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A retrospective experience of right atrial and superior vena caval thrombi diagnosed by transesophageal echocardiography
A Retrospective Experience of Right Atrial and Superior Vena Caval Thrombi Diagnosed by Transesophageal Echocardiography Michael A. Shapiro, MD, Mahala Johnson, and Steven B. Feinstein, MD, Chicago, Illinois
Central venous catheter (CVC) thrombosis and infection has become a frequent finding in immunosuppressed and chronically ill medical patients, particularly those with end-stage renal disease. Transeophageal echocardiography (TEE), as the only reliable noninvasive method of imaging the superior vena cava (SVC) is appreciated to be very
useful in the evaluation of these lesions. We retrospectively review our findings of TEE for this purpose, with regard to frequency of positive findings, patient characteristics, and microbiologic findings from SVC and right atrial thrombi and vegetations associated with CVCs. (J Am Soc Echocardiogr 2002;15:76-79.)
Central venous catheterization is a well-known
METHODS
nidus for infection and thrombosis.1 There have been many reports as to the imaging modalities best suited for evaluation of catheters in the right atrium and superior vena cava. Echocardiography, and in particular, transesophageal echocardiography (TEE), has become standard in the imaging of venous catheters placed in the superior vena cava or right atrium and to evaluate other cardiac structures in patients with these devices in place.2-5 Patients with indwelling central catheters nearly always have chronic medical conditions; the patient population, in general experience, tends to be complex, with multiple medical problems, including various degrees of immunosuppression.Among the most common reasons for longterm indwelling central venous catheters is chronic renal failure, hemodialysis access catheters seem to be particularly problematic in terms of thrombotic and infectious complications.6-9 We report on our experience with right atrial and superior vena cava masses, both thrombotic and infectious, found by TEE.
From the Laboratory of Echocardiography, Rush Heart Institute, Rush-Presbyterian-St. Luke’s Medical Center. Reprint requests: Steven B. Feinstein, MD, Laboratory of Echocardiography, Rush Heart Institute, Rush-Presbyterian-St. Luke’s Medical Center, 1015 Jelke Building, 1653 West Congress Parkway, Chicago, IL 60612 (E-mail: [email protected]). Copyright © 2002 by the American Society of Echocardiography. 0894-7317/2002/$35.00 + 0 27/1/116533 doi:10.1067/mje.2002.116533
76
A retrospective database evaluation was done of all echocardiograms performed over a 10-month period at Rush-Presbyterian-St. Luke’s Medical Center. All cases revealing a thrombus or vegetation in the right atrium or superior vena cava were noted. Even when these lesions were first detected on transthoracic echocardiography, all patients with these findings underwent TEE to better delineate their lesions (Figure 1).All patients were sent for these ultrasound studies by their primary and consultative physicians.All studies were performed for the usual clinical indications, including but not exclusively, to rule out a central venous catheter thrombosis or vegetation. There was no prospective study protocol. All patients who underwent TEE signed informed consent for the procedure.
RESULTS Between May 1999 and March 2000, 610 TEE studies were performed in the echocardiography laboratory at the Rush Heart Institute. Fourteen patients (2.3%) were found to have masses in the right atrium or superior vena cava that were associated with central venous catheterization. Table 1 summarizes the patient characteristics and findings of these 14 patients.The patient characteristics include 9 patients (56%) with end-stage renal disease in whom catheters were placed for hemodialysis. There were 4 patients (37%) with diabetes mellitus, 3 who were corticosteroid dependent (21%), 1 each with systemic lupus, rheumatoid arthritis, and status-postfunctional renal allograft. Additional immunosuppressing factors in this patient group include: advanced HIV-disease, asplenia, hemo-
Journal of the American Society of Echocardiography Volume 15 Number 1
A
Shapiro, Johnson, Feinstein 77
B Figure 1 TEE images of RA and SVC thrombi. ESRD, end-stage renal disease; CVC, central venous catheter; HTN, hypertension; DM, diabetes mellitus; MSSA, methacillin-sensitive Staphlococcus aureus; MRSA, methacillin-resistant S aureus; CAD, coronary artery disease; AVR, aortic valve replacement; LVEF, left ventricular ejection fraction; CVA, cerebrovascular accident; VRE, vancomycin-resistant enterococcus; MRSE, methacillin-resistant S epidermatis; SSA, sickle cell anemia; RA, rheumatoid arthritis; PE, pulmonary embolism; PVD, peripheral vascular disease; LE, lower extremity.
