Recurrent catheter-related right atrial thrombosis in a hemodialysis patient: A case report and literature review

Abstract

Right atrial thrombus is an uncommon yet potentially life-threatening complication associated with central venous catheterization. We report an unusual case of catheter-associated right atrial thrombosis (CRAT) in a patient receiving maintenance hemodialysis, who presented with recurrent thrombus on the fifth day following surgical thrombectomy. This report summarizes the clinical presentation, diagnostic modalities, and management strategies for CRAT. Our intention is to improve clinicians' awareness of this complication and provide practical insights into optimal management in hemodialysis patients.

Introduction

Catheter-associated right atrial thrombosis (CRAT) is a severe potential complication that may arise following the insertion of central venous catheters (CVCs) [1], particularly in patients requiring long-term vascular access for maintenance hemodialysis. The reported incidence of CRAT ranges from 5.4% to 12.5%, and is influenced by factors such as catheter type‌, ‌tip location‌, and ‌patient-specific characteristics [2]. While some patients with CRAT‌ remain asymptomatic, others may develop clinical manifestations including ‌fever, syncope, or dyspnea [3,4]. Therefore, these features highlight the importance of early detection and timely intervention.

We present the case of a 48-year-old male on maintenance hemodialysis, who developed recurrent CRAT shortly after surgical thrombectomy. This case demonstrates the significance of optimal catheter tip positioning and indicates challenges involved in managing CRAT in the hemodialysis population.

Case report

A 48-year-old male on maintenance hemodialysis, receiving 3 sessions per week through a tunneled cuffed catheter (TCC) for long-term vascular access, developed intermittent left-sided facial and limb convulsions consistent with a typical seizure pattern. These episodes had begun approximately 5 months prior to presentation. His medical history was notable for hypertension (5 years), cerebral hemorrhage (3 years), and epilepsy (6 months). Two weeks prior to admission, computed tomography (CT) revealed a right frontotemporoparietal subdural hematoma (Fig. 1). Cardiovascular and pulmonary examinations demonstrated ‌no significant abnormalities.

Fig. 1.

Computed tomography (CT) demonstrating a subdural hematoma involving the right frontotemporal-parietal area.

On March 26, 2024, transthoracic echocardiography (TTE) revealed a mixed-echo mass measuring 20.9 × 17.4 mm, attached to the right atrial wall near the inferior vena cava orifice by a stalk-like structure (Fig. 2). The findings were suggestive of a myxoma. Chest X-ray showed that the catheter tip was positioned within the right atrium (Fig. 3). The patient was referred to the cardiovascular surgery department, where he underwent right atrial thrombectomy and atrial wall reconstruction. Despite advice to catheter removal and temporary hemodialysis via a femoral catheter, the patient and his family declined. Intraoperative right atriotomy revealed a 3 × 4 cm thrombus firmly adherent to the atrial wall within the right atrial cavity (Fig. 4). The thrombus and adjacent tissue were excised. Histopathological examination confirmed an organized thrombus with myocardial cell degeneration, consistent with CRAT (Fig. 5). Postoperatively, transesophageal echocardiography demonstrated complete resolution of the right atrial thrombus (Fig. 6).

Fig. 2.

Transthoracic echocardiography (TTE) revealing a mixed-echo mass (asterisk) located opposite the tip of the dialysis catheter (arrow), attached to the right atrium near the opening of the inferior vena cava. LV, left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium.

Fig. 3.

Chest X-ray showing the catheter tip positioned within the right atrium.

Fig. 4.

(A) Visualization of the catheter tip during right atrial thrombectomy (white arrow). (B) Intraoperative finding of a 3 × 4 cm mass infiltrating the atrial wall near the right atrium.

Fig. 5.

Histopathological examination confirming the thrombus, consists of layered fibrin strands (pink amorphous material) interspersed with aggregated red blood cells (RBCs, anucleate eosinophilic discs) and scattered inflammatory cells (lymphocytes and neutrophils with segmented nuclei) Hematoxylin–eosin stain, ×200 magnification.

Fig. 6.

Postcardiac surgery transesophageal echocardiography demonstrating complete resolution of the right atrial mass at the previous site of the mass (asterisk). LV, left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium.

However, on postoperative day 4, repeat TTE detected a new mixed-echo mass measuring 30.7 × 16.5 mm, confirming early CRAT recurrence (Fig. 7). The catheter tip remained within the right atrium, likely contributing to rapid thrombus reformation. One week postoperatively, follow-up TTE continued to demonstrate the presence of right atrial thrombus (Fig. 8). As the patient persistently refused catheter removal or repositioning, anticoagulation therapy was initiated. Unfortunately, he died of heart failure at another hospital 3 months later.

Fig. 7.

Transesophageal echocardiography performed 7 days postoperatively revealing a new 30.7 × 16.5 mm mixed-echo mass (asterisk). LV, left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium.

Fig. 8.

One week postoperatively, transthoracic echocardiography in the apical 4-chamber view demonstrating persistence of the right atrial thrombus (asterisk). LV, left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium.

