Haemodialysis catheter-related giant right atrial and superior cava thrombi.

To cite: Weinberg L, Zia F, Tay S, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015209350 DESCRIPTION A 22-year-old woman with end-stage renal failure secondary to membranoproliferative glomerulonephritis presented with methicillin-sensitive Staphylococcus aureus sepsis from an infected haemodialysis catheter-related giant right atrial (RA) thrombus (figure 1A) with an additional mobile thrombus in the superior vena cava (SVC; figure 1B, C). The patient was undergoing haemodialysis via a tunnelled dual lumen 13.5 Fr, 36 cm Hickman chronic dialysis catheter inserted 9 months prior (figure 1D). Thrombophilia screening was negative. In view of the size and separate intracardiac locations of the thrombi, management with systemic anticoagulation was considered prohibitive due to risks of fatal pulmonary embolus, right heart failure, infective endocarditis and progressive sepsis. Urgent surgical thrombectomies of the RA and SVC thrombi were performed uneventfully via a midline sternotomy requiring cardiopulmonary bypass. Histopathology is presented in figure 2A, B. Symptomatic catheter-related thrombosis occurs in up to 28% adults with mortality rates in excess of 15%. 2 Pathophysiological mechanisms of the catheter-related thrombi include activation of the coagulation cascade from direct mechanical trauma to the RA wall from the catheter tip, exacerbated by altered fluid dynamics in the RA around the catheter. While positioning the catheter tip in the right atrium is consistent with the National Kidney Foundation recommendations, achieving better blood flow rates during haemodialysis is often offset against the increased risks of catheter-related RA thrombi, as seen in this case.