1
|
Gholinataj Jelodar M, Mirzaei S, Dehghan Chenari H, Tabkhi M. Diagnosis of the right atrial myxoma after treatment of COVID-19: A case report. Clin Case Rep 2023; 11:e7216. [PMID: 37143454 PMCID: PMC10152069 DOI: 10.1002/ccr3.7216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/24/2023] [Accepted: 04/04/2023] [Indexed: 05/06/2023] Open
Abstract
Key Clinical Message Atrial myxoma is a rare disease but has a broad clinical presentation and complication that involves several systems- heart, lungs, brain, and systemic. An interdisciplinary approach is very important to optimize the outcome in patients with atrial myxomas. A thorough examination by primary care providers is crucial. Then radiologists or cardiologists can help with imaging modalities that can help diagnose and characterize the tumor. Prior to surgical resection by cardiothoracic surgeons, patients need to be evaluated by pulmonologists, cardiologists, and anesthesiologists for preoperative risk stratifications. In patients with neurological complications, pulmonary complications, or infectious endocarditis, input from neurologists, hematologists, infectious disease specialists is essential for patient care. In case antiplatelet/anticoagulation therapy or antibiotic treatment is warranted, pharmacists can provide valuable recommendations. Abstract Myxoma is the most common benign cardiac primary tumor, occurring in the right atrium in only 15%-20% of cases. This disease is asymptomatic initially depending upon size of the tumor, and symptoms develop as the tumor spreads. Atrial myxomas are associated with a triad of complications, including obstruction, emboli, and constitutional symptoms (such as fever and weight loss). This regard, embolization of the pulmonary circulation system is a complication of right myxoma. The patient was a 40-year-old male who presented to the emergency department complaining of fever and confusion. He had been previously hospitalized due to COVID-19 and treated with Remdesivir and plasmapheresis. He had tachycardia, tachypnea, thrombocytopenia, and increased liver enzymes. Chest imaging showed nodular lesions with necrotic areas and cavitary lesions in both lungs and the right atrium infected clot was seen in echocardiography. He was treated with intravenous antibiotics and finally underwent heart surgery due to the diagnosis of pulmonary septic embolism. The patient was finally diagnosed with right atrial myxoma according to heart mass histopathology. It is worth noting that the patient's thrombosis had already developed on the right atrial myxoma, which delayed the diagnosis in this patient. This thrombus formation was due to the hypercoagulability state of COVID-19 and following the insertion of a central venous catheter to perform plasmapheresis as a complication of treatment. Special attention should be paid to thromboprophylaxis and the early diagnosis of intravascular and intracardiac thrombosis in COVID-19 patients. Furthermore, the use of imaging modalities is recommended to differentiate thrombus from myxoma.
Collapse
Affiliation(s)
| | - Samaneh Mirzaei
- Department of Health in Emergencies and Disasters, School of Public HealthShahid Sadoughi University of Medical SciencesYazdIran
| | | | | |
Collapse
|
2
|
Jahanshahi F, Parsaei A, Naderi D, Zeraatian Nejad Davani S, Khaleghian M. Potentially fatal atrium perforation due to right jugular vein catheterization recognized by venography: A case report. Clin Case Rep 2023; 11:e6911. [PMID: 36789307 PMCID: PMC9909251 DOI: 10.1002/ccr3.6911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/10/2022] [Accepted: 01/16/2023] [Indexed: 02/11/2023] Open
Abstract
Central venous catheters are the prevalent path for dialysis. Our case was a 54-years-old male with a new case of end-stage renal disease with a complaint of right jugular hemodialysis catheter dysfunction. In our case, the early dysfunctional catheter should be evaluated with contrast studies to achieve accurate information.
Collapse
Affiliation(s)
- Fatemeh Jahanshahi
- Faculty of MedicineIran University of Medical ScienceTehranIran
- Urology Research CenterTehran University of Medical SciencesTehranIran
| | | | - Delaram Naderi
- Allied Medical SciencesIran University of Medical SciencesTehranIran
| | - Sam Zeraatian Nejad Davani
- Rockingham Medical Research Center, ADKWA MedicalPerthWestern AustraliaAustralia
- Department of Cardiovascular Surgery and Faculty of Transplant and Organ DonationIran University of Medical ScienceTehranIran
| | - Mohsen Khaleghian
- Department of Vascular SurgeryIran University of Medical ScienceTehranIran
| |
Collapse
|
3
|
Asymptomatic pulmonary thromboembolism due to hemodialisys catheter thrombosis: case series and literature review. CEN Case Rep 2022. [PMID: 36574198 PMCID: PMC10393924 DOI: 10.1007/s13730-022-00757-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
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.
Collapse
|
4
|
Abdelsalam H. Cephalic arch stenosis in autologous hemodialysis fistula; to stent or not to stent? Long-term follow up. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-022-00772-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
A retrospective study of 44 patients with autologous arteriovenous fistula (AVF) presenting with cephalic arch stenosis was carried out. The aim is to assess the effectiveness of angioplasty and stenting in cephalic arch stenosis in autologous AVF in hemodialysis patients and also to assess the outcome of metal stents at this distinctive anatomical site. All patients were subjected to Doppler examination, where the stenotic lesion and the AVF flow volume were assessed prior to intervention. The follow-up period reached up to 57 months in some patients. All patients were under surveillance and were assessed for patency and flow volume. The primary and secondary stenosis-free rates were calculated. Re-intervention during the follow-up period was recorded.
Results
The technical success rate was 100%. Twenty-six patients had balloon angioplasty. Eighteen patients had primary and/or secondary stents inserted. The primary patency rate at 6 and 12 months for the balloon angioplasty group was 80% and 60% and for the stent group was 86% and 71%, respectively. The mean primary patency rate in balloon angioplasty patients was 12.9 months, while in the primary stented patients was 19.9 months. Twenty-six patients had secondary intervention. The average secondary patency rate for patients with balloon angioplasty was 25.5 months, while it was 33.6 months in the stented patients.
Conclusion
Cephalic arch angioplasty and stenting is an effective intervention increasing the longevity of the AVF that is crucial for hemodialysis patients. The use of metal stents whether bare metal stents or covered stents is safe and adds significant increase in patency rates.
