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Correspondence |
Jichi Medical School Omiya Medical Center, Saitama, Japan, E-mail: sanui{at}omiya.jichi.ac.jp
To the Editor:
Thrombotic complications of central venous catheters (CVCs) are reported to occur in 2–26% of patients, and all thrombi have the potential to embolize.1 Paradoxical cerebral air embolism during placement or withdrawal of CVCs has been described in numerous case reports,2 but cerebral thromboembolism after central venous catheterization procedures is a rare complication. We present a case of pulmonary and cerebral embolism immediately after removal of an internal jugular venous (IJV) catheter with evidences of right-side thrombi and right-to-left shunt.
A 78-yr-old male, who had a history of stroke with residual right hemiparesis, underwent a distal gastrectomy for cancer. The postoperative course was complicated with an anastomotic leak, which required a re-exploration of the abdomen and correction on postoperative day 11. In the operating room, a double-lumen, heparin-coated CVC (M2714HSI, Edwards Life Science, Irvine, CA, USA) was uneventfully placed into the right IJV for postoperative nutritional support.
One week after the re-exploratory surgery, the patient still spent most of the day in bed due to his preoperative morbidity and delayed wound healing, while sc heparin administration for deep venous thrombosis (DVT) prophylaxis was already discontinued. Two days later, when the patient became febrile, the IJV catheter was removed. The removal procedure was uneventful with the legs elevated, and the puncture hole covered with a tight bandage. Soon after this procedure, the patient developed respiratory distress, hypotension, loss of consciousness, and a seizure. While standard resuscitation was initiated, the diagnostic interventions began with transthoracic echocardiography, which revealed a clot trapped in the right ventricle (Figure
) and moderate tricuspid insufficiency suggesting an elevated pulmonary artery pressure. Also, snowstorm-like bubbles in the right heart, accidentally created by a rapid resuscitation fluid bolus, were simultaneously seen in the left heart (Figure). Computed tomography pulmonary angiography suggested an embolus in the right middle pulmonary artery. Venous duplex ultrasonography showed a residual linear thrombus in the right IJV and no thrombus in the lower extremities.
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In this case, the radiographic studies and the clinical scenario strongly suggested that the embolic source was not the air, but clot in the right IJV, which fragmented and dislodged during the catheter removal. One of these fragments then embolized to the pulmonary artery, raising the right heart pressure, which facilitated the flow through a right-to-left shunt, assumingly a patent foramen ovale. It is likely that one of these fragments emerged in the systemic circulation, and embolized to a cerebral artery. The potential thrombogenic factors in this patient include the presence of malignancy, limited activity in the right upper arm, prolonged bed rest, and insufficient DVT prophylaxis, although in most cases the causality has not been studied in a comprehensive fashion.3 Since it has been shown that the majority of thrombi develop within eight days after insertion of CVCs,3 this early thrombosis is not surprising. For high risk patients, venous duplex ultrasonography should be considered not only before the placement of the CVCs, but also before their removal.
Footnotes
Accepted for publication January 10, 2007.
The authors have no financial support, commercial affiliations or any other associations to produce a conflict of interest.
References
1 McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348: 1123–33.
2 Heckmann JG, Lang CJ, Kindler K, Huk W, Erbguth FJ, Neundorfer B. Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization. Crit Care Med 2000; 28: 1621–5.[Medline]
3 Kuter DJ. Thrombotic complications of central venous catheters in cancer patients. Oncologist 2004; 9: 207– 16.
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