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.