Management of hemodialysis catheter-related atrial thrombi

PFO: patent foramen ovale; SVC: superior vena cava; IVC: inferior vena cava.
* CRAT includes mural thrombus and catheter-tip thrombus. Antimicrobial therapy is warranted for patients with CRAT and bacteremia.
¶ If the patient requires ongoing hemodialysis, place a catheter with its tip in a different location. Another option is early cannulation arteriovenous graft placement.
Δ Examples include bacterial endocarditis, PFO, other surgically correctable cardiac abnormalities.
◊ For large CRAT, especially if interfering with cardiac function, surgery is considered first-line therapy.
§ Remove the thrombus, remove the catheter, and perform other procedures as indicated.
¥ For patients who are not candidates for any treatment, long-term survival is reduced.
‡ Options include catheter-directed thrombolysis, ultrasound-assisted thrombolysis, catheter-directed suction thrombectomy.
† The choice between anticoagulation or systemic thrombolysis depends upon clinical judgement, institutional resources, and clinician experience.
** For mural thrombus, image 7 to 10 days after resolution to rule out recurrence.
¶¶ For residual thrombus following systemic thrombolysis, those who are candidates are anticoagulated.