Factor V Leiden in central venous catheter-associated thrombosis

Complications of Factor V Leiden in Adults Undergoing Noncardiac Surgical Procedures: A Systematic Review

Factor V Leiden is the commonest hereditary prothrombotic allele, affecting 1% to 5% of the world's population. The objective of this study was to characterize the perioperative and postoperative outcomes of patients with Factor V Leiden compared to patients without a diagnosis of hereditary thrombophilia. This was a focused systematic review of studies including adult (>18 years) patients with Factor V Leiden (heterozygous or homozygous) undergoing noncardiac surgery. Included studies were either randomized controlled trials or observational. The primary clinical outcomes of interest were thromboembolic events occurring from the perioperative period up to 1 year postoperatively, defined as deep venous thrombosis, pulmonary embolism, or other clinically significant thrombosis occurring during or after a surgical procedure. Secondary outcomes included cerebrovascular events, cardiac events, death, transplant-related outcomes, and surgery-specific morbidity. Pediatric and obstetrical patients were excluded, as were case reports and case series. Databases searched included MEDLINE and EMBASE from inception until August 2021. Study bias was assessed through the CLARITY (Collaboration of McMaster University researchers) Risk of Bias tools, and heterogeneity through analysis of study design and end points, as well as the I 2 statistic with its confidence interval and the Q statistic. A total of 5275 potentially relevant studies were identified, with 115 having full text assessed for eligibility and 32 included in the systematic review. On the whole, the literature suggests that patients with Factor V Leiden have an increased risk of perioperative and postoperative thromboembolic events compared to patients without the diagnosis. Increased risk was also seen in relation to surgery-specific morbidity and transplant-related outcomes, particularly arterial thrombotic events. The literature did not support an increased risk for mortality, cerebrovascular, or cardiac complications. Limitations of the data include predisposition toward bias due in many study designs and small sample sizes across the majority of published studies. Variable outcome definitions and durations of patient follow-up across different surgical procedures resulted in high study heterogeneity precluding the effective use of meta-analysis. Factor V Leiden status may confer additional risk for surgery-related adverse outcomes. Large, adequately powered studies are required to accurately estimate the degree of this risk by zygosity.

Management of Extremity Venous Thrombosis in Neonates and Infants: An Experience From a Resource Challenged Setting

We aimed to evaluate the outcome of different treatment modalities for extremity venous thrombosis (VT) in neonates and infants, highlighting the current debate on their best tool of management. This retrospective study took place over a 9-year period from January 2009 to December 2017. All treated patients were referred to the vascular and pediatric surgery departments from the neonatal intensive care unit. All patients underwent a thorough history-taking as well as general clinical and local examination of the affected limb. Patients were divided into 2 groups: group I included those who underwent a conservative treated with the sole administration of unfractionated heparin (UFH), whereas group II included those who were treated with UFH plus warfarin. Sixty-three patients were included in this study. They were 36 males and 27 females. Their age ranged from 3 to 302 days. Forty-one (65%) patients had VT in the upper limb, whereas the remaining 22 (35%) had lower extremity VT. The success rate of the nonsurgical treatment was accomplished in 81% of patients. The remaining 19% underwent limb severing, due to established gangrene. The Kaplan-Meier survival method revealed a highly significant increase in both mean and median survival times in those groups treated with heparin and warfarin compared to heparin-only group ( P < .001). Nonoperative treatment with anticoagulation or observation (ie, wait-and-see policy) alone may be an easily applicable, effective, and a safe modality for management of VT in neonates and infants, especially in developing countries with poor or highly challenged resource settings.

The development of central venous thrombosis in hemodialyzed patients is associated with catheter tip depth and localization

INTRODUCTION

The aim of our work was to analyze the incidence of tunneled hemodialysis catheters-related thrombosis in hemodialyzed patients depending on catheter tip depth and position and to evaluate the impact of other established risk factors responsible for development of central venous thrombosis.