Collapse
|
5
|
Soh NYT, Tan BS, Chan SJM, Patel A, Gogna A, Zhuang KD, Tashi S, Venkatanarasimha N, Tay KH, Chandramohan S. Deeper may not be better: relationship between catheter dysfunction and location of the catheter tip in right-sided tunnelled haemodialysis catheters. Clin Radiol 2022; 77:678-683. [PMID: 35717409 DOI: 10.1016/j.crad.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 04/27/2022] [Indexed: 11/19/2022]
Abstract
AIM To examine the relationship between catheter tip location and catheter dysfunction in the context of tunnelled central venous catheters (CVCs) for haemodialysis. MATERIALS AND METHODS This was a retrospective study of 993 haemodialysis patients who underwent insertion of tunnelled CVCs of step-tip design via the right internal jugular vein (IJV). Based on intra-procedural radiographs, the catheter tip was characterised as being in the superior vena cava (SVC), cavo-atrial junction (CAJ), or deep right atrium (DRA). Patients were tracked for 90 days post-procedure for complications resulting in catheter replacement, and these were compared between cohorts. Statistical analysis was performed with Pearson's chi-square and Fisher's exact tests for categorical variables and two-sample t-test and one-way analysis of variance (ANOVA) for continuous variables. RESULTS Ninety-five patients (9.6%) experienced catheter dysfunction necessitating replacement within 90 days of insertion. Tip location in SVC was associated with lower occurrence of catheter dysfunction (1.9%) as compared with the CAJ (8%) and DRA (11%; p=0.049). Catheter replacement due to other complications (catheter-associated bacteraemia, cuff dislodgement, exit-site infection, external catheter damage) showed no statistically significant relation to location of the CVC tip. CONCLUSION When utilising tunnelled CVCs with a step-tip design inserted via the right IJV, location of the catheter tip in the SVC is associated with reduced occurrence of catheter dysfunction as compared to either the CAJ or DRA.
Collapse
Affiliation(s)
- N Y T Soh
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - B S Tan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - S J M Chan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - A Patel
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - A Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - K D Zhuang
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - S Tashi
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - N Venkatanarasimha
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - K H Tay
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - S Chandramohan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore.
| |
Collapse
|
6
|
Sieverding L, Michel J, Urla C, Sturm E, Winkler F, Hofbeck M, Fuchs J, Hilberath J, Warmann SW. Spectrum of Interventional Procedures During Hybrid Central Line Placement in Pediatric Intestinal Rehabilitation Patients With End-Stage Vascular Access. Front Nutr 2022; 9:863063. [PMID: 35419386 PMCID: PMC8995563 DOI: 10.3389/fnut.2022.863063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/07/2022] [Indexed: 12/01/2022] Open
Abstract
Background Loss of available central vein access sites for parenteral nutrition delivery represents one of the main indications for intestinal transplantation in children with intestinal failure. Placement of central venous catheters can be challenging in advanced loss of patent venous pathways. We recently described the hybrid technique (interventional plus surgical approach) of central line placement in children. The aim of this study was to describe and analyze the interventions used during the hybrid procedures regarding feasibility, safety and outcome. Methods We retrospectively analyzed the course of all children in our intestinal rehabilitation program undergoing hybrid central line placement. We evaluated patients' conditions, interventional techniques and surgical peculiarities as well as outcome. Results 203 children were treated in our intestinal rehabilitation program between 2010 and 2021. Due to loss of venous access, hybrid technique was performed in 53 children during 76 interventions. In 40 cases the same vessel was reused via Seldinger technique. Among the 30 ultrasound-guided new vessel punctures, 12 were performed by puncture of collateral vessels. Extended interventions due to thoracic central venous obstruction and/or thrombosis requiring additional access via a femoral vein for rehabilitation of the vascular system was performed during 29 procedures including catheter extraction (1), angioplasties (18), stent placement (1), revascularization (5) and thrombectomy (4). Placement of a central line was not possible in 6 children which eventually underwent extended thoracic/vascular surgery: in three children the previously placed catheter could not be removed, in one child, placement of a thrombectomy-catheter was not possible because of inferior vena cava occlusion, and in two children, revascularization failed. Intestinal transplantation was considered in one patient because of impending loss of vascular access. Two self-limiting minor extravasations and one intervention-associated pericardial effusion occurred. Conclusions Hybrid interventions for central venous catheter placement and vascular rehabilitation enable a high success rate in children with intestinal failure and end-stage vascular access, circumventing the need for intestinal transplantation or advanced surgery. The relevant procedures are complex and require a foresighted and individualized approach with a wide range of interventional techniques. If performed with expertise, this combined interventional/surgical approach is feasible and safe.
Collapse
Affiliation(s)
- Ludger Sieverding
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Christian Urla
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Ekkehard Sturm
- Department of Pediatric Gastroenterology and Hepatology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Franziska Winkler
- Department of Pediatric Gastroenterology and Hepatology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Johannes Hilberath
- Department of Pediatric Gastroenterology and Hepatology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Steven Walter Warmann
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| |
Collapse
|
7
|
Stiru O, Dragulescu R, Geana RC, Chibulcutean A, Raducu L, Tulin A, Stroescu AB, Diaconu C, Savu C, Bacalbasa N, Balescu I, Iliescu VA. Catheter-related giant right atrial thrombosis mimicking a myxoma: A case report. Exp Ther Med 2021; 21:603. [PMID: 33936260 DOI: 10.3892/etm.2021.10035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/02/2021] [Indexed: 11/05/2022] Open
Abstract
Despite the development of imagistic methods, the differential diagnosis of a right atrial mass may be difficult to be established, the most common pathologies which should be taken in consideration being represented by thrombus, tumors, prominent crista terminalis, or vegetation of infectious endocarditis. In this study, we present the case of a 63-year-old man with chronic kidney disease, in hemodialysis (HD) with a silicone central venous catheter (CVC) with the incidental transthoracic echocardiography (transthoracic echocardiogram, TTE) finding of a tumoral mass of 35x26 mm in the right atrium (RA), not related with the catheter, which was diagnosed as right atrial myxoma and underwent surgical excision. After reviewing the histopathology probe, the diagnosis of right atrial thrombus was confirmed. In conclusion, differentiating intracardiac right atrial masses (RAMs) could may prove challenging. In our patient, clinical presentation and the preoperative investigations could not differentiate the right atrial thrombus from a myxoma, and only the postoperative histopathology diagnosis was able to guide correct diagnosis.
