Venous thromboembolism associated with long-term use of central venous catheters in cancer patients

Management of cancer-associated upper extremity deep vein thrombosis with and without venous catheters at a tertiary care center

INTRODUCTION

Data on management of upper extremity deep vein thrombosis (UEDVT) in patients with cancer is limited. The objective of this study was to determine risk factors for UEDVT and the rates of recurrence and bleeding in a real-world setting.

METHODS

Retrospective review of consecutive patients assessed for cancer-associated UEDVT. Outcome measures were recurrent venous thromboembolism (VTE), and major and clinically relevant non-major bleeding (CRNMB). Risk factors for recurrent VTE and bleeding were assessed.

RESULTS

Mean duration of follow-up was 7.2 months. Two hundred cases were identified; 69% were associated with a central line. Non-line associated UEDVT occurred more frequently in the setting of breast cancer, lung cancer and documented local mass effect. The incidence of recurrent VTE was 18.5%, of which 14 (37.8%) were ipsilateral UEDVT. The risk of recurrence is higher with male gender (HR 2.0, 95% CI; 1.0-4.0). Major and CRNMB occurred in 1% and 11.5%, respectively. Concurrent use of an antiplatelet agent was associated with a higher risk of CRNMB compared to anticoagulant therapy alone (HR 3.9, 95% CI; 1.4-10.7).

CONCLUSIONS

Presence of a venous catheter was the primary risk factor for UEDVT, however, extrinsic compression by local tumour may be just as important for some cancer types. Furthermore, the majority of recurrent events did not occur in the same upper limb suggesting that UEDVT may be predictive of increased thrombotic risk rather than just a local effect of catheters.

Central Venous Catheter-Associated Thrombosis in the Perioperative Period: A Frequent Complication in Cancer Patients that can be Detected Early with Doppler Examination

Aims and background

The aim of the study was to determine the incidence of venous thrombosis in cancer patients with central venous catheters inserted perioperatively.

Methods and study design

A prospective analysis was performed with 68 patients in whom central venous catheters were placed perioperatively. Cancer patients with planned central venous catheters had prophylaxis with low-molecular-weight heparin. Patient characteristics, procedure-related complications and venous thrombosis related to central venous catheters were recorded. In order to detect the venous thrombosis, color Doppler sonography was used after removal of the central venous catheter.

Results

The median age of the 68 patients was 55 years (range, 24–83). The median duration of catheter placement in patients was 9 days (range, 1–24). Venous thrombosis was detected in 45 (66.2%) patients: at the superficial veins (jugular and subclavian veins) in 27 patients, stretching from superficial veins into the vena cava in 8 cases, in the vena cava in 2 cases, in the right atrium in 2 cases, and at more then one place in 6 patients. Total thrombosis was detected only in 3 patients.

Conclusions

Cancer patients have a high central venous catheter-related thrombosis risk perioperatively despite prophylactic anticoagulation. Color Doppler sonography is a rapid and noninvasive technique and it is accurate in the diagnosis of venous thrombosis. Early detection of venous thrombosis is important to prevent the systemic and fatal complication of the thrombosis. Free full text available at www.tumorionline.it

Chemotherapy, Genetic Susceptibility, and Risk of Venous Thromboembolism in Breast Cancer Patients

PURPOSE

Venous thromboembolism (VTE) is highly heritable and a serious complication of cancer and its treatment. We examined the individual and joint effects of chemotherapy and genetic susceptibility on VTE risk in patients with breast cancer.

EXPERIMENTAL DESIGN

A Swedish population-based study including 4,261 women diagnosed with primary invasive breast cancer between 2001 and 2008 in Stockholm, followed until 2012. Risk stratification by chemotherapy and genetic susceptibility [a polygenic risk score (PRS), including nine established VTE loci] was assessed using Kaplan-Meier and flexible parametric survival analyses, adjusting for patient, tumor, and treatment characteristics.

RESULTS

In total, 276 patients experienced a VTE event during a median follow-up of 7.6 years. Patients receiving chemotherapy [HR (95% CI) = 1.98; 1.40-2.80] and patients in the highest 5% of the PRS [HR (95% CI) = 1.90; 1.24-2.91] were at increased risk of developing VTE. Chemotherapy and PRS acted independently on VTE risk and the 1-year cumulative incidence in patients carrying both risk factors was 9.5% compared with 1.3% in patients not having these risk factors (P < 0.001). Stratified analyses by age showed that the risk-increasing effect of PRS was stronger in older patients (P interaction = 0.04), resulting in an excess risk among genetically susceptible patients receiving chemotherapy aged ≥ 60 years (1-year cumulative incidence = 25.0%).

CONCLUSIONS

Risk stratification by chemotherapy and genetic susceptibility identifies patients with breast cancer at high VTE risk, who could potentially benefit from thromboprophylaxis. Our results further suggest that genetic testing is more informative in older patients with breast cancer. Clin Cancer Res; 22(21); 5249-55. ©2016 AACR.

Use of Pleuroperitoneal Shunt in Chylothorax Related to Central Line Associated Thrombosis in Sickle Cell Disease

Central vein thrombosis as a cause of chylothorax is uncommon, and in a few cases in the literature was related to thrombotic complications of central venous access devices (CVAD). Superior vena cava (SVC) occlusion-induced chylothorax has been described in adult sickle cell disease (SCD) in a setting of chronic indwelling CVAD. There are limited reports on chylothorax induced by central venous thrombosis secondary to chronic CVAD in children with SCD. We describe an 8-year-old male patient, with a history of SCD, maintained on long term erythrocytapheresis for primary prevention of stroke, and whose clinical course was complicated by chylothorax which was successfully treated with a pleuroperitoneal shunt.

Increased incidence of chemoport-related thrombosis in patients with colorectal cancer receiving bevacizumab: A single-institutional experience

Objective

Chemoport-related thrombosis (CRT) is a serious complication that causes morbidities and interrupts administration of intravenous cancer therapy. We investigated the incidence and risk of CRT in colorectal cancer (CRC) patients treated with bevacizumab (BEV).

Methods

We retrospectively reviewed 1,534 CRC patients who received chemotherapy with or without BEV using a chemoport between 2014 and 2016.

