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Table of Contents
LETTERS TO EDITOR  
Year : 2021  |  Volume : 24  |  Issue : 4  |  Page : 512-514
Catheter-related superior vena cava thrombosis—how do we face it?


Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India

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Date of Submission08-Jun-2020
Date of Decision07-Aug-2020
Date of Acceptance28-Dec-2020
Date of Web Publication18-Oct-2021
 

How to cite this article:
Arasu M, Thangaswamy CR, Chakravarthy D, Elakkumanan LB. Catheter-related superior vena cava thrombosis—how do we face it?. Ann Card Anaesth 2021;24:512-4

How to cite this URL:
Arasu M, Thangaswamy CR, Chakravarthy D, Elakkumanan LB. Catheter-related superior vena cava thrombosis—how do we face it?. Ann Card Anaesth [serial online] 2021 [cited 2021 Nov 30];24:512-4. Available from: https://www.annals.in/text.asp?2021/24/4/512/328489




To the Editor,

Occlusion in central venous catheter (CVC) lumen is encountered because of various causes including CVC-related thrombosis (CRT) with a reported incidence of 14–18%.[1] There is an inevitable need for all anesthesiologists to differentiate between the non-thrombotic and thrombotic causes for appropriate management. We report the management of an unusual case of CVC-related superior vena cava (SVC) thrombus.

A 36-year-old female sustained an extensive lower limb degloving injury and was bedridden in the hospital for 5 months. She had undergone multiple debridements and was receiving enoxaparin for thromboprophylaxis. She was also receiving albumin IV and TPN via a CVC placed in the right internal jugular vein (IJV) to improve nutrition.

A week later, debridement was planned again. Before anesthetic induction, the CVC (6 days old) lumens were checked for patency by aspiration. Only the distal lumen had backflow and free flow of IV fluids. We planned to commence anesthetic induction via it. Intra-operatively, we noticed that IV fluid was not flowing freely as compared to pre-induction and there was an inability to aspirate blood via the distal lumen too. Immediately, we placed a 20 G IV cannula in the dorsum of hand (with difficulty) for rescue. We evaluated the course of the CVC with USG to confirm its position. Surprisingly, we found a thrombus engulfing the CVC circumferentially [Figure 1]a. Transthoracic echo (TTE) did not reveal any extension into right atrium. Postoperatively, CT venogram revealed 1.7 × 1.8 cm thrombus engulfing the CVC for a length of 5.5 cm, extending upto the proximal one-third of SVC [Figure 1]b. After multidisciplinary team discussion, therapeutic anticoagulation was commenced, thrombolysis was deferred because of the high risk of bleeding because of the extensive lower limb wound. We didn't attempt to remove the CVC considering the possibility of thromboembolism during removal as the thrombus was completely engulfing it. Hence, surgical removal was planned. Midline sternotomy and surgical thrombectomy (with CPB standby) were done. SVC was opened and the entire thrombus was removed in pieces along with the CVC. She was observed in HDU for 24 h and extubated uneventfully. Thereafter, she was managed for the lower limb wound with the continuation of anticoagulation and oral protein-rich nutrition, thereby avoiding the need for CVC.
Figure 1: (a) Ultra sonogram (short-axis view) of right IJV showing thrombus (red arrow) engulfing the CVC (encircled). (b) CT venogram (coronal plane) showing the thrombus (red arrow) seen as filling defect extending upto proximal one-third of SVC

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A blocked CVC is an infrequently confronted situation especially during the handling of protracted CVCs.[1],[2],[3],[4],[5] Diverse risk factors contribute towards Virchow's trial of coagulation and CRT [Table 1].[3]
Table 1: Risk factors for the development of Catheter-related thrombosis[3]

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The ISTH guidelines recommend addressing the modifiable risk factors to minimize the occurrence of CRT.[5] Whenever feasible, CVCs should be inserted in right IJV with the tip located at the cavoatrial junction, regular flushing, avoidance of PICC lines, use of positive pressure devices/maintaining a positive-end pressure flush technique is recommended.[2],[5] There is no recommendation for routine prophylactic anticoagulation.[4]

Still, there is a dispute in the management of CRT/malpositioned CVC. The use of a guidewire through CVC lumen for repositioning has been in practice, though it is not recommended as it entails the risk of hematoma, loss of IV access, clot fragmentation, and embolization. Hence it is vital to understand the safe approaches. Duplex USG and TTE can serve as a bedside tool for earlier detection. Yet contrast venogram is the gold standard. Serial evaluation of CVC patency, avoidance of modifiable risk factors and maintaining a high index of suspicion of CRT in the event of difficult aspiration or sluggish infusion is necessary even in asymptomatic patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Verso M, Agnelli GJ. Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. J Clin Oncol 2003;21:3665-75.  Back to cited text no. 1
    
2.
Baskin JL, Pui CH, Reiss U, Wilimas JA, Metzger ML, Ribeiro RC, et al. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet 2009;374:159-69.  Back to cited text no. 2
    
3.
Wall C, Moore J, Thachil J. Catheter-related thrombosis: A practical approach. J Intensive Care Soc 2016;17:160-7.  Back to cited text no. 3
    
4.
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American college of chest physicians evidence-based clinical practice guidelines. Chest 2012;141 (2 Suppl):e419S-94S.  Back to cited text no. 4
    
5.
Debourdeau P, Farge D, Beckers M, Baglin C, Bauersachs RM, Brenner B, et al. International clinical practice guidelines for the treatment and prophylaxis of thrombosis associated with central venous catheters in patients with cancer. J Thromb Haemost 2013;11:71-80.  Back to cited text no. 5
    

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Correspondence Address:
Chitra R Thangaswamy
Department of Anaesthesiology, JIPMER, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_119_20

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