Case # 15: When Lines Go Wild

A 35 year old woman with sickle cell disease presented to the emergency department with localized swelling and pain near her port site. The pain started two days prior to arrival, when she was at an infusion center and her port was found to be inaccessible by the staff. She stated that the staff were unable to draw back any blood. She denied shortness of breath, chest pain, fever, or any other skin changes aside from the swelling.

Vitals: T: 97.8, HR: 64, BP: 144/80, RR: 16, Sat: 96% on RA

A bedside ultrasound ECHO was preformed to evaluate the distal tip of the port.  What do you see?

Answer and Learning Points

Answer

These ultrasound images show an apical 4 view of the heart. There is a hyperechoic mass in the right atrium that does not shadow, suggestive of a line thrombosis. A CT angio confirmed the diagnosis, showing a large clot adhered to the distal tip of the catheter.

Learning Points

    • Catheter-related complications are common and are the cause of significant morbidity and mortality for patients that have chronic indwelling lines. Symptomatic rates are reported to be 5% with asymptomatic rates increasing to nearly 20%(1).
    • Typical imaging beings with an upper extremity ultrasound. However, challenges arise as compression is unattainable when dealing with subclavian vessels(2). CT can improve the sensitivity and specificity(3).
    • In our case, a DVT ultrasound would not have been adequate, as the port is inserted over the subclavian vessel. However, a clot located in the heart can be easily detected on a cardiac echo. A CT angio was used to confirm there was a clot adhered to the line, but no pulmonary embolism.
    • Ultrasound can be used to evaluate for RV strain and at times may note RA thrombosis (such as in this case), clots in transit, and can be helpful in evaluating lines that extend into the right atrium/right ventricle.  

Ultrasound findings of clots on the cardiac echo:

Non-adhered clots will typically be floating/tumbling with cardiac motion. Since they are non-calcified, shadowing does not typically occur.

Right Atrial Thrombus
Dr. Scheels. The POCUS Atlas. http://www.thepocusatlas.com/

This can be difficulty to distingue from other masses, such as an atrial myxoma. However the correct clinical context is able to help.

Atrial Myxoma
Dr. Russell. The POCUS Atlas. http://www.thepocusatlas.com/

Using echo to check line placement/wire tips is not uncommon. Obtaining an apical 4 view as done in this case, one can evaluate the right atrium and right ventricle.


Dr. Ftacnikova et al. 3D ECHO 360. http://3decho360.com/cc19/

Author

Sukhdeep Singh, MD. Clinical Faculty, UCSD Department of Emergency Medicine. Director of POCUS, El Centro Regional Medical Center

References

  1. Verso M, Agnelli GJ. Venous thromboembolism associated with long-term use of central venous catheters in cancer patientsJ Clin Oncol 2003; 21: 3665–3675.
  2. Sartori M, Migliaccio L, Favaretto E, et al. Whole-Arm Ultrasound to Rule Out Suspected Upper-Extremity Deep Venous Thrombosis in Outpatients. JAMA Intern Med. 2015;175(7):1226–1227. doi:10.1001/jamainternmed.2015.1683
  3. Gita Yashwantrao Karande, Sandeep S. Hedgire, Yadiel Sanchez, Vinit Baliyan, Vishala Mishra, Suvranu Ganguli, Anand M. Prabhakar
    Cardiovasc Diagn Ther. 2016 Dec; 6(6): 493–507. doi: 10.21037/cdt.2016.12.06

Leave a Reply

Your email address will not be published. Required fields are marked *