Results

The participants had a median age of 58 (18−85) years, and 60.3% were male. All participants were stratified into three groups: adjuvant chemotherapy (AC) (n=670), palliative chemotherapy (PC) without BEV (n=356), and PC with BEV (n=508). The median follow-up was 20.19 (interquartile range, 14.07−27.19) months. CRT occurred in 3.8% of all patients; incidence of symptomatic and asymptomatic CRT was 2.9% and 0.9%, respectively. CRT occurred more in patients with BEV (5.7%) than in patients without BEV (2.9%, P=0.008). The cumulative incidence of CRT in patients administered PC with BEV was significantly higher than that in those administered AC (P=0.011) and there was a trend toward increased CRT in patients administered PC with BEV compared with those administered PC without BEV (P=0.044). Multivariate analysis found that BEV treatment was the only variable that was significantly associated with CRT (hazard ratio, 2.06; 95% confidence interval, 1.24−3.43; P=0.006).

Conclusions

BEV treatment was significantly associated with increased incidence of CRT in CRC patients.

Anti-fouling strategies for central venous catheters

Central venous catheters (CVCs) are ubiquitous in the healthcare industry and carry two common complications, catheter related infections and occlusion, particularly by thrombus. Catheter-related bloodstream infections (CRBSI) are an important cause of nosocomial infections that increase patient morbidity, mortality, and hospital cost. Innovative design strategies for intravenous catheters can help reduce these preventable infections. Antimicrobial coatings can play a major role in preventing disease. These coatings can be divided into two major categories: drug eluting and non-drug eluting. Much of these catheter designs are targeted at preventing the formation of microbial biofilms that make treatment of CRBSI nearly impossible without removal of the intravenous device. Exciting developments in catheter impregnation with antibiotics as well as nanoscale surface design promise innovative changes in the way that physicians manage intravenous catheters. Occlusion of a catheter renders the catheter unusable and is often treated by tissue plasminogen activator administration or replacement of the line. Prevention of this complication requires a thorough understanding of the mechanisms of platelet aggregation, signaling and cross-linking. This article will look at the advances in biomaterial design specifically drug eluting, non-drug eluting, lubricious coatings and micropatterning as well as some of the characteristics of each as they relate to CVCs.

Incidence, risk factors, and outcomes of central venous catheter-related thromboembolism in breast cancer patients: the CAVECCAS study

Previous epidemiologic studies investigating central venous catheter (CVC)‐related venous thromboembolism (CRT) were conducted in heterogenous cancer populations and data in breast cancer (BC) remain limited. To investigate the Doppler ultrasound (DUS)‐CRT incidence, risk factors and outcomes in BC, we designed a prospective, multicenter cohort of nonmetastatic invasive BC patients undergoing insertion of a CVC for chemotherapy. All patients underwent double‐blind DUS before, 7, 30, and 90 days after CVC insertion and a 6 months clinical follow‐up. Symptomatic DUS‐CRT were treated by anticoagulants. D‐Dimers, thrombin generation, and platelet‐derived microparticles were measured before and 2 days after CVC placement. In DUS‐CRT patients, a nested case–control study analyzed the role of thrombophilia. Among 524 patients, the DUS‐CRT (14 symptomatic, 46 asymptomatic) cumulative probability was 9.6% at 3 months and 11.5% at 6 months (overall incidence rate: 2.18/100 patient‐months). Ten/14 symptomatic DUS‐CRT were detected on double‐blind DUS before the clinical symptoms, and 3/14 had a simultaneous pulmonary embolism. No clinical thrombotic event subsequently occurred in untreated asymptomatic DUS‐CRT. Age >50 years (OR, 1.80; 95% CI, 1.01–3.22), BMI >30 kg/m² (OR, 2.64; 95% CI, 1.46–4.76) and comorbidities (OR, 2.05; 95% CI, 1.18–3.56) were associated with DUS‐CRT. No biomarkers was found to predict DUS‐CRT. In multivariate analysis, BMI >30 kg/m² (OR, 2.66; 95%CI, 1.46–4.84) and lobular carcinoma histology (OR, 2.56; 95%CI, 1.32–4.96) remained the only significant DUS‐CRT risk factors. Thrombophilia did not account for DUS‐CRT. Only clinical parameters identified high risk DUS‐CRT patients who may be considered for thromboprophylaxis.

The Michigan Risk Score to predict peripherally inserted central catheter-associated thrombosis

Essentials How best to quantify thrombosis risk with peripherally inserted central catheters (PICC) is unknown. Data from a registry were used to develop the Michigan Risk Score (MRS) for PICC thrombosis. Five risk factors were associated with PICC thrombosis and used to develop a risk score. MRS was predictive of the risk of PICC thrombosis and can be useful in clinical practice.

SUMMARY

Background Peripherally inserted central catheters (PICCs) are associated with upper extremity deep vein thrombosis (DVT). We developed a score to predict risk of PICC-related thrombosis. Methods Using data from the Michigan Hospital Medicine Safety Consortium, image-confirmed upper-extremity DVT cases were identified. A logistic, mixed-effects model with hospital-specific random intercepts was used to identify factors associated with PICC-DVT. Points were assigned to each predictor, stratifying patients into four classes of risk. Internal validation was performed by bootstrapping with assessment of calibration and discrimination of the model. Results Of 23 010 patients who received PICCs, 475 (2.1%) developed symptomatic PICC-DVT. Risk factors associated with PICC-DVT included: history of DVT; multi-lumen PICC; active cancer; presence of another CVC when the PICC was placed; and white blood cell count greater than 12 000. Four risk classes were created based on thrombosis risk. Thrombosis rates were 0.9% for class I, 1.6% for class II, 2.7% for class III and 4.7% for class IV, with marginal predicted probabilities of 0.9% (0.7, 1.2), 1.5% (1.2, 1.9), 2.6% (2.2, 3.0) and 4.5% (3.7, 5.4) for classes I, II, III, and IV, respectively. The risk classification rule was strongly associated with PICC-DVT, with odds ratios of 1.68 (95% CI, 1.19, 2.37), 2.90 (95% CI, 2.09, 4.01) and 5.20 (95% CI, 3.65, 7.42) for risk classes II, III and IV vs. risk class I, respectively. Conclusion The Michigan PICC-DVT Risk Score offers a novel way to estimate risk of DVT associated with PICCs and can help inform appropriateness of PICC insertion.

