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.

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.

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.

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?

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.

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.

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.

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.