Discussion

CRAT is a potentially fatal complication associated with central venous catheterization in hemodialysis patients [5]. In this case, the refusal to remove the TCC most likely led to rapid thrombus recurrence despite surgical thrombectomy and anticoagulation therapy. A recognized risk factor for CRAT is malposition of the catheter tip within the right atrium, where turbulent blood flow can cause endothelial injury. The condition mainly develops as a result of mechanical irritation of the endothelium by the catheter tip. When positioned in the right atrium, prolonged contact between the catheter tip and the atrial wall, compounded by turbulent blood flow, may trigger endothelial damage and activate the coagulation cascade [6]. Additionally, the low-pressure hemodynamic environment of the right atrium predisposes to blood stasis, further increasing the risk of thrombus formation [6]. In this case, chest X-ray confirmed that the catheter tip was located within the right atrium, likely contributing significantly to thrombus recurrence.

Primary imaging modalities for CRAT detection include TTE, transesophageal echocardiography (TEE), and cardiac magnetic resonance imaging (CMR). Although TTE is convenient and noninvasive, its sensitivity for small or early-stage thrombi is limited by acoustic interference from the lungs and chest wall structures [7]. TEE provides superior spatial resolution, enabling the detection of small or pedunculated thrombi and precise visualization of the catheter tip [8]. For complex cases requiring detailed anatomical assessment, CMR offers diagnostic accuracy comparable to TEE and can reliably differentiate acute from chronic thrombi [9]. In this case, the patient remained in the intensive care unit with unstable hemodynamic status, making CMR examination unfeasible due to the risks associated with patient mobilization. While both TEE and CMR are superior for detailed thrombus characterization—particularly for recurrence assessment—TTE was selected as the primary modality for this patient due to clinical constraints [10]. It proved sufficient for initial diagnosis and for serial monitoring of the right atrial thrombus in this context.

Currently, there are no universally accepted protocols for venous thrombosis or thromboembolism prophylaxis in hemodialysis patients with CVCs [11]. Anticoagulation therapy must be individualized, weighing the risk of bleeding against the risk of thrombosis based on comorbidities. Early catheter removal is considered the first-line intervention for CRAT, as catheter retention is strongly associated with increased mortality and recurrence [12]. In some cases, thrombus resolution has been observed following catheter removal alone [13]. Anticoagulation is typically recommended as adjunct, typically continued for up to 6 months, and can result in complete resolution in over half of cases [14].

In this case, the chronological progression of thrombus formation was closely monitored. Preoperative Phase‌: Baseline echocardiography (Fig. 2) confirmed the presence of a right atrial thrombus. Laboratory tests showed a PT/INR of 14.9/1.18 and a platelet count of 172 ×10⁹/L, indicating normal coagulation status. Intraoperative phase‌: immediate post-thrombectomy echocardiography (Fig. 6) showed complete thrombus removal. However, anticoagulation was withheld due to the risk of subdural hematoma. Early postoperative phase‌: on postoperative day 4 (Fig. 7), recurrent thrombus formation was detected. Anticoagulation therapy was initiated, at which time the PT/INR of 17.2/1.42 and the platelet count of 78 × 10⁹/L. HRCT was not performed during thrombus recurrence due to the absence of respiratory symptoms (dyspnea, hypoxemia, or pleuritic chest pain), which reduced clinical suspicion for pulmonary embolism. This decision aligned with current guideline recommendations for symptom-directed imaging for pulmonary embolism diagnosis [18]. Furthermore, the combination of recurrent thrombosis and thrombocytopenia supports the hypothesis of platelet consumption in a hypercoagulable state. This paradoxical process of simultaneous coagulation activation may represent a key mechanistic pathway in CRAT and warrants further investigation in similar cases.

Additionally, catheter removal was not feasible, as it remains the sole viable vascular access. When removal is not possible or in cases of recurrent thrombus, thrombectomy and localized thrombolysis may be considered [15]. These invasive interventions require careful patient selection due to their inherent risks. For extensive thrombus and concurrent pulmonary embolism, systemic thrombolysis can also be indicated [16]. A conservative approach combining systemic anticoagulation with loco-regional thrombolysis has been reported as a potential method for preserving vascular access (VA), suggesting that catheter retention may be viable. However, this strategy shows only a 60% success rate [5]. While catheter removal could mitigate the risks of CRAT recurrence, thromboembolic, and sepsis, the procedure may be technically challenging due to potential catheter adherence and carries perioperative complications such as embolization [17].

Routine echocardiography surveillance in TCC patients is recommended according to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines, particularly when the catheter tip lies within the atrium [18]. In high-risk patients, regular imaging combined with proactive anticoagulation may help prevent CRAT occurrence [19]. The recurrence in this case highlights the necessity of thorough risk-benefit discussions in terms of optimal catheter management.

Conclusion

CRAT remains a serious clinical challenge in hemodialysis patients with TCCs. This case highlights the importance of optimal catheter tip positioning and avoidance to prevent initial thrombus formation and recurrent thrombosis. Serial echocardiographic monitoring as well as comprehensive patient education regarding catheter management, is crucial in the management of CRAT. Given the high risk of recurrence associated with persistent catheters, prompt removal and replacement with AVFs, when feasible, should be prioritized.

Patient consent

Informed consent for publication of the patient’s clinical information was obtained.