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Facial and neck swelling for a week with RIJ catheter present

Posted By James Lin, Thursday, October 6, 2016
Updated: Thursday, October 6, 2016

This is a 60y man with a RIJ tunneled catheter for many months who was referred for facial and neck swelling for 1 week. He does not have any running accesses and had a recent pneumonia with cavitary lesions which responded to therapy. I noted on exam that there was a non healing wound along the tunnel tract with no drainage and pt did not have any fever or chills. I initially planned on using a femoral approach to study the central veins and if SVC stenosis is present then move the catheter to the femoral vein, remove the chest wall cath and treating the SVC stenosis.

 

Then I thought it would be easier to make a cutdown over the venotomy, transecting and wiring the catheter and then evaluating the centrals via a RIJ sheath. If there is a good response to PTA of the centrals then replacing the catheter, tunneling more lateral away from the nonhealing wound over the existing tunnel.

 

After removing the catheter I was able to manipulate the wire through a 8Fr sheath into the IVC. It was very difficult to manipulate the wire past the mid SVC level and based on the angle and looping of the tip of the wire it was suspicious for either a high grade stenosis or thrombus.  Tactile sensation suggested that it was bouncing off something and I did not think it was a stenotic lesion. I also injected through the catheter initially through a 12Fr dilator inserted into the transected catheter and there appeared to be SVC thrombus. Later injections through the 8Fr sheath revealed a massive SVC thrombus with most of the flow through the azygos vein.

 

I ended up putting in a femoral catheter and sending the patient to the hospital for a heparin gtt and lytic catheter by VIR.

 

Questions:

1) Should I have had a higher suspicion of SVC thrombus given the 1 week history of facial and neck swelling? I went into the case thinking it was a SVC stenosis with the catheter occupying the stenotic lumen.

 

2) If there is a suspicion of SVC thrombus would the therapy be removing the offending agent and placing the catheter elsewhere + anticoagulation +/- lytics or treating with the catheter in place.  There is literature in pts with malignancies and central thrombus of leaving the offending agent (infusion catheter) in place and treating with heparin + lytics so the thrombus doesn't migrate.

 

3) The CT scan (picture #4) showed a massive SVC thrombus extending into the right atrium; because the thrombus did not appear to be adherent to the wall the radiologist thought it was acute/subacute. Should surgery be considered; concern is that much of the massive thrombus appears to be free floating.

 

4) What's the likelihood of having thrombus adherent to the catheter or fibrin sheath? This makes me concerned when we just remove catheters without any imaging. That being said I've never had a complication associated with a catheter removal. But if you are scheduled to remove a catheter and the patient has facial and neck swelling are additional studies necessary before pulling the catheter?

 

Pic#1 is the initial injection after transecting the catheter and injecting through the catheter pulling the catheter back so the tip is in the innominate vein. There is a fibrin sheath present.

 

Pic#2-3 are both injections through the 8Fr sheath in the RIJ.

 

Pic#4 is the CT scan of the chest with contrast.

 

 

 

 

 

 

 Attached Thumbnails:

Tags:  SVC thrombus PE 

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Permalink | Comments (8)
 

Comments on this post...

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Kevin C. Harned says...
Posted Thursday, October 6, 2016
I think quick onset of sx's does indeed lean more towards a thrombus rather than a stenosis AS LONG as the pt hasn't had catheters in the past...previous catheters could have caused some SVC stenosis that was clinically silent until the lumen was further occluded by a new catheter and thus promote sx's to show themselves.

I would have likely kept the catheter in place and tried to get a colleague to initiate EKOS therapy. There are many ways to attempt this case, as it is very challenging with a high potential for complications...but that is how we would address at our facility.
Permalink to this Comment }

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Wesley A. Gabbard says...
Posted Thursday, October 6, 2016
What a nice case James.
I would say that there is no way of knowing if the SVC syndrome symptoms were due to a venous stenosis versus a thrombus. All patients act differently.
Although I am not certain you would have known there was a thrombus prior to transecting the catheter, I do not think I would have removed the catheter if I had known there was a SVC thrombus. I think the best treatment would be to leave the catheter in place and anticoagulate the patient until symptoms resolve. The thrombus must have been adherent to the vessel somewhere, or it would have embolized. I would think that removing the catheter would have predisposed the patient to a massive pulmonary embolus if the thrombus were only adherent to the catheter.
Permalink to this Comment }