The risk of venous thromboembolism associated with peripherally inserted central catheters in ambulant cancer patients

Background

Deep vein thrombosis (DVT) is a common complication of peripherally inserted central catheters (PICCs). PICCs are increasingly utilised in the management of cancer patients, a group which carries both additional risks for vascular thromboembolism as well as for complex morbidity. We analysed a cohort of cancer patients subjected to PICC insertion in a single cancer centre for the incidence of all-type vascular thromboembolism (VTE) and investigated relative risk factors.

Methods

In this clinical audit, the records of patients referred for PICC insertion in our centre in the period between 1/1/2011 and 1/4/2014 were retrospectively reviewed. The primary outcomes investigated were a) PICC-related deep vein thrombosis (PRDVT) and b) distant VTE (lower limb DVT and pulmonary embolism). 4Fr single lumen PICCs were placed in all patients. The Kaplan Meier method was used to study time from PICC insertion to PRDVT/VTE. Survival curves were compared using the log rank method. Logistic and Cox regression analyses were used to assess local, distant and combined endpoints.

Results

Four hundred ninety patients were included in the analysis of which 27 (5.5%) developed a PRDVT. Statistically significant risk factors for developing PRDVT in multivariate analysis included more than one attempt for insertion (OR 2.61, 95%CI: 1.12–6.05) and the use of fluoropyrimidine containing chemotherapy (OR 4.27, 95%CI 1.3–14.07). Twenty-six patients developed a distant VTE. Male gender was the only significant risk factor for distant VTE. When all-type VTE were considered together fluoropyrimidine containing chemotherapy (OR 4.54, 95% CI 1.63–12.61), male gender (OR 2.03, 95% CI 1.04–3.93) and white cell count (OR 1.12, 95% CI 1.00–1.26) were statistically significant as risk factors in this analysis.

Conclusions

This is a large study of VTE following PICC insertion in cancer patients which also looks at the rate of distant VTE. The observed PRDVT incidence is comparable with available literature. Fluoropyrimidine containing chemotherapy and more than one attempt for PICC insertion were independent predictors of PICC-associated VTE whilst the former remained an independent predictor of all-type VTE. Anticoagulation did not prevent thrombotic events in this cohort.

Prevalence of deep venous thrombosis detected by ultrasonography before surgery in patients with gastric cancer: a retrospective study of 1140 consecutive patients

BACKGROUND

The prevalence of deep venous thrombosis (DVT) in patients with gastric cancer before surgery is unknown. This study aimed to clarify the risk factors for DVT of the lower extremities in patients with gastric cancer before surgery and to evaluate the usefulness of ultrasonographic screening for prevention of postoperative pulmonary thromboembolism (PTE).

METHODS

Patients who had undergone lower-extremity venous ultrasonography before surgery for gastric cancer were retrospectively analyzed. Univariate and multivariate logistic regression analyses were performed to identify the predictors of DVT before surgery. Perioperative management of patients with DVTs and the incidence of postoperative PTE were investigated.

RESULTS

Of the total 1140 patients, 86 had DVT preoperatively. On univariate analysis, the incidence of DVT was significantly higher with: female sex; age ≥80 years; PS ≥ 1 (vs. PS = 0); stage IV (vs. stages I-III); history of preoperative chemotherapy; and the presence of a central venous catheter (CVC). Multivariate logistic regression analysis demonstrated that sex, age ≥80 years, PS ≥ 1, history of preoperative chemotherapy, and the presence of CVC were significantly correlated with DVT before surgery. Postoperative PTE occurred in 2 patients with proximal DVT. No patients in whom DVT was not detected developed PTE.

CONCLUSIONS

Female sex, older age, worse PS, the presence of CVC, and a history of preoperative chemotherapy were the independent risk factors for DVT. Routine lower-extremity venous ultrasonographic screening is useful for prevention of PTE because it can identify patients at high or low risk for PTE.

Cateteres venosos totalmente implantáveis: histórico, técnica de implante e complicações

O acesso ao sistema venoso, seja para coleta de amostras de sangue ou para infusão de soluções, é de vital importância para o diagnóstico e tratamento de pacientes com as mais variadas condições clínicas. Desde que Harvey, em 1616, descreveu o sistema circulatório a partir de estudos em animais e que Sir Christopher Wren, 4 décadas depois, realizou a primeira infusão endovenosa em seres vivos, a evolução na técnica de acesso e nos dispositivos para infusão tem sido constante. Merece destaque a criação dos cateteres de longa duração na década de 1970, em especial os totalmente implantáveis, que revolucionaram o tratamento do câncer, aumentando a segurança e o conforto dos pacientes oncológicos. Este artigo tem como objetivo a revisão de dados históricos relativos ao acesso vascular e a discussão da técnica de implante e das principais complicações associadas ao procedimento de colocação e ao uso dos cateteres totalmente implantáveis.

Catheter-related infections in patients with haematological malignancies: novel preventive and therapeutic strategies

Central venous catheters are essential for the treatment of patients with haematological malignancies and the recipients of stem-cell transplant. This patient population is, however, at high risk for catheter-related bloodstream infections that can result in substantial morbidity, mortality, and health-care-associated costs. Efficient prevention, early diagnosis, and effective treatment are essential to providing the best care to these patients. Although confirming the catheter as a source of infection remains challenging, the Infectious Diseases Society of America definition of catheter-related bloodstream infection remains the most precise definition to use in these patients. Gram-positive bacteria, particularly coagulase-negative Staphylococcus spp, remain the leading cause of catheter-related bloodstream infection, although an increase in Gram-negative bacteria as the causative agent has been noted. Although removal of the line and appropriate intravenous antibiotics remain the mainstay of treatment in most cases, novel technologies, including exchange with antibiotic-coated catheters and treatment with lock solutions, are particularly relevant in this patient population. In this Review we present the types of central venous catheters used in this patient population and analyse the different definitions of catheter-related infections, with an overview of their prevention and management.

