Right atrial thrombi complicating haemodialysis catheters. A meta-analysis of reported cases and a proposal of a management algorithm.

Background: Little is known about the potentially fatal complication of catheter-related right atrial thrombus (CRAT) in dialysis patients, and the optimal management is controversial. The aims of our study were to identify the prognostic factors of mortality in cases of CRAT in dialysis patients and to compare treatment options.

Methods: Retrospective analysis of all reported cases of CRAT in adult dialysis patients, in English-language literature (PubMed search), in which therapy and outcome data were available.

Results: Up to December 2010, we identified 71 cases of CRAT in dialysis patients (including our patient). Overall mortality was 18.3% (13/71) and significant predictors were advanced age, presence of complications and non-removal of the catheter. Nine patients received no treatment, except for catheter removal and antibiotics, four of them died. Systemic thrombolysis was administered in eight patients but was successful only in two with pulmonary embolism, the remaining required further treatment. Finally, 37 patients received anticoagulation and 23 underwent surgical thrombectomy (one percutaneous intravascular removal of the thrombus). Mortality was 16.2% (6/37) and 13% (3/23), respectively, P=1. Regarding presence of various complications, no treatment choice was superior over the other. Five of the six patients who had a thrombus≥60 mm underwent successful surgical thrombectomy.

Conclusions: We propose a management algorithm emphasizing the removal of the catheter and recommending anticoagulation as first-line treatment. Surgical thrombectomy is valuable when other treatments fail or in special circumstances. Thrombolysis has a poor success rate but may be useful in pulmonary embolism.