Case report
Open heart surgery for management of right auricular thrombus related to central venous catheterization
Cirugía a corazón abierto para el tratamiento de trombo auricular derecho relacionado con cateterización venosa central
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Ribeiro, I.S. Neto, I. Maia, C. Dias" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A.F." "apellidos" => "Ribeiro" "email" => array:1 [ 0 => "ana.filipa.ribeiro@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I.S." "apellidos" => "Neto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Maia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Dias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Anesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Anesthesiology, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Neurocritical Care Unit, Intensive Care Department, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cirugía a corazón abierto para el tratamiento de trombo auricular derecho relacionado con cateterización venosa central" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 882 "Ancho" => 950 "Tamanyo" => 64310 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Contrast-enhanced computed tomography scan showing right atrial thrombus (arrow) attached to the central venous catheter.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Central venous catheterization is often necessary to treat critically ill patients hospitalized in intensive care units. However, this procedure can lead to serious and sometimes life-threatening mechanical, infectious, or thrombotic complications.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Thrombosis associated with central venous catheters (CVC) may be classified into three types: pericatheter sheath, thrombotic occlusion of the catheter lumen, and mural thrombosis, either superficial or deep vein.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Catheter-induced right atrial thrombosis (CRAT) is a serious complication of central venous cannulation, and has a reported incidence of 2–29%, depending on the series.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> It usually occurs 6–8 weeks after catheter insertion, and has been associated with triple-lumen catheters for chemotherapy, intravenous fluids or parenteral nutrition, pulmonary artery catheters, and implantable venous access devices.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">CRAT may have severe consequences, leading to pulmonary embolism, partial obstruction of the tricuspid valve, endocarditis, right heart failure, electromechanical dissociation, cardiac arrest, cardiogenic or septic shock,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> which have a mortality rate of up to 45%. No controlled studies to define the optimal management of CRAT have been performed.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We describe the case of a 38-year-old man who developed CRAT 35 days after placement of a CVC.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case presentation</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 38-year-old man with a history of chronic alcohol abuse and smoking was found unconscious in his home, with an initial Glasgow Coma Scale score of 4 (O1V1M2), anisocoria and clinical suspicion of bronchoaspiration. Head computed tomography (CT) showed a large left acute subdural hematoma with mass effect and cerebral edema causing a 24<span class="elsevierStyleHsp" style=""></span>mm right midline shift. Laboratory tests on admission were normal, including coagulation screening, except for liver function tests (alanine transaminase 75<span class="elsevierStyleHsp" style=""></span>U/L, gamma-glutamyl transferase 853<span class="elsevierStyleHsp" style=""></span>U/L), mean cell volume 109.4<span class="elsevierStyleHsp" style=""></span>fL, and urine positive for benzodiazepines.</p><p id="par0035" class="elsevierStylePara elsevierViewall">He was admitted to the neurocritical care unit after primary left frontotemporoparietal decompressive craniectomy, intubated, sedated, mechanically ventilated, with normal intracranial pressure despite persistent anisocoria. On day 4, head CT showed radiological improvement without ischemia. However, several complications occurred during hospitalization (Supplementary Material Online), including acute renal failure, which called for continuous hemofiltration with citrate anticoagulation for about 3 months, and required long-term intravenous calcium/phosphate infusion.</p><p id="par0040" class="elsevierStylePara elsevierViewall">On day 114, a control CT scan revealed an irregular mass at the tip of the CVC, measuring ∼55<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>mm and extending from the superior vena cava to the right atrium, confirmed by echocardiography.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The CVC, placed in the right-sided cervical vessels, had been changed 4 times before thrombus diagnosis, the last change being 35 days previously. All CVCs were triple-lumen 7 Fr indwelling catheters made of radiopaque polyurethane. Cannulation was always performed using the anatomical landmark approach, under sterile conditions, using chlorhexidine as the preferred antiseptic solution. Nursing care involved cleaning the injection ports with 70% alcohol before use, daily catheter insertion site evaluation, and change of transparent dressings at least every 7 days. The catheters were replaced as needed, namely in the case of suspicion of catheter-related infection, signs of phlebitis, or malfunction.