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International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101010Z01JY2019. www.ijcasereportsandimages.com
Yan et al. 1
CASE REPORT PEER REVIEWED | OPEN ACCESS
Catheter-directed thrombolysis for thrombi in right atrium and upper extremity caused by peripherally inserted
central catheters
Junwei Yan, Jiang Wu, Bing Liu, Xuefei Jiao, Wei Li, Mingjin Guo
ABSTRACT
Introduction: Peripherally inserted central catheters (PICC) are widely applied in clinical practice. One of the foremost complications is the potential risk for thrombosis associated with their use. Especially the thrombi within the cardiac chambers are rarely observed in clinical practice, but they are potentially deadly to patients for pulmonary embolism. There are no evidence-based guidelines for their treatment, and the optimal treatment is controversial (conservative or positive). Case Report: We report the case of a 52-year-old female, who presented with both a right atrial thrombus and upper extremity deep vein thrombi on three days following PICC insertion. After an elaborate surgery with two catheters for thrombolysis and one filter for prevention of pulmonary embolism, the thrombi were dissolved effectively without occurrence of any complications. Conclusion: In summary, regarding the treatment choice of complex thrombi in both right atrium and upper extremity, with the development of vascular surgery and interventional equipment, interventional treatment might be a well-tolerated therapeutic option. The ingenious surgical design of two catheters for thrombolysis and one filter for prevention of pulmonary embolism highlights a safe and feasible treatment for this kind of thrombi with minimal trauma.
Junwei Yan1, Jiang Wu1, Bing Liu1, Xuefei Jiao1, Wei Li1, Mingjin Guo1
Affiliations: 1Department of Vascular Surgery, Affiliated Hos-pital of Qingdao University, Qingdao, Shandong, China.Corresponding Author: Mingjin Guo, Department of Vascular Surgery, Affiliated Hospital of Qingdao University, No. 1677 Wutaishan Rd., Qingdao, Shandong 266000, China; Email: [email protected]
Received: 17 December 2018Accepted: 04 February 2019Published: 07 March 2019
Keywords: Catheter-directed thrombolysis, Peripherally inserted central catheters, Right atrium, Thrombi
How to cite this article
Yan J, Wu J, Liu B, Jiao X, Li W, Guo M. Catheter-directed thrombolysis for thrombi in right atrium and upper extremity caused by peripherally inserted central catheters. Int J Case Rep Images 2019;10:101010Z01JY2019.
Article ID: 101010Z01JY2019
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doi: 10.5348/101010Z01JY2019CR
INTRODUCTION
Peripherally inserted central catheters (PICC) are widely used in clinical practice. But some complications and risks exit with their use, such as deep vein thrombosis of the upper extremity, infection, and even pulmonary embolism [1–3]. The incidence of venous thrombosis is 6.67–13.91%, [3, 4] and the incidence of pulmonary embolism is up to 36–40% among those patients [5, 6] with a mortality rate of 17.4% [7].
In patients with thrombotic complication, catheter-related right atrial thrombi are rarely seen in clinical practice, but they are potentially deadly since the high possibility of pulmonary embolism. There are several treatment choices for those patients, including surgical thrombectomy, systemic anticoagulation, and systemic thrombolysis, etc., but the optimal treatment is controversial (conservative or positive) [8].
Only a few cases were reported to solve the problem by catheter-directed thrombolysis but with good results [8–11]. Here we report another even more complicated case with PICC-related thrombi in both right atrium and upper extremity. The thrombi were dissolved by two
International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101010Z01JY2019. www.ijcasereportsandimages.com
Yan et al. 2
catheters for thrombolysis and a filter for prevention of pulmonary embolism. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
CASE REPORT
A 52-year-old female was diagnosed with breast cancer and underwent a mastectomy without complications. A PICC was placed in her right cephalic vein for chemotherapy. Three days later, the patient’s right arm was marked swelling. Her upper extremity and heart were examined by Doppler ultrasound, which showed thrombi in both the right atrium and around the PICC line. The size of the blood clot in the right atrium was 2.5×2.3 cm (Figure 1A). After consultation with a cardiac surgeon, the patient was not recommended for cardiac surgery because of the high risk and severe trauma. She was then referred to vascular surgery.
The patient did not suffer from any other systematic disease, and her only other pertinent history was a 30–year allergy to penicillin. She neither smoked nor drank. Physical examination revealed an edematous right arm. The PICC could be seen in her right elbow joint, and the skin around the catheter was erythematous. The temperature of the skin was normal, and the radial artery could be palpated. Cardiac and pulmonary auscultation and abdominal examination were normal. The patient did not have neck rigidity, and the neurologic examination was normal.