Analysis of anticoagulation strategies for venous thromboembolism during severe thrombocytopenia in patients with hematologic malignancies: a retrospective cohort

The safety and efficacy of anticoagulation for venous thromboembolism (VTE) at times of severe thrombocytopenia is unclear. In this retrospective study, we evaluated patients with hematologic malignancy and either (1) acute or chronic VTE on anticoagulation before platelet count dropped below 50 × 10⁹/L or (2) acute VTE occurring while platelets were <50 × 10⁹/L. In 78 eligible patients, the primary outcomes of time to recurrent VTE or clinically significant bleeding within 100 d were compared by management strategy. Bleeding occurred in 27% of patients receiving anticoagulation versus 3% when anticoagulation was held (IRR 10.1, 95% CI 1.5-432.6). Recurrent VTE occurred in 2% of patients receiving anticoagulation versus 15% when anticoagulation was held (IRR 0.17, 95% CI 0.0-1.51). Most bleeding occurred before day 31(11/13), but recurrent VTE mostly occurred after day 40 (5/6). Our findings suggest that temporarily withholding anticoagulation for VTE during severe thrombocytopenia in patients with hematologic malignancies might reduce adverse outcomes.

Cancer and Venous Thromboembolic Disease: A Review

Venous thromboembolism (VTE), including deep-vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in cancer patients. Patients with cancer are six times more likely to develop VTE than their noncancer counterparts, and VTE is the second leading cause of death in cancer patients. Despite the publication of major consensus guidelines setting out recommendations for thromboprophylaxis in cancer patients, there remains a gulf between these guidelines and clinical practice. In general, thromboprophylaxis is recommended for most patients hospitalized with active cancer. Furthermore, outpatient thromboprophylaxis may be used in carefully selected high-risk ambulatory patients. Certain areas of controversy still remain. Although low-molecular-weight heparin has been shown to be superior to vitamin K antagonists in cancer patients, the role of direct oral anticoagulants is still uncertain. Moreover, recurrent thromboembolism, bleeding, and thrombocytopenia are frequently seen in cancer patients. Optimal anticoagulation in such instances presents a major challenge to clinicians. Modern computed tomography techniques have resulted in an increase in the detection of "incidental" VTE. Despite a growing body of evidence promulgating standard anticoagulant treatment in such cases, these cases present further challenges for members of the multidisciplinary team. The Oncologist 2017;22:199-207Implications for Practice: This article discusses venous thromboembolism (VTE) in patients with malignancy. Practical guidance is offered on how to prevent, diagnose, and treat VTE in cancer patients. The management of "challenging" cases of VTE is also discussed.

Twenty-five Years of Advances in Vascular Access: Bridging Research to Clinical Practice

Vascular access has become a key component for a multitude of IV therapies, including parenteral nutrition. Access of the central venous system has been long recognized for its associated complications of infection, thrombosis, and occlusion. Over the past 25 years, clinical practice based on research and innovation has attempted to decrease complication rates and therefore improve the safety of vascular access. This article highlights the research and its influence on catheter care procedures, technology, and education that has led to advances in vascular access. An improved understanding of the pathophysiology associated with catheter-related complications and an ongoing evaluation of new treatment modalities has provided clinicians today with new options for improved patient care and the ability to preserve vascular access options for patients.

Thrombosis in an Internal Jugular Vein and an Upper Limb Deep Vein Treated with Edoxaban

A 45-year-old man complained of swelling of the left side of his neck and left upper limb. Ultrasonography and enhanced computed tomography (CT) revealed thrombosis of the left internal jugular, subclavian, and brachiocephalic vein. Based on various examinations, the patient was diagnosed with idiopathic venous thrombosis early in his clinical course. There were no findings to suggest malignancy or abnormal coagulability. However, two months after the start of treatment, the patient was diagnosed with gastric cancer. Despite the presence of Trousseau syndrome, treatment with edoxaban (an oral anticoagulant), reduced the swelling dramatically without any bleeding complications.

A Missing Guide Wire After Placement of Peripherally Inserted Central Venous Catheter

BACKGROUND Central venous catheterization is a common tool used in critically ill patients to monitor central venous pressure and administer fluids and medications such as vasopressors. Here we present a case of a missing guide wire after placement of peripherally inserted central catheter (PICC), which was incidentally picked up by bedside ultrasound in the intensive care unit.  CASE REPORT A 50-year-old Hispanic male was admitted to the intensive care unit for alcohol intoxication. He was managed for septic shock and required placement of a peripherally inserted central line in his left upper extremity for antibiotics and vasopressor administration. A bedside ultrasound performed by the intensivist to evaluate upper extremity swelling revealed a foreign body in the left arm. Percutaneous procedure by Interventional radiologist was required for retrieval of the guidewire. CONCLUSIONS Guide wire related complications are rarely reported, but are significantly associated with mortality and morbidity. The use of ultrasound guidance placement of PICC lines decreases the risk of complications, provides better optimal vein selection, and enhances success.

Implantable port thrombosis in cancer patients: a monocentric experience

Objective:

Implantable port thrombosis (IPT) in cancer patients is a relatively rare but severe complication. Several factors are reportedly associated with the occurrence of thrombosis. We aimed to describe the prevalence and the anatomoclinical features of IPT observed in cancer patients who were treated in a medical oncology department in Tunisia.

Methods:

A total of 600 cancer patients who had port implantation from January 2013 to December 2015 were retrospectively identified. Cases with symptomatic/incidental IPT (radiologically confirmed) were further identified. Epidemiological and anatomoclinical features were collected from patient records and the department database.

Results:

We observed that 33 of the 600 patients had IPT; thus, the prevalence was 5.5%. The median age was 57 years, and the gender ratio was 0.43. Overweight or obesity was observed in 73% of the patients. IPT occurred mainly in patients with breast (36.4%) and colorectal (33.3%) cancers, which were mostly nonmetastatic (79%). At least one identified classical thromboembolic risk factor was found in 13 patients (smoking in 9, tamoxifen in 2). IPT was symptomatic in 93% of the cases, occurring within an average time of 56 days. Implantable ports were removed because of infection in 2 cases and nonfunctionality in 3 cases. IPT treatment was based on low-molecular-weight heparins (94%) and antivitamin K (6%) for an average of 130 days. Four patients had post-therapy complications: one thrombosis recurrence and three infections.