globin SS disease, sarcoma with chemotherapyinduced neutropenia, chronic mesenteric ischemia with malabsorption, chronic glomerulonephritis, and chronic respiratory failure due to cerebrovascular accidents. Of these masses, 12 were judged infective vegetations based on blood culture, catheter tip culture, or surgical thrombectomy specimen culture data. Of the infected patients, 5 (36%) had multiple organisms.There were 20 separate organisms isolated from cultures, many organisms were isolated in multiple culture bottles from the same patients. When multiple isolates of the same species were isolated from a patient, these were considered the same infecting organism if the antibiotic resistance profile was the same. There were no cases, however, of cultures of the same microbial species from a single patient having different sensitivities. Among infecting organisms, there were 2 positive fungal cultures (10%). Eight (40%) of the organisms grown were staphylococcal species, 6 of which were Staphylococcus aureus. Among the highly atypical organisms isolated from blood cultures were Propionobacterium acnes, usually a harmless skin saprophyte, and Prevotela bivia, a dental anaerobe. The latter came from a patient with a history of self-infecting her central catheters.All 20 organisms grown were considered to merit treatment by the infectious disease specialists who were consulted on every case that was culture-positive. However, the possibility that some of these cultures were contaminants and not truly pathologic cannot be excluded. Of the organisms grown from culture, there were 4 Gram-positive cocci that required vancomycin, 2
each of methacillin-resistant S aureus and S epidermatus (MRSA and MRSE, respectively). The one Pseudomonas aeruginosa grown was sensitive only to aminoglycosides, having high-level resistance to both third-generation cephalosporins and all quinolones tested. Of note, both the enterococci isolated were Enterococcus faecium that were resistant to vancomycin, one was sensitive to chloramphenicol. The other required removal and extensive multiple intravenous antibiotics under the attending infectious disease specialist’s supervision. Of the 9 infected dialysis catheters, the average dwell time was 12.4 weeks (SD ± 7.9 weeks). This estimate is conservative, because in 3 cases the precise time of catheter placement could not be determined by chart review, but the catheter was known to be in place at a previous hospitalization, this interval was used to estimate the minimum dwell time. The other 2 masses were sterile by multiple blood and catheter cultures. Both of these patients had well-recognized and previously diagnosed hypercoagulability disorders. One patient had lupus anticoagulant syndrome, and the other a congenital protein C deficiency. Both of these patients had been on chronic anticoagulation therapy with coumadin; however, both had a subtherapeutic PT INR value of less than 2 on initial presentation.
DISCUSSION We were unable to pursue outcomes data; however, it is known that at least 2 patients were taken to the operating room for open clot/vegetation evacuation
Journal of the American Society of Echocardiography January 2002
78 Shapiro, Johnson, Feinstein
Table 1 Summary of patient characteristics and findings
Patient no.
