Right atrial thrombus in an asymptomatic hemodialysis patient with malfunctioning catheter and patent foramen ovale
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.
SourceAvailable from: Mourad H Senussi[Show abstract] [Hide abstract]
ABSTRACT: Central venous catheters (CVC) are used commonly in clinical practice. Incidences of CVC-related right atrial thrombosis (CRAT) are variable, but, when right atrial thrombus is present, it carries a mortality risk of 18% in hemodialysis patients and greater than 40% risk in nonhemodialysis patients. Different pathogenic mechanisms have been postulated for the development of CRAT, which includes mechanical irritation of the myocardial wall, propagation of intraluminal clot, hypercoagulability, and hemodynamics of right atria. Presentation of CRAT may be asymptomatic or may be associated with one of the complications of CRAT like pulmonary embolism, systemic embolism, infected thrombi, or hemodynamic compromise. There are no established treatment guidelines for CRAT. We describe an interesting case of a 59-year-old asymptomatic male successfully treated with open heart surgery after failure of medical treatment for a large CRAT discovered during a preoperative evaluation for a kidney transplant. Our case underscores that early detection of CRAT may carry a favorable prognosis as opposed to waiting until catastrophic complications arise. It also underscores the importance of transesophageal echocardiography in the detection of thrombus and perhaps guides clinicians on which treatment modality to be used according to the size of the thrombus.Case Reports in Medicine 11/2012; 2012:501303. DOI:10.1155/2012/501303
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ABSTRACT: Little is known about the potentially fatal complication of catheter-related right atrial thrombus (CRAT) in dialysis patients, and the optimal management is controversial. The aims of our study were to identify the prognostic factors of mortality in cases of CRAT in dialysis patients and to compare treatment options. Retrospective analysis of all reported cases of CRAT in adult dialysis patients, in English-language literature (PubMed search), in which therapy and outcome data were available. Up to December 2010, we identified 71 cases of CRAT in dialysis patients (including our patient). Overall mortality was 18.3% (13/71) and significant predictors were advanced age, presence of complications and non-removal of the catheter. Nine patients received no treatment, except for catheter removal and antibiotics, four of them died. Systemic thrombolysis was administered in eight patients but was successful only in two with pulmonary embolism, the remaining required further treatment. Finally, 37 patients received anticoagulation and 23 underwent surgical thrombectomy (one percutaneous intravascular removal of the thrombus). Mortality was 16.2% (6/37) and 13% (3/23), respectively, P=1. Regarding presence of various complications, no treatment choice was superior over the other. Five of the six patients who had a thrombus≥60 mm underwent successful surgical thrombectomy. We propose a management algorithm emphasizing the removal of the catheter and recommending anticoagulation as first-line treatment. Surgical thrombectomy is valuable when other treatments fail or in special circumstances. Thrombolysis has a poor success rate but may be useful in pulmonary embolism.Nephrology Dialysis Transplantation 12/2011; 27(7):2936-44. DOI:10.1093/ndt/gfr739 · 3.49 Impact Factor
Therapeutic apheresis and dialysis: official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy 12/2013; 17(6):638-640. DOI:10.1111/1744-9987.12039 · 1.53 Impact Factor