Conclusions:

IPT cases in the 600 patients were observed to occur in obese nonmetastatic cancer patients within the first 3 months after IP implantation.

Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices: a meta-analysis of comparative studies

Background

A totally implantable venous access device (TIVAD) provides reliable, long-term vascular access and improves patients’ quality of life. The wide use of TIVADs is associated with important complications. A meta-analysis was undertaken to compare the internal jugular vein (IJV) with the subclavian vein (SCV) as the percutaneous access site for TIVAD to determine whether IJV has any advantages.

Methods

All randomized controlled trials (RCTs) and cohort studies assessing the two access sites, IJV and SCV, were retrieved from PubMed, Web of Science, Embase, and OVID EMB Reviews from their inception to December 2015. Random-effects models were used in all analyses. The endpoints evaluated included TIVAD-related infections, catheter-related thrombotic complications, and major mechanical complications.

Results

Twelve studies including 3905 patients published between 2008 and 2015, were included. Our meta-analysis showed that incidences of TIVAD-related infections (odds ratio [OR] 0.71, 95 % confidence interval [CI] 0.48–1.04, P = 0.081) and catheter-related thrombotic complications (OR 0.76, 95 % CI 0.38–1.51, P = 0.433) were not significantly different between the two groups. However, compared with SCV, IJV was associated with reduced risks of total major mechanical complications (OR 0.38, 95 % CI 0.24–0.61, P < 0.001). More specifically, catheter dislocation (OR 0.43, 95 % CI 0.22–0.84, P = 0.013) and malfunction (OR 0.42, 95 % CI 0.28–0.62, P < 0.001) were more prevalent in the SCV than in the IJV group; however, the risk of catheter fracture (OR 0.47, 95 % CI 0.21–1.05, P = 0.065) were not significantly different between the two groups. Sensitivity analyses using fixed-effects models showed a decreased risk of catheter fracture in the IJV group.

Conclusion

The IJV seems to be a safer alternative to the SCV with lower risks of total major mechanical complications, catheter dislocation, and malfunction. However, a large-scale and well-designed RCT comparing the complications of each access site is warranted before the IJV site can be unequivocally recommended as a first choice for percutaneous implantation of a TIVAD.

Significance of Echocardiographically Detected Central Venous Catheter Tip-Associated Thrombi

PURPOSE

To explore significance, management, and outcomes of central venous catheter (CVC) tip-associated thrombi incidentally detected on echocardiography.

MATERIALS AND METHODS

Echocardiogram data from all patients with CVCs from October 2009 to June 2011 were reviewed (N = 170). Patients with CVC tip-associated thrombi were selected (n = 49). Echocardiograms were reviewed for ejection fraction, presence of patent foramen ovale (PFO), presence of other intracardiac shunts, and mean thrombus size. Management decisions, thrombus extension, pulmonary embolism, paradoxical emboli, and stroke within 3 months were recorded.

RESULTS

Mean thrombus size was 2.1 cm (range, 0.5-5.7 cm). Of patients with thrombi, 11 (22%) were already on anticoagulation, and there was no change in management. Anticoagulation was started without complications in 17 (35%) patients, the catheter was removed in 4 (8%) patients, and no new treatment was initiated in 17 (35%) patients. Of these 17 patients, 16 (94%) developed no complications. One (6%) patient with a PFO and right-to-left shunt experienced a stroke before PFO closure. After surgical closure of the PFO, the same patient developed catheter tip-associated thrombus without complication. There were no pulmonary emboli, strokes, or other detected embolic phenomena.

CONCLUSIONS

In this sample with CVC tip-associated thrombi but without PFO or other intracardiac shunts, no embolic or other complications were detected, regardless of anticoagulation status. These data suggest a benign course for such thrombi and that anticoagulation, catheter removal, thrombectomy, and thrombolysis may be unnecessary when catheter tip-associated thrombi are incidentally detected on echocardiography.

Peripherally Inserted Central Catheter-Related Upper Extremity Venous Thrombosis in Oncology Patients: A Prospective Study Based on Doppler Sonography

OBJECTIVES

Peripherally inserted central catheters (PICCs) are associated with an increased risk of venous thrombosis. This study had 2 objectives: to estimate the incidence of upper extremity venous thrombosis associated with PICCs in oncology patients and to evaluate the role of Doppler sonography in antithrombotic prophylaxis.

METHODS

We conducted a prospective study with each patient being followed for 6 weeks. From April 2014 to October 2014, we analyzed a series of 245 consecutive oncology patients undergoing chemotherapy via PICCs, for an overall number of 246 PICC placements. We assessed the role of Doppler sonography for initiation of antithrombotic prophylaxis. The study group encompassed 2 cohorts of patients: those who received regular weekly Doppler screening for thrombosis prophylaxis and those who did not.

RESULTS

Of 246 insertions, we observed 90 episodes of upper extremity venous thrombosis (36.59%); 62 of them were asymptomatic in the Doppler group, and 28 were symptomatic in the no-Doppler group. Patients in the Doppler group had a significantly lower rate of thrombosis (0%) than those in the no-Doppler group (23.53%; P < .01).

CONCLUSIONS

Our prospective study suggests that the rate of PICC-related upper extremity venous thrombosis in oncology patients is high, and the occurrence of symptomatic thrombosis could be lowered with regular weekly Doppler screening after PICC insertions.

