Catheter-related right atrial thrombosis

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.

624 Surgical Management of Right Atrial Mass Associated With a Vascular Access Catheter

“…This is related to factors including the intra-atrial prothrombotic foreign body, frequent complicating infections in the 2 Case Reports in Cardiology immunosuppressed, and thrombotic predisposition in the chronic kidney disease population [11]. Atrial thrombi complicating vascular catheters are associated with mortality rates of 18.3-20.6%, most often due to pulmonary embolism, cardiac failure, and overwhelming sepsis [3,12]. Mortality rates appear high (44%) in those managed without thrombus specific intervention [3].…”

“…A longer course of anticoagulation may be required if thrombus resolution is not achieved. Anticoagulation failure occurs in 30% of treated patients, and second-line options are thrombectomy or thrombolysis, though the latter is associated with failure rates of 30-75% [12].…”

Authors' response to letter to the editor: “Therapeutic strategy of dialysis catheter‐associated massive thrombus”

“…The mechanism of thrombus formation in such cases is attributed to the relative stagnation of blood in the RA compared with the SVC and/or mechanical irritation of the endocardium by the catheter tip. [3][4][5][6] We, therefore, suspect our patient developed CRAT by one of these mechanisms related to the intraatrial positioning of the catheter tip.…”

“…To the Editor, CRAT occurred exclusively in patients with catheter tip located in the RA as opposed to the SVC or SVC/RA junction. 3 Tran et al 4 reported intracardiac tip position to be a more significant risk factor for CRAT than thrombophilia. The mechanism of thrombus formation in such cases is attributed to the relative stagnation of blood in the RA compared with the SVC and/or mechanical irritation of the endocardium by the catheter tip.…”

Surgical management of catheter‐related right atrial thrombus with superior vena cava syndromeA Case Report

“…DISCUSSIONCRAT is an infrequent complication of dialysis catheter placement that may lead to pulmonary embolism, bacteremia, endocarditis, tricuspid regurgitation, right heart failure, arrhythmias, or cardiac arrest if left untreated 1,3. Management options for right atrial thrombus include observation, anticoagulation, systemic thrombolysis, catheter-directed thrombolysis, percutaneous retrieval of thrombus with basket versus vacuum-assisted thrombectomy, and surgical thrombectomy 1,[3][4][5][6][7][8][9]. Anticoagulation alone is commonly selected as first-line therapy for smallF I G U R E 1 Transthoracic echocardiogram demonstrates a large right atrial mass (red arrow) F I G U R E 2 Right atrial mass as seen on cardiac MRI, axial view (red arrow).…”