SESSION TITLE: Pulmonary Vascular Disease Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Superior vena cava (SVC) syndrome results from obstruction of blood flow through the SVC, usually due to compression from an adjacent intra-thoracic malignancy. Thrombosis is another much less frequent cause of SVC syndrome, despite the relatively common occurrence of thrombosis from central venous and hemodialysis (HD) catheters and pacemaker electrodes. To our knowledge, pulmonary embolism (PE) in the setting of catheter-related SVC syndrome and thrombosis has rarely been reported in living patients, and occasionally in patients observed at autopsy.
CASE PRESENTATION: A 28 year old female nonsmoking hairstylist with end-stage renal disease secondary to IgA nephropathy presented to an outside hospital with a few days of facial swelling, nausea, dizziness and pain with bending forward. She had initiated hemodialysis via right internal jugular (IJ) tunneled HD catheter 8 weeks prior. Her substance use, social and family history was unremarkable. Contrast-enhanced chest computed tomography (CT) was performed, demonstrating SVC obstruction with a large thrombus surrounding the HD catheter. A heparin drip was initiated, along with vancomycin after the patient developed Staphylococcus epidermidis bacteremia. Since the thrombus was situated proximal to the catheter lumen, HD was unaffected and was therefore continued. The patient was transferred to the Johns Hopkins Hospital for further management. On presentation, her temperature was 38.3, heart rate 96, blood pressure 134/61, oxygen saturation 99% on room air. Her physical exam was pertinent only for facial swelling and neck fullness. An SVC thrombus was confirmed with a repeat contrast-enhanced chest CT, which again showed an adherent, non-occlusive thrombus from the junction of the right IJ and subclavian vein, through the SVC to the level of the cavoatrial junction. Hypercoaguable workup was negative. The catheter was removed uneventfully, and a new catheter placed in the right internal jugular vein. On the ninth day of admission, she developed right-sided pleuritic chest pain with high-grade fevers and was found to have large emboli in the right main, middle, and lower pulmonary arteries. Echocardiogram was unremarkable, unchanged since admission. Three days later, she again developed similar chest pain with blood-tinged sputum. A non-contrast CT chest showed right middle and lower lobe infarction. The patient was treated with IV heparin and analgesics, and discharged on a 6-month course of warfarin. Nine months later, she underwent successful renal transplant.
DISCUSSION: We present a case of HD catheter-related thrombosis leading to SVC syndrome and subsequent pulmonary embolism with pulmonary infarction. While SVC thrombosis arising from a HD catheter is rare, and a PE in this setting is even rarer, physicians should consider this potential complication in any patient with a HD catheter who develops shortness of breath, head fullness, facial edema, and/or neck vein distension. Once SVC syndrome is suspected, workup should include contrast-enhanced chest CT and consideration for empiric anticoagulation and line removal.
CONCLUSIONS: Pulmonary embolism is a potential consequence of hemodialysis catheter-related thrombosis. Given the frequent use of central venous and HD catheters, future investigations are warranted to clarify the prevalence, pathophysiology, and risk factors for this potentially life-threatening complication.
Reference #1: Goldstein MF, Nestico P, Olshan AR, Schwartz AB. Superior vena cava thrombosis and pulmonary embolus: association with right atrial mural thrombus. Arch Int Med. 1982;142(9):1726-1728.
Reference #2: Madan AK, Almon JC, Harding M, Cheng SS, Slakey DP. Dialysis access-induced superior vena cava syndrome. Am Surgeon. 2002;68(10):904-906.
Reference #3: Otten TR, Stein PD, Patel KC, Mustafa S, Silbergleit A. Thromboembolic Disease Involving the Superior Vena Cava and Brachiocephalic Veins. Chest. 2003;123(3):809-812.
DISCLOSURE: The following authors have nothing to disclose: Sritika Thapa, Biren Kamdar, Peter Terry
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