Treatment of superior vena cava thrombosis with recombinant tissue type plasminogen activator

Thrombotic occlusion of the superior vena cava is an uncommon but serious complication of chronic indwelling venous catheters. Several reports have shown thrombolytic therapy with intravenous streptokinase or urokinase to be effective in the treatment of this condition. We report a case of superior vena cava thrombosis in a 53-year-old woman receiving chemotherapy for breast carcinoma through a subcutaneously implanted venous access catheter who was successfully treated with peripheral infusion of recombinant tissue type plasminogen activator (rtPA).     

Recurrent edema of the face and neck in a chronically hemodialyzed patient

We report the case of a patient undergoing long-term hemodialysis admitted to hospital for diagnosis of recurrent face and neck edema influenced by dialysis sessions with paroxysmal dyspnea. We considered the possible role of allergy to ethylene oxide and to formaldehyde without diagnostic confirmation. Dialyzer complement activation was suspected but changing the dialyzer did not improve the symptoms. Anti-histaminic and corticosteroid therapy did not modify symptoms. A mild hemithoracic collateral circulation occurred and led to the discovery of a superior vena cava syndrome. Computed tomography and bilateral upper limb contrast venography visualized a thrombus in the superior vena cava extending into the right venous brachiocephalic arm from the central vein catheter. A stent was inserted into the superior vena cava which, together with anticoagulant therapy, led to rapid resolution of the symptoms. Superior vena cava syndrome related to a central catheter and hypersensitivity reactions should always be considered as possible causes of recurrent face and neck edema in patients on long-term hemodialysis.     

Right atrial thrombus--a complication of central venous catheters

We describe the development, in three days, of a pediculate mass hanging on the right atrial lateral wall in a 39-year-old woman with a subclavian venous catheterization. She was a current smoker and alcoholic but without drug addict. The hypothesis of a non valvular right atrial infective endocarditis was considered at first, but subsequent events directed the diagnosis towards a thrombus, which was resorbed by heparin. We discuss the incidence, the complications, the treatment and the differential diagnosis of thrombus caused by a central venous catheter. The prevention of right atrial thrombus caused by a central venous catheter depends on the position of the central venous catheter tip, either in the superior vena cava or at the superior vena cava-right atrium junction. A more distal position is a frequent source of thrombotic and embolic complications.     

Serologic diagnosis of access device-related staphylococcal bacteremia.

Staphylococcal bacteremia occurs frequently in patients undergoing long-term hemodialysis (dialysis patients). Although such bacteremia is frequently uncomplicated, it may be associated with endocarditis, metastatic infection or suppuration at the access site requiring excision of the access device for control of the infection (complicated bacteremia). To distinguish patients with uncomplicated bacteremia from those with complications, we measured staphylococcal teichoic acid antibodies by agar-gel diffusion and immunoglobulin G (IgG) antibodies by radioimmunoassay in 18 patients with staphylococcal bacteremia undergoing long-term hemodialysis. Although teichoic acid antibodies were not detected in five patients with uncomplicated bacteremia, they were observed in only three of 13 patients with complicated bacteremia. IgG staphylococcal antibodies were present in 10 of 13 patients with complicated bacteremia compared to none of five patients with uncomplicated bacteremia compared to none of five patients with uncomplicated bacteremia (p less than 0.05). Thus, radioimmunoassay was spuerior to agar-gel diffusion in identifying dialysis patients with complicated bacteremia. In patients with increased concentrations of IgG staphylococcal antibodies by radioimmunoassay, the diagnosis of endocarditis, metastatic infection and suppuration at the access site should be considered. Prolonged antibiotic therapy and/or operative removal of the access device may be necessary.     

