Tunneled Catheter–Associated Atrial Thrombi: Successful Treatment with Chronic Anticoagulation

Tunneled dialysis catheter-associated right atrial thrombus (RAT) is a rarely reported complication. We reviewed hospital records of 10 patients from a teaching hospital dialysis unit, in whom RAT was diagnosed by trans-esophageal echocardiography (TEE). Patients were treated with chronic anticoagulation (heparin followed by warfarin) and followed over time. The group included 7 women; 6 patients were African American, 3 were Caucasian, and 1 was Hispanic. The average age was 52.1 ± 15.3 years. The most common presenting symptom was poor catheter flow on hemodialysis followed by fever and chills. On average, the patients had had 3.4 ± 2.7 catheter insertions before diagnosis of RAT, and the tunneled dialysis catheter (TC) had been in place for a mean of 91 ± 89.4 days when the thrombi were diagnosed. Trans-thoracic echocardiography (2-D echo) was done in 4 patients, but it identified RAT in only 1 patient. The catheter tip was at the junction of the superior vena cava and right atrium (SVC/RA) in most patients. Thrombolysis (unsuccessful) was attempted with urokinase in 3 patients, complicated in 2 patients by hemorrhage. After anticoagulation, 90% of the RAT resolved on repeated TEE. One patient had persistent RAT for 23 weeks and underwent surgical thrombolysis, but died postoperatively. We conclude that RAT is a frequently missed complication of a TC. Positioning the tip of the TC at the SVC/RA junction may not prevent RAT. Trans-esophageal echocardiography is a more sensitive diagnostic tool than 2-D echo and should be obtained early. Most patients can be successfully treated with anticoagulation alone. Thrombolytic therapy and surgical thrombolysis have high morbidity and mortality.