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James Lin says...
Posted Thursday, October 6, 2016
Interestingly, the radiology reading was thrombus in the SVC from the fibrin sheath. Makes it sound like the thrombus is adherent to the sheath. Sometimes a central stenosis acts like a filter preventing a very large thrombus from moving but I don't think that's the case here bec it's extending into the right atrium. In the future when I get a history of a more acute SVC syndrome picture i'm certainly going to treat it as a massive SVC thrombus until proven otherwise.
Permalink to this Comment }

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Felix W. Perez Ramos says...
Posted Friday, October 7, 2016
Great case!
I had a similar case, but I did suspect SVC thrombus due to how fast the symptoms developed. She was admitted to the hospital. I ordered a CT, confirmed the thrombus, started her on heparin and we gave lytics. I placed a temporary HD catheter in the femoral vein. After the third day post lytics symptoms almost resolved completely. CT showed the thrombus resolved. I removed the catheter and did an angioplasty in the stenotic lesion.

Points
1. Every time that the patient develops
very acute central lession symptoms we have to think central vein stenosis + thrombus

2. I think that catheter should be removed once the thrombus resolves to avoid pulmonary emboli. A repeat CT scan can help us with this.

3. How long do we need to anticoagulate this patient?
4. What is the correct dose for lytics in this kind of situation?
5. Will you give the lytics through the HD catheter or other IV line?
Permalink to this Comment }

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Wesley A. Gabbard says...
Posted Friday, October 7, 2016
I still think it is difficult to know if someone has a thrombus versus stenosis (even with acute symptoms) unless this is a recently placed catheter in a patient without prior catheters. I think the idea of an Ekos catheter is excellent in this situation. There really is no literature on how long to anticoagulate these patients. This is a Central Vein Thrombosis and not a DVT. I would probably anticoagulate the patient as long as the catheter is in place. Although it is low yield, work up for a coagulopathy (I think) is still warranted. We have found several cases of HIT from internal jugular vein DVTs associated with catheters. I still think the catheter should be left in place as long as it is working well. There is no reason to think that a catheter in a different position would not have the same issue. As long as the thrombus had resolved after anticoagulation, the catheter should probably be left alone.
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James Lin says...
Posted Tuesday, October 11, 2016
Thanks for all the thoughtful comments. The most important lesson for me is to pay more attention to the clinical presentation. As Kevin and Felix mentioned it was suspicious for thrombus based on the acuity of the symptoms. I like the work up mentioned with the CT and then lytics. I would probably err on the side of caution by removing the catheter after the thrombus resolves but certainly understand Wes' point that thrombus could still occur at a different site.
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Marc Webb says...
Posted Wednesday, October 12, 2016
The problem here is acceptance of the catheter. The 1997 DOQI Guidelines state three main points: minimizing the use of central catheters to avoid loss of central patency; maximizing prevalence of fistulas as dialysis access; and pursuing a practice of monitoring and maintenance of dialysis access to avoid loss of access (and return to a catheter). In my practice, we note a fourth key point - correct and consistent cannulation of the dialysis access. In this patient the catheter has been in too long.
I see 300-400 new patients annually - 50% present with failed or problematic access - most of these are dialyzing with a catheter. My feeling is that a majority of these failures and problematic accesses would not have happened if an experienced operator had seen the patient first. This is an argument for funneling patients to "Centers of Excellence" rather than to "hand surgeons", and in the words of Dr. Ross, "getting the amateurs out of the business".
Of the remaining patients, 35% of the total have a catheter and no previous access surgery - at least one can start fresh, but the clock is ticking - the patients have been exposed to a catheter for months, and choices are skewed by a need to "get something in and get the catheter out'. In one galling case, we were called to see a patient in June, and gave her an appointment in two weeks - which she skipped, and the next, and the third. When we finally saw her in August we recommended a fistula, whereupon the nephrologist asked for a graft "because her nine catheters haven't been working well". Should we compromise and coddle this patient and nephrologist? If your fistula maturation rate is 50% within 6 months, you put in a graft - if your fistula maturation rate is 90% within 60 days you go ahead with the fistula.
And finally, 15% of the patients come "pre-hemo", but with GFRs ranging from 25% to 5%. The vast majority come with a GFR less than 15%, and a quarter of the group with a GFR less than 10. The defense of the nephrologists is that they get the patients from the PCPs late, but if you read the office notes they frequently sit on them for months prior to the referral and then want "a fistula" right away. What folly.
**** We need to get the patients early enough to create and mature fistulas.
**** We need to do a thoughtful examination and make a defensible, sensible, high yield recommendation - which means by people who know what they are doing, not by the local "hand surgeon", nor by the "three-years-and-out" assistant professors at the local university. We need "Centers of Excellence".
**** We need to ensure that our access creations are done by experienced, high volume practitioners with a record of success, again not by the local "hand surgeons", nor by the "three-years-and-out" assistant professors.
**** We need to provide aggressive follow-up of new access to identify deviations from successful healing and maturation, and to instititute corrective action early, or change course when necessary. "Wishful thinking is not a plan, and denial is not a strategy".
When we attain this ideal new world, we will have fewer of these catheter cluster bombs to worry about.
I find that I have overstayed my time, and the man has come to lock me in my room for the night - good night all.
Permalink to this Comment }