Collapse
Affiliation(s)
- Ovidiu Stiru
- Department of Cardiovascular Surgery, 'Prof. Dr. C. C.' Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania.,Department of Cardiovascular Surgery, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Razvan Dragulescu
- Department of Cardiovascular Surgery, 'Prof. Dr. C. C.' Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Roxana Carmen Geana
- Department of Cardiovascular Surgery, 'Prof. Dr. C. C.' Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Andreea Chibulcutean
- Department of Cardiovascular Surgery, 'Prof. Dr. C. C.' Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Laura Raducu
- Department of Plastic and Reconstructive Microsurgery, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, 'Prof. Dr. Agripa Ionescu', Clinical Emergency Hospital, 011356 Bucharest, Romania
| | - Adrian Tulin
- Department of General Surgery, 'Prof. Dr. Agripa Ionescu', Clinical Emergency Hospital, 011356 Bucharest, Romania.,Department of Anatomy, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Andra Balcangiu Stroescu
- Department of Cardiovascular Surgery, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Camelia Diaconu
- Department of Internal Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Cornel Savu
- Department of Thoracic Surgery, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Thoracic Surgery, 'Marius Nasta' National Institute of Pneumology, 050159 Bucharest, Romania
| | - Nicolae Bacalbasa
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Obstetrics and Gynecology, 'I. Cantacuzino' Clinical Hospital, 030167 Bucharest, Romania.,Department of Visceral Surgery, Center of Excellence in Translational Medicine, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Irina Balescu
- Department of Surgery, 'Ponderas' Academic Hospital, 021188 Bucharest, Romania
| | - Vlad Anton Iliescu
- Department of Cardiovascular Surgery, 'Prof. Dr. C. C.' Iliescu Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania.,Department of Cardiovascular Surgery, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| |
Collapse
|
8
|
Clark JR, Hoffman SC, Shlobin NA, Bavishi A, Narang A. Incidence of catheter-associated right atrial thrombus detected by transthoracic echocardiogram. Echocardiography 2021; 38:435-439. [PMID: 33523518 DOI: 10.1111/echo.14987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/09/2021] [Indexed: 11/28/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jeffrey R Clark
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Steven C Hoffman
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nathan A Shlobin
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Aakash Bavishi
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Akhil Narang
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
9
|
Jheengut Y, Fan B. Intraoperative identification of persistent left superior vena cava with intracavitary electrocardiogram during venous port insertion: A report of eight cases. J Vasc Access 2020; 22:834-839. [PMID: 32546056 DOI: 10.1177/1129729820931308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Persistent left superior vena cava is a rare congenital anomaly, occurring in 0.3% to 0.5% of general population and up to 10% in patients with congenital heart disease. This anomaly is usually discovered incidentally during central venous catheterization from left side. Since 2015, we have identified eight cases of persistent left superior vena cava out of a total of 2637 patients who had left sided venous port insertion in our department. The persistent left superior vena cavae were identified with the aid of intracavitary electrocardiogram. The characteristic finding was an initial negative P-wave (in lead II), followed by a biphasic P-wave pattern during catheter insertion. All the ports worked properly, with a total catheter dwelling time of 2586 days (range: 96-756 days, mean: 323.25 days), and no catheter-related complication was observed. However, because of the paucity of clinical evidence, we should still be prudent in the long-term use of venous ports in persistent left superior vena cava.
Collapse
Affiliation(s)
- Yogesh Jheengut
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Boqiang Fan
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
10
|
Rossi L, Covella B, Libutti P, Teutonico A, Casucci F, Lomonte C. How to manage catheter-related right atrial thrombosis: Our conservative approach. J Vasc Access 2020; 22:480-484. [PMID: 32410490 DOI: 10.1177/1129729820922703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Luigi Rossi
- Department of Nephrology, "F.Miulli" General Hospital, Acquaviva delle Fonti, Italy
| | - Bianca Covella
- Department of Nephrology, "F.Miulli" General Hospital, Acquaviva delle Fonti, Italy
| | - Pasquale Libutti
- Department of Nephrology, "F.Miulli" General Hospital, Acquaviva delle Fonti, Italy
| | - Annalisa Teutonico
- Department of Nephrology, "F.Miulli" General Hospital, Acquaviva delle Fonti, Italy
| | - Francesco Casucci
- Department of Nephrology, "F.Miulli" General Hospital, Acquaviva delle Fonti, Italy
| | - Carlo Lomonte
- Department of Nephrology, "F.Miulli" General Hospital, Acquaviva delle Fonti, Italy
| |
Collapse
|
11
|
Abstract
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.
Collapse
Affiliation(s)
- Minh-Ha Tran
- Department of Pathology and Laboratory Medicine, School of Medicine, University of California, Irvine, Irvine, CA, USA.,Department of Internal Medicine, School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Tanya Wilcox
- Department of Internal Medicine, School of Medicine, New York University, New York, NY, USA
| | - Phu N Tran
- Department of Hematology and Oncology, Genesis Cancer Center, Zanesville, OH, USA
| |
Collapse
|
12
|
Management of tunneled-cuffed catheter-related right atrial thrombosis in hemodialysis patients. J Vasc Surg 2018; 68:1491-1498. [DOI: 10.1016/j.jvs.2018.02.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 02/20/2018] [Indexed: 11/20/2022]
|
13
|
Van Hulle F, Bonkain F, De Clerck D, Aerden D, Vanwijn I, Tielemans C, Wissing KM. Efficacy of urokinase lock to treat thrombotic dysfunction of tunneled hemodialysis catheters: A retrospective cohort study. J Vasc Access 2018; 20:60-69. [PMID: 29893163 DOI: 10.1177/1129729818779549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND: There are few data to inform decisions about the optimal management of occluded tunneled cuffed hemodialysis catheters with thrombolytic locking solutions. The effect of dose, dwell-time, and number of administrations remains controversial. METHODS: In this retrospective single-center review of tunneled cuffed catheters used between 2010 and 2014, restoration of blood flow as well as pre- and post-pump pressures after either short (30 min) or prolonged (48-72 h) administration of 100,000 IU of urokinase locking solution was evaluated in all thrombotic dysfunctions. We also assessed if multiple urokinase locks for the same thrombotic dysfunction event were more efficient to restore catheter performance than single administration. RESULTS: Data on 773 thrombotic events in 148 patients (236 catheters) were collected during observation period. After urokinase treatment, blood flow and pre-pump pressure improved (median of 50 mL/min and 20 mmHg) whereas post-pump pressure decreased (median of 15 mmHg) (all P < 0.0001). The short thrombolytic procedure, used in more severely dysfunctional catheters, resulted in significantly larger improvements in catheter function than the long procedure. Multiple administrations for the same thrombotic event further improved access function in case of persisting dysfunction after first lock but had no added beneficial effect if blood flow and/or pump pressures were normalized after first urokinase lock. CONCLUSION: Both short and prolonged administration of urokinase locks were efficient in restoring blood flow and pre- and post-pump pressures in dialysis catheters with thrombotic dysfunction. Multiple urokinase locks provide added benefit on these outcomes only in case of persisting dysfunction after the first lock.
