervised care.

Clinical Characteristics, Treatment and Long-Term Outcomes of Patients with Right-Sided Cardiac Thrombus

BACKGROUND

Right-sided cardiac thrombus is rare and may be caused by venous thromboembolism, in association with medical devices or stasis of blood in atrial fibrillation and cardiomyopathies. Complications include pulmonary embolism (PE) and paradoxical stroke. Current data are limited and mostly from case series and PE registries. We aimed to describe the clinical characteristics, echocardiographic features, treatment and outcomes of right-sided cardiac thrombus patients.

METHODS

This was a retrospective observational study of 97 consecutive patients with right-sided cardiac thrombus detected on echocardiography. We studied co-morbidities, predisposing factors, thrombus characteristics and therapeutic interventions and assessed their associations with development of PE, paradoxical stroke, circulatory collapse and all-cause mortality.

RESULTS

Mean age was 58.7 years and 55/97 (56.7%) were female. Ischaemic heart disease, heart failure, chronic kidney disease and malignancy were common co-morbidities. Right atrial thrombus was often associated with medical devices while right ventricular thrombus was more commonly associated with cardiomyopathy. Thrombus mobility did not affect embolic events but was associated with greater short-term mortality. On multivariable analysis, anticoagulation (HR 0.25, 95% CI 0.09-0.68) and thrombus resolution (HR 0.28, 95% CI 0.13-0.62) were associated with greater survival.

CONCLUSIONS

Right-sided cardiac thrombus is rare but may have potentially life-threatening complications such as PE and paradoxical stroke. Further research is needed to determine optimal therapeutic strategies in this poorly-studied population.

Thromboprophylaxis Reduced Venous Thromboembolism in Sickle Cell Patients with Central Venous Access Devices: A Retrospective Cohort Study

Sickle cell disease (SCD) induces a chronic prothrombotic state. Central venous access devices (CVADs) are commonly used for chronic transfusions and iron chelation in this population. CVADs are an additional venous thromboembolism (VTE) risk factor. The role of thromboprophylaxis in this setting is uncertain. The objectives are: (1) to determine whether thromboprophylaxis reduces VTE risk in SCD patients with CVAD and (2) to explore characteristics associated with VTE risk. We identified adults with SCD and CVAD intended for chronic use (≥3 months) at two comprehensive SCD centers. Thromboprophylaxis presence; type; intensity; and patient-, catheter-, and treatment-related VTE risk factors were recorded. Among 949 patients, 49 had a CVAD (25 without and 24 with VTE prophylaxis). Thromboprophylaxis type and intensity varied widely. Patients without thromboprophylaxis had higher VTE rates (rate ratio (RR) = 4.0 (95% confidence interval: 1.2−12.6), p = 0.02). Hydroxyurea was associated with lower VTE rates (RR = 20.5 (6.4−65.3), p < 0.001). PICC lines and Vortex and Xcela Power implantable devices were associated with higher rates compared with Port-a-Cath (RR = 5.8 (1.3−25.9), p = 0.02, and RR = 58.2 (15.0−225.0), p < 0.001, respectively). Thromboprophylaxis, hydroxyurea, and CVAD subtype were independently associated with VTE. The potentially protective role of thromboprophylaxis and hydroxyurea for VTE prevention in patients with SCD and CVAD merits further exploration.

Detection of BRAF V600E in Fine-Needle Aspiration Samples of Thyroid Nodules by Droplet Digital PCR

BACKGROUND

BRAF exon 15 p.V600E (BRAF V600E) mutation has been established as an important molecular marker for papillary thyroid carcinoma diagnosis by ultrasound-guided fine-needle aspiration biopsy (FNAB). Sanger sequencing is the gold standard for detecting BRAF V600E mutations but fails to identify low-frequency mutations. However, droplet digital PCR (ddPCR) is a popular new method for detecting low-frequency mutations. Here, we compare the efficiency of droplet digital PCR (ddPCR) and Sanger sequencing for detection of the BRAF V600E mutation in thyroid fine-needle aspiration (FNA) samples.