The patient was admitted for emergency surgery of a pulmonary artery catheter-directed thrombolysis (CDT) + superior vena cava filter implantation + right subclavian vein CDT. The intraoperative angiogram demonstrated a long thrombus in right axillary and subclavian vein around the PICC, and another thrombus in right atrium. The blood flow was fluent in superior vena cava, the left and right pulmonary artery branch. Regarding the surgery, firstly a catheter for thrombolysis was implanted in the trunk of the right pulmonary artery through the right femoral vein. The purpose was to dissolve the thrombus in right atrium and increase the local drug concentration in pulmonary artery in case of a pulmonary embolism. Secondly, after we confirmed that no thrombus was in the superior vena cava through the PICC catheter by angiography, a superior vena cava filter was inserted through the left femoral. The filter was used to capture the possible clots detaching from right axillary and subclavian vein thrombosis around the PICC during the process of thrombolysis, and prevent the pulmonary embolism. Thirdly, we replaced the PICC with a catheter for thrombolysis in the right subclavian vein, and the tip was placed in the superior vena cava (Figure 2). A dosage of 100,000 IU urokinase was injected through the two catheters respectively. After surgery, low-dose urokinase of 100,000 IU/24 h/catheter was continuously pumped through the catheters, which was heparinized from
the catheter sheath. Hematological indexes, including hemoglobin, platelet, activated partial thromboplastin time (APTT) and fibrinogen, were tested every day to monitor and avoid the risk of bleeding.
On the third day after surgery, Doppler ultrasonography of the right upper extremity and the heart showed no obvious thrombosis around the catheter, and the thrombus in the right atrium had decreased to 2.3×1.3 cm (Figure 1B). On the sixth day after surgery, the thrombus in the right atrium had decreased to 1.3×0.9 cm (Figure 1C). Confirmed the normal blood flow in right axillary and subclavian vein by angiography, we removed the catheter of right upper extremity. Pulmonary artery CDT was continued with pumping of low-dose urokinase. On the tenth day after surgery, the thrombus in the right atrium dissolved, which was revealed by ultrasonic cardiogram (Figure 1D). The following day, angiography showed normal blood flow in superior vena cava and pulmonary artery, then the filter in superior vena cava and the catheter in pulmonary artery were all removed. We found that some thrombi were captured in the filter, and they were pathologically confirmed to be blood clots. On postoperative day 12, the patient was discharged from the hospital with a prescription for daily oral warfarin for continuous anticoagulation. International normalized ratio (INR) and D-dimmer was monitored to adjust the dosage of warfarin during the follow-up time.
DISCUSSION
Catheter-related right atrial thrombus (CRAT) is a rare complication in PICC. As a foreign body, PICC related local damage and hemodynamic abnormalities are the main reason for thrombus. On the one hand, the
Figure 1: Cardiac Doppler ultrasonography preoperatively, and 3, 6, 10 days postoperatively. (A) The thrombosis in right atrium was 2.5×2.3 cm before operation. (B) The thrombosis in right atrium was decreased to 2.3×1.3 cm on three days after operation. (C) The thrombosis in right atrium was decreased to 1.3×0.9 cm on six days after operation. (D) There was no thrombosis in the right atrium on 10 days after operation.
International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101010Z01JY2019. www.ijcasereportsandimages.com
Yan et al. 3
catheter tip continuously moves with the heartbeat, and the repeated friction could damage the right atrium or the vascular intima and lead to activation of the clotting cascade, platelet aggregation, and thrombosis. On the other hand, the local hemodynamic abnormalities around the catheter tip could lead to eddy current and blood flow stasis, which tend to form thrombus. In previous case reports about CRAT, [12–14] the majority of the catheter tips were located in the right atrium. Therefore, the primary risk factor for atrial thrombosis lies in a PICC tip in the right atrium, and we should never place the tip of a PICC in the right atrium to avoid CRAT.
Regarding the treatment options for this patient, the following plans were considered:
1. Conservative treatment, including removal of the PICC, anticoagulants or peripheral intravenous thrombolysis. The risk was that the clots from either around the PICC or the right atrium could detach at any time, which would lead to a pulmonary embolism without the protection of a filter, especially when the PICC was removed.
2. Surgical treatment. After consultation with a cardiac surgeon who considered the patient’s overall condition, the patient was not recommended to undergo cardiac surgery. Although previous reports indicate that surgery could remove the blood clots, [12, 15] surgical trauma is massive and more difficult.
3. Catheter-directed thrombolysis (CDT). According to previous literature, only a few cases of right atrial thrombus have been treated by interventional surgery [8–11]. There were no clear guidelines for this kind of treatment. In accordance with the medical history of this patient, the duration of her upper extremity swelling was short, so we speculated that the blood clots might be fresh and that CDT might be a good choice. Therefore, after obtaining informed consent from the patient, we chose the proactive CDT option with the following treatment program:
(1) Because of the thrombosis in her right atrium, there was a high risk for pulmonary embolism caused by deciduous blood clots; therefore, a catheter was inserted into the pulmonary artery through the heart. Taking advantage of the many side holes in the catheter, not only was the thrombus dissolved but also a pathway for the pulmonary artery was built so that once the thrombus detached, the pulmonary artery could still maintain blood flow.
(2) A filter was placed in the superior vena cava to capture the clots detached from the thrombi in right axillary and subclavian vein around the PICC during the process of thrombolysis, and prevent the pulmonary embolism.
(3) An infusion catheter was inserted through the PICC pathway to dissolve the thrombi in the upper extremity vein. Through the above surgical plan, we successfully dissolved the thrombi in the patient’s upper extremity vein and in the right atrium simultaneously and avoided the occurrence of pulmonary embolism. This kind of surgical plan and implementation has not yet been reported.
CONCLUSION
In summary, regarding the treatment choice of complex thrombi in both right atrium and upper extremity, with the development of vascular surgery and interventional equipment, interventional treatment might be a well-tolerated therapeutic option. The ingenious surgical design of two catheters for thrombolysis and one filter for prevention of pulmonary
Figure 2: Digital subtraction angiography (DSA) demonstrating the catheter for thrombolysis in the right subclavian vein (a), the superior vena cava filter (b), and catheter in the right pulmonary artery trunk (c) respectively.
International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101010Z01JY2019. www.ijcasereportsandimages.com
Yan et al. 4
embolism highlights a safe and feasible treatment for this kind of thrombi with minimal trauma.
REFERENCES
1. Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol 2000;11(10):1309–14.
2. Liem TK, Yanit KE, Moseley SE, et al. Peripherally inserted central catheter usage patterns and associated symptomatic upper extremity venous thrombosis. J Vasc Surg 2012;55(3):761–7.
3. Robinson A, Souied O, Bota AB, et al. Optimal vascular access strategies for patients receiving chemotherapy for early-stage breast cancer: A systematic review. Breast Cancer Res Treat 2018;171(3):607–20.
4. Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: A systematic review and meta-analysis. Lancet 2013;382(9889):311–25.
5. Moser KM, Fedullo PF, LitteJohn JK, Crawford R. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis. JAMA 1994;271(3):223–5.
6. Prandoni P, Polistena P, Bernardi E, et al. Upper-extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med 1997;157(1):57–62.
7. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: Clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353(9162):1386–9.
8. Orgeron GM, Pollard JL, Pourmalek P, Sloane PJ. Catheter-directed low-dose tissue plasminogen activator for treatment of right atrial thrombus caused by a central venous catheter. Pharmacotherapy 2015;35(10):e153–8.
9. Amankwah KS, Seymour K, Costanza MJ, Gahtan V. Ultrasound accelerated catheter directed thrombolysis for pulmonary embolus and right heart thrombus secondary to transvenous pacing wires. Vasc Endovascular Surg 2011;45(3):299–302.
10. Maron BA, Goldhaber SZ, Sturzu AC, et al. Catheter-directed thrombolysis for giant right atrial thrombus. Circ Cardiovasc Imaging 2010;3(1):126–7.
11. Shammas NW, Padaria R, Ahuja G. Ultrasound-assisted lysis using recombinant tissue plasminogen activator and the EKOS EkoSonic endovascular system for treating right atrial thrombus and massive pulmonary embolism: A case study. Phlebology 2015;30(10):739–43.
12. Hussain N, Shattuck PE, Senussi MH, et al. Large right atrial thrombus associated with central venous catheter requiring open heart surgery. Case Rep Med 2012;2012:501303.
13. Gilon D, Schechter D, Rein AJ, et al. Right atrial thrombi are related to indwelling central venous catheter position: Insights into time course and possible mechanism of formation. Am Heart J 1998;135(3):457–62.
14. Chan J, Kumar J, Cheng A, Yap CH, Zhang XB. Right atrial mass associated with a dialysis catheter. J Card Surg 2012;27(3):362.
15. Islam M, Nesheim D, Acquah S, et al. Right heart thrombi: Patient outcomes by treatment modality and predictors of mortality: A pooled analysis. J Intensive Care Med 2018:885066618808193.
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Author ContributionsJunwei Yan – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedJiang Wu – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedBing Liu – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedXuefei Jiao – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedWei Li – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedMingjin Guo – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone.
Consent StatementWritten informed consent was obtained from the patient for publication of this case report.
Conflict of InterestAuthors declare no conflict of interest.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101010Z01JY2019. www.ijcasereportsandimages.com
Yan et al. 5
Copyright© 2019 Junwei Yan et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in
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