The risk of venous thromboembolism associated with midline catheters compared with peripherally inserted central catheters: A systematic review and meta-analysis

Thrombosis and infections associated with PICC in onco-hematological patients, what is their relevance?

PURPOSE

Peripherally inserted central venous catheters (PICC) in the onco-hematological patients may be associated with thrombosis or infections that may have short- to medium-term repercussions.

MATERIAL AND METHODS

Single-centre retrospective analysis of a prospectively collected cohort. Primary objective was to establish the PICC-thrombosis and infections incidence. Secondary objectives were to analyze profile of patients suffering from these complications and variables associated with an increased likelihood of developing these events.

RESULTS

549 patients were recruited. 58.5% (n = 321) were oncology patients and 41.5% (n = 228) hematology patients. The incidence of PICC-associated thrombosis was 3.5% (n = 19). Thrombosis was associated with progression of the underlying malignant pathology in 10.6% (n = 2) of cases. No association was found between clinical variables analysed and development of thrombosis. Incidence of PICC-associated infections was 7.65% (n = 42). In the 30 days prior to PICC infection, 57.1% (n = 24) had a febrile syndrome of another focus, 73.8% (n = 11) had been hospitalized, 49.5% (n = 25) had a neutrophil count of 0-500 cells/mm3 and 47.6% (n = 20) had an episode of neutropenic fever. Variables significantly associated with the development of infection were hematological patients, high-flow PICC, 3-lm PICC or PICC insertion because of administration of vesicant therapy.

CONCLUSIONS

Incidence of PICC-associated thrombosis is low and apparently less prognostically aggressive than other forms of thrombosis associated with cancer, without identify predictive factors. Infection was more prevalent and the identification of risk factors in our series could facilitate its prevention.

Poland's first vascular access team 3-year analysis: Insights and learnings

BACKGROUND

During the COVID-19 pandemic, Poland saw a surge in interest in midline catheters (MCs) and Long Peripheral Catheters (LPCs) for intravenous therapy. Before this, MCs were not extensively utilised in the country, and there was no formally established Polish vascular access team. MCs, which have been used for years in many countries, are now becoming increasingly common in Poland. This study aimed to analyse the use of MCs in a 3-year perspective of their introduction in daily clinical practice based on a nurse-led Vascular Access Team (VAT).

METHODS

The records of adult patients who received intravenous therapy with 727 MCs and 293 LPCs from January 2021 to December 2023 at the University Clinical Centre of the Medical University of Warsaw were analysed.

RESULTS

The main indication for cannulation was expected intravenous therapy over 5 days (81.66%, n = 833), of which 71.37% (n = 728) of patients in this group had concomitant difficult intravenous access (DIVA). Over 6 years, centrally inserted central catheters (CICCs) inserted due to DIVA were reduced from n = 108 in 2017 to n = 18 in 2023. The end of intravenous therapy was the reason for the removal of 64.6% of catheters (n = 659), including death and switch to CICCs as well. Complications leading to premature removal accounted for 31.2%, such as: occlusion (14.6%), patient self-removal (7.1%) and thrombosis (3.43%).

CONCLUSIONS

The introduction of MCs as a possible option for peripheral venous access reduces the use of CVCs. Developing MCs programmes should be based on investing in staff competencies, which increases success rates. The nurses and physicians should be trained in infusion care to achieve better results in the use of MCs and LPCs. Increasing the competence of nurses in Poland is necessary for the implementation of full-service and top-level functioning of VAT.

Complications associated to midline- and long peripheral catheters in adults. Systematic review of literature and proposal for a standardized model for data collection

INTRODUCTION

Long peripheral catheters (LPCs) and midline catheters (MCs) are indiscriminately labelled with different names, leading to misclassifications both in primary and secondary studies. The available studies used different methods to report the incidence of catheter-related complications, affecting the possibility of properly comparing the catheter outcomes. The aim of this review was to explore the complications related to LPCs and MCs after reclassifying according to their length.