METHODS

The presence of central vein thrombosis, location, and the depth of the catheter tip was reviewed by two experienced radiologists. All patients with suspected central venous thrombosis had factor V Leiden, lupus anticoagulant, and cardiolipin antibodies checked (acIgM and acIgG) and were evaluated with cat-scan venography.

FINDINGS

A total of 68 tunneled hemodialysis catheters were analyzed with CT venography for central venous thrombosis. There were no signs of central venous thrombosis when catheter tips were placed in the right atrium. There was significantly higher number of catheter tips located on the vein wall than located centrally in patients with central venous thrombosis. Higher percentage of central venous thrombosis, smaller number of tips placed in the right atrium, higher values of IgM cardiolipin antibodies, and higher number of patients with positive factor V Leiden mutation were found in group of patients with catheter tips located on vein wall.

DISCUSSION

Higher incidence of central venous thrombosis in patients with the catheter tip placed on the vein wall is a consequence of a catheter tip depth proximal of the right atrium. Increased factor V Leiden mutation and acIgM values in these patients should be observed as a result of the vein stasis caused by inappropriate catheter tip depth and localization.

Risk associated with central catheters for malignant tumor patients: a systematic review and meta-analysis

The risk of venous thrombosis and mortality associated with central catheter (PICC/CICC) for malignant tumor patients is not definite. So, we carried out a systematic review and meta-analysis to evaluate it. Among patients with comparing PICC with CICC, odds ratio (OR) or risk ratio (RR) was calculated with a random effect model meta-analysis. The result of the stratification analysis of 7 studies (PICC vs CICC) supported the theory that CICCs were associated with a decrease in the odds ratio of thrombosis compared with PICCs. 7 of 15 studies provided the information about the compared mortality rate of the patients. The result showed that CICCs were associated with a decrease in the odds ratio of thrombosis compared with PICCs (OR = 0.45, 95% CI:0.32-0.62, p < 0.0001, I2 = 0%,Tau2 = 0.00). Meta-analysis of 8 studies of 2639 patients showed that pharmacological deep vein thrombosis prophylaxis drugs could decrease the risk of mortality of malignant tumor patients with CICCs (RR = 0.58, 95% CI:0.48-0.71, Z = 5.32, p < 0.0001, I2 = 71%). We found that PICCs are associated with a raised risk of deep vein thrombosis, and pharmacological deep vein thrombosis prophylaxis drugs is a beneficial factor in decreasing the incidence of thrombosis, while warfarin may decrease the risk of mortality of malignant tumor patients with CICCs.

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.

No impact of endogenous prothrombotic conditions on the risk of central venous line-related thrombotic events in children: results of the KIDCAT study (KIDs with Catheter Associated Thrombosis)

BACKGROUND AND OBJECTIVE

Central venous lines (CVLs) are the major exogenous risk factor for deep venous thrombosis (DVT) in children. The study objective was to assess whether endogenous prothrombotic conditions contribute to the risk of CVL-related DVT in children.

METHODS

This was a cohort study of consecutive children with heart disease requiring CVLs for perioperative care. CVLs were inserted percutaneously in the upper venous system and patients received prophylaxis with continuous unfractionated heparin (50 u kg(-1)  d(-1) ). Blood samples to test for prothrombotic conditions were collected prospectively and assayed in a blinded fashion. Outcome assessment was by screening for DVT by venography, venous ultrasound and echocardiography.

RESULTS

The study population consisted of 90 children, median age 2.7 years (0 months-18 years). Prevalence rates of antithrombin deficiency, protein C deficiency, protein S deficiency, heterozygous factor V Leiden, prothrombin G20210A mutation, methylentetrahydrofolate C677TT genotype, hyperhomocysteinemia, lupus anticoagulant, anticardiolipin antibodies and increased levels of lipoprotein (a) were within the range reported for the general population. At least one prothrombotic condition was present in 38% of children and combined abnormalities in 8%. The incidence of DVT was 28% (25/90), and most DVTs were asymptomatic. None of the prothrombotic conditions showed a significant association with DVT. The population attributable risk (i.e. the risk of DVT in the overall population attributable to a specific condition) did not exceed 2.2%.

CONCLUSION

Prothrombotic conditions did not have an important impact on the risk of DVT in children with short-term CVLs. The results of the study suggest that screening for prothrombotic conditions is not justified in this setting.

Central venous access devices in patients with hemophilia

Hemophilia is a hereditary disorder in which the major clinical manifestation is bleeding into the joints, muscles, internal organs and the CNS, often without any obvious trauma. Bleeding can be fatal as in the case of CNS hemorrhage, or severely debilitating following repeated bleeding into joints that results in crippling arthritis. Treatment for hemophilia includes the intravenous administration of clotting factor concentrates to replace the missing or defective protein. Venous access is therefore critical to the treatment of hemophilia and the prevention of complications due to bleeding. According to the US Centers for Disease Control and Prevention, approximately half of patients less than 16 years of age and one-third of all patients with hemophilia receive regular prophylactic injections of clotting factor concentrates. Prophylaxis, or the regular scheduled administration of antihemophilic factor concentrate, is effective in preventing bleeding. Among those patients with severe disease, in the absence of prophylaxis, approximately 13 bleeds, including nine joint hemorrhages, occur annually. In contrast, when prophylaxis is administered, the annual number of total and joint bleeds decreases to five and three, respectively. One of the major barriers to the more wide-spread use of prophylaxis is venous access. While peripheral venipuncture remains the first choice for venous access, central venous access devices are frequently used to facilitate repeated and/or urgent administration of clotting factor concentrates. The advantages of central venous access devices are well recognized in certain treatment regimens such as prophylaxis and immune tolerance therapy, as well as certain patient groups such as young children in whom venipuncture is often difficult and traumatic, and adults with scarred veins. Central venous access devices also allow earlier commencement of both home treatment and prophylaxis. The goal of this review is to discuss the different types of central venous access devices and their role in the management of hemophilia to provide practitioners that care for patients with hemophilia with the necessary information to make sound therapeutic recommendations to their patients.

Incidence and risk factors for central venous catheter-related thrombosis in hematological patients

Catheter-related thrombosis (CRT) is a serious complication in hematological patients, but the risk factors for its occurrence are not well established. The study objectives were to estimate the incidence of CRT and to identify the risk factors for developing CRT in hematological patients. In a prospective setting, 104 consecutive patients with 200 insertions of central venous catheters were enrolled into the study. The patients were screened for CRT by compression Doppler ultrasound every 10–14 days. Additionally, ultrasonography was performed in the case of clinical symptoms suggesting CRT. Over the course of 6,098 catheter days of follow-up, the incidence of CRT was 13.5 %. In 18/27 cases (66.6 %), radiological evidence of CRT was preceded by clinical symptoms. However, in 9/27 (33.3 %), CRT was clinically asymptomatic. The median times to symptomatic and asymptomatic CRT were 17 (range 1–49) and 8 (range 1–16) catheter days, respectively. In univariate analysis, the risk factors for CRT were exit-site infection (ESI) (P < 0.001), two or more prior chemotherapy lines (P = 0.015), catheter-related blood stream infection (P < 0.001), and Coagulase-negative staphylococci infection (P = 0.002). In multivariate analysis, ESI (OR 5.0; 95 % CI 1.6–6.3; P = 0.006) and two or more prior chemotherapy lines (OR 3.57; 95 % CI 1.27–10.11; P = 0.015) remained significantly associated with the risk of CRT. The results of our study provide information regarding the characteristic features of the patients who are at high risk of thrombosis, for whom Doppler ultrasound screening should be considered.

Deep Vein Thrombosis Following Non-myeloablative Allogeneic Stem Cell Transplantation: Presentation of Three Cases and Literature Review

The incidence of deep vein thrombosis (DVT) after non-myeloablative (NMA) allogeneic stem cell transplantation (allo-SCT) is unknown. In addition, very few studies on the predisposing factors for DