Asian Cardiovasc Thorac Ann 2002;10:251-253
© 2002 Asia Publishing EXchange Pte Ltd
Septic Pulmonary Emboli Caused by a Hemodialysis Catheter
Qamar Abid, FRCS(CTh),
Dallas Price, MRCP1,
Michael J Stewart, FRCP1,
Simon Kendall, FRCS(CTh)
Department of Cardiothoracic Surgery
1 Department of Cardiology South Cleveland Hospital Middlesborough, Cleveland, England, UK
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For reprint information contact: Qamar Abid, FRCS(CTh) Tel: 44 1253 30 0000 Fax: 44 1253 30 3853 email: qumarabid{at}hotmail.com Flat 4, Whinpark Avenue, Blackpool, Lancashire FY3 8NZ, UK.
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ABSTRACT
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We present an unusual complication caused by a dialysis catheter inserted through the internal jugular vein into the central venous system. The 49-year-old male patient developed a right atrial thrombus, which became infected with Staphylococcus aureus, resulting in septic pulmonary embolism and septicemic shock. The thrombus was excised on cardiopulmonary bypass. The patient made an uneventful recovery.
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INTRODUCTION
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Septic pulmonary embolism (PE) resulting from an infected right atrial thrombus, caused by a dialysis catheter inserted into the internal jugular vein, is an infrequently reported complication. We report the clinical and diagnostic features and management of a patient who developed recurrent septic PE following insertion of a dialysis catheter.
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CASE REPORT
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A 49-year-old male, obese, a chronic smoker and a known hypertensive, was admitted with recent onset of breathlessness. At the time of admission, he was found to be suffering from severe renal failure with urea of 49.5 mmoláL-1, creatinine 2,177 µmoláL-1, potassium 6.7 mmoláL-1, and hemoglobin 87 gáL-1. Ultrasound examination revealed hypotrophic kidneys with no tubular dilatation.
He was started on intermittent hemodialysis through a temporary right subclavian catheter. Two attempts at creating an arteriovenous fistula for definitive vascular access failed because of intraoperative arterial spasm. A temporary uncuffed Gamcath dialysis catheter (Gambro, Lund, Sweden) was inserted via the right internal jugular vein, and regular dialysis was started. No prophylactic antibiotic was given, following hospital protocol for clean procedures, and there was no clinical evidence of any infection. When the flow during dialysis was found to remain below 200 mLámin-1, contrast angiography was performed, which showed the tip of the catheter adhering to the right atrial wall between the inferior vena cava (IVC) and the coronary sinus. Dialysis was continued through the same line while awaiting renal transplantation.
The patient had three admissions in the following 2 months with chest pain and breathlessness, but without any physical or radiological findings suggestive of PE, leading to the diagnosis of nonspecific chest pain. All these episodes were managed with oral analgesics and settled spontaneously. The duration of these admissions was 2, 3, and 2 days, respectively.
The last admission, 2 months after the first one, was complicated by a temperature of 39.5°C, rigor, and chest pain. Admission blood pressure was 70/30 mm Hg with a white blood cell count of 31 x 109 L-1, platelet count of 63 x 109 L-1, and two positive blood cultures for Gram-positive cocci (Staphylococcus aureus). He was resuscitated successfully with intravenous fluids. Flucloxacillin 1 g 6 hourly was given (according to sensitivity) for 7 days. Multiple pulmonary infiltrate, shown on a chest radiograph, and oligemia raised the suspicion of PE. The internal jugular dialysis catheter was removed and a femoral dialysis catheter inserted.
A transthoracic echocardiogram revealed a pedunculated mobile mass in the right atrium (RA) protruding into the right ventricle, which was thought to be a myxoma (Figure 1
). A transesophageal echocardiogram showed a mobile right atrial mass of 7 x 5 cm with a broad pedicle attached to the free right atrial wall between the IVC and the coronary sinus. The possibility of a right atrial thrombus or tumor was discussed. In view of suspected earlier episodes of PE and a definite episode of septic PE, excision of the mass was planned.
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Figure 1. Transthoracic echocardiogram: modified parasternal view angled anteriorly showing a large homogenous right atrial mass protruding into the right ventricle. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.
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A median sternotomy was carried out. After full heparinization and with separate inferior and superior vena caval cannulation, cardiopulmonary bypass was instituted at 37°C. The myocardium was protected with St. Thomas crystalloid cardioplegia and a continuous cold circuit. The RA was opened via a transverse incision. The mass originated from the free right atrial wall between the IVC and the coronary sinus and involved the full thickness of the RA (Figure 2). It was totally excised with the free right atrial wall (Figure 3), and the defect was repaired with a pericardial patch. Pulmonary artery exploration did not reveal any residual mass in the main pulmonary artery. Histopathological examination of the mass showed an organized thrombus with a large amount of Staphylococcus aureus embedded in it.
Postoperative recovery was smooth except for an episode of atrial fibrillation, which was successfully treated with amiodarone. In the 9 months since the operation, he had had no further episode of chest pain and was stable as an outpatient on hemodialysis awaiting renal transplantation.
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DISCUSSION
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The formation of a thrombus around the intracardiac end of a central line catheter is rare.1 The possibility of thrombosis is much higher if the end of the catheter rubs against the free right atrial wall. The endothelial damage induced by trauma predisposes to platelet aggregation and thrombus formation. In a study of 55 patients with a Hickman catheter, an abnormal mass consistent with a thrombus was found in 12.5% of the patients by transesophageal echocardiography.2 All the patients with the mass had the tip of the catheter placed in the RA.
Right atrial thrombus formation in children with a central venous catheter, with or without infection, is a well-reported complication.3 However, infection of a right atrial thrombus is very rare in adults with a central venous catheter.4 There are a few reported cases of right atrial thrombosis complicating a ventriculoatrial shunt in adults.1 Right atrial thrombosis caused by a dialysis catheter in adults has also been reported,5 but experience with surgical management is lacking. Continuing sepsis and septic PE due to an infected right atrial thrombus can lead to multiorgan failure and death.5
The superiority of transesophageal echocardiography over transthoracic echocardiography for imaging intracardiac masses has been reported.6 In our experience, a transesophageal echocardiogram clearly showed the location of the mass. Histopathological diagnosis of the mass is necessary and is usually made on the excised mass. The use of fine needle aspiration in the diagnosis of a right atrial myxoma has been reported.7 Removal of atrial tumors is generally recommended to avoid potential PE, although successful conservative management in an elderly man of 88 years with biatrial tumor was reported.8
Our case suggests that a mass in the RA should be excised for 2 reasons: to avoid any potential recurrent PE and to avoid infection and septic shock. The condition may become lifethreatening when it is not recognized and treated appropriately.
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REFERENCES
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ABSTRACT
INTRODUCTION