METHODS

Systematic literature review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, conducted on PubMed, Scopus and CINAHL databases. The study protocol was registered in the International Prospective Register of Systematic Reviews. Data regarding LPCs and MCs were compared. Catheter outcomes were classified into major and minor complications, recomputed and reported as cases/1000 catheter-days.

RESULTS

Fourteen studies were included. Over-half of the devices were correctly labelled by the authors, misclassifications affected particularly LPCs improperly labelled MCs. The cumulative incidence of catheter-related bloodstream infections was 0.3 and 0.4/1000 catheter-days, that of symptomatic catheter-related thrombosis was 0.9 and 1.8/1000 catheter-days for MCs and LPCs, respectively. Minor complications and catheter failure were higher for LPCs.

CONCLUSIONS

A misclassification exists in the labelling of MCs and LPCs. A widespread heterogeneity of diagnostic criteria adopted to classify the catheters' outcomes was found, exposing the risk of misestimating the incidence of complications and undermining the possibility of effectively comparing results of the published research. We proposed a list of definitions and relevant variables as a first step toward the development of standardized criteria to be adopted for research purposes.

Risk factors analysis and the establishment of nomogram prediction model for PICC-related venous thrombosis in patients with lymphoma: a double-center cohort-based case-control study

Objective

The objective of this study is to examine the risk factors associated with the occurrence of PICC-Related Venous Thrombosis (PICC-RVTE) in individuals diagnosed with lymphoma, as well as to develop a predictive risk nomogram model.

Methods

A total of 215 patients with lymphoma treated at Yunnan Provincial Tumor Hospital from January 2017 to December 2020 were retrospectively evaluated as the training cohort; 90 patients with lymphoma treated at the Department of Oncology of the First People's Hospital of Anning, Affiliated to Kunming University of Science and Technology during the January 2021 to September 2023 were evaluated as the validation cohort. Independent influencing factors were analyzed by logistic regression, a nomogram was developed and validated, and the model was evaluated using internal and external data cohorts for validation.

Results

A total of 305 lymphoma patients were selected and 35 (11.48%) PICC-RVTE occurred, the median time was 13 days. The incidence within 1-2week was 65.71%. Multivariate analysis suggested that the activity amount, thrombosis history(within the last 12 months), ATIII, Total cholesterol and D-dimer levels were independently associated with PICC-RVTE, and a nomogram was constructed based on the multivariate analysis. ROC analysis indicated good discrimination in the training set (area under the curve [AUC] = 0.907, 95%CI:0.850-0.964) and the testing set (AUC = 0.896, 95%CI: 0.782-1.000) for the PICC-RVTE nomogram. The calibration curves showed good calibration abilities, and the decision curves indicated the clinical usefulness of the prediction nomograms.

Conclusions

Patients should be advised to undergo color Doppler ultrasound system testing within two week after the implantation of a PICC catheter to detect PICC-RVTE at an early stage. The validated nomogram can be used to predict the risk of catheter-related thrombosis (CRT) in patients with lymphoma who received at least one chemotherapy after PICC catheterization, no bleeding tendency, no recent history of anticoagulant exposure and no severe heart, lung, renal insufficiency. This model has the potential to assist clinicians in formulating individualized treatment strategies for each patient.

Complications of Pediatric Midline Catheters: A Prospective Observational Pilot Study

BACKGROUND

Midline catheters are peripheral intravenous (IV) catheters in which the tip of the catheter does not reach the central circulation. In children, the use of midline catheters could lead to decreased complications from central venous catheters. To validate the safety of midline catheter use in children, we aimed to describe the complications and dwell time of pediatric midline catheters. The primary outcome was the incidence of catheter-related venous thromboembolism (VTE).

METHODS

We conducted an observational, prospective study including consecutive patients at a tertiary multidisciplinary pediatric hospital. One hundred pediatric midline catheters were followed for thrombotic, infectious, and mechanical complications. After catheter removal, Doppler ultrasonography was performed to detect asymptomatic VTE.