Collapse
Affiliation(s)
- Freya Van Hulle
- 1 Department of Nephrology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Florence Bonkain
- 1 Department of Nephrology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Dieter De Clerck
- 1 Department of Nephrology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Dimitri Aerden
- 2 Departments of Vascular Surgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Isabelle Vanwijn
- 1 Department of Nephrology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Christian Tielemans
- 1 Department of Nephrology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Karl Martin Wissing
- 1 Department of Nephrology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| |
Collapse
|
14
|
Rossi L, Libutti P, Casucci F, Lisi P, Teutonico A, Basile C, Lomonte C. Is the removal of a central venous catheter always necessary in the context of catheter-related right atrial thrombosis? J Vasc Access 2018; 20:98-101. [DOI: 10.1177/1129729818774438] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Luigi Rossi
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Pasquale Libutti
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Francesco Casucci
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Piero Lisi
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Annalisa Teutonico
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Carlo Basile
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Carlo Lomonte
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| |
Collapse
|
15
|
Tonkin J, Campbell G, Golding L, Hamblin M, Hunter S, Jaggia A. Atrial Thrombosis: A near Fatal Complication of a Portacath. J Vasc Access 2018. [DOI: 10.1177/112972980800900213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Portacaths™ (Bard Medical Division, Georgia, USA) are routinely used for central venous access in patients with poor peripheral veins who require regular long-term venous access. Complications associated with central venous access devices, including infection and thrombosis, are well described in the literature; however, to our knowledge there have been few case reports of right atrial thrombi and pulmonary emboli related to implanted ports. This paper discusses the case of a patient who developed an atrial thrombosis 4 months after port placement and subsequent pulmonary emboli.
Collapse
Affiliation(s)
- J.L. Tonkin
- Hematology Department, Essex Rivers NHS Trust, Colchester, Essex - UK
| | - G. Campbell
- Hematology Department, Essex Rivers NHS Trust, Colchester, Essex - UK
| | - L. Golding
- Hematology Department, Essex Rivers NHS Trust, Colchester, Essex - UK
| | - M. Hamblin
- Hematology Department, Essex Rivers NHS Trust, Colchester, Essex - UK
| | - S. Hunter
- Hematology Department, Essex Rivers NHS Trust, Colchester, Essex - UK
| | - A. Jaggia
- Hematology Department, Essex Rivers NHS Trust, Colchester, Essex - UK
| |
Collapse
|
16
|
Shah A, Murray M, Nzerue C. Right Atrial Thrombi Complicating use of Central venous Catheters in Hemodialysis. J Vasc Access 2018; 6:18-24. [PMID: 16552678 DOI: 10.1177/112972980500600105] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- A Shah
- Department of Medicine, Nephrology Section, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | | | | |
Collapse
|
17
|
De Carvalho BR, Eagar GM. Immediate post-insertion tip migration of peripherally inserted central catheters dependent on arm position and depth of inspiration. J Med Imaging Radiat Oncol 2017; 62:324-329. [DOI: 10.1111/1754-9485.12698] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 11/07/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - Gerard M Eagar
- Department of Radiology; Tauranga Hospital; Tauranga New Zealand
| |
Collapse
|
18
|
Wong K, Marks BA, Qureshi A, Stemm JJ. Migration of a Central Venous Catheter in a Hemodialysis Patient Resulted in Left Atrial Perforation and Thrombus Formation Requiring Open Heart Surgery. ACTA ACUST UNITED AC 2016; 7:21-3. [DOI: 10.1213/xaa.0000000000000323] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
19
|
Complex Perioperative Decision-Making: Liver Resection in a Patient with Extensive Superior Vena Cava/Right Atrial Thrombus and Superior Vena Cava Syndrome. Case Rep Anesthesiol 2016; 2016:2106242. [PMID: 26904303 PMCID: PMC4745874 DOI: 10.1155/2016/2106242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 11/17/2022] Open
Abstract
The perioperative management of patients suffering from extensive superior vena cava (SVC) thrombus complicated by SVC syndrome presents unique challenges. The anesthesiologist needs to be prepared for possible thrombus dislodgement resulting in pulmonary embolism and also has to assess the need for fluid resuscitation given the dangers of massive intravenous fluid application via the upper extremities. We present our perioperative approach in management of a patient scheduled for right hepatectomy who was previously diagnosed with extensive SVC and right atrial (RA) thrombus complicated by SVC syndrome.
Collapse
|
20
|
Dilek M, Kaya C, Karatas A, Ozer I, Arık N, Gulel O. Catheter-related atrial thrombus: tip of the iceberg? Ren Fail 2015; 37:567-71. [PMID: 25694191 DOI: 10.3109/0886022x.2015.1007461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Although guidelines recommend catheters as a last resort for establishing a vascular access in patients undergoing dialysis, they continue to be used widely for this purpose. Catheter-related atrial thrombus (CRAT) is rarely reported in this group of patients, and it can lead to serious complications. The aim of this study was to determine the incidence of CRAT in patients undergoing hemodialysis with permanent-tunneled catheters. A total of 50 patients undergoing hemodialysis with permanent catheters were included in this study. The diagnosis of CRAT was based on transthoracic echocardiography findings. Thrombus was present in nine patients (18%) and related to the tip of the catheter in all cases. Except for one patient with two foci of thrombus, all patients had a single focus. There were no significant associations between the development of thrombus and the duration of catheter use or the location of the catheter. Furthermore, catheter-related atrial thrombus did not appear to have a significant effect on mortality. The asymptomatic character of CRAT can be responsible for the low reporting rates, and its exact role in increased mortality and morbidity related with catheter use remains unknown. While planning management strategies, information on different options for vascular access routes and possible catheter-related complications should be provided to all patients who will undergo dialysis, together with a discussion involving other replacement alternatives for end-stage renal disease.
Collapse
Affiliation(s)
- Melda Dilek
- Department of Nephrology, Ondokuz Mayıs University School of Medicine , Samsun , Turkey
| | | | | | | | | | | |
Collapse
|
21
|
Aatif T, El Farouki MR, Mouaine N, Raissouni M. Catheter-related atrial thrombus in a patient on hemodialysis. Ther Apher Dial 2013; 17:638-40. [PMID: 24330560 DOI: 10.1111/1744-9987.12039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Taoufiq Aatif
- Department of Nephrology, Dialysis and Renal Transplantation, Military Hospital Mohammed V, Rabat, Morocco.
| | | | | | | |
Collapse
|
22
|
Davenport A. Why do hypertonic citrate locks lead to dialysis catheter malfunction; more than a weighty problem? Nephrol Dial Transplant 2012; 27:2621-4. [PMID: 22802579 DOI: 10.1093/ndt/gfs274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London Medical School, London, UK.
| |
Collapse
|
23
|
Stavroulopoulos A, Aresti V, Zounis C. Right atrial thrombi complicating haemodialysis catheters. A meta-analysis of reported cases and a proposal of a management algorithm. Nephrol Dial Transplant 2012; 27:2936-2944. [DOI: 10.1093/ndt/gfr739] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
|
24
|
Prevention and management of catheter-related infection in hemodialysis patients. Kidney Int 2011; 79:587-598. [DOI: 10.1038/ki.2010.471] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
25
|
Neonatal and childhood right atrial thrombosis: recognition and a risk-stratified treatment approach. Blood Coagul Fibrinolysis 2010; 21:301-7. [DOI: 10.1097/mbc.0b013e3283333c7c] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
26
|
Willicombe MK, Vernon K, Davenport A. Embolic Complications From Central Venous Hemodialysis Catheters Used With Hypertonic Citrate Locking Solution. Am J Kidney Dis 2010; 55:348-51. [DOI: 10.1053/j.ajkd.2009.06.037] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Accepted: 06/29/2009] [Indexed: 11/11/2022]
|
27
|
Tan CH, Pua U, Chia PL. Multidetector row CT diagnosis of an infected right atrial thrombus following repeated dialysis catheter placement. Br J Radiol 2010; 82:e240-2. [PMID: 19934063 DOI: 10.1259/bjr/86275378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Right atrial thrombus formation is a known complication of dialysis catheter placements. We describe the case of a 61-year-old woman with end-stage renal failure who presented with gram-negative septicaemia. A gas-containing filling defect was noted incidentally in the right atrium during a CT scan of the abdomen and pelvis, indicative of a thrombus infected by a gas-forming organism. The finding correlated with a positive blood culture of Klebsiella pneumoniae and the two-dimensional echocardiography finding of an echogenic atrial thrombus.
Collapse
Affiliation(s)
- C H Tan
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore.
| | | | | |
Collapse
|
28
|
Abstract
Magnetic resonance is known to be a superior modality for the evaluation of pericardial disease and intracardiac masses because of its unmatched capacity for tissue characterization and high spatial resolution. New real-time sequences complement the standard morphologic imaging of the pericardium with dynamic image acquisitions that also can provide hemodynamic information indicative of constriction. Magnetic resonance also is becoming increasingly recognized as a superior modality for the detection and characterization of intracardiac thrombus. This article reviews the use of magnetic resonance imaging for the evaluation of pericardial disease and the detection of intracardiac thrombus, with particular emphasis on the newer pulse sequences currently available for cardiac imaging.
Collapse
Affiliation(s)
- John D Grizzard
- Non-invasive Cardiovascular Imaging, Department of Radiology, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0615, USA.
| |
Collapse
|
29
|
RAM R, SWARNALATHA G, RAKESH Y, JYOSTNA M, PRASAD N, DAKSHINAMURTY KV. Right atrial thrombus due to internal jugular vein catheter. Hemodial Int 2009; 13:261-5. [DOI: 10.1111/j.1542-4758.2009.00385.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
30
|
Catheter-Related Atrial Thrombus Resolved After Catheter Removal in a Patient on Hemodialysis. South Med J 2008; 101:662-3. [DOI: 10.1097/smj.0b013e3181757b4c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
31
|
Chen CY, Liu CC, Sun WZ. Evidence-Based Review on Catheter-Related Thrombosis of the Implantable Venous Access Device. Tzu Chi Med J 2007. [DOI: 10.1016/s1016-3190(10)60018-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
32
|
Lacson E, Lazarus JM, Himmelfarb J, Ikizler TA, Hakim RM. Balancing Fistula First With Catheters Last. Am J Kidney Dis 2007; 50:379-95. [PMID: 17720517 DOI: 10.1053/j.ajkd.2007.06.006] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Accepted: 06/15/2007] [Indexed: 11/11/2022]
Abstract
The success of Fistula First nationwide has been accompanied by an unplanned increase in hemodialysis catheters. Complications related to prolonged hemodialysis catheter use include increased morbidity, mortality, and cost. We hypothesize that the national focus on increasing fistulas may have inadvertently diverted attention away from initiatives to decrease dependence on hemodialysis catheters. Based on a synthesis of guidelines, reviews, published evidence, and the authors' opinions, we propose that the national vascular access initiative be revised to have a dual goal of Fistula First and "Catheters Last." These goals are not mutually exclusive, but rather complementary. We recommend a systematic refocus on interventions that not only increase fistulas, but help avoid extended catheter use. Clearly, the ideal practice for hemodialysis vascular access remains early placement of fistulas with enough maturation time such that they can be used for initiating long-term hemodialysis therapy when the need arises. To effect this change, a reimbursement policy covering the costs associated with permanent access placement before the need for dialysis is essential. Individualized patient management strategies may consider such innovative approaches as initiating patients on peritoneal dialysis therapy or using nonautogenous grafts as bridge accesses in lieu of catheters. For patients who are dialyzing using catheters, immediate active planning for permanent access placement and removal of the catheter is necessary. In the same vein as Fistula First, the renal community should once again be galvanized in working together toward controlling the catheter epidemic in our dialysis population.
