Sticky Situations: Persistent Bacteremia Resolved Only After Thrombus Aspiration

Introduction: Central venous access devices have been associated with risk of thrombus formation. Septic thrombosis in cardiac chambers and central veins are rare complications. Management includes prolonged antibiotics with or without clot removal. We present a case of port-associated septic thrombus and persistent bacteremia that resolved after thrombus aspiration.


Description: A 64-year-old male with past medical history of thymus cancer and known port-associated right atrial thrombus presented with hypoxemia. Notably, the patient had a known 25 mm x 13 mm thrombus on the basal inferior wall of the right atrium noted on prior cardiac MRI weeks prior to admission. The patient’s hypoxemia progressed, needing intubation as well as pressor support for septic shock. A computed tomography pulmonary angiogram was negative for pulmonary embolism but revealed tree-in-bud nodularity with consolidated opacities in multiple lobes bilaterally concerning for multifocal pneumonia. Blood cultures and pneumonia panel were positive for methicillin-resistant Staphylococcus aureus. Due to the concern for septic emboli, his port was removed. However, despite port removal and appropriate antibiotic coverage with vancomycin and ceftaroline, repeat blood cultures remained positive. A transesophageal echocardiogram (TEE) confirmed persistence of the right atrial thrombus despite being on anticoagulation. It was therefore determined that the patient may benefit from removal of the thrombus in order to clear his blood cultures. Thrombus aspiration was performed utilizing a minimally invasive catheter approach rather than surgical, and his repeat blood cultures post-thrombectomy were negative.


Discussion: Clinicians should maintain a high index of suspicion in patients with persistent bacteremia. Thrombus that has been seeded with infectious organisms runs the risk of hematogenous dissemination and septic emboli. Moreover, in a retrospective analysis of device-related intracardiac septic thrombosis, source control with surgical removal of clot has lower rates of complication when compared to patients that were medically managed. However, open surgical interventions carry risk and require careful pre-surgical assessment; non-surgical thrombectomy may offer a safer option for smaller clots to achieve bacterial clearance.