ESRD on hemo Age/ dialysis sex (Y/N)
Type of CVC
Duration of CVC in place (wk)
16 20 >24 3
Other cardiac pathology
1 2 3 4
51 y F 56 y F 60 y M 84 y M
Y Y Y N
PermCath PermCath PermCath 3-lumen CVC
5
59 y F
Y
PermCath
2
6 7 8
62 y F 23 y F 45 y M
Y N Y
PermCath PermCath Quinton cath NOS
11 7 >6
9
39 y F
Y
10 11
49 y F 53 y F
Y N
PermCath in subcl, Permacath other Quinton in 8 mo, femoral Quinton 4d Quinton NOS 9 Grashong 8
12
39 y F
N
Portacath
5
None known
13
56 y M
N
PICC line
3
HTN
14
63 y F
Y
Quinton cath NOS
>20
Other immunosuppressive factors
Pulmonary HTN HTN HTN CAD, s/p AVR, LVEF 15% Mitral vegetation
DM DM None known Chronic mesenteric ischemia S/p CVA, resp. failure
HTN None known Dilated Cardiomyopathy, EF 15-20% None known
DM SSA, self-infecting behavior DM
HTN CAD, HTN
HTN, CAD, PVD
Organisms from blood or catheter culture
Klebsiella pneumonia MSSA MRSA MSSA, Candida albicans, Enterobacter koseri MRSE, VRE Propionibacterium acnes E cloacae VRE, Prevotella bivia Pseudomonas aerugenosa, Serratia marcesens
AIDS (CD4 count 10), s/p splenectomy
MRSA
Lupus anticoag, nephrotic syn. RA on prednisone, s/p bowel resection Neutropenic, sarcoma, s/p ChemoRx S/p renal transplant, PE, Prot. C def. Debility, s/p bilat. LE amputations
Sterile MRSE, Torulopsi glabrata MSSA, Kleb pneumonia Sterile
MSSA
Y, Yes; N, no; ESRD, end-stage renal disease; CVC, central venous catheter; HTN, hypertension; DM, diabetes mellitus; MSSA, methacillin-sensitive Staphlococcus aureus; MRSA, methacillin-resistant S aureus; CAD, coronary artery disease; AVR, aortic valve replacement; LVEF, left ventricular ejection fraction; CVA, cerebrovascular accident; VRE, vancomycin-resistant enterococcus; MRSE, methacillin-resistant S epidermatis; SSA, sickle cell anemia; RA, rheumatoid arthritis; PE, pulmonary embolism; PVD, peripheral vascular disease; LE, lower extremity.
by a cardiothoracic surgeon, and 3 patients died before hospital discharge.The available literature on the subject of management of these patients is sparse.There have been other case reports and brief series discussing novel management techniques, such as catheter removal under TEE,10 and routine TEE surveillance of long-dwelling central catheters as a preventative measure.11 It is unclear what will be the best methods for researching therapeutics for these clinical situations. However, good diagnostic data are available, a randomized trial by Mugge et al12 convincingly concluded that TEE was superior to TTE for diagnosing, among other lesions, right heart and superior vena cava lesions. As for preventive measures, this has been a fertile field for clinical research.13-15 Certainly, common sense dictates the removal of central catheters at the earliest feasible time, and meticulous local catheter care. One provocative small study by Gilon et al16 suggested that right atrial placement of a catheter tip is a risk for subsequent thrombosis, and perhaps infection, they recommend all care be taken to keep the central catheter in the superior vena cava. The general
risks and management of central venous catheters are out of the scope of this discussion, but cardiovascular specialists and echocardiographers should be fully familiar with these issues.
CONCLUSIONS Superior vena cava and right atrial thrombi are occasional findings in a high-volume echocardiography laboratory. In our experience, they are usually infected.They are associated with multiple complex medical problems and immunosupression. Long dwell times of large-bore dialysis catheters seem to have a particularly strong association. In infected thrombosed superior caval or right atrial catheters, multiple infectious agents and atypical agents are common. REFERENCES 1. Henderson D. Bacteremia due to percutaneous intravascular devices. In: Mandell G, Bennett J, Dolin R, editors. Principles
Journal of the American Society of Echocardiography Volume 15 Number 1
2.
3.
4.
5.
6.
7.
8.
9.
and practice of infectious diseases. 4th ed. New York: Churchill Livingstone; 1994. p. 2587-99. Weber T, Huemer, G, Tschernich H, Kranz A, Imhof M, Sladden R. Catheter induced thrombus in the superior vena cava diagnosed by transesophageal echocardiography. Acta Anaesthesiol Scand 1998;42:1227-30. Cohen G, Klein A, Chan K, Stewart W, Salcedo E. Transesophageal echocardiographic diagnosis of right sided cardiac masses in patients with central lines. Am J Cardiol 1992;70: 925-9. Podolsky L, Manginas, A, Jacobs L, Kotler M, Ioli A. Superior vena caval thrombosis detected by transesophageal echocardiography. J Am Soc Echocardiogr 1991;4:189-93. Reeder G, Khandheria B, Seward J, Tajik A. Transesophageal echocardiography and cardiac masses. Mayo Clin Proc 1991; 66:1101-9. Dittmer I, Sharp D, McNulty C, Williams A, Banks R. A prospective study of central venous hemodialysis catheter colonization and peripheral bacteremia. Clin Nephrol 1999;51: 34-9. Nielsen J, Kolmos H, Espersen F. Staphylococcus aureus bacteraemia among patients undergoing dialysis – focus on dialysis catheter related cases. Nephrol Dial Transplant 1998;13: 139-45. Vanherweghem J, Cabolet P, Dhaene M, Goldman M, Stolear J, Sabot J, et al. Complications related to subclavian catheters for hemodialysis: report and review. Am J Nephrol 1986;6:339-45. Pezzarossi H, Ponce de Leon S, Calva J, Lazo de Vega S,
Shapiro, Johnson, Feinstein 79
10.