Collapse
Affiliation(s)
- Eduardo Lacson
- Fresenius Medical Care, North America, Waltham, MA 02451-1457, USA.
| | | | | | | | | |
Collapse
|
33
|
Abstract
Central vein stenosis is commonly associated with placement of central venous catheters and devices. Central vein stenosis can jeopardize the future of arteriovenous fistula and arteriovenous graft in the ipsilateral extremity. Occurrence of central vein stenosis in association with indwelling intravascular devices including short-term, small-diameter catheters such as peripherally inserted central catheters, long-term hemodialysis catheters, as well as pacemaker wires, has been recognized for over two decades. Placement of multiple catheters, longer duration, location in subclavian vein, and placement on the left-hand side of neck seem to predispose to the development of central vein stenosis. Endothelial injury with subsequent changes in the vessel wall results in development of microthrombi, smooth muscle proliferation, and central vein stenosis. Central vein stenosis is often asymptomatic in nondialysis patients, but can result in edema of ipsilateral extremity and breast when challenged by increased flow from an arteriovenous fistula or arteriovenous graft. Bilateral central vein stenosis or superior vena cava stenosis can produce a clinical picture of superior vena cava syndrome, associated with engorgement of face and neck. Endovascular interventions are the mainstay of management of central vein stenosis. Percutaneous angioplasty and stent placement for elastic and recurring lesions can restore the functionality of the vascular access, at least temporarily. Frequent or multiple interventions are usually required. In recalcitrant cases, surgical bypass of the obstruction is an option. In resistant cases with severe symptoms, occlusion of the functioning vascular access will usually provide relief of symptoms. Further study of mechanisms of development of central vein stenosis and search for a targeted therapy is likely to lead to better ways of managing central vein stenosis. Prevention of central vein stenosis is the key to avoid access failure and other complications from central vein stenosis and relies upon avoidance of central vein stenosis placement and timely placement of arteriovenous fistula in prospective dialysis patient.
Collapse
Affiliation(s)
- Anil K Agarwal
- Division of Nephrology, Department of Internal Medicine, Ohio State University, Columbus, Ohio 43210, USA.
| | | | | |
Collapse
|
34
|
Alomari AI, Falk A. The Natural History of Tunneled Hemodialysis Catheters Removed or Exchanged: A Single-Institution Experience. J Vasc Interv Radiol 2007; 18:227-35. [PMID: 17327555 DOI: 10.1016/j.jvir.2006.12.719] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To track the natural history of tunneled hemodialysis catheters requiring removal or exchange at a single institution. MATERIALS AND METHODS Over a 2-year period, tunneled hemodialysis catheters that presented to interventional radiology for removal or exchange were entered into this retrospective study. Patient demographics, catheter location, dwell time, and indication for removal were recorded. Pull-back contrast venography was performed with imaging over the chest. Catheters were then removed or exchanged. RESULTS Three hundred thirty-four tunneled dialysis catheters were removed or exchanged in 207 patients; 108 male, median age 53 years. Dwell time, available from 296 catheters, ranged from 1 to 114 days (median, 66 days) for a total of 32,847 catheter days. One hundred three catheters were removed for infection, yielding a rate of infection requiring catheter removal of 3.0 per 1,000 catheter days. One hundred catheters were removed for other working access, and 96 catheters were exchanged for poor function. Two hundred sixty-five were removed or exchanged from the internal jugular vein, 22 from the subclavian vein, and 24 from the femoral vein. One hundred seventy-two (76%) of the 226 catheters studied with contrast had fibrin sheaths; of which 42 had thrombus identified along the catheter tract. One hundred ninety-three catheters were removed, and 141 catheters were exchanged for new catheters with 82 catheters receiving balloon disruption of the fibrin sheath. CONCLUSIONS Approximately one third of tunneled dialysis catheters are removed for infection, one third for other working access, and one third for poor function. Catheters usually remain in the patient for a median of 2 months. Fibrin sheaths associated with hemodialysis catheters are very common. Thrombus formation around the sheath is frequent.
Collapse
Affiliation(s)
- Ahmad I Alomari
- Department of Radiology, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA
| | | |
Collapse
|
35
|
Horng HC, Yuan CC, Chao KC, Cheng MH, Wang PH. A simple method to accurately position Port-A-Cath without the aid of intraoperative fluoroscopy or other localizing devices. J Surg Oncol 2007; 95:582-6. [PMID: 17230542 DOI: 10.1002/jso.20754] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND To evaluate the efficacy and acceptability of the Port-A-Cath (PAC) insertion method with (conventional group as II) and without (modified group as I) the aid of intraoperative fluoroscopy or other localizing devices. METHODS A total of 158 women with various kinds of gynecological cancers warranting PAC insertion (n = 86 in group I and n = 72 in group II, respectively) were evaluated. Data for analyses included patient age, main disease, dislocation site, surgical time, complications, and catheter outcome. RESULTS There was no statistical difference between the two groups in terms of age, main disease, complications, and the experiencing of patent catheters. However, appropriate positioning (100% in group I, and 82% in group II) in the superior vena cava (SVC) showed statistical differences between the two groups (P = 0.001). In addition, the surgical time in group I was statistically shorter than that in group II (P < 0.001). CONCLUSIONS The modified method for inserting the PAC offered the following benefits: including avoiding X-ray exposure for both the operator and the patient, defining the appropriate position in the SVC, and less surgical time.