RESULTS

The mean age was 6.0 years (standard deviation [SD], 4.7), and median catheter dwell time was 6 (4-8) days. Most midline catheters were inserted in arm veins, most commonly in the basilic vein (56%). Catheter-related VTE was diagnosed in 30 (30%; 95% confidence interval [CI], 21%-40%) cases, corresponding to an incidence rate of 39 (95% CI, 26-55) cases per 1000 catheter days. Eight of 14 saphenous vein catheters were complicated by VTE compared to 22 of 86 arm vein catheters, suggesting an imbalance in favor of arm vein insertion site. Two patients needed anticoagulation therapy due to catheter-related VTE. Thirty (30%) catheters were removed unintentionally or due to complications, 22 of these needed additional IV access to complete the intended therapy. No catheter-related bloodstream infection (95% CI, 0%-4%) occurred. Mechanical complications occurred in 33 (33%; 95% CI, 24%-43%) midline catheters.

CONCLUSIONS

In children, thrombotic and mechanical complications of midline catheters are common, but only few VTEs are severe enough to warrant anticoagulation therapy. Systemic infectious complications are rare. Seventy-eight percent of patients did not need additional venous access to complete short-term IV therapy. Considering the rate of clinically relevant complications and the catheter dwell time, pediatric midline catheters could be an alternative to central venous access for short-term (5-10 days) IV therapy.

Risk Factors for Coated Midline Catheter-Related Thrombosis: A Secondary Analysis of Existing Trial Data

Midline catheter-related thrombosis (MCRT) is a high-stakes complication. The authors aimed to explore risk factors for the development of symptomatic MCRT, including patient, procedure, catheter, and vein characteristics. This study performed an analysis of existing trial data that compared MCRT in 2 MCs with differing antithrombotic properties. Cox regression was used for univariable and multivariable analyses to evaluate the primary outcome of MCRT. Among 191 patients in this analysis, the average age was 60.2 years (standard deviation = 16.7 years), and 59.7% were female (114/191). Clinical indications for MC placement included antibiotics (60.7%), difficult venous access (32.5%), or both (6.8%). Body temperature ≥38°C (adjusted hazard ratio [aHR] = 6.26; 95% CI, 1.24-20.29; P = .03), catheter-to-vein ratio >0.40 (aHR = 2.65; 95% CI, 0.99-6.74; P = .05), and MC distance from antecubital fossa >7.0 cm (aHR = 2.82; 95% CI, 1.10-7.90; P = .03), were each significantly associated with the higher risk of the occurrence of symptomatic MCRT. This study found that catheter-to-vein ratio >0.40, distance from the antecubital fossa >7 cm, and body temperature ≥38°C were each associated with higher risk of MCRT. Current practices should be modified to include a minimum vein size to avoid MC insertions that occupy >40% of a given vein. Further research is needed to explain the impact of the catheter tip position and fever in relation to MCRT.

Risk of midline catheter-related thrombosis due to catheter diameter: An observational cohort study

OBJECTIVE

Deep vein thrombosis is a common and serious complication associated with midline catheters (MC). The aim of this investigation was to determine if catheter diameter is related to development of thrombosis.

METHODS

This was an observational cohort study conducted at a tertiary care academic center in Southeastern Michigan. Hospitalized adults that required a MC were eligible participants. Primary outcome was symptomatic MC associated upper extremity deep vein thrombosis (DVT) comparing three catheter diameters. Secondary outcomes included complications based on size and DVT comparing catheter to vein ratio.