11.
12.
13.
14. 15.
16.
Ruiz-Palacios G. High Incidence of subclavian dialysis catheter related bacteremias. Infect Control 1986;7:596-9. Sivaram C, Craven P, Chandrasekaran K. Transesophageal echocardiography during removal of central venous catheter associated with thrombus in superior vena cava. Am J Cardiac Imaging 1996;10:266-9. Grote J, Lufft V, Nikutta P, van der Lieth H, Bahlman J, Daniel W. Transesophageal echocardiographic assessment of superior vena cava thrombosis in patients with long-term central venous hemodialysis catheters. Clin Nephrol 1994;42: 183-8. Mugge A, Daniel W, Haverich A, Lichtlen P. Diagnosis of noninfective cardiac mass lesions by two-dimensional echocardiography: comparison of the transthoracic and transesophageal approaches. Circulation 1991;83:70-8. Maki D, Stolz S, Wheeler S, Mermel L. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: a randomized, controlled trial. Ann Intern Med 1997;127:257-66. Mermel L. Prevention of catheter-related infections. Ann Intern Med 2000;132:391-402. Darouiche R, Raad I, Heard S, Thornby J, Wenker O, Gabrielli A, et al. A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group. N Engl J Med 1999;340:1-8. Gilon D, Schechter D, Rein A, Gimmon Z, Or R, Rozenman, Y, et al. Right atrial thrombi are related to indwelling central venous catheter position: insights into time course and possible mechanism of formation. Am Heart J 1998;135:457-62.
Central venous catheter (CVC) thrombosis and infection has become a frequent finding in immunosuppressed and chronically ill medical patients, particularly those with end-stage renal disease. Transeophageal echocardiography (TEE), as the only reliable noninvasive method of imaging the superior vena cava (SVC) is appreciated to be very
useful in the evaluation of these lesions. We retrospectively review our findings of TEE for this purpose, with regard to frequency of positive findings, patient characteristics, and microbiologic findings from SVC and right atrial thrombi and vegetations associated with CVCs. (J Am Soc Echocardiogr 2002;15:76-79.)
Central venous catheterization is a well-known
METHODS
nidus for infection and thrombosis.1 There have been many reports as to the imaging modalities best suited for evaluation of catheters in the right atrium and superior vena cava. Echocardiography, and in particular, transesophageal echocardiography (TEE), has become standard in the imaging of venous catheters placed in the superior vena cava or right atrium and to evaluate other cardiac structures in patients with these devices in place.2-5 Patients with indwelling central catheters nearly always have chronic medical conditions; the patient population, in general experience, tends to be complex, with multiple medical problems, including various degrees of immunosuppression.Among the most common reasons for longterm indwelling central venous catheters is chronic renal failure, hemodialysis access catheters seem to be particularly problematic in terms of thrombotic and infectious complications.6-9 We report on our experience with right atrial and superior vena cava masses, both thrombotic and infectious, found by TEE.