Local complications associated with indwelling Swan-Ganz catheters: Autopsy study of 36 cases

Thirty-six hearts of patients who died with indwelling Swan-Ganz catheters in place were prospectively examined to assess the incidence and extent of localized lesions in the right side of the heart. Bland mural thrombosis in the superior vena cava, the right atrium and the pulmonary artery was found in 22 of 36 cases (61 %). Patients with catheter periods > 2 days had a greater incidence and extent of bland mural thrombosis (79%) than patients with short-term catheterization (41%, p < 0.01). Anticoagulation had no influence on bland mural thrombosis. Valvular hemorrhage occurred in 31% and aseptic valvular vegetations in 8% of the hearts. No case of infective endocarditis was found. Four of 36 cases (11%) had evidence of pulmonary infarction that appeared to be unrelated to the lesions in the right side of the heart. Endocardial lesions were common complications of indwelling Swan-Ganz catheters but had no significant impact on the clinical courses of the patients.     

Infective tricuspid valve endocarditis with septic pulmonary emboli due to puncture of an endogenous arteriovenous fistula in a chronic hemodialysis patient

BACKGROUND: Patients on chronic hemodialysis are at high risk for infectious endocarditis due to prosthetic access devices such as cuffed venous catheters and polytetrafluoroethylene grafts. Right-sided endocarditis without any predisposing factors is rare in dialysed patients. CASE REPORT: A 42-year-old man with chronic renal failure was referred to hospital due to febrile temperatures. Hemodialysis was performed via an autogenous arteriovenous fistula. He had neither any recognized underlying valve disease nor any percutaneous interventions previously. Chest radiography and computed-tomography revealed numerous lung abscesses caused by tricuspid endocarditis detected by transesophageal echocardiography. Antibiotics were given for 5 weeks curing the infection without necessity of surgical treatment. CONCLUSIONS: Primary arteriovenous fistulas have the lowest rates of infections and are the access of choice for chronic hemodialysis patients. However, repeated vascular punctures even of autogenous grafts expose dialysis patients to bacteremia and imply a higher risk of infectious endocarditis.     

Profile of right-sided endocarditis: an Indian experience

The clinical profile of right-sided infective endocarditis in India was studied from a review of records of patients with infective endocarditis admitted to this hospital. From November 1982 to November 1989, 109 patients with infective endocarditis showed vegetations on cross-sectional echocardiography confirming the diagnosis of infective endocarditis. In 19 (17.4%) patients, only the right side of the heart was involved: specifically the tricuspid valve alone in 10; tricuspid and pulmonary valves in 4; tricuspid valve and right ventricular outflow tract in 1; tricuspid valve and right ventricular free wall in 1; pulmonary valve alone in 2; and bifurcation of pulmonary trunk in 1. Eleven patients (57.9%) had underlying congenital heart disease whereas the remaining 8 patients (42.1%) did not have any underlying heart disease. The latter group, therefore, had isolated right-sided infective endocarditis. Previous illnesses leading to isolated right-sided infective endocarditis were: puerperal sepsis in 4; septic abortion in 1; staphylococcal pneumonia in 2; and epididymoorchitis in one. Eight out of 11 patients with congenital heart disease did not report any previous illness. In the remaining 3, right-sided endocarditis followed cardiac surgery in one; dental extraction without prophylaxis in one; and pulmonary balloon valvoplasty in one. All patients with isolated right-sided infective endocarditis had features of septicaemia, but a murmur of tricuspid regurgitation was audible in only 4 (50%) of them. We conclude that, unlike western reports, the pattern of right-sided infective endocarditis in India is different. No drug addict with right-sided infective endocarditis was seen; puerperal sepsis and septic abortion were the commonest causes of isolated right-sided infective endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)     

临时中心静脉插管所致的血液透析并发症

目的 探讨临时中心静脉插管血液透析患者发生的导管相关并发症及其与插管时间、部位的关系.方法 将本院收入的临时插管血液透析患者753例为研究对象,分析血液透析导管相关并发症的危险因素,观察各种并发症与插管时间、部位的关系.结果 透析导管相关感染、导管功能不全、上腔静脉梗阻综合征与中心静脉插管部位、留置时间存在相关性.通过右颈内静脉置管可明显降低患者出现透析导管相关感染、上腔静脉梗阻综合征的机会,同时证明导管功能不全与置管位置无关而与置管时间有关.结论 导管留置部位、留置时间、年龄是透析导管相关感染、导管功能不全、上腔静脉梗阻综合征发生的重要危险因素.     

An unusual presentation of right coronary artery fistula.

A four year old girl with infective endocarditis had unexplained facial swelling. Cross sectional echocardiography showed that a large right coronary artery fistula to the right atrium was obstructing the distal superior vena cava. The diagnosis was confirmed by cardiac catheterisation and at operation. The child was symptom free one year after operation.     

An unusual presentation of right coronary artery fistula

A four year old girl with infective endocarditis had unexplained facial swelling. Cross sectional echocardiography showed that a large right coronary artery fistula to the right atrium was obstructing the distal superior vena cava. The diagnosis was confirmed by cardiac catheterisation and at operation. The child was symptom free one year after operation.     

Staphylococcus aureus bacteremia and endocarditis associated with a removable infected intravenous device

Records of 21 patients with Staphylococcus aureus bacteremia associated with a removable infected intravenous device were reviewed. Sixteen patients had a peripheral intravenous catheter, four had a central venous catheter and one had a transvenous cardiac pacer. The duration of the indwelling intravenous device in situ prior to the detection of infection ranged from two to 11 (mean 5.2) days. The infected intravenous device was promptly removed as soon as bacteremia was suspected. Endocarditis was diagnosed in eight patients: in two patients an aortic murmur developed; in two the diagnosis was made clinically and was confirmed at necropsy (one mitral and one aortic); in four the diagnosis was made at necropsy (two tricuspid and two atrial wall). In patients with Staph. aureus bacteremia associated with a removable infected intravenous device, the risk of endocarditis developing was significant.     

Intracardiac mass complicating Malassezia furfur fungemia

Malassezia furfur is a lipophilic yeast known to colonize indwelling catheters. Although progression to vasculitis and sepsis has been described, it has rarely caused fungemia in adults receiving nutrition via an indwelling catheter. Difficulty in diagnosis occurs as M furfur does not grow on routine culture media unless it is supplemented with fatty acids. We present the first case of M furfur fungemia in an adult, complicated by a pedunculated septic thrombus arising from the superior vena cava and extending into the right atrium. Removal of the catheter, amphotericin-B therapy, and surgical debridement were required for cure.     

Urokinase. A cost-effective alternative treatment of superior vena cava thrombosis and obstruction

Venous thrombosis and subsequent obstruction of the superior vena cava may be life threatening and therefore warrant immediate attention. This case report represents the successful treatment of superior vena cava thrombosis with urokinase in a patient with an indwelling Hickman catheter. Patency of the occluded vessel and resolution of clinical symptoms were achieved within 24 hours of initiation of a 12-hour urokinase infusion.     

Vascular and cardiac infections in end-stage renal disease

Patients with end-stage renal disease (ESRD) receiving hemodialysis (HD) are vulnerable to intravascular and endocardial infections. These include vascular access infections, vascular stent infections, and bacterial endocarditis. Staphylococcus aureus is the most commonly encountered microorganism in these conditions. Prolonged intravenous antibiotic therapy is often indicated in these infections. Surgical removal of the infected vascular access or stent may be required. Infective endocarditis occurs less frequently in renal transplant recipients than in patients on HD. Although bacterial endocarditis may occur, fungal endocarditis with organisms such as Aspergillus and Candida species occurs with disproportionately high frequency among renal transplant recipients because of immunosuppression. Prolonged intravenous antibiotic or antifungal therapy is indicated, and valve replacement is often necessary.     

Use of cardiopulmonary bypass for thrombectomy in acute superior vena cava syndrome

An increasing incidence of nonmalignant, indwelling catheter cases has been reported in relation to superior vena cava syndrome. Such cases may be life-threatening, with rapid development of facial and neck edema and the production of respiratory distress. This is the first reported case of atrial and superior vena caval thrombectomy requiring cardiopulmonary bypass; it is only the second case reported in which operative thrombectomy has been used. Because of the problems associated with an increase in the use of indwelling venous catheters and the satisfactory results we obtained in this case, such an aggressive form of treatment for acute, benign superior vena cava syndrome may be used more frequently in the future.     