RESULTS

Between January 1, 2017, and December 31, 2021, 3088 MCs met inclusion criteria; the distribution of 3 French (Fr), 4 Fr, and 5 Fr MCs was 35.1 %, 57.0 %, and 7.9 %, respectively. The majority of the population was female (61.2 %) and the average age was 64.2 years old. DVT occurred in 4.4 %, 3.9 %, and 11.9 % of 3 Fr, 4 Fr, and 5 Fr MCs, respectively (p < 0.001). In multivariable regression analysis, there was no difference in the odds of developing DVT for the 4 Fr MC compared to the 3 Fr (aOR 0.88; 95 % CI 0.59-1.31; p = 0.5243), however, there was significantly higher odds for the 5 Fr (aOR 2.72; 95 % CI 1.62-4.51; p = 0.001). Additionally, for every additional day the MC was in place, the odds of DVT increased by 3 % (aOR 1.03; 95 % CI 1.01-1.05; p = 0.0039). When comparing accuracy of the size model versus catheter to vein ratio model for predicting DVT, receiver operating characteristic curve analysis demonstrated the area under the curve for size was 73.70 % (95 % CI 68.04 %-79.36 %) compared to 73.01 % (95 % CI: 66.88 %-79.10 %) for catheter-to-vein ratio.

CONCLUSIONS

Smaller diameter catheters should be preferentially chosen to mitigate the risk of thrombosis when therapy via midline catheters is required. Choosing a catheter based on reduced size or 1:3 catheter to vein ratio threshold has similar accuracy in predicting DVT.

The Association of Vasopressor Administration through a Midline Catheter with Catheter-related Complications

Rationale: Little is known about the safety of infusing vasopressors through a midline catheter. Objectives: To evaluate safety outcomes after vasopressor administration through a midline. Methods: We conducted a cohort study of adults admitted to 39 hospitals in Michigan (December 2017-March 2022) who received vasopressors while either a midline or peripherally inserted central catheter (PICC) was in place. Patients receiving vasopressors through a midline were compared with those receiving vasopressors through a PICC and, separately, to those with midlines in place but who received vasopressors through a different catheter. We used descriptive statistics to characterize and compare cohort characteristics. Multivariable mixed effects logistic regression models were fit to determine the association between vasopressor administration through a midline with outcomes, primarily catheter-related complications (bloodstream infection, superficial thrombophlebitis, exit site infection, or catheter occlusion). Results: Our cohort included 287 patients with midlines through which vasopressors were administered, 1,660 with PICCs through which vasopressors were administered, and 884 patients with midlines who received vasopressors through a separate catheter. Age (median [interquartile range]: 68.7 [58.6-75.7], 66.6 [57.1-75.0], and 67.6 [58.7-75.8] yr) and gender (percentage female: 50.5%, 47.3%, and 43.8%) were similar in all groups. The frequency of catheter-related complications was lower in patients with midlines used for vasopressors than PICCs used for vasopressors (5.2% vs. 13.4%; P < 0.001) but similar to midlines with vasopressor administration through a different device (5.2% vs. 6.3%; P = 0.49). After adjustment, administration of vasopressors through a midline was not associated with catheter-related complications compared with PICCs with vasopressors (adjusted odds ratios [aOR], 0.65 [95% confidence interval, 0.31-1.33]; P = 0.23) or midlines with vasopressors elsewhere (aOR, 0.85 [0.46-1.58]; P = 0.59). Midlines used for vasopressors were associated with greater risk of systemic thromboembolism (vs. PICCs with vasopressors: aOR, 2.69 [1.31-5.49]; P = 0.008; vs. midlines with vasopressors elsewhere: aOR, 2.42 [1.29-4.54]; P = 0.008) but not thromboses restricted to the ipsilateral upper extremity (vs. PICCs with vasopressors: aOR, 2.35 [0.83-6.63]; P = 0.10; model did not converge for vs. midlines with vasopressors elsewhere). Conclusions: We found no significant association of vasopressor administration through a midline with catheter-related complications. However, we identified increased odds of systemic (but not ipsilateral upper extremity) venous thromboembolism warranting further evaluation.

Quantified versus willful handgrip exercises for the prevention of PICC-related thrombosis: A meta-analysis and systematic review

BACKGROUND

Thrombosis is a common yet serious complication in patients with peripherally inserted central venous catheter (PICC), the prevention of thrombosis is very important to the prognosis of PICC patients. We aimed to evaluate the effects of quantified versus willful grip exercises for the prevention of PICC-related thrombosis, to provide evidence to the clinical nursing care of PICC patients.