From the Laboratory of Echocardiography, Rush Heart Institute, Rush-Presbyterian-St. Luke’s Medical Center. Reprint requests: Steven B. Feinstein, MD, Laboratory of Echocardiography, Rush Heart Institute, Rush-Presbyterian-St. Luke’s Medical Center, 1015 Jelke Building, 1653 West Congress Parkway, Chicago, IL 60612 (E-mail: [email protected]). Copyright © 2002 by the American Society of Echocardiography. 0894-7317/2002/$35.00 + 0 27/1/116533 doi:10.1067/mje.2002.116533
76
A retrospective database evaluation was done of all echocardiograms performed over a 10-month period at Rush-Presbyterian-St. Luke’s Medical Center. All cases revealing a thrombus or vegetation in the right atrium or superior vena cava were noted. Even when these lesions were first detected on transthoracic echocardiography, all patients with these findings underwent TEE to better delineate their lesions (Figure 1).All patients were sent for these ultrasound studies by their primary and consultative physicians.All studies were performed for the usual clinical indications, including but not exclusively, to rule out a central venous catheter thrombosis or vegetation. There was no prospective study protocol. All patients who underwent TEE signed informed consent for the procedure.
RESULTS Between May 1999 and March 2000, 610 TEE studies were performed in the echocardiography laboratory at the Rush Heart Institute. Fourteen patients (2.3%) were found to have masses in the right atrium or superior vena cava that were associated with central venous catheterization. Table 1 summarizes the patient characteristics and findings of these 14 patients.The patient characteristics include 9 patients (56%) with end-stage renal disease in whom catheters were placed for hemodialysis. There were 4 patients (37%) with diabetes mellitus, 3 who were corticosteroid dependent (21%), 1 each with systemic lupus, rheumatoid arthritis, and status-postfunctional renal allograft. Additional immunosuppressing factors in this patient group include: advanced HIV-disease, asplenia, hemo-
Journal of the American Society of Echocardiography Volume 15 Number 1
A
Shapiro, Johnson, Feinstein 77
B Figure 1 TEE images of RA and SVC thrombi. ESRD, end-stage renal disease; CVC, central venous catheter; HTN, hypertension; DM, diabetes mellitus; MSSA, methacillin-sensitive Staphlococcus aureus; MRSA, methacillin-resistant S aureus; CAD, coronary artery disease; AVR, aortic valve replacement; LVEF, left ventricular ejection fraction; CVA, cerebrovascular accident; VRE, vancomycin-resistant enterococcus; MRSE, methacillin-resistant S epidermatis; SSA, sickle cell anemia; RA, rheumatoid arthritis; PE, pulmonary embolism; PVD, peripheral vascular disease; LE, lower extremity.
globin SS disease, sarcoma with chemotherapyinduced neutropenia, chronic mesenteric ischemia with malabsorption, chronic glomerulonephritis, and chronic respiratory failure due to cerebrovascular accidents. Of these masses, 12 were judged infective vegetations based on blood culture, catheter tip culture, or surgical thrombectomy specimen culture data. Of the infected patients, 5 (36%) had multiple organisms.There were 20 separate organisms isolated from cultures, many organisms were isolated in multiple culture bottles from the same patients. When multiple isolates of the same species were isolated from a patient, these were considered the same infecting organism if the antibiotic resistance profile was the same. There were no cases, however, of cultures of the same microbial species from a single patient having different sensitivities. Among infecting organisms, there were 2 positive fungal cultures (10%). Eight (40%) of the organisms grown were staphylococcal species, 6 of which were Staphylococcus aureus. Among the highly atypical organisms isolated from blood cultures were Propionobacterium acnes, usually a harmless skin saprophyte, and Prevotela bivia, a dental anaerobe. The latter came from a patient with a history of self-infecting her central catheters.All 20 organisms grown were considered to merit treatment by the infectious disease specialists who were consulted on every case that was culture-positive. However, the possibility that some of these cultures were contaminants and not truly pathologic cannot be excluded. Of the organisms grown from culture, there were 4 Gram-positive cocci that required vancomycin, 2
each of methacillin-resistant S aureus and S epidermatus (MRSA and MRSE, respectively). The one Pseudomonas aeruginosa grown was sensitive only to aminoglycosides, having high-level resistance to both third-generation cephalosporins and all quinolones tested. Of note, both the enterococci isolated were Enterococcus faecium that were resistant to vancomycin, one was sensitive to chloramphenicol. The other required removal and extensive multiple intravenous antibiotics under the attending infectious disease specialist’s supervision. Of the 9 infected dialysis catheters, the average dwell time was 12.4 weeks (SD ± 7.9 weeks). This estimate is conservative, because in 3 cases the precise time of catheter placement could not be determined by chart review, but the catheter was known to be in place at a previous hospitalization, this interval was used to estimate the minimum dwell time. The other 2 masses were sterile by multiple blood and catheter cultures. Both of these patients had well-recognized and previously diagnosed hypercoagulability disorders. One patient had lupus anticoagulant syndrome, and the other a congenital protein C deficiency. Both of these patients had been on chronic anticoagulation therapy with coumadin; however, both had a subtherapeutic PT INR value of less than 2 on initial presentation.