...
Marc Webb says...
Posted Wednesday, October 12, 2016
The problem here is acceptance of the catheter. The 1997 DOQI Guidelines state three main points: minimizing the use of central catheters to avoid loss of central patency; maximizing prevalence of fistulas as dialysis access; and pursuing a practice of monitoring and maintenance of dialysis access to avoid loss of access (and return to a catheter). In my practice, we note a fourth key point - correct and consistent cannulation of the dialysis access. In this patient the catheter has been in too long.
I see 300-400 new patients annually - 50% present with failed or problematic access - most of these are dialyzing with a catheter. My feeling is that a majority of these failures and problematic accesses would not have happened if an experienced operator had seen the patient first. This is an argument for funneling patients to "Centers of Excellence" rather than to "hand surgeons", and in the words of Dr. Ross, "getting the amateurs out of the business".
Of the remaining patients, 35% of the total have a catheter and no previous access surgery - at least one can start fresh, but the clock is ticking - the patients have been exposed to a catheter for months, and choices are skewed by a need to "get something in and get the catheter out'. In one galling case, we were called to see a patient in June, and gave her an appointment in two weeks - which she skipped, and the next, and the third. When we finally saw her in August we recommended a fistula, whereupon the nephrologist asked for a graft "because her nine catheters haven't been working well". Should we compromise and coddle this patient and nephrologist? If your fistula maturation rate is 50% within 6 months, you put in a graft - if your fistula maturation rate is 90% within 60 days you go ahead with the fistula.
And finally, 15% of the patients come "pre-hemo", but with GFRs ranging from 25% to 5%. The vast majority come with a GFR less than 15%, and a quarter of the group with a GFR less than 10. The defense of the nephrologists is that they get the patients from the PCPs late, but if you read the office notes they frequently sit on them for months prior to the referral and then want "a fistula" right away. What folly.
**** We need to get the patients early enough to create and mature fistulas.
**** We need to do a thoughtful examination and make a defensible, sensible, high yield recommendation - which means by people who know what they are doing, not by the local "hand surgeon", nor by the "three-years-and-out" assistant professors at the local university. We need "Centers of Excellence".
**** We need to ensure that our access creations are done by experienced, high volume practitioners with a record of success, again not by the local "hand surgeons", nor by the "three-years-and-out" assistant professors.
**** We need to provide aggressive follow-up of new access to identify deviations from successful healing and maturation, and to instititute corrective action early, or change course when necessary. "Wishful thinking is not a plan, and denial is not a strategy".
When we attain this ideal new world, we will have fewer of these catheter cluster bombs to worry about.
I find that I have overstayed my time, and the man has come to lock me in my room for the night - good night all.
Permalink to this Comment }

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