CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 2, May – August 2024 124 AFRICA Case Reports Identification and treatment of asymptomatic central venous catheter thrombosis after TAVI Xin Huang Abstract One of the most serious complications of central venous catheterisation is thrombus, particularly asymptomatic thrombus. If not recognised and promptly treated, it can result in pulmonary emboli. Here, we describe transcatheter aortic valve implantation performed in a 77-year-old female patient with the insertion of a central venous catheter into the right internal jugular vein as part of the procedure. The patient experienced no associated discomfort and received standard antiplatelet and antibiotic treatment. Given that the catheterisation procedure was unsuccessful on the first attempt, an ultrasonographic examination of the blood vessel was performed in order to prepare for extubation of the patient. A thrombus was identified, which was resolved with low-molecular-weight heparin anticoagulation therapy. The patient experienced no complications with removal of the central venous catheter. Keywords: central venous catheterisation, transcatheter aortic valve implantation, thrombus, low-molecular-weight heparin, ultrasound Submitted 16/9/22, accepted 28/3/23 Published online 24/4/23 Cardiovasc J Afr 2024; 35: 124–126 www.cvja.co.za DOI: 10.5830/CVJA-2023-015 Case report A 77-year-old female sought medical attention for a two-month history of fatigue and shortness of breath after exercising. Severe stenosis of the aortic valve was observed on echocardiography. She had a history of hypertension and diabetes but no evidence of malignancy. A bioprosthetic aortic valve was implanted through the right femoral artery after complete pre-operative evaluation, and a central venous catheter (CVC) was inserted into the right jugular vein as part of the procedure. Dual antiplatelet and antibiotic therapies were administered after transcatheter aortic valve implantation (TAVI). On day two after the procedure, echocardiography indicated normal aortic valve function. The CVC was to be removed on the fifth day post procedure. However, the procedure to install the catheter was not successful on the first attempt and ultrasonographic examination was not performed during CVC implantation and use. Therefore, ultrasonographic assessment of the vasculature was performed as a safety precaution before extraction. Ultrasonography revealed a floating thrombus in the distal part of the right internal jugular vein and a mural thrombus in the proximal part of the right internal jugular vein (Figs 1, 2). This resulted in cessation of the dual antiplatelet therapy and the addition of 12-hourly 0.4-ml subcutaneous doses of low-molecular-weight heparin (LMWH), continuing after the antibiotic course was completed. After four days of anticoagulation treatment, there was still a floating thrombus in the distal jugular vein; however, it was smaller than before, based on colour Doppler ultrasonography of the local blood vessels (Figs 3, 4). The presence of residual jugular vein thrombosis was re-assessed after eight days of anticoagulation therapy, and no apparent thrombosis was observed (Fig. 5). Thereafter, LMWH was discontinued, the CVC was removed, and the patient did not experience a pulmonary embolism or any other complications. Fig. 1. Ultrasonography revealing a proximal mural thrombus (red arrow) in the right internal jugular vein catheterisation. Department of Cardiology, West China Hospital and West China School of Nursing, Sichuan University, Chengdu, Sichuan, China Xin Huang, BSc, huangsanjin1234@163.com
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