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Mechanical thromboprophylaxis with intermittent pneumatic compression was initially chosen. Later, initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) required anticoagulation with unfractionated heparin (UFH). Therapeutic anticoagulation was maintained for 10 days after withdrawal of VA-ECMO, following which prophylaxis with low molecular weight heparin was administered, until thrombus diagnosis.</p><p id="par0055" class="elsevierStylePara elsevierViewall">A few management options were considered. We followed the suggestion of the vascular surgery department to start UFH under clinical surveillance. The interventional radiologist was consulted about the possibility of CRAT removal, but this was ruled out due to the risk of embolization. Consequently, an alternative approach was considered: systemic thrombolysis through the catheter lumen with 0.5<span class="elsevierStyleHsp" style=""></span>mg/h alteplase for 24<span class="elsevierStyleHsp" style=""></span>h, with no complications. Despite this treatment, a new contrast-enhanced CT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed a calcified CRAT of 80<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>mm. Finally, despite the initial reluctance of the thoracic surgery team, the patient underwent on-pump cardiac surgery 3 months after diagnosis. The mass, firmly adhered to the walls of the superior vena cava, was resected and the catheter was withdrawn. Pathological examination showed a 60<span class="elsevierStyleHsp" style=""></span>mm fibrin thrombus with calcifications. Microbiological culture of the thrombus and catheter was negative.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Eight months later, the patient was discharged to the intermediate care unit, conscious, oriented and cooperative, with no neurological deficits, and with good pain control.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Right atrial thrombi (RAT) are diagnosed and characterized by echocardiography: type A are highly mobile, thromboembolic in nature, and found in structurally normal atria; type B thrombi are attached to the atrial wall, and found in structurally abnormal atria or in the presence of foreign bodies,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> namely catheters, such as the one described in this case. Indeed, some studies suggest that the presence of a catheter in the vein will decrease blood flow and potentially create venous stasis. Furthermore, the risk of thrombosis has been shown to increase in parallel with catheter size. The material used in the manufacture of the catheter influences the risk of thrombosis: prospective trials have shown that silicone and second- and third-generation polyurethane, as used in our patient, have fewer thrombotic complications than materials such as polyvinylchloride or polyethylene.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Some authors recommend positioning the tip of the catheter in the distal portion of the superior vena cava or at its junction with the right atrium (RA).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> In our patient, the tip of the catheter was placed within the RA, and this may have increased the risk of RAT.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The presumptive mechanism of thrombus calcification is precipitation of calcium salts and their deposition on a pre-existing thrombus. In total parenteral nutrition, the mechanism of calcification seems to be multifactorial. In our case, citrate anticoagulation for continuous hemofiltration and total parenteral nutrition may have played a role in this event.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The CVC management protocol in use in our unit includes CVC replacement on demand instead of scheduled changes, as recommended by most guidelines.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Ultrasound-guided CVC placement was not used, since it is not available in our unit. An anterior/posterior chest radiograph is performed after insertion to rule out complications, such as pneumothorax, and to confirm the position of the catheter tip. However, it is often inaccurate and subject to inter-observer variability. Although our practice is to place the catheter tip in the superior vena cava (SVC) or the SVC/atrial junction, in this case the real position of the CVC tip in the RA was not noticed until thrombus diagnosis. The main complications associated with positioning the tip of the CVC in the RA include cardiac perforation and tamponade, cardiac arrhythmia, and catheter-induced thrombosis. However, the RA location provides optimal performance and superior functional durability.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Thromboprophylaxis in this patient was based on American College of Chest Physicians Guidelines for prevention of venous thromboembolism in critically ill patients, which recommend mechanical prophylaxis with intermittent pneumatic compression until bleeding risk decreases, followed by pharmacologic thromboprophylaxis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In our patient, who was admitted for an acute subdural hematoma, the balance between the risk of bleeding versus thrombosis was initially hard to determine; later, however, it became clear that the risk of thrombosis outweighed the risk of bleeding.