DISCUSSION We were unable to pursue outcomes data; however, it is known that at least 2 patients were taken to the operating room for open clot/vegetation evacuation
Journal of the American Society of Echocardiography January 2002
78 Shapiro, Johnson, Feinstein
Table 1 Summary of patient characteristics and findings
Patient no.
ESRD on hemo Age/ dialysis sex (Y/N)
Type of CVC
Duration of CVC in place (wk)
16 20 >24 3
Other cardiac pathology
1 2 3 4
51 y F 56 y F 60 y M 84 y M
Y Y Y N
PermCath PermCath PermCath 3-lumen CVC
5
59 y F
Y
PermCath
2
6 7 8
62 y F 23 y F 45 y M
Y N Y
PermCath PermCath Quinton cath NOS
11 7 >6
9
39 y F
Y
10 11
49 y F 53 y F
Y N
PermCath in subcl, Permacath other Quinton in 8 mo, femoral Quinton 4d Quinton NOS 9 Grashong 8
12
39 y F
N
Portacath
5
None known
13
56 y M
N
PICC line
3
HTN
14
63 y F
Y
Quinton cath NOS
>20
Other immunosuppressive factors
Pulmonary HTN HTN HTN CAD, s/p AVR, LVEF 15% Mitral vegetation
DM DM None known Chronic mesenteric ischemia S/p CVA, resp. failure
HTN None known Dilated Cardiomyopathy, EF 15-20% None known
DM SSA, self-infecting behavior DM
HTN CAD, HTN
HTN, CAD, PVD
Organisms from blood or catheter culture
Klebsiella pneumonia MSSA MRSA MSSA, Candida albicans, Enterobacter koseri MRSE, VRE Propionibacterium acnes E cloacae VRE, Prevotella bivia Pseudomonas aerugenosa, Serratia marcesens
AIDS (CD4 count 10), s/p splenectomy
MRSA
Lupus anticoag, nephrotic syn. RA on prednisone, s/p bowel resection Neutropenic, sarcoma, s/p ChemoRx S/p renal transplant, PE, Prot. C def. Debility, s/p bilat. LE amputations
Sterile MRSE, Torulopsi glabrata MSSA, Kleb pneumonia Sterile
MSSA
Y, Yes; N, no; ESRD, end-stage renal disease; CVC, central venous catheter; HTN, hypertension; DM, diabetes mellitus; MSSA, methacillin-sensitive Staphlococcus aureus; MRSA, methacillin-resistant S aureus; CAD, coronary artery disease; AVR, aortic valve replacement; LVEF, left ventricular ejection fraction; CVA, cerebrovascular accident; VRE, vancomycin-resistant enterococcus; MRSE, methacillin-resistant S epidermatis; SSA, sickle cell anemia; RA, rheumatoid arthritis; PE, pulmonary embolism; PVD, peripheral vascular disease; LE, lower extremity.
by a cardiothoracic surgeon, and 3 patients died before hospital discharge.The available literature on the subject of management of these patients is sparse.There have been other case reports and brief series discussing novel management techniques, such as catheter removal under TEE,10 and routine TEE surveillance of long-dwelling central catheters as a preventative measure.11 It is unclear what will be the best methods for researching therapeutics for these clinical situations. However, good diagnostic data are available, a randomized trial by Mugge et al12 convincingly concluded that TEE was superior to TTE for diagnosing, among other lesions, right heart and superior vena cava lesions. As for preventive measures, this has been a fertile field for clinical research.13-15 Certainly, common sense dictates the removal of central catheters at the earliest feasible time, and meticulous local catheter care. One provocative small study by Gilon et al16 suggested that right atrial placement of a catheter tip is a risk for subsequent thrombosis, and perhaps infection, they recommend all care be taken to keep the central catheter in the superior vena cava. The general
risks and management of central venous catheters are out of the scope of this discussion, but cardiovascular specialists and echocardiographers should be fully familiar with these issues.
