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

Abstract

Background Catheter-associated right atrial thrombus (CRAT) is a recognised complication of central venous catheter (CVC) use for haemodialysis (HD) patients. Methods This was a single-centre retrospective longitudinal observational study of consecutive children aged 6 months–18 years over a 7-year period receiving in-centre chronic HD. Echocardiograms as per routine cardiac surveillance were performed 6 months or earlier given clinical concerns. Results Sixty-five children, 36 boys (55.4%), median (IQR) age 11.8 (5.3, 14.7) years, received HD for kidney failure with replacement therapy (KFRT). Initial modality was HD in 45 (69.2%), with CVC as initial access in 42 (93.3%) and AVF in 3 (6.7%); in the remaining 20 (30.8%) patients PD was the initial modality before switching to HD. Seven of 65 (10.8%) developed CRAT at median 2 (0.8, 8.4) months from CVC insertion, with one CRAT detected 3 days following insertion. One child had 2 episodes of CRAT and one additionally thrombosed their AVF. No patient had an underlying primary kidney disease associated with a pro-thrombotic state. Those with CRAT were younger, had more frequent CVC change and received dialysis for longer duration compared to those with no CRAT. Six episodes of CRAT (75%) received anticoagulation therapy. Infective complications were observed in 25% and catheter malfunction in 50%. Five CRAT episodes (62.5%) resulted in CVC loss. One patient died after a haemorrhagic complication of anticoagulation and sepsis, and another developed life-threatening superior vena cava obstruction syndrome. Overall mortality 14% (1/7). Conclusions This is the first report of CRAT in a paediatric HD population. There was ~ 11% incidence of CRAT in patients receiving chronic HD detected by surveillance echocardiography. Although frequently asymptomatic, CRAT is associated with serious sequelae. Anticoagulation and surveillance with expert echocardiography remain mainstays of management. Graphical abstract

Hemodialysis Catheter-Associated Right Atrial Thrombus Diagnosed via Point of Care Transesophageal Echocardiogram

“…CRAT is often insidious and a potentially life-threatening complication that may arise in association with any CVC. However, it predominantly presents in cases involving tunneled HD catheters, typically emerging 12 weeks post-catheter insertion 1 . There is a paucity of data describing the occurrence of HDCRAT in the context of temporary HD catheters used for acute renal replacement therapy in critically ill medical ICU patients.…”

“…In the past decade, there has been a noticeable paradigm shift in the application of TEE 14 , 15 , 16 . This shift has extended its utility beyond cardiologists and cardiothoracic anesthesiologists, to employment by intensivists at the bedside 1 . Notably, Lau et al have substantiated that intensivist-performed limited TEE exhibits diagnostic accuracy equal to that achieved by cardiologists 15 .…”

“…Catheter-associated right atrial thrombus (CRAT) is a cause of significant morbidity in adult and pediatric patients following the placement of central venous catheters (CVCs). Potential complications of CRAT include pulmonary embolism, infection, septic emboli, arrhythmia, tricuspid regurgitation, catheter malfunction, superior vena cava obstruction, and in cases of CRAT associated with hemodialysis (HD) (hemodialysis catheter-associated right atrial thrombus (HDCRAT)), the loss of vascular access in the affected vein and incomplete dialysis 1 , 2 . In a retrospective study of published cases of HDCRAT in the adult HD population before 2010, mortality was reported at 18.3% 2 .…”

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

“…The optimal treatment for PE due to CVC-related thrombosis is still unknown, but a conservative approach in terms of anticoagulant and systemic thrombolytic therapy has been recently proposed for children on chronic haemodialysis ( 22 ). This strategy neither lead to atrial thrombus resolution, nor restoration of pulmonary circulation in both of the presented patients.…”

Friction injury of the central vein caused by catheter for hemodialysis: an in vitro study

“…Previous studies have suggested that the catheter or the guiding medium may cause acute mechanical friction damage to the vascular intima during insertion 12 , 13 . Moreover, factors such as the position or morphology of the catheter tip, the size of the catheter relative to the central vein, and changes in right atrial hemodynamics are also associated with catheter-related complications such as CVS 14 – 16 . In addition, imaging confirmed that the catheter had sustained regular or irregular multidirectional displacement in the blood vessel because of blood flow, heartbeat, breathing, body position, and regular negative pressure suction produced by the blood pump of the dialysis machine 17 , 18 .…”