</p><p id="par0090" class="elsevierStylePara elsevierViewall">CRAT may be found incidentally on imaging, as in our patient, or may be clinically suspected, although symptoms are non-specific,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> and may require echocardiography for confirmation. Transthoracic echocardiography (TTE) can easily and quickly diagnose an intracardiac mass; however, transesophageal echocardiography has greater sensitivity and specificity, and can detect small thrombi beyond the resolution of TTE.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Cardiac magnetic resonance imaging with gadolinium contrast can be a useful tool for diagnosis and tissue characterization.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Determining the best treatment approach that guarantees complete resolution of the thrombus while avoiding fragmentation and subsequent pulmonary embolism is a challenge for physicians. As there is no standard treatment, the strategy must be individualized.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Management strategies for CRAT include anticoagulation (heparin, warfarin), thrombolysis (streptokinase, urokinase and recombinant tissue-type plasminogen activator), surgical evacuation, percutaneous retrieval, and some recent alternative therapies, combined with removal of the CVC after an initial period of anticoagulation. According to some authors, catheter removal is recommended as the first step in the management of CRAT.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Surgical thrombectomy is not superior to anticoagulation; however, it is indicated in certain situations. Percutaneous intravascular removal of the thrombus is an alternative if performed by experienced surgeons.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Systemic thrombolysis is particularly indicated for type A thrombi, but is less effective in type B thrombi, especially when associated with a structurally abnormal atrium or with catheters.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Nevertheless, some successful cases have been described in the literature.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The use of recombinant tissue-type plasminogen activators, such as alteplase, has proved successful in dissolving intracardiac thrombi, especially if used early. Perhaps the greatest concern when using thrombolytic agents in patients with RAT is the risk of thrombus displacement into the pulmonary artery, circulatory collapse, and major bleeding. In this case, systemic thrombolysis following our alteplase protocol was attempted, without success. Transcatheter thrombolysis was also reported; however, no studies have directly compared catheter-directed with systemic thrombolysis for the management of CRAT.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The emergence of ultrasound-guided catheter-directed thrombolysis, which uses sound wave to enhance local thrombolytic delivery by accelerating the fibrinolytic process, is another treatment modality with a relatively lower risk of hemorrhage compared to systemic thrombolysis.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Surgical thrombectomy, usually performed under cardiopulmonary bypass, is recommended in cases where anticoagulation is contraindicated or in the presence of large thrombi >60<span class="elsevierStyleHsp" style=""></span>mm, and allows concomitant cardiac abnormalities to be corrected during the procedure.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Percutaneous intravascular removal of CRAT is recommended when other treatment modalities are contraindicated due to the risk of mechanical displacement, perforation, and technical difficulties, especially in dealing with large thrombi. It should only be performed by experienced surgeons.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Our case illustrates the management of an incidentally diagnosed calcified CRAT. Due the lack of validated recommendations, a multidisciplinary team met on several occasions to discuss treatment alternatives. Initially, surgery and percutaneous thrombectomy were ruled out, since the risks seemed to out-weigh the benefit. Instead, the thrombus was treated medically; but this was unsuccessful. Three months after the initial diagnosis, the patient underwent surgery, which was considered the best option, given thrombus size and calcification.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The most appropriate therapeutic management of such thrombi remains to be determined.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,9</span></a> Further studies are required to identify risk factors for calcified CRAT and define the best treatment, in order to prevent catastrophic complications such as massive pulmonary embolus, right heart failure, endocarditis and sepsis.