Intravascular Cooling Catheter-Related Venous Thromboembolism After Hypothermia: A Case Report and Review of the Literature

Abstract

Fifty-four year-old man with recent history of myocardial infarction and a percutaneous coronary intervention who suffered a ventricular fibrillation arrest at home. He was resuscitated in the field. His heart rhythm was in atrial fibrillation. The cardiac catheterization showed a patent stent from his previous myocardial infarction and no new occlusions. He subsequently underwent hypothermia protocol using the Alsius CoolGard 3000 Temperature Control System and Icy Catheter. Heparin drip was started for atrial fibrillation 36 hours after catheter insertion and became therapeutic 2 hours before the end of cooling maintenance phase. Heparin drip was stopped 4 hours into the rewarming phase because of spontaneous conversion to sinus rhythm. Subcutaneous heparin was resumed for deep venous thrombosis prophylaxis. He was extubated to room air after hypothermia protocol. The cooling catheter was removed 88 hours after insertion. Within 1 minute of catheter removal, his oxygen saturation dropped to 80%. Transthoracic echocardiogram showed a mobile thrombus in the right atrium prolapsing into the right ventricle. Computer tomography angiography of the chest confirmed a large saddle embolus. Ninety minutes later, patient went into cardiac arrest with pulseless electrical activity while he was being considered for surgical embolectomy, but he could not be resuscitated. The temporal relationship of the catheter removal and his acute clinical decompensation led to believe that this was an intravascular cooling catheter (ICC)-related event. Providers should be cognizant of the complications of central venous catheters such as thrombosis formation, as it could lead to fatal pulmonary embolism. Physicians should promote frequent assessment of the access site(s) during routine physical examinations and potentially use point of care vascular ultrasound in high-risk cases to rule out a catheter-associated thrombus before catheter removal.

Intravascular Versus Surface Cooling in Patients Resuscitated From Cardiac Arrest: A Systematic Review and Network Meta-Analysis With Focus on Temperature Feedback

“…One explanation for a possible better outcome in patients cooled with intravascular cooling compared with surface cooling with temperature feedback might be the ability of intravascular cooling devices to react more quickly to the temperature feedback mechanism, resulting in a faster adjustment of the patient's target body temperature, less temperature fluctuations, and less overcooling/undercooling/unexpected rewarming events (32). At the same time, intravascular cooling is associated with a certain rate of infection, hemorrhage, and catheter related thrombosis, which might cause pulmonary embolism (32,(45)(46)(47)(48). Taking into account the potential complications of intravascular cooling devices, the use of a surface cooling device with temperature feedback should be considered as a safe alternative.…”

Endovascular Cooling Catheter-Related Thrombosis After Targeted Temperature Management for Out-of-Hospital Cardiac Arrest: A Case Report

“…It was widely believed that there was no difference in the incidence of catheter-related thrombosis between endovascular cooling catheters and standard central venous catheters (Diringer, 2004;Deye et al, 2015); however, a recent study has shown that the former are associated with a greater risk of catheter-related thrombosis as compared with the latter (Andremont et al, 2018). A case of endovascular cooling catheter-related thrombosis that resulted in fatal pulmonary embolism has been reported (Wang et al, 2018). Clinicians should consider the potential risk of catheter-related thrombosis when employing endovascular cooling systems.…”

Esophageal Temperature Management in Patients Suffering from Traumatic Brain Injury

“…In comparison, more invasive methods report higher complication rates, including occult or asymptomatic thrombosis, some of which are considered higher risk due to their more proximal (including caval) location (Simosa et al , 2007; Prunet et al , 2009; Lau et al , 2010; Gierman et al , 2013; Maze et al , 2014; Gillon et al , 2015; Reccius et al , 2015; Wang et al , 2018).…”

“…The thrombosis risk from endovascular cooling catheters has been suggested to be higher than standard central line intravascular catheters due to differences in materials (Wang et al , 2018), or shape, where the nonuniform diameter may cause distal eddy flow, blood pooling, and stagnation, in turn, promoting activation of coagulation and the formation of clot in a more proximal location than can be easily visualized with standard compression ultrasonography (Gierman et al , 2013; Gillon et al , 2015; Reccius et al , 2015).…”