Venous Thromboembolism in Cancer: An Update of Treatment and Prevention in the Era of Newer Anticoagulants

Cancer patients are at major risk of developing venous thromboembolism (VTE), resulting in increased morbidity and economic burden. While a number of theories try to explain its pathophysiology, its risk stratification can be broadly done in cancer-related, treatment–related, and patient-related factors. Studies report the prophylactic use of thrombolytic agents to be safe and effective in decreasing VTE-related mortality/morbidity especially in postoperative cancer patients. Recent data also suggest the prophylactic use of low molecular weight Heparins (LMWHs) and Warfarin to be effective in reducing VTEs related to long-term central venous catheter use. In a double-blind, multicenter trial, a new ultra-LMWH Semuloparin has shown to be efficacious in preventing chemotherapy-associated VTE’s along with other drugs, such as Certoparin and Nadoparin. LMWHs are reported to be very useful in preventing recurrent VTEs in advanced cancers and should be preferred over full dose Warfarin. However, their long-term safety beyond 6 months has not been established yet. Furthermore, this paper discusses the safety and efficacy of different drugs used in the treatment and prevention of recurrent VTEs, including Bemiparin, Semuloparin, oral direct thrombin inhibitors, parenteral and direct oral factor Xa inhibitors.

Outcome of Sub-Massive Pulmonary Thromboemboli in Patients Who Received Thrombolytic and or Non-Thrombolytic Therapy

Background

Thrombolytic therapy in patients with sub-massive pulmonary embolism (SMPTE) needs further assessment.

Objectives

The current study aimed to assess a potential benefit of thrombolytic and non-thrombolytic therapy in patients with SMPTE.

Patients and Methods

One hundred-nineteen patients were enrolled with SMPTE from 2006 to 2010 in the tertiary care center of Rajaie medical and research center. The patients who had pulmonary thromboemboli (PTE) and received thrombolytic plus heparin therapy and or non-thrombolytic (unfractionated heparin alone) were evaluated for hemodynamic changes (blood pressure, pulse rate, pulmonary artery systolic pressure, right ventricular failure and right ventricle enlargement), before and after 48 hours of treatment. The mortality rate was also assessed.

Results

Forty-five percent of the patients with SMPTE received thrombolytic therapy (streptokinase) and 55% of SMPTE patients received non-thrombolytic therapy (unfractionated heparin). Pulse rate, pulmonary arterial pressure and tricuspid regurgitation gradient in patients receiving thrombolytic therapy reduced significantly (P = 0.001, P = 0.01 and P = 0.001, respectively). There was no significant difference before and after treatment regarding systolic blood pressure (P = 0.4), diastolic blood pressure (DBP) (P = 0.5), systolic arterial pressure (SPAP) (P = 0.1), Right ventricular (RV) function (P = 0.1) and RV size (P = 0.1). In patients who received a non-thrombolytic therapy, there were no significant differences between the groups regarding SBP (P = 0. 2), DBP ( P= 0. 4) and PR (P = 0. 1), SPAP (P = 0.6), TRG (P = 0.4), RV function (P = 0.4) and RV size (P = 0.2) before and after treatment. There were no significant differences between the groups according to mortality rate.

Conclusions

Thrombolytic therapy lead to earlier relief of hemodynamic condition in comparison to non-thrombolytic therapy but no changes were observed in mortality rate.

The Role of Inferior Vena Cava Filters in Cancer Patients

Cancer induces a hypercoagulable state and renders patients susceptible to venous thromboembolism. While anticoagulation remains the mainstay of treatment, many of these patients require placement of an inferior vena cava (IVC) filter, often due to a contraindication to or failure of anticoagulation. In this article, the available data on IVC filter usage in cancer patients will be reviewed.

Catheter-related thrombosis: A practical approach

Catheter-related thrombosis is a relatively common complication of central venous catheter insertion. Central venous catheter use is ubiquitous in the critical care setting and often in patients with multiple risk factors for venous thromboembolism. With a trend towards increased use of peripherally inserted central catheters, the incidence of catheter-related thrombosis is likely to increase further. Despite the scale of the problem, there is a paucity of evidence-based guidelines concerning the management of patients with catheter-related thrombosis, particularly in critically unwell patients. This has led to heterogeneity in clinical practice. In this review, we describe the risk factors for developing catheter-related thrombosis and provide practical advice for clinicians on how to recognise, diagnose and treat this common problem.

Intestinal Failure: Adaptation, Rehabilitation, and Transplantation

Intestinal failure (IF) is a state in which the nutritional demands are not met by the gastrointestinal absorptive surface. A majority of IF cases are associated with short-bowel syndrome, which is a result of malabsorption after significant intestinal resection for numerous reasons, some of which include Crohn's disease, vascular thrombosis, and radiation enteritis. IF can also be caused by obstruction, dysmotility, and congenital defects. Recognition and management of IF can be challenging, given the complex nature of this condition. This review discusses the management of IF with a focus on intestinal rehabilitation, parenteral nutrition, and transplantation.

Surface modification of a polyethylene film for anticoagulant and anti-microbial catheter

A functional anticoagulant and anti-bacterial coating for polyethylene (PE) films is described. The stepwise preparation of this nanocomposite surface coating involves O2 plasma etching of PE film, carbodiimide coupling of cysteamine to the etched PE film, binding of Ag to sulfhydryl groups of cysteamine, and assembly of heparin capped AgNPs on the PE film. The nanocomposite film and its components were characterized by 1H-nuclear magnetic resonance spectroscopy, attenuated total reflectance-Fourier transform infrared spectroscopy, X-ray photoelectron spectroscopy, and field emission-scanning electron microscopy. The resulting PE films demonstrate anticoagulant activity using a hemoglobin whole blood clotting assay, and anti-bacterial activity against Bacillus cereus 3551 (Gram-positive) and Escherichia coli BL21 (Gram-negative) bacteria. The hydrophilicity of the heparin coated PE was determined by contact angle measurements; and the stability of the nanocomposite film, with respect to Ag leaching, was assessed by atomic absorption spectroscopy.

The Role of New Oral Anticoagulants (NOACs) in Cancer Patients

New oral anticoagulants (NOACs) are likely to have a major impact in the next few years, changing clinical practice of anticoagulation therapy. Evidence on its efficacy and superiority to vitamin K antagonists (VKAs) in treating non-cancer patients have been reported in a few clinical trials. However, patients with cancer are complicated by the prothrombotic nature of the disease, need for potentially invasive surgery and interventions, and altered drug handling. This chapter examines the available evidence and guidelines on the use of NOAC in patients with cancer.

Presentation and impact of catheter-associated thrombosis in patients with infected long-term central venous catheters: a prospective bicentric observational study

BACKGROUND

Catheter-associated thrombosis (CAT) in patients with infected long-term central venous catheter (LTCVC) has been poorly studied.

