title: Large atrial thrombus formation associated with tunneled cuffed hemodialysis catheters.
abstract: OBJECTIVE
  In the existing literature, there is a paucity of data regarding large atrial thrombus (AT) formation occurring as a complication of tunneled cuffed hemodialysis catheter (TCC) use. This study was performed to determine the risk factors, mortality and the appropriate management of TCC-AT.
  
  
  METHODS
  We report 6 new cases of TCC-AT and have amalgamated these data with data from 16 previously published cases of TCC-AT found by performing a PubMed literature search (total of 22 cases). Demographic data were collected prospectively over 2 years in 85 consecutive patients initiating hemodialysis who were using a TCC as their primary vascular access, so that comparisons could be made between the 6 patients with TCC-AT versus all patients with a TCC at our center.
  
  
  RESULTS
  In patients with TCC-AT, the mean time from TCC insertion was 4.5 months, and infection was present at the time of diagnosis in 68% of cases. The mean thrombus size was 3.7 cm, range 1.5-8 cm. All but 1 case were visualized by echocardiography; the remaining case required magnetic resonance imaging. Management included TCC removal and thrombectomy (n = 9), TCC removal and anticoagulation (AC) (n = 6), TCC removal alone (n = 5), and no intervention (n = 2). The overall mortality was 27%, and 5 of the 6 deaths (83%) occurred in patients with bacteremia. The mortality associated with each management strategy was as follows: TCC removal and thrombectomy (0%), TCC removal and AC (33%), TCC removal alone (40%), and no intervention (100%).
  
  
  CONCLUSIONS
  AT is a serious complication of TCC use in hemodialysis patients and may be associated with a high mortality rate. TCC-AT may occur more commonly than previously reported and therefore warrants a high index of suspicion.
authors.affiliation: Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10467, USA.
authors.forename: O
authors.initials: O
authors.lastname: Negulescu
authors.forename: M
authors.initials: M
authors.lastname: Coco
authors.forename: J
authors.initials: J
authors.lastname: Croll
authors.forename: M H
authors.initials: MH
authors.lastname: Mokrzycki
mesh_terms: D000328:Adult; D000368:Aged; D002404:Catheterization / Q000009:adverse effects*; D003328:Coronary Thrombosis / Q000209:etiology* / Q000401:mortality* / Q000628:therapy; D005260:Female; D006325:Heart Atria; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000009:adverse effects*; D012307:Risk Factors; D012720:Severity of Illness Index