Collapse
MESH Headings
- Anesthesia, Local
- Anesthetics, Local
- Catheterization, Central Venous/economics
- Catheterization, Central Venous/instrumentation
- Catheterization, Central Venous/methods
- Catheterization, Central Venous/standards
- Catheters, Indwelling/adverse effects
- Catheters, Indwelling/economics
- Cost-Benefit Analysis
- Equipment Design
- Evaluation Studies as Topic
- Female
- Fluoroscopy/instrumentation
- Genital Neoplasms, Female/surgery
- Humans
- Infusions, Intravenous
- Intraoperative Care
- Lidocaine
- Middle Aged
Collapse
Affiliation(s)
- Huann-Cheng Horng
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan
| | | | | | | | | |
Collapse
|
36
|
Hsu JH, Wang CK, Chu KS, Cheng KI, Chuang HY, Jaw TS, Wu JR. Comparison of radiographic landmarks and the echocardiographic SVC/RA junction in the positioning of long-term central venous catheters. Acta Anaesthesiol Scand 2006; 50:731-5. [PMID: 16987369 DOI: 10.1111/j.1399-6576.2006.01025.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND When implanting a permanent central venous catheter, the usual aim is to place the tip at the superior vena cava/right atrial (SVC/RA) junction. However, data validating radiographic landmarks of the SVC/RA junction are limited. This investigation was undertaken to compare the radiographic landmarks with the SVC/RA junction as determined by transesophageal echocardiography (TEE). METHODS In 20 adult oncologic patients undergoing implantation of a permanent subcutaneous central venous catheter, the catheter tip was placed in the SVC/RA junction under TEE guidance. The position of the catheter tip on chest X-ray, which represented the echocardiographic SVC/RA junction, was then compared with a standard radiographic landmark of the SVC/RA junction and with thoracic vertebral levels. RESULTS In all but two patients radiographic SVC/RA junctions were identified. The echocardiographic SVC/RA junction ranged from 0.6 cm above to 2.8 cm below the radiographic SVC/RA junction. There was a significant difference between the distance from the carina to the radiographic SVC/RA junction and the distance from the carina to the echocardiographic SVC/RA junction. The thoracic vertebral body correlating with the echocardiographic SVC/RA junction ranged from the sixth to the ninth level. CONCLUSION Both the radiographic SVC/RA junction and the thoracic vertebral bodies are not reliable landmarks for the SVC/RA junction defined by TEE. Physicians should be aware that using the radiographic SVC/RA junction to confirm proper positioning of permanent central venous catheters risks placing the catheter tip in the upper SVC, with subsequent potential long-term complications. More reliable radiographic landmarks for the SVC/RA junction should be investigated.
Collapse
Affiliation(s)
- J-H Hsu
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | | | | | | | | | | | | |
Collapse
|
37
|
Lalor PF, Sutter F. Surgical Management of a Hemodialysis Catheter-Induced Right Atrial Thrombus. ACTA ACUST UNITED AC 2006; 63:186-9. [PMID: 16757370 DOI: 10.1016/j.cursur.2005.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
Collapse
Affiliation(s)
- Peter F Lalor
- Department of Surgery, Lankenau Hospital, Wynnewood, Pennsylvania 19096, USA.
| | | |
Collapse
|
38
|
Hassan A, Khalifa M, Al-Akraa M, Lord R, Davenport A. Six cases of retained central venous haemodialysis access catheters. Nephrol Dial Transplant 2006; 21:2005-8. [PMID: 16632560 DOI: 10.1093/ndt/gfl123] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Amir Hassan
- University College London Center for Nephrology, Royal Free Hospital, Pond Street, London NW3 2QG
| | | | | | | | | |
Collapse
|
39
|
Banerjee A, Davenport A. Ascites due to right atrial myxoma in a haemodialysis patient. BMC Nephrol 2006; 7:4. [PMID: 16519807 PMCID: PMC1450266 DOI: 10.1186/1471-2369-7-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Accepted: 03/06/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Persistent fluid overload in patients on renal replacement therapy despite good dialysis adequacy or obvious cardiac dysfunction should prompt a search for rarer causes. CASE PRESENTATION We report here a rare cause of persistent peripheral oedema and ascites in a well-dialysed patient. CT scanning revealed a right atrial myxoma that was later confirmed on an echocardiogram. CONCLUSION Fluid overload states are common in patients on dialysis. Common causes are inadequacy of dialysis and non-compliance. Where aetiology is not easily apparent further investigations into rarer causes should be sought.
Collapse
Affiliation(s)
- Anindya Banerjee
- University College London, Centre for Nephrology, Royal Free Hospital, London, UK
| | - Andrew Davenport
- University College London, Centre for Nephrology, Royal Free Hospital, London, UK
| |
Collapse
|
40
|
Yoshizawa K, Kissling GE, Johnson JA, Clayton NP, Flagler ND, Nyska A. Chemical-induced atrial thrombosis in NTP rodent studies. Toxicol Pathol 2006; 33:517-32. [PMID: 16048847 DOI: 10.1080/01926230591034429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Katsuhiko Yoshizawa
- Laboratory of Experimental Pathology, National Institute of Environmental Health Sciences (NIEHS), Research Triangle Park, North Carolina 27709, USA
| | | | | | | | | | | |
Collapse
|
41
|
Ribot S, Siddiqi SW, Chen C. Right Heart Complications of Dual Lumen Tunneled Venous Catheters in Hemodialysis Patients. Am J Med Sci 2005; 330:204-8. [PMID: 16234616 DOI: 10.1097/00000441-200510000-00011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Seven hemodialysis patients with infected right atrial thrombi and/or tricuspid valve endocarditis are reported. All cases were attributed to use of tunneled venous catheters. Staphylococcus aureus was the preponderant organism isolated on blood culture. Therapeutic measures included antibiotics, catheter exchange, and surgery. One patient died with pulmonary embolism, and the remainder survived the infectious episodes. Experimental evidence further confirms the relationship of venous catheters placed in or proximate to the right atrium as the cause for the reported infected thrombotic and tricuspid valve complications. Measures to reduce the incidence of right heart complications must begin with recognition of the need for a surgically created arterial venous dialysis access placed early in the course of kidney disease. There is no entirely satisfactory method for prevention of venous catheter--induced endocarditis.
Collapse
Affiliation(s)
- Seymour Ribot
- Division of Nephrology and Non-Invasive Cardiac Laboratory, Department of Medicine, Newark Beth Israel Medical Center, Newark, New Jersey 07112, USA.