METHODS

We prospectively included patients with infected LTCVC and collected clinical data. Doppler ultrasound was systematically performed to screen for CAT. Outcome (death or infection relapse) was evaluated 12 weeks after infection diagnosis.

RESULTS

90 patients were included and CAT was diagnosed in 27 (30%). Local signs suggesting infection were more frequent in patients with CAT than without (11/27 versus 8/63, p = 0.03). Outcome was similar in patients with and without CAT. However, median duration of antimicrobials was longer (18 versus 14 days, p = 0.02), catheter removal tended to be more frequent (24/27 versus 46/63, p = 0.08), and anticoagulant therapy more often prescribed (17/27 versus 6/63, p < 0.01) in patients with CAT than without. Patients with occlusive thrombosis were more likely to have Staphylococcus aureus infections (4/7 versus 1/17, p = 0.02) and prolonged positivity of blood-cultures (3/7 versus 1/15, p = 0.02), than patients with non-occlusive thrombosis.

CONCLUSION

CAT is associated with local signs suggesting infection. A more aggressive treatment in CAT cases allowed a similar outcome at 12 weeks between patients with and without CAT. Occlusive thrombosis represented a subgroup of patients at risk of delayed clearance of bacteremia.

Cisplatin-Based Chemotherapy for Testicular Germ Cell Tumors: Complication Rates of Peripheral versus Central Venous Administration

OBJECTIVE

Despite the low local toxicity of the used agents, Cisplatin-based chemotherapy (CBP) for patients with testicular germ cell tumors (TGCT) is mostly delivered via a central venous access (CVA). Since 2008, CBP is given peripherally in our hospital.

METHODS

Medical reports of TGCT patients who received CBP between September 1991 and August 2014 were evaluated. Complications regarding the way of administration (CVA vs. peripheral venous catheter [PVC]) were classified according to the Common Terminology Criteria of Adverse Events. The complication rates were compared using chi square test and propensity score matching.

RESULTS

During 288 cycles in 109 patients, 85 complications (29.5%) were observed with similar rates for overall (PVC 31.3%, CVA 29.9%; p = 0.820) and grade I complications (21.3%, 25.4%; p = 0.470). More grade II complications were observed in the PVC group (10.0 vs. 1.5%; p < 0.001). Grade III complications requiring invasive treatment were found only in the CVA group (3.0%; p = 0.120). Using propensity score matching, no differences in overall (p = 0.950), grade I (p = 0.540) and grades II/III (p = 0.590) complications were seen.

CONCLUSION

The peripheral and central administration of CBP has similar overall complication rates. Despite more grade II complications, the peripheral administration of CBP is a safe alternative for TGCT patients. Additionally, no severe grade III complications occurred.

Venous Thromboembolism in Patients Diagnosed With Lung Cancer

PURPOSE

Considering the high prevalence of lung cancer, our purpose was to summarize the existing literature to identify the several factors that contribute to the increased risk of venous thromboembolism (VTE) in patients with lung cancer and to analyze the current recommendations for thromboprophylaxis and treatment of VTE in those patients.

METHODS

We searched the Medline and EMBASE databases from February 1985 to February 2014 to identify retrospective and prospective randomized controlled studies that investigate one or more risk factors for VTEs in patients with lung cancer.

RESULTS

A VTE is a major complication for patients diagnosed with lung cancer. The risk factors for VTE events in patients with lung cancer consist of cancer-related (histological type and stage of cancer), treatment-related (surgery, chemotherapy, angiogenic agents, and supportive care agents), and patient-related factors (comorbidities, immobility, performance status, and prior thrombosis). Low-molecular-weight heparins are recommended for long-term treatment of cancer-associated thrombosis. Duration of anticoagulant therapy beyond 6 months should be based on individual clinical evaluation. Thromboprophylaxis for patients with lung cancer during hospitalization and immediate postoperative period is well established.

CONCLUSIONS

Efforts to assess thrombotic risk in patients with lung cancer may improve therapeutic and preventive strategies in the future, with final goal to minimize the burden and consequences of thrombotic events in patients with lung cancer.

Incidence of Venous Thromboembolic Events in Mandated Risk Assessment versus Optional DVT Prophylaxis Era at a Large Tertiary Cancer Center

Cancer patients are thought to be at high risk for venous thromboembolic events (DVT/PE). Beginning in October 2007, our tertiary cancer center instituted “mandated risk assessment” computerized DVT prophylaxis order entry, for all hospital admissions with an option for active opt out by the physician with a stated reason. Retrospective review of all DVT/PE events within 30 days of a hospital admission [any inpatient admission (IA) and outpatient surgery (OPS)] in comparable “optional (O)” (January 2005—September 2007) vs “mandated risk assessment (M)” (October 2007–May 2010) DVT prophylaxis order eras. Patient demographics, admission details, type of prophylaxis, treatment, and outcome were also analyzed. There were 16,363 for the O (11,944 IA/4,419 OPS) and 17,757 for the M (12,957 IA/4,800 OPS) DVT prophylaxis order eras. The number of DVT/PE events in the O era was 67 (prevalence 0.41%) versus 102 for the M era (prevalence 0.57%), P = 0.037. In the DVT/PE patients, DVT prophylaxis had been ordered during the index admission in 66 per cent for O versus 83 per cent for M ( P = 0.008). Low-molecular-weight heparin was increasingly used in M era (33% vs 16%, P = 0.009). There was also no difference between O vs M era for status at DVT/PE diagnosis (outpatient 36% vs 24%) or associated symptoms. There were no deaths attributable to DVT/PE in the O era versus 3 deaths in the M era. Although DVT prophylaxis use improved with “mandated risk assessment” ordering, the DVT/PE incidence did not decrease. It may be difficult to overcome the surprisingly low baseline prevalence and multiple risk factors in this population.