METHODS

Two authors searched PubMed et al databases for randomized controlled trials (RCTs) comparing the effects of quantified versus willful grip exercises in PICC patients up to August 31, 2022. Quality assessment and data extraction were independently performed by 2 researchers, and meta-analysis was performed using RevMan 5.3 software.

RESULTS

15 RCTs involving 1741 PICC patients were finally included in this meta-analysis. Synthesized outcomes indicated that compared with willful grip exercises, quantified grip exercises reduced the incidence of PICC-related thrombosis (odds ratio = 0.19, 95% confidence interval [CI]: 0.12-0.31) and infection (odds ratio = 0.30, 95% CI: 0.15-0.60) in PICC patients, increased the maximum venous velocity (mean difference = 3.02, 95% CI: 1.87-4.17) and mean blood flow (mean difference = 3.10, 95%CI: 1.57-4.62) in PICC patients (all P < .05). There were no publication biases amongst the synthesized outcomes (all P > .05).

CONCLUSION

Quantified grip exercises can effectively reduce the occurrence of PICC-related thrombosis and infection, improve the venous hemodynamics. Limited by study population and regions, large-sample, and high-quality RCTs are still needed in the future to further evaluate the effects and safety of quantified grip exercises in PICC patients.

Clinical study of complications of a peripherally inserted central catheter in cancer patients

AIM

To evaluate complications after PICC use in cancer patients.

DESIGN

This was a clinical and retrospective study in which the risk factors and complications of PICC use were evaluated.

METHODS

This study was carried out in the patient, emergency room, and intensive care units through the evaluation of electronic medical records. To assess the association between qualitative variables, the chi-squared test or Fisher's exact test was used, and to compare the reason for withdrawal, the Kruskal-Wallis test was applied.

RESULTS

A total of 359 patients (53.5% men) with 43.1 ± 14 years who had a PICC (88% with solid tumours) were evaluated. The most common complications were mechanical complications (61.2%), infection (38%), and thrombosis (57.1%). Patients with double-lumen catheters experienced thrombosis (85.7%). This study demonstrated the effectiveness of PICC and that patients with haematological cancer are more prone to multiple PICC passages and more mechanical complications and infections.

Thrombophilia Impact on Treatment Decisions, Subsequent Venous or Arterial Thrombosis and Pregnancy-Related Morbidity: A Retrospective Single-Center Cohort Study

(1) Background: Thrombophilia testing utility has remained controversial since its clinical introduction, because data on its influence on treatment decisions are limited. (2) Methods: We conducted a single-center retrospective cohort study of 3550 unselected patients referred for thrombophilia consultation at the Bern University Hospital in Switzerland from January 2010 to October 2020. We studied the influence of thrombophilia testing results on treatment decisions and evaluated the association between thrombophilia and thromboembolic and pregnancy-related morbidity events after testing up to 03/2021. (3) Results: In 1192/3550 patients (34%), at least one case of thrombophilia was found and 366 (10%) had high-risk thrombophilia. A total of 211/3550 (6%) work-ups (111/826 (13%) with low-risk thrombophilia and 100/366 (27%) with high-risk thrombophilia) led to an appropriate decision to extend or initiate anticoagulation, and 189 (5%) negative results led to the withholding of anticoagulation therapy inappropriately. A total of 2492 patients (69%) were followed up for >30 days, with a median follow-up of 49 months (range, 1−183 months). Patients with high-risk thrombophilia had a higher risk of subsequent venous thromboembolic events and pregnancy-related morbidity compared to those without thrombophilia. (4) Conclusions: Our study demonstrated the limited usefulness of thrombophilia work-up in clinical decision-making. High-risk thrombophilia was associated with subsequent venous thromboembolism and pregnancy-related morbidity.