Successful management of complications after inappropriate positioning of a hemodialysis catheter.

A 61-year-old woman with a history of diabetes mellitus, hypertension, and chronic renal impairment was admitted with complaints of fever and inadequate hemodialysis. She had been undergoing catheter-based hemodialysis 3 times a week for 6 months. Chest X-ray revealed that the tip of the catheter was positioned inappropriately in the right ventricular apex (Fig. 1a). Transthoracic echocardiography (TTE) revealed that the catheter entered the right ventricular apex and that there was a 63x12 mm semi-mobile mass attached to it (Fig. 1b, Fig. 1 Video 1). The catheter was removed surgically. During the operation, the tricuspid valve was reported to be intact and without any abnormality. Although empirical antibiotherapy was initiated for the patient due to the suspicion of infective endocarditis, no bacterial growth was found on the catheter tip or in blood cultures. Pathological examination of the catheter tip showed organized thrombus with fibrin structure, so antibiotherapy was discontinued. Control TTE unexpectedly revealed a mobile mass on the lateral leaflet of the tricuspid valve with dimensions of 27x9 mm (Fig. 1c, Fig. 1 Video 2). Since the tricuspid valve had no abnormality during the ope- ration and postoperative blood cultures were negative, it was thought that thrombus occurred due to trauma during withdrawal of the catheter. Heparin infusion was initiated and control TTE performed 8 days later (Fig. 1d, Fig. 1 Video 3) indicated that the thrombus had disappeared completely. Warfarin therapy was initiated and the patient was discharged without any problem.

Figure 1

(a) Chest X-ray showing the catheter (arrow) extending to the right ventricle. (b) Transthoracic echocardiographic view showing the catheter and the thrombus attached to it (arrow indicates the catheter; RV - right ventricle). (c) Transthoracic echocardiographic view after surgical removal of the catheter demonstrating the thrombus attached to the tricuspid valve (arrow indicates the thrombus; RV - right ventricle, TV - tricuspid valve). (d) Transthoracic echocardiographic view after heparin infusion complete resolution of the thrombus (RV - right vent- ricle, TV - tricuspid valve)

Frequent complications of hemodialysis catheter include thrombosis, embolism, infection, and inappropriate positioning. TTE is important in the diagnosis and follow-up of these complications. Percutaneous or surgical retrieval, anticoagulation or thrombolytic therapy, and antibiotics are the main treatment options.

Video 1

Transthoracic echocardiographic view showing the catheter and the attached thrombus.

Video 2

Transthoracic echocardiographic view after surgical removal of the catheter showing the thrombus attached to the tricuspid valve.

Video 3

Transthoracic echocardiographic view after heparin infusion showing complete resolution of the thrombus.