METHODS

Thyroid fine-needle aspiration samples from 278 patients with 310 thyroid nodules were collected. Sanger sequencing and ddPCR were conducted to detect the BRAF V600E mutation.

RESULTS

The BRAF V600E mutation was found in 94 nodules (30.32%) by ddPCR and 40 nodules (12.90%) by Sanger sequencing in 310 FNA samples. A total of 119 nodules were confirmed PTC by postsurgical pathology. Among which the BRAF mutation was found in 80 (67.23%) nodules by ddPCR and 31 (26.05%) by Sanger sequencing. All nodules carrying the mutation detected by Sanger sequencing (SS+) were verified by ddPCR (ddPCR+). Also, all nodules with no mutation detected by ddPCR were interpreted as wild-type by Sanger sequencing (SS-). In addition. Almost all SS+/ddPCR + nodules (95.00%; 38/40) and SS-/ddPCR + nodules (100.00%; 54/54) displayed a BRAF mutation rate of >5% and <15%, respectively, indicating easy misdetection by Sanger sequencing when the mutation rate is between 5 and 15%.

CONCLUSION

ddPCR has higher sensitivity than Sanger sequencing and we propose ddPCR as a supplement to Sanger sequencing in molecular testing of BRAF using FNAB samples.

Catheter-Related Right Atrial Thrombus Requiring Surgical Embolectomy

Temporary central venous hemodialysis (HD) catheters are commonly used in end-stage renal disease (ESRD) patients while awaiting peritoneal dialysis catheter, arterio-venous fistula or graft placement and maturation. Catheter-related right atrial thrombus (CRAT) is a common finding in patients with central venous catheters (CVCs) and can cause CVC to malfunction. The incidence of CRAT is about 29% with a mortality of 18.3% or greater if not identified and managed appropriately. Two major types of right atrial (RA) thrombi have been identified. Type A thrombus usually originates in the peripheral veins embolizing to the RA. Type B originates within a structurally abnormal RA and is usually attached to the chamber walls or foreign bodies like CVC or intra-cardiac wires. There is a high risk of thrombi embolization leading to pulmonary embolism as in our patient, systemic embolization if a right to left shunt is present and potential hemodynamic compromise. The optimal therapeutic approach is still a subject of discussion, but timely catheter removal with prompt initiation of systemic anticoagulation is key. Surgical management is pursued when medical therapy fails or if the thrombus is greater than 6 cm. Our case is that of a 30-year-old male with CRAT successfully treated with surgical embolectomy after the failure of systemic anticoagulation. This case highlights the importance of early detection of CRAT, initiation of optimal medical therapy and the need for surgical intervention when medical therapy fails.

Atypical imaging presentation of a massive intracavitary cardiac thrombus: A case report and brief review of the literature

Intracavitary cardiac thrombi, uncommonly found in the right chambers, have been shown to form secondary to endocardial and myocardial diseases. The differential diagnosis for an intracavitary cardiac mass is broad, including primary cardiac tumors, cardiac metastases, anatomic variants, vegetations, and thrombi. Here we present a unique case with a large calcified intracavitary cardiac thrombus in a 26-year-old woman with obesity, immune thrombocytopenic purpura, and a new diagnosis of systemic lupus erythematosus. Initial imaging presentation in this case masqueraded as a tumor, delaying the true diagnosis. A combination of cardiac imaging techniques, including transthoracic and transesophageal echocardiograms, cardiac CT, and cardiac MRI were required to correctly diagnose this calcified bland thrombus.

Incidence of catheter-associated right atrial thrombus detected by transthoracic echocardiogram

INTRODUCTION

The development of right atrial (RA) thrombus (RAT) is a known complication of central venous catheter insertion (CVC). Deeper insertion of CVC within the RA may increase the risk for RAT development versus those placed at the superior vena cava (SVC)-RA junction. We sought to evaluate the incidence of catheter-associated RAT as detected by transthoracic echocardiograms (TTEs), characterize thrombi though multimodal imaging, and evaluate thrombi management with follow-up imaging.

