Catheter-Directed Low-Dose Tissue Plasminogen Activator for Treatment of Right Atrial Thrombus Caused by a Central Venous Catheter

Abstract

Catheter-related atrial thrombosis is a potentially deadly complication of central venous catheters. Options for treatment include surgical thrombectomy, systemic anticoagulation, and systemic thrombolysis, but the optimal method of treatment remains unknown. We describe a 48-year-old woman with a large right atrial thrombus who was successfully treated with localized recombinant tissue plasminogen activator (tPA). She was treated with an 18-hour infusion of localized low-dose tPA administered through her central venous catheter. The dimensions of the thrombus decreased from 30 × 16 × 22 mm to 10 × 8 × 5 mm after treatment with tPA, corresponding to an associated 96% reduction in thrombus volume. No major bleeding complications were observed. Catheter-directed thrombolysis provides the theoretical advantage of a decreased rate of major bleeding by reducing the exposure to and duration of high-dose systemic thrombolytic therapy. To our knowledge, this is the second case report describing the use of this novel therapy. Although no guidelines for the treatment of atrial thrombosis or consensus on the optimal regimen for catheter-directed thrombolysis (and intensity of concomitant anticoagulation) exist, we believe that this intervention may be a well-tolerated alternative to systemic thrombolysis and surgery in certain patients.

Catheter-related right atrial thrombosis

“…Our search produced a total of eight case series encompassing 32 cases and 32 additional individual case reports. 7–46 Same-patient CRAT recurrences were described in five reports 9,13,14,19,24 for a total of 68 cases of CRAT among 63 patients. Table 1 provides demographic details.…”

Direct thrombolysis of multiple thrombi in both right and left heart atrium in a patient on extracorporeal membrane oxygenation support following urgent double-lung transplantation: a case report

“… 13 The shear stress created by the mechanical pumps causes changes in the hemocoagulation system in almost all patients treated with ECMO. 9 ECMO and the surgical procedure carry a risk of considerable bleeding which is caused by the surgical wound itself and by the use of heparin along with other causes such as hypothermia, anemia, inflammation, and/or drug effects (eg, antiplatelet agents, low-molecular-weight heparins). 13 Massive bleeding leads to massive allogeneic blood transfusions, which are a known independent risk factor for poor wound healing.…”

“… 8 Catheter-related atrial thrombosis is a potentially deadly complication of intravascular devices. 9 Hemodynamic status remains the most important short-term prognostic factor for patients with acute massive thrombosis. 6 In concordance with the use of thrombolytic therapy recommendation for patients with acute symptomatic pulmonary embolism, we decided to thrombolyse with tissue plasminogen activator.…”

“… 8 Catheter-related atrial thrombosis is a potentially deadly complication of intravascular devices. 9 Hemodynamic status remains the most important short-term prognostic factor for patients with acute massive thrombosis.…”

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).…”