</p><p id="par0130" class="elsevierStylePara elsevierViewall">This case report highlights the difficulty of reaching an early, accurate diagnosis, which is so important in patients with the previously mentioned risk factors. When radiographic control of CVC placement is uncertain, ultrasound should be performed to avoid positioning the tip of the CVC within the RA, especially in long-standing CVCs. More regular CVC replacement in patients with multiple risk factors for thrombosis must be considered in our unit. Suspicion of CRAT can be rapidly and accurately confirmed by cardiac ultrasound. Given the limited recommendations available, especially for a thrombus with such characteristics, the therapeutic strategy should be individualized in each patient.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1065105" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1013117" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1065106" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1013116" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case presentation" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 8 => array:2 [ "identificador" => "xack360407" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-30" "fechaAceptado" => "2018-01-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1013117" "palabras" => array:5 [ 0 => "Central venous catheter" 1 => "Catheter-related thrombosis" 2 => "Calcified right atrial thrombus" 3 => "Surgical removal" 4 => "Thrombolysis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1013116" "palabras" => array:5 [ 0 => "Catéter venoso central" 1 => "Trombosis asociada a catéter" 2 => "Trombo auricular derecho calcificado" 3 => "Extirpación quirúrgica" 4 => "Trombólisis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Central venous catheters are widely used in critically ill patients; however, they are also associated with increased morbidity and mortality. The literature may underestimate the incidence of catheter-inducible right atrial thrombi that are asymptomatic but potentially life threatening. The recognized risk factors for its development include infections related to the catheter, endothelial injury secondary to mechanical and chemical damage induced by certain medications and infused fluids. The characteristics of the patient and the catheter, such as size, material, type, location and ease of insertion, as well as the duration of placement play an additional role.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 38-year-old man, who developed an asymptomatic catheter-inducible right atrial thrombi requiring open-heart surgery, after taking a central venous catheter for thirty-five days. The present case highlights existing limitations in making a correct and fast diagnosis, which should be anticipated in patients with multiple risk factors for thrombosis. Given the limited recommendations available, we consider that the most appropriate strategy should be individualized.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Los catéteres venosos centrales se utilizan de manera generalizada en pacientes críticos; sin embargo, también se asocian a una elevada morbimortalidad. La literatura puede subestimar la incidencia de los trombos auriculares derechos asociados a catéter venoso, que son asintomáticos, pero potencialmente de riesgo. Los factores de riesgo reconocidos para su desarrollo incluyen infecciones relativas al catéter y lesiones endoteliales secundarias al daño mecánico y químico inducido por ciertos fármacos y líquidos infundidos. También desempeñan un papel añadido las características del paciente y del catéter, tales como tamaño, material, tipo, localización y facilidad de inserción, y duración de la misma.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reportamos el caso de un varón de 38 años que desarrolló trombos auriculares derechos asintomáticos asociados a catéter venoso y precisó cirugía a corazón abierto tras cateterización venosa central durante 35<span class="elsevierStyleHsp" style=""></span>días. El presente caso destaca las limitaciones existentes a la hora de realizar un diagnóstico correcto y rápido, que debería anticiparse en pacientes con factores de riesgo múltiples de trombosis. Dadas las recomendaciones disponibles limitadas, consideramos que debería individualizarse la estrategia más adecuada.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ribeiro AF, Neto IS, Maia I, Dias C. Cirugía a corazón abierto para el tratamiento de trombo auricular derecho relacionado con cateterización venosa central. Rev Esp Anestesiol Reanim. 2018;65:398–402.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0155" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 882 "Ancho" => 950 "Tamanyo" => 64310 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Contrast-enhanced computed tomography scan showing right atrial thrombus (arrow) attached to the central venous catheter.</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 799916 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. 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We also acknowledge the staff of the neurocritical care unit for their contribution to this case.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006500000007/v1_201807260406/S2341192918300842/v1_201807260406/en/main.assets" "Apartado" => array:4 [ "identificador" => "65601" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000007/v1_201807260406/S2341192918300842/v1_201807260406/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300842?idApp=UINPBA00004N" ]