CONCLUSIONS Superior vena cava and right atrial thrombi are occasional findings in a high-volume echocardiography laboratory. In our experience, they are usually infected.They are associated with multiple complex medical problems and immunosupression. Long dwell times of large-bore dialysis catheters seem to have a particularly strong association. In infected thrombosed superior caval or right atrial catheters, multiple infectious agents and atypical agents are common. REFERENCES 1. Henderson D. Bacteremia due to percutaneous intravascular devices. In: Mandell G, Bennett J, Dolin R, editors. Principles
Journal of the American Society of Echocardiography Volume 15 Number 1
2.
3.
4.
5.
6.
7.
8.
9.
and practice of infectious diseases. 4th ed. New York: Churchill Livingstone; 1994. p. 2587-99. Weber T, Huemer, G, Tschernich H, Kranz A, Imhof M, Sladden R. Catheter induced thrombus in the superior vena cava diagnosed by transesophageal echocardiography. Acta Anaesthesiol Scand 1998;42:1227-30. Cohen G, Klein A, Chan K, Stewart W, Salcedo E. Transesophageal echocardiographic diagnosis of right sided cardiac masses in patients with central lines. Am J Cardiol 1992;70: 925-9. Podolsky L, Manginas, A, Jacobs L, Kotler M, Ioli A. Superior vena caval thrombosis detected by transesophageal echocardiography. J Am Soc Echocardiogr 1991;4:189-93. Reeder G, Khandheria B, Seward J, Tajik A. Transesophageal echocardiography and cardiac masses. Mayo Clin Proc 1991; 66:1101-9. Dittmer I, Sharp D, McNulty C, Williams A, Banks R. A prospective study of central venous hemodialysis catheter colonization and peripheral bacteremia. Clin Nephrol 1999;51: 34-9. Nielsen J, Kolmos H, Espersen F. Staphylococcus aureus bacteraemia among patients undergoing dialysis – focus on dialysis catheter related cases. Nephrol Dial Transplant 1998;13: 139-45. Vanherweghem J, Cabolet P, Dhaene M, Goldman M, Stolear J, Sabot J, et al. Complications related to subclavian catheters for hemodialysis: report and review. Am J Nephrol 1986;6:339-45. Pezzarossi H, Ponce de Leon S, Calva J, Lazo de Vega S,
Shapiro, Johnson, Feinstein 79
10.
11.
12.
13.
14. 15.
16.
Ruiz-Palacios G. High Incidence of subclavian dialysis catheter related bacteremias. Infect Control 1986;7:596-9. Sivaram C, Craven P, Chandrasekaran K. Transesophageal echocardiography during removal of central venous catheter associated with thrombus in superior vena cava. Am J Cardiac Imaging 1996;10:266-9. Grote J, Lufft V, Nikutta P, van der Lieth H, Bahlman J, Daniel W. Transesophageal echocardiographic assessment of superior vena cava thrombosis in patients with long-term central venous hemodialysis catheters. Clin Nephrol 1994;42: 183-8. Mugge A, Daniel W, Haverich A, Lichtlen P. Diagnosis of noninfective cardiac mass lesions by two-dimensional echocardiography: comparison of the transthoracic and transesophageal approaches. Circulation 1991;83:70-8. Maki D, Stolz S, Wheeler S, Mermel L. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: a randomized, controlled trial. Ann Intern Med 1997;127:257-66. Mermel L. Prevention of catheter-related infections. Ann Intern Med 2000;132:391-402. Darouiche R, Raad I, Heard S, Thornby J, Wenker O, Gabrielli A, et al. A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group. N Engl J Med 1999;340:1-8. Gilon D, Schechter D, Rein A, Gimmon Z, Or R, Rozenman, Y, et al. Right atrial thrombi are related to indwelling central venous catheter position: insights into time course and possible mechanism of formation. Am Heart J 1998;135:457-62.