Embolic complications from central venous hemodialysis catheters used with hypertonic citrate locking solution

Many hemodialysis patients continue to dialyze using central venous access catheters in clinical practice. Catheters are associated with a number of recognized complications, including infection, catheter-associated fibrin sheath and thrombus leading to malfunction, central venous stenosis, and right atrial thrombus. However, symptomatic catheter embolus rarely is reported. We report our experience of catheter-associated emboli in patients dialyzing with a twin catheter designed with multiple small side holes in combination with a hypertonic citrate locking solution. 8 patients developed symptomatic emboli from catheter-associated thrombus, typically resulting in sudden hypotension and chest pain shortly after starting hemodialysis, with documented pulmonary and cerebral emboli in 3 cases. Catheters with multiple side holes are susceptible to seepage of the catheter locking solution through the side holes and therefore may be at greater risk of catheter thrombus formation. This may be exacerbated by the use of a hypertonic citrate lock given to just fill the internal catheter lumen because hyperosmolar locks are more likely to leave the catheter tip, resulting in increased risk of catheter associated thrombus.