The surgery of the long-term central venous accesses in oncology

The implantation of Long-Term Central Venous Catheters (LTCVC) in cancer patients has been essential to conduct the oncological treatments of today. The complexity of the protocols requires accuracy on the management of such devices in order to keep them long-functioning. The article focuses on such subject from an oncological perspective, pointing out threats of the disease to the central venous system (CVS) and the ways to face them successfully. The most salient points related to surgical techniques and the insights to follow-up long-term inserted catheters are discussed. An anatomical classification is suggested to help understand occurrence of malpositions and to north the necessary maneuvers of repositioning. Such matters are based on 3000 LTCVC-placements performed by the author at the Brazilian National Cancer Institute (INCA) between 1999 and 2011. As nearly 30% of the patients presented some sort of anatomical disorder at the moment of the surgery, it was judged worthy to address such experience to those young surgical oncologists willing to tackle LTCVCs in Cancer Units.

A RIETE registry analysis of recurrent thromboembolism and hemorrhage in patients with catheter-related thrombosis

BACKGROUND

Few studies have investigated the treatment and the outcomes of patients with catheter-related thrombosis (CRT).

METHODS

The RIETE registry (Registro Informatizado de Enfermedad TromboEmbólica [Computerized Registry of Patients with Venous Thromboembolism]) is a prospective international registry of consecutive patients with objectively confirmed venous thromboembolism (VTE). We analyzed the characteristics, treatment, and outcomes of patients with CRT.

RESULTS

Of 558 patients with CRT, 45 (8%) presented with a pulmonary embolism (PE) concomitantly. More patients had central line-associated thrombosis compared with port systems, but catheter type did not influence the risk of presenting with a PE. Patients with only CRT were more often prescribed low-molecular-weight heparin for the duration of their anticoagulant treatment compared with patients presenting with concomitant PE. VTE recurrences and major bleeding events occurred frequently during treatment with anticoagulation (7 per 100 patient-years and 8.9 per 100 patient years, respectively). The rates of fatal PE recurrences (1.85 per 100 patient-years) and fatal bleeding (2.32 per 100 patient-years) were similar. Patients with an additional transient risk factor for VTE had the lowest risk for VTE recurrences (odds ratio [OR], 0.07; 90% confidence interval [CI], 0.01-0.45) compared with patients with CRT and no additional transient risk factors. PE at presentation increased the risk of recurrent thrombosis by 2.4 times. Renal insufficiency was also an independent predictor of recurrent thrombosis (OR, 3.93; 90% CI, 2.0-7.7). The odds of recurrent thrombosis was decreased by 77% in patients who received anticoagulation therapy for >90 days compared with patients with a shorter treatment (OR, 0.23; 90% CI, 0.1-0.56).

CONCLUSIONS

Concomitant PE occurs less frequently in CRT than lower extremity deep venous thrombosis, but it is associated with a worse outcome. CRT occurs in high-risk patients, and duration of anticoagulation must be predicated on balancing these risks.

Central venous catheter-related thrombosis in senile male patients: New risk factors and predictors

Central venous catheterization (CVC)-related venous thrombosis is a common but serious clinical complication, thus prevention and treatment on this problem should be extensively investigated. In this research, we aimed to investigate the incidence rate of CVC-related venous thrombosis in senile patients and give a further discussion on the related risk factors and predictors. A total of 324 hospitalized senile male patients subjected to CVC were selected. Retrospective investigation and analysis were conducted on age, underlying diseases, clinical medications, catheterization position and side, catheter retention time, and incidence of CVC-related venous thrombosis complications. Basic laboratory test results during catheterization and thrombogenesis were also collected and analyzed. Among the 324 patients, 20 cases (6.17%) of CVC-related venous thrombosis were diagnoseds. The incidence rate of CVC-related venous thrombosis in subclavian vein catheterization was significantly lower than that in femoral vein catheterization (P<0.01) and that in internal jugular vein catheterization (P<0.05). No statistically significant difference was found between femoral vein catheterization and internal jugular vein catheterization (P<0.05). Previous venous thrombosis history (P<0.01), high lactate dehydrogenase level (P<0.01), low high-density lipoprotein (HDL) level (P<0.05), and low albumin level (P<0.05) were found as risk factors or predictors of CVC-related venous thrombosis in senile male patients. Subclavian vein catheterization was the most appropriate choice among senile patients to decrease the incidence of CVC-related venous thrombosis. Previous venous thrombosis history, high lactate dehydrogenase level, low HDL level, and low albumin level were important risk factors in predicting CVC-related venous thrombosis.

Incidence of ultrasound-detected asymptomatic long-term central vein catheter-related thrombosis and fibrin sheath in cancer patients

BACKGROUND

Most central venous catheter (CVC)-related deep vein thromboses (DVT) are asymptomatic and their incidence and clinical relevance are still under debate. Data on CVC-related fibrin sheaths are scarce. We investigated the incidence of asymptomatic DVT and fibrin sheaths in cancer patients with long-term CVC implantation who underwent Doppler ultrasound surveillance at 1, 6, and 12 months after implantation. Effects of low-weight molecular heparin (LWMH) therapy on DVT and fibrin sheaths were also analyzed.

MATERIAL AND METHODS

This prospective study was performed on a large cohort (n = 400) of patients with cancer aged >18 requiring long-term CVC implantation for chemotherapy infusion. CVC was implanted by a trained qualified staff, according to standardized protocol in a specific surgery. Patients underwent ultrasound examination at 1 and 6 months after CVC implantation to detect 'early' (1 month) and 'late' (6 months) asymptomatic DVT or fibrin sheaths incidence. Sixty-nine patients underwent US examination also 12 months after CVC implantation.

RESULTS

The incidence of CVC-related thrombosis was 0.10 events per 1000 catheter days. Anticoagulation therapy with LWMH resolved 50% of DVT, but no CVC needed removing. Incidence of new onset fibrin sheaths was 0.71 events per 1000 catheter days. Fibrin sheaths resolution occurred independently of LWMH therapy.

DISCUSSION

The incidence of asymptomatic DVT in our patients with long-term CVC is very low and does not represent per se an indication for removal of functioning CVC in patients with cancer. Fibrin sheaths are frequent (13%) and never associated with CVC dysfunction.

CONCLUSION

Asymptomatic DVT and fibrin sheaths do not represent per se an indication for removal of functioning CVC in cancer patients who need central vein access.