Yang Hongliu, Chen Feng, Jiao He, Luo Han, Yu Yang, Hong Hyokyoung G, Li Yi, Fu Ping, Cui Tianlei
Department of Nephrology, West China Hospital, Sichuan University, Sichuan, China.
Department of Radiology, West China Hospital, Sichuan University, Sichuan, China.
J Vasc Surg. 2018 Nov;68(5):1491-1498. doi: 10.1016/j.jvs.2018.02.039. Epub 2018 May 24.
Catheter-related right atrial thrombosis (CRAT) is an underreported but potentially life-threatening complication associated with the use of tunneled-cuffed catheters among hemodialysis (HD) patients. Because little is known about the evidence-based guidelines for the optimal management of CRAT among HD patients, this article reports findings based on 20 patients diagnosed with CRAT after catheter replacement and anticoagulation treatment.
The article retrospectively reviews the hospital records of 20 HD patients treated in the West China Hospital with diagnosis of CRAT from March 2013 to May 2016. Once CRAT was diagnosed, tunneled-cuffed catheters were exchanged over a guidewire in situ and the locations of the new catheter tips were adjusted to be away from the original sites. Immediately after the insertion of a new tunneled-cuffed catheter and at the end of each HD session, both ports of the catheters were locked with unfractionated heparin solution. Patients younger than 70 years of age were treated with warfarin at a target International Normalized Ratio of 1.5 to 1.9, whereas those older than 70 years were treated with dual antiplatelet therapy. All patients were on regular dialysis without thrombolysis or thrombectomy.
During the follow-up, two patients died of gastrointestinal massive hemorrhage and one died of acute myocardial infarction. No fatal pulmonary embolism or other CRAT complication-related deaths were observed. A total of eight patients had complete dissolution of CRAT, and 12 patients had reduction in thrombi size.
Maintenance of HD by replacing catheters and providing oral anticoagulation/antiplatelet therapies may be an effective strategy for treating HD patients with CRAT.
导管相关右心房血栓形成（CRAT）是血液透析（HD）患者使用带隧道带涤纶套导管时一种报告不足但可能危及生命的并发症。由于对于HD患者CRAT的最佳管理的循证指南了解甚少，本文报告了20例在导管置换和抗凝治疗后被诊断为CRAT的患者的研究结果。
本文回顾性分析了2013年3月至2016年5月在华西医院接受治疗并诊断为CRAT的20例HD患者的医院记录。一旦诊断为CRAT，就在导丝引导下原位更换带隧道带涤纶套导管，并将新导管尖端位置调整至远离原部位。在插入新的带隧道带涤纶套导管后以及每次HD治疗结束时，用普通肝素溶液封管。年龄小于70岁的患者接受华法林治疗，目标国际标准化比值为1.5至1.9，而年龄大于70岁的患者接受双联抗血小板治疗。所有患者均接受规律透析，未进行溶栓或取栓治疗。
随访期间，2例患者死于胃肠道大出血，1例死于急性心肌梗死。未观察到致命性肺栓塞或其他与CRAT并发症相关的死亡。共有8例患者的CRAT完全溶解，12例患者血栓大小缩小。
通过更换导管并给予口服抗凝/抗血小板治疗来维持HD，可能是治疗CRAT的HD患者的有效策略。
