Stroke due to migration of a hemodialysis catheter across the atrial septum.
[FIGURE 1 OMITTED]
A 35-year-old woman with end-stage renal disease due to systemic lupus erythematosus had a dual-lumen catheter, HemoSplit Dialysis Catheter (CR Bard Inc, MurrayHill, NJ), tunneled from a right infraclavicular incision into the cervical portion of the right internal jugular vein. The tip was placed at the junction of the middle and lower thirds of the right atrial cavity as confirmed by chest radiograph. During hemodialysis 13 months later she noted weakness of her left arm that progressed until she was unable to lift it. During her previous hemodialysis, she had had a similar episode that resolved spontaneously. Magnetic resonance imaging showed an acute right frontal lobe hyperintensity consistent with an ischemic stroke. A transesophageal echocardiogram showed that the catheter entered the right atrium through the superior vena cava and crossed into the left atrium via a patent foramen ovale (Figure 1). A thrombus was attached to the right atrial side of the catheter at the area of the fossa ovalis. Doppler examination and a bubble study showed no intracardiac shunt.
[FIGURE 2 OMITTED]
Fluoroscopy showed that contrast injected through the arterial port of the catheter entered the right atrium and flowed into the pulmonary artery; contrast put into the venous port entered the left atrium and flowed into the aorta (Figure 2). The catheter tip was withdrawn into the right atrium. She received anticoagulation for four weeks and showed rapid neurological improvement. Repeat transesophageal echocardiography did not reveal any interatrial shunt.
Determining the best position for a catheter tip requires an understanding of numerous clinical variables, including catheter type, insertion site, the patient's body habitus, and the intended use of the catheter. (2) In general, the right atrial catheter tip is best placed at or just below the junction of the superior vena cava and right atrium. Catheters that are advanced farther have the potential for perforating the right atrium, entering the right ventricle and causing ventricular tachycardia, or crossing a patent foramen ovale and becoming a source for systemic emboli. To our knowledge, this is the first description of an embolic stroke resulting from a hemodialysis catheter migrating across the atrial septum into the left atrium. Because intravascular catheters can migrate, they should be firmly secured at the time of placement, and their position should be checked periodically.
(1.) Bittl JA. Catheter interventions for hemodialysis fistulas and grafts. JACC Interventions 2010;3:1-11.
(2.) Vesely TM. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol 2003;14:527-534.
Prashanthi Atluri, MD; Viviana Falco, MD; Royce Dean Yount, MD; and D. Luke Glancy, MD
Dr. Atluri is a cardiology fellow at the Louisiana State University Health Sciences Center in New Orleans. Drs. Falco and Yount are clinical assistant professors of medicine at the Louisiana State University Health Sciences Center in New Orleans and are staff cardiologists at the Touro Infirmary. Dr. Glancy is a professor of medicine at the Louisiana State University Health Sciences Center in New Orleans.
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|Author:||Atluri, Prashanthi; Falco, Viviana; Yount, Royce Dean; Glancy, D. Luke|
|Publication:||The Journal of the Louisiana State Medical Society|
|Date:||Jul 1, 2010|
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