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Abstract

We greatly appreciate the comment of Drs Ghannam, Chick, and Srinivasa. Chick and colleagues have conducted a study examining the benign management of catheter tip-associated thrombi1Chick J.F. Reddy S.N. Bhatt R.D. Shin B.J. Kirkpatrick J.N. Trerotola S.O. Significance of echocardiographically detected central venous catheter tip-associated thrombi.J Vasc Interv Radiol. 2016; 27: 1872-1877Abstract Full Text Full Text PDF Scopus (10) Google Scholar and have raised the question of the necessity of anticoagulation and catheter removal in hemodialysis patients. For the management of catheter-related right atrial thrombosis (CRAT) in hemodialysis patients in our study, we treated our patients effectively by replacing catheters and providing oral anticoagulation and antiplatelet therapies. Of note, the differences between Chick's study and ours should be taken into consideration. First, among the 170 patients recorded in Chick's study, 49 patients experienced central venous catheter (CVC) tip-associated thrombi and were selected for management evaluation. Of these 49, only 9 patients had tunneled dialysis catheters (TDCs). Whereas Chick et al evaluated other CVCs, including Swan-Ganz, nontunneled, and peripherally inserted CVCs, our study focused on TDC because it is the lifeline of hemodialysis patients. Compared with TDCs, other catheters have relatively small lumens, which may be associated with less irritation of atrial wall and may contribute to the good outcome of CRAT.2Clinical practice guidelines for vascular access.Am J Kidney Dis. 2006; 48: S248-S273PubMed Google Scholar Second, in Chick's study, 16 patients with conservative therapies were free of thrombus extension during the follow-up. These data lacked in details regarding the outcome of thrombi. Of the 20 patients in our study, 8 patients had complete dissolution of CRAT and 12 patients had reduction in thrombi size. These positive outcomes demonstrate the benefit of our management. Third, it is difficult to compare the outcome of short-term, 3-month follow-up conducted in Chick's study and the relatively long follow-up period of our study. Our study had an average follow-up of nearly 18 months, ranging from approximately 10 months to nearly 39 months. Fourth, given that many patients in Chick's study have other major comorbidities, including heart failure, sepsis, and malignant disease, unnecessary treatment may result in increased morbidity or mortality. Thus, it is suggested in Chick's study that thrombolysis, anticoagulation, and intervention, including catheter removal and thrombectomy, are unnecessary in the absence of patent foramen ovale or other intracardiac shunts. Also notable, however, is that patients included in our study had already exhausted vascular access because of previous repeated catheterization. The chief complaint of most of these patients was catheter dysfunction due to the CRAT. If the problem of catheter dysfunction could not be solved, patients could not reach sufficient blood flow rate, resulting in serious complications of inadequate hemodialysis. It was crucial not only to regain catheter blood flow for our patients but also to preserve the current vascular access site because they had no other alternative vascular accesses. On the other hand, extended catheter placement may also increase the risk of the extension of thrombi.3Stavroulopoulos A. Aresti V. Zounis C. Right atrial thrombi complicating haemodialysis catheters. A meta-analysis of reported cases and a proposal of a management algorithm.Nephrol Dial Transplant. 2012; 27: 2936-2944Crossref PubMed Scopus (65) Google Scholar The adjustment of the location of catheter tips not only helped reduce the irritation to right atrium but provided adequate blood flow required for dialysis as well. In summary, we think there is not enough evidence supporting that conservative therapy (namely, either catheter removal or anticoagulation) benefits dialysis patients with CRAT. Regarding “Management of tunneled-cuffed catheter-related right atrial thrombosis in hemodialysis patients”Journal of Vascular SurgeryVol. 69Issue 1PreviewWe read, with interest, “Management of tunneled-cuffed catheter-related right atrial thrombosis in hemodialysis patients” by Yang et al.1 Central venous catheter insertion is associated with morbidity and mortality,2 with catheter-related right atrial thrombosis (CRAT) described as one common complication in end-stage renal disease patients requiring hemodialysis.3 Yang et al described 20 end-stage renal disease patients with tunneled-cuffed catheters treated for CRAT. Tunneled-cuffed catheter placement was performed secondary to recurrent arteriovenous fistula failure in 18 (90%) patients and refusal of arteriovenous fistula for personal reasons in two (10%) patients. Full-Text PDF Open Archive