Prävention hämodialysekatheterassoziierter Infektionen

Catheter-related infections are common, cost-intensive and potentially fatal. Catheter-related bacteremia is the most common infective complication and infections are the second most common cause of death in hemodialysis patients. When possible the placement of a hemodialysis catheter should be avoided. If there are no alternatives including peritoneal dialysis and an anticipated duration of more than 3 weeks, a permanent tunnel catheter should be implanted in the right jugular vein. The most important preventive measures are hygienic hand disinfection and strict aseptic conditions during catheter implantation, dressing changes and handling during dialysis. The implementation of simple hygiene standards through training leads to a clear, sustainable reduction of catheter-related bacteremia and is cost-effective. Technical innovations play a subordinate role and the best evidence has been found for the use of antimicrobial ointments and so-called lock solutions.     

Urokinase recanalization of extensive thrombosis of the superior vena cava secondary to an implantable perfusion device

A superior vena cava syndrome developed suddenly in a 36 year old man who had been undergoing chemotherapy via an implanted venous access catheter for 18 months. Venography showed superior vena cava thrombosis extending bilaterally to the subclavian veins. Direct local thrombolysis with low-dose Urokinase resulted in partial recanalisation with an excellent clinical result despite the persistence of an endovenous sequestrum situated at the catheter tip, a sequela of previous thrombosis. This case underlines the importance of direct local thrombolysis in patients with a Port-a-Cath system complicated by a thrombosis.     

经下腔静脉途径拔除起搏导线的初步体会

目的 介绍应用血管内反推力技术经下腔静脉途径拔除起搏导线的初步临床体会。方法 对１８例患者的２８根导线应用血管内反推力牵引技术拔除导线,其中１６例（２５根导线）首选经上腔静脉途径,失败后改用经下腔静脉途径;２例（３根导线）直接用经下腔静脉途径拔除。结果 １６例患者的２５根导线,经上腔静脉途径完全拔除２２根（８８％）,３根经此途径拔除失败后改用下腔静脉途径,其中２根完全拔除。２例患者的３根导线直接先     

Neonatal intensive care unit bacteremia: emergence of gram-positive bacteria as major pathogens

An outbreak of nosocomial Staphylococcus epidermidis bacteremia in a neonatal intensive care unit in 1981 was epidemiologically linked to use of Broviac central venous catheters (p = 0.05) and prompted a review of nosocomial infection surveillance data for the previous 6 years, which indicated a striking shift from gram-negative to gram-positive bacteria, especially coagulase-negative staphylococci, as major bloodstream pathogens. In a case-control study with 68 patients with bacteremia between 1979 and September 1981 and 64 control patients, stratified by birth weight, three risk factors were identified: use of Broviac central venous catheters, surgical procedures, and intravenous hyperalimentation. The risk factors varied with the birth weight category. In the group of cases and controls with birth weights less than 1500 gm, only the use of Broviac catheters, which are usually left in the superior vena cava for several weeks, was associated with subsequent bacteremia (odds ratio = 7.1, p = 0.001). These observations, as well as the temporal association of the introduction of Broviac catheters with the subsequent shifts in causes to gram-positive organisms, suggest that the long-term indwelling vascular access devices contributed greatly to the changing pattern.     

Increased risk of bacteremia in patients hemodialyzed through central catheters

As part of an ongoing prospective survey of nosocomial bacteremias, patients developing bacteremia while undergoing in-centre hemodialysis were observed over a 23 month period. Thirty-six episodes of bacteremia occurred in 30 patients: every episode was directly attributable to hemodialysis. In 28 of the 36 episodes (78%), there was evidence of inflammation with or without drainage of pus at the hemodialysis access site. Staphylococcus aureus accounted for 76% of the bacteremic isolates. Patients hemodialyzing through central venous catheters had a far higher incidence of bacteremia (0.01 per dialysis run) than patients hemodialyzing through vascular grafts (0.0005 per dialysis run).