METHODS

A retrospective analysis was conducted of consecutive TTEs from our institution between October 1, 2018, and January 1, 2020, in which a venous catheter was visualized in the RA. Studies were reviewed in detail to determine the presence of suspected RAT. Demographic data, comorbidities, laboratory values, characteristics of the catheter and the thrombus, subsequent imaging and management, and outcomes were collected.

RESULTS

A total of 364 TTEs were performed in 290 patients with a venous catheter visualized in the RA. Of these 290 patients, 15 had an imaging suspicion for RAT yielding an incidence of 5.2%. Management strategies included anticoagulation in 13 (86.7%) patients and catheter removal in 11 (73.3%) patients. At eight months of follow-up, 11 (73.3%) patients had resolution of RAT based on subsequent imaging.

CONCLUSION

In patients with deeply placed CVC catheters, the incidental detection of RAT by TTE was not trivial. Anticoagulation and catheter removal and replacement, if deemed safe, were effective methods of thrombus management. RAT as a complication of CVCs must be accounted for when addressing factors that influence depth of CVC insertion.

Systemic thrombolysis and anticoagulation therapy for catheter-related right atrial thrombosis caused by TIVAP: A case report and review of the literature

INTRODUCTION

As an under-reported, severe, and life-threatening complication, catheter-related right atrial thrombosis (CRAT) can appear at any age with any type of central venous catheter (CVC). However, most reports are limited to hemodialysis patients with CVC. Totally implantable venous access port (TIVAP) is widely used for the infusion of high-concentration chemotherapeutic drugs in cancer patients. However, these catheters may cause CRAT.

CASE DESCRIPTION

A 27-year-old female patient with TIVAP was referred for neoadjuvant chemotherapy because of breast cancer. At 60 days after TIVAP implantation, routine transthoracic ultrasound examination confirmed a mass of 3.4 × 2.5 cm in the right atrium (RA). The mass was attached to the atrial wall and close to the catheter tip. Initially, we chose systemic anticoagulation therapy, but it failed. Subsequently, we decided to adopt a combination of systemic thrombolysis and anticoagulation therapy via a cubital vein. After 9 days of treatment, the thrombus disappeared, and the TIVAP was eventually removed.

CONCLUSIONS

Systemic thrombolysis and anticoagulation therapy seemed to be safe and effective for asymptomatic patients who had TIVAP-induced CRAT. We should position the catheter tip at the junction of the Superior Vena Cava with the Right Atrium during the implantation procedure in cancer patients undergoing chemotherapy.

Silent and dangerous: catheter-associated right atrial thrombus (CRAT) in children on chronic haemodialysis

BACKGROUND

Catheter-associated right atrial thrombus (CRAT) is a recognised complication of central venous catheter (CVC) use for haemodialysis (HD) patients.

METHODS

This was a single-centre retrospective longitudinal observational study of consecutive children aged 6 months-18 years over a 7-year period receiving in-centre chronic HD. Echocardiograms as per routine cardiac surveillance were performed 6 months or earlier given clinical concerns.

RESULTS

Sixty-five children, 36 boys (55.4%), median (IQR) age 11.8 (5.3, 14.7) years, received HD for kidney failure with replacement therapy (KFRT). Initial modality was HD in 45 (69.2%), with CVC as initial access in 42 (93.3%) and AVF in 3 (6.7%); in the remaining 20 (30.8%) patients PD was the initial modality before switching to HD. Seven of 65 (10.8%) developed CRAT at median 2 (0.8, 8.4) months from CVC insertion, with one CRAT detected 3 days following insertion. One child had 2 episodes of CRAT and one additionally thrombosed their AVF. No patient had an underlying primary kidney disease associated with a pro-thrombotic state. Those with CRAT were younger, had more frequent CVC change and received dialysis for longer duration compared to those with no CRAT. Six episodes of CRAT (75%) received anticoagulation therapy. Infective complications were observed in 25% and catheter malfunction in 50%. Five CRAT episodes (62.5%) resulted in CVC loss. One patient died after a haemorrhagic complication of anticoagulation and sepsis, and another developed life-threatening superior vena cava obstruction syndrome. Overall mortality 14% (1/7).

CONCLUSIONS

This is the first report of CRAT in a paediatric HD population. There was ~ 11% incidence of CRAT in patients receiving chronic HD detected by surveillance echocardiography. Although frequently asymptomatic, CRAT is associated with serious sequelae. Anticoagulation and surveillance with expert echocardiography remain mainstays of management. Graphical abstract.

The concoction of cancer, catheter, and intracardiac clot: a case report describing a potential treatment strategy

Background

Patients with cancer often pose a unique challenge to anticoagulation, as they have a higher risk of bleeding and clotting than the general population. Patients with cancer and catheter-related intracardiac thrombus are a very specific subset of people who do not have specific recommendations guiding their treatment. This article aims to address the existing knowledge gaps in this scenario and provide a possible treatment approach for these patients.

Case summary

We describe the case of a 46-year-old lady with invasive breast cancer, who was on chemotherapy through a central venous catheter and was found to have a right atrial thrombus on routine echocardiography. Due to the paucity of data in this scenario and because the patient requested an oral anticoagulant which did not need frequent monitoring, we started her on apixaban for a total of 3 months. Echocardiogram was repeated at 4 and 8 weeks. In the 8-week echocardiogram, the right atrial thrombus was no longer visualized.

Discussion

Malignancy and central venous catheters significantly increase the risk of thrombosis. Although low molecular weight heparin is the preferred anticoagulant to manage thrombosis in patients with cancer, direct oral anticoagulants have been proven to be non-inferior. In patients with catheter-related intracardiac thrombus, anticoagulation should be continued for at least 3 months or until the catheter is removed, whichever is longer.

Surgical Management of Right Atrial Mass Associated with a Vascular Access Catheter

Atrial masses are an uncommon but serious clinical problem. The authors report a case of an atrial mass associated with a tunnelled vascular access catheter in an immunosuppressed haemodialysis patient. In the setting of immunosuppression with fevers, a broad differential for the atrial mass was considered. Multidisciplinary team review was pursued to guide management decisions. Ultimately, surgical excision of the mass was pursued with an excellent result. The causes and management of this complex clinical scenario are discussed.

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.

Surgical management of catheter-related right atrial thrombus with superior vena cava syndrome A Case Report

There are no consensus guidelines on the management of catheter-related right atrial thrombus. We present the case of a 29-year-old female with end-stage renal disease who was found to have a large right atrial thrombus associated with her tunneled dialysis catheter during preoperative workup for renal transplant. She exhibited signs and symptoms of superior vena cava syndrome and NYHA class III congestive heart failure. She was successfully treated with surgical thrombectomy and demonstrated rapid resolution of her symptoms postoperatively.

Diagnostic utility and clinical implication of late gadolinium enhancement cardiac magnetic resonance for detection of catheter associated right atrial thrombus

PURPOSE

To use delayed enhancement cardiac magnetic resonance (DE-CMR) as a reference standard to evaluate the prevalence and predictors of right atrial (RA) thrombus.

METHODS

In this retrospective study, 130 cancer patients with central venous catheters undergoing CMR from August 2012-January 2018 were included. CMR (cine-CMR and DE-CMR) and echocardiography were interpreted for RA thrombus blinded to other imaging results and clinical data. RA thrombus properties including the number of discrete masses, size, total thrombus area, and perimeter were also assessed. Cine-CMR was also used to quantify cardiac structure and function as markers of RA thrombus. Student's t-test was used to assess continuous variables; chi-square or Fisher's exact test were used to assess categorical variables.

RESULTS

31/130 (24%) patients had RA thrombus on DE-CMR. Echocardiography (attained in 64% of the study population) demonstrated moderate sensitivity and specificity (75%, 90% respectively) in relation to DE-CMR; cine-CMR performance was higher (sensitivity 90%, specificity 98%). Patients with and without RA thrombus had similar right-sided structure/function and cancer diagnosis. Catheter depth approached significance in patients with RA thrombus (p = 0.05). 13% of patients with RA thrombus had concomitant pulmonary embolism within 60 days of CMR vs. 2% of patients without RA thrombus (p = 0.03). Embolic events were independent of RA thrombus size (p = 0.66).

CONCLUSION

Morphologic imaging by cine-CMR and echocardiography provide limited diagnostic utility for RA thrombus as established by DE-CMR tissue characterization. Catheter-associated RA thrombus occurs independently of right-sided structure or function and is associated with clinical embolic events and catheter depth.

Contemporary management and outcomes of infective tunnelled haemodialysis catheter-related right atrial thrombi: a case series and literature review

INTRODUCTION

Infective haemodialysis catheter-related right atrial thrombus (CRAT) is a complication of tunnelled catheter use. Management recommendations are based mainly on published case series prior to 2011. We report our institution's recent experience in managing infective haemodialysis CRAT and correlate treatment with outcomes.

METHODS

We conducted a retrospective analysis of haemodialysis CRAT cases diagnosed on transthoracic echocardiography between 1 January 2011 and 31 December 2017. Clinical outcomes, including mortality at 180 days post diagnosis and thrombus resolution, were traced from electronic medical records.

RESULTS

There were 14 cases identified. The median age was 59 (range 47-88) years and 11 (78.6%) were male. Sepsis was the most common reason for hospitalisation (71.4%). Blood cultures identified Staphylococcus aureus in seven cases, of which two were methicillin-resistant. Three had coagulase-negative Staphylococcus. All cases received antibiotics with infectious disease physician input. Seven were treated with catheter removal alone, of which three died within 180 days. Both cases treated with catheter removal plus anticoagulation survived at 180 days. Of the two cases who had anticoagulation without catheter removal, one died within 180 days and the other did not have thrombus resolution. Three underwent surgical thrombus removal, of which two died postoperatively and the last required repeated operations and prolonged hospitalisation. Mortality at 180 days post diagnosis was 42.9%.

CONCLUSION

Catheter removal and anticoagulation are modestly effective. Surgery is associated with poor outcomes. Despite contemporary management, infective haemodialysis CRAT still results in high mortality. Prospective studies are needed to identify the optimal management.

How to get rid of the bug in the heart-An infected catheter-associated thrombus treated successfully with antibiotics only

We present a case of a 53-year-old woman with end-stage renal disease, on hemodialysis for 4 years, who was diagnosed with an infected catheter-associated right atrial thrombus (CRAT). CRAT is an underreported and potentially life-threating complication of a central venous catheter and usually warrants a surgical approach. The patient was, however, disqualified by cardiac surgeons due to her overall poor condition. We used a combination of anticoagulation and antibiotics in the reported case as "rescue therapy" and showed that the successful resolution of CRAT complicated by infection might sometimes be feasible with pharmacological treatment only.

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.

Detection of BRAF V600E mutation in fine-needle aspiration fluid of papillary thyroid carcinoma by droplet digital PCR

OBJECTIVES

Papillary thyroid carcinoma (PTC) accounts for 85% of thyroid carcinoma, which is the most common endocrine tumor. For the diagnosis of PTC, ultrasound-guided fine needle aspiration (FNA) with pathological evaluation is the standard test and BRAF V600E mutation is the most common molecular marker associated with the occurrence, progression and poor clinicopathological characteristics of PTC. However, because of the small amount of the tumor cells obtained by FNA for pathological evaluation or BRAF V600E mutation detection, more sensitive and accurate methods are required. Our study aimed to investigate the performance of droplet digital PCR (ddPCR) in detecting BRAF V600E mutation in FNA samples from PTC patients.

METHODS

One hundred and sixty suspected thyroid cancer patients were enrolled, including 146 PTC patients, 2 follicular thyroid carcinoma (FTC) and 12 benign patients, identified by FNA biopsy according to the NCCN clinical practice guidelines of Thyroid Carcinoma. ddPCR and amplification-refractory mutation system (ARMS, AmoyDx) were used to detect BRAFV600E mutation and the results were compared.

RESULTS

ddPCR had high reproducibility (CV0.1% = 22.82% and CV10% = 4.85%) and the detection sensitivity can reach 1–2 copies/μl (0.01%). Among the 160 patients, 128 BRAF V600E mutations were detected, including 4 ARMS negative patients and 3 benign cases [corrected].

CONCLUSIONS

Our results demonstrated that ddPCR could be used in detecting BRAF V600E mutation from FNA fluid samples with higher sensitivity and accuracy than ARMS.

A Case Series of Asymptomatic Hemodialysis Catheter-Related Right Atrial Thrombi That Are Incidentally Detected Prior to Kidney Transplantation

A hemodialysis (HD) catheter-related right atrial thrombus (RAT) is rarely encountered prior to kidney transplantation (KT) but necessitates a decision about whether to anticoagulate and/or delay the surgery. There is controversy surrounding the clinical implications of a RAT in this situation. It is sometimes considered fatal but other opinions consider it to be benign, especially when incidentally detected. We reviewed the clinical characteristics, management, and outcomes of a patient series with HD catheter-related RAT detected prior to KT and speculated on its clinical significance. Among 3677 cases of KT performed on 3607 patients between January 1997 and September 2015 in our single tertiary center, 11 cases of HD catheter-related RAT detected on transthoracic echocardiography (TTE) prior to KT were included for analysis. The average maximal diameter of the RAT was 23.2 ± 16.3 (SD in mm) and 9 (81.8%) of these 11 patients had no symptoms associated with the RAT. Four patients (36.3%) had their catheters replaced, 5 patients (45.5%) had their catheters removed, and the catheters were maintained in the remaining 2 patients (18.2%). Six patients (54.5%) were anticoagulated with either heparin or warfarin. However all 11 patients had a successful KT suggesting that a HD catheter-related RAT incidentally detected prior to this surgery may not be as serious as previously considered and should not be a reason for delaying the transplantation.

Hemodialysis Catheter-Related Central Venous Thrombosis: Clinical Approach to Evaluation and Management

Central venous catheter (CVC) use is common among patients undergoing hemodialysis. Catheter-related vascular thrombosis is a frequent complication, which results in catheter dysfunction. This may eliminate the affected vein as a potential route of vascular access and leads to significant morbidity of the limbs involved. Despite increasing prevalence, there is a dearth of evidence-based guidelines for managing such catheter-related thrombi, often leading to treatment dilemmas in clinical practice. Minimizing the use of CVCs for hemodialysis remains the best approach in preventing such adverse complications. Furthermore, meticulous planning and care when using such catheters in unavoidable circumstances along with vigilant surveillance to identify complications early will allow to avoid associated morbidity.

Is the removal of a central venous catheter always necessary in the context of catheter-related right atrial thrombosis?

Catheter-related right atrial thrombosis is a severe and life-threatening complication of central venous catheters in both adult and young patients. Catheter-related right atrial thrombosis can occur with any type of central venous catheters, utilized either for hemodialysis or infusion. Up to 30% of patients with central venous catheter are estimated to be affected by catheter-related right atrial thrombosis; however, neither precise epidemiological data nor guidelines regarding medical or surgical treatment are available. This complication seems to be closely associated with positioning of the catheter tip in the atrium, whereas it is unlikely with a tip located within superior vena cava. Herein, we report the case of a patient affected by catheter-related right atrial thrombosis, who showed a quick resolution of thrombosis with a new therapeutic scheme combining loco-regional thrombolytic therapy (urokinase as a locking solution) and systemic anticoagulation therapy (vitamin K antagonists), thus avoiding catheter removal. Neither complications of the combination therapy were reported, nor recurrence of catheter-related right atrial thrombosis occurred. In conclusion, the combination therapy here described was safe, quick and effective, achieving the goal of not removing the catheter.

Open heart surgery for management of right auricular thrombus related to central venous catheterization

Central venous catheters are widely used in critically ill patients; however, they are also associated with increased morbidity and mortality. The literature may underestimate the incidence of catheter-inducible right atrial thrombi that are asymptomatic but potentially life threatening. The recognized risk factors for its development include infections related to the catheter, endothelial injury secondary to mechanical and chemical damage induced by certain medications and infused fluids. The characteristics of the patient and the catheter, such as size, material, type, location and ease of insertion, as well as the duration of placement play an additional role. We report the case of a 38-year-old man, who developed an asymptomatic catheter-inducible right atrial thrombi requiring open heart surgery, after taking a central venous catheter for thirty-five days. The present case highlights existing limitations in making a correct and fast diagnosis, which should be anticipated in patients with multiple risk factors for thrombosis. Given the limited recommendations available, we consider that the most appropriate strategy should be individualized.

The Dilemma in Treatment of hemodialysis patients with catheter-induced right atrial thrombi (CRAT): A case report

Catheter-induced right atrial thrombi (CRAT) is a serious complication of central venous catheterization. Herein we report a case of large hypermobile right atrial thrombi in a 57-year-old man with hemodialysis catheter in the right internal jugular vein.

Catheter-related right atrial thrombus in sickle cell disease

Catheter‐related right atrial thrombus (CRAT) can occur in patients with sickle cell disease, particularly if additional risk factors for thrombosis are present. Cardiac MRI may differentiate thrombi from other types of atrial masses. Treatment should include anticoagulation and the timing of catheter removal should balance the potential risk of embolization.

Hemodialysis Tunneled Catheter Noninfectious Complications

Noninfectious hemodialysis catheter complications include catheter dysfunction, catheter-related thrombus, and central vein stenosis. The definitions, causes, and treatment strategies for catheter dysfunction are reviewed below. Catheter-related thrombus is a less common but serious complication of catheters, requiring catheter removal and systemic anticoagulation. In addition, the risk factors, clinical manifestation, and treatment options for central vein stenosis are outlined.

Management of Cavoatrial Deep Venous Thrombosis: Incorporating New Strategies

Cavoatrial deep venous thrombosis (DVT) is diagnosed with increasing prevalence. It can be managed medically with anticoagulation or with directed interventions aimed to efficiently reduce the thrombus burden within the target venous segment. The type of management chosen depends greatly on the etiology and chronicity of the thrombosis, existing patient comorbidities, and the patient's tolerance to anticoagulants and thrombolytic agents. In addition to traditional percutaneous catheter-based pharmacomechanical thrombolysis, other catheter-based suction thrombectomy techniques have emerged in recent years. Each therapeutic modality requires operator expertise and a coordinated care paradigm to facilitate successful outcomes. Open surgical thrombectomy is alternatively reserved for specific patient conditions, including intolerance of anticoagulation, failed catheter-based interventions, or acute emergencies.

Massive Fulminant Thrombosis During Liver Transplantation in a Patient With a Previously Unknown Antithrombin Pathway Mutation

We describe a case of fulminant intraoperative thrombosis during deceased donor liver transplantation. Despite significant medical bleeding, the patient suddenly developed diffuse thrombosis in all chambers of the heart and pulmonary vasculature resulting in intraoperative death. The patient's postmortem genetic analysis demonstrated a deleterious missense mutation in a coagulation pathway gene, SERPINC1, which codes for antithrombin III. The level of antithrombin III was not available to directly prove the causality of thrombosis, but our findings suggest that this mutation, in combination with antifibrinolytic administration in a hypercoagulable cirrhotic patient, might have contributed to the development of this catastrophic thrombotic event.