Paradoxical Thromboembolic Ischemic Stroke Following Tissue Plasminogen Activator Instillation for Clogged Central Venous Dialysis Catheter.

Ifeanyi Nwosu,Amit Gulati,Britney Clemen,Sehajpreet Singh,Emeka Ibeson,Anna Derman,Geraldine Nsofor,Annabel U Ogar,Arjun Basnet,Ranbir Singh,Dmitriy Zadushlivy,Yizhak Kupfer

doi:10.7759/cureus.20346

Abstract

Central venous catheters including dialysis catheters are a potential source of venous thrombosis and pose a risk for paradoxical embolic events including ischemic stroke and systemic embolism in patients with a patent foramen ovale (PFO). The adult population with a PFO and patients with a central venous dialysis catheter (CVDC) are at increased risk of a paradoxical embolic event. Since bubble study is not routinely done during echocardiogram in a patient with CVDC, it is difficult to identify at-risk patients for paradoxical embolic events during catheter manipulation, especially for clogged CVDC.We report a rare case of a 79-year-old lady with end-stage renal disease on hemodialysis (HD) using a CVDC who developed a paradoxical embolic ischemic stroke following the use of tissue plasminogen activator (tPA) for unclogging a dialysis catheter. We aimed to highlight the existing risks of thromboembolism associated with the long-term use of central CVDC, especially the potential risk of paradoxical embolism and ischemic stroke with the use of tPA for management of clogged dialysis catheters. We emphasize the questionable need for a bubble study echocardiogram in all patients requiring long-term dialysis catheters.

Highlights

Paradoxical thromboembolism is a venous thrombosis causing systemic embolization through a right to left cardiac shunt; about 70% occur through a patent foramen ovale (PFO) [1,2]
We report a rare case of a 79-year-old lady with end-stage renal disease on hemodialysis (HD) using a central venous dialysis catheter (CVDC) who developed a paradoxical embolic ischemic stroke following the use of tissue plasminogen activator for unclogging a dialysis catheter
Paradoxical embolism through a PFO is a common cause of ischemic stroke, paradoxical embolic stroke associated with a central venous dialysis catheter (CVDC) is relatively uncommon and only a few cases among adult patients have been reported in the literature [7,8,9,10,11]

Summary

Introduction

Paradoxical thromboembolism is a venous thrombosis causing systemic embolization through a right to left cardiac shunt; about 70% occur through a patent foramen ovale (PFO) [1,2]. Paradoxical embolism through a PFO is a common cause of ischemic stroke, paradoxical embolic stroke associated with a central venous dialysis catheter (CVDC) is relatively uncommon and only a few cases among adult patients have been reported in the literature [7,8,9,10,11]. To the best of our knowledge, this is the first case of paradoxical embolism associated with the use of a tissue plasminogen activator (tPA) for unclogging a hemodialysis (HD) catheter. Non-invasive management of a clogged dialysis catheter typically employs the use of fibrinolytic agents such as tissue plasminogen activator (tPA) like alteplase and has proven to be effective [13,14,15]

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Conclusion