| | | | | |
Collapse
|
42
|
van Laecke S, Dhondt A, de Sutter J, Vanholder R. Right atrial thrombus in an asymptomatic hemodialysis patient with malfunctioning catheter and patent foramen ovale. Hemodial Int 2005; 9:236-40. [PMID: 16191073 DOI: 10.1111/j.1492-7535.2005.01137.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- S van Laecke
- Nephrology Section of Department of Internal Medicine, University of Ghent, Ghent, Belgium
| | | | | | | |
Collapse
|
43
|
Shah A, Murray M, Nzerue C. Right atrial thrombi complicating use of central venous catheters in hemodialysis. Int J Artif Organs 2005; 27:772-8. [PMID: 15521217 DOI: 10.1177/039139880402700907] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- A Shah
- Department of Medicine, Nephrology Section, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | | | | |
Collapse
|
44
|
Dreyer G, Bingham C. Right atrial thrombus as a complication of a temporary haemodialysis catheter--a potentially avoidable complication. Nephrol Dial Transplant 2005; 20:474-5. [PMID: 15673710 DOI: 10.1093/ndt/gfh626] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
45
|
Aggeli C, Brili S, Frogoudaki A, Barbetseas J, Stefanadis C. Four-Month Warfarin Therapy Results in a Dissolution of a Superior Vena Cava Thrombus. Echocardiography 2004; 21:435-6. [PMID: 15209724 DOI: 10.1111/j.0742-2822.2004.03145.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
46
|
Chu KS, Hsu JH, Wang SS, Tang CS, Cheng KI, Wang CK, Wu JR. Accurate central venous port-A catheter placement: intravenous electrocardiography and surface landmark techniques compared by using transesophageal echocardiography. Anesth Analg 2004; 98:910-914. [PMID: 15041571 DOI: 10.1213/01.ane.0000105865.94157.4c] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
UNLABELLED Using transesophageal echocardiography (TEE) to locate the tip of central venous catheters inserted via the right subclavian vein, we compared IV electrocardiography (IV-ECG)-guided catheter tip placement with the conventional surface landmark technique. Sixty patients were randomly assigned into two groups. In Group E, the IV-ECG signal was conducted along an NaHCO(3)-filled catheter to facilitate catheter placement. In Group S, surface landmarks on the chest wall were used to determine the appropriate catheter length. The goal was to visualize the catheter tip with TEE at the superior edge of the crista terminalis, which is the junction of the superior vena cava (SVC) and right atrium (RA). The catheter tip position was considered to be satisfactory, as the tip was within 1.0 cm of the upper crista terminalis edge. All 30 Group E patients had satisfactory catheter tip placement when the ECG P wave was at its maximum. In contrast, 16 of the 30 patients in Group S had satisfactory tip positions (P < 0.001). All catheters were repositioned under TEE guidance to adjust the tip to the SVC-RA junction. After the catheter tips were confirmed to be located at the SVC-RA junction, the catheter tips were still visualized in the mid portion of RA in 12 of 60 patients on supine chest radiographs. We concluded that IV-ECG guidance to position a catheter resulted in satisfactory catheter tip placement that is in accordance with TEE views. Catheter placement at the SVC-RA junction with the surface landmark technique was unreliable. IMPLICATIONS Intravenous electrocardiography guidance to position catheters obtains a satisfactory catheter tip placement that is in accordance with transesophageal echocardiography views. The surface landmark technique does not result in reliable placement at the superior vena cava-right atrium junction.
Collapse
Affiliation(s)
- Koung-Shing Chu
- *Department of Anesthesiology, Kuo General Hospital, Tainan, Taiwan; and Departments of †Pediatrics, ‡Surgery, §Anesthesiology, and Medical Imaging, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | | | | | | | | | | | | |
Collapse
|
47
|
Raymond-Carrier S, Dubé M, Nolin L, Ouimet D, Leblanc M. Hemodialysis Catheter Tip Embolization in the Right Pulmonary Vasculature: Report of a Cardiac Arrest. ASAIO J 2003; 49:751-4. [PMID: 14655748 DOI: 10.1097/01.mat.0000093960.78469.3c] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A 44 year old woman on hemodialysis presented a sudden cardiorespiratory arrest at the end of an otherwise uneventful dialysis session. It occurred while disconnecting the circuit from her tunneled catheter. She was reanimated and then transferred to the intensive care unit; the endotracheal intubation had been difficult, and she had been severely hypoxic. It was noted that the external venous clamp of the tunneled catheter was broken and the hypothesis of a break during the reanimation process was entertained. The routine chest x-ray postintubation showed that the tip of the catheter was ruptured and visible in one branch of the right pulmonary artery. The catheter was changed over a guide wire, and the broken catheter was sent for analysis to the manufacturer. A selective angiography of the right pulmonary artery was performed with the purpose of removing the fractured catheter tip but was unsuccessful. The patient recovered neurologic function slowly over the next 4 months. The exact etiology of the arrest remains incompletely understood; it is unknown whether it was caused by the catheter tip embolization or if an air embolism occurred.
Collapse
|
48
|
Mailloux PT, Bhopatkar S, Boyd TK, Rousou JA, Jiang L, Higgins TL. Right atrial thrombus leading to altered mental status. J Cardiothorac Vasc Anesth 2003; 17:509-11. [PMID: 12968243 DOI: 10.1016/s1053-0770(03)00158-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
49
|
Abstract
There is continuing debate among physicians, nurses, and federal regulatory agencies regarding the correct position for the tip of a central venous catheter. The traditional approach has been to place the catheter tip within the superior vena cava. However, many interventionalists believe that the performance and durability of the catheter will be improved by positioning the catheter tip within the upper right atrium. Recently, this variability in clinical practice has become an increasingly divisive issue among physicians who insert these catheters and nurses who use them. This article is intended to elucidate the controversial issues and provide a brief review of the extensive literature on this important topic.
Collapse
Affiliation(s)
- Thomas M Vesely
- Mallinckrodt Institute of Radiology, 510 South Kingshighway Boulevard, St. Louis, Missouri 63110, USA.
| |
Collapse
|
50
|
Abstract
Although renal failure has classically been associated with a bleeding tendency, thrombotic events are common among patients with end-stage renal disease (ESRD). A variety of thrombosis-favoring hematologic alterations have been demonstrated in these patients. In addition, "nontraditional" risk factors for thrombosis, such as hyperhomocysteinemia, endothelial dysfunction, inflammation, and malnutrition, are present in a significant proportion of chronic dialysis patients. Hemodialysis (HD) vascular access thrombosis, ischemic heart disease, and renal allograft thrombosis are well-recognized complications in these patients. Deep venous thrombosis and pulmonary embolism are viewed as rare in chronic dialysis patients, but recent studies suggest that this perception should be reconsidered. Several ESRD treatment factors such as recombinant erythropoietin (EPO) administration, dialyzer bioincompatibility, and calcineurin inhibitor administration may have prothrombotic effects. In this article we review the pathogenesis and clinical manifestations of thrombosis in ESRD and evaluate the evidence that chronic renal failure or its management predisposes to thrombotic events.
Collapse
Affiliation(s)
- Liam F Casserly
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts 02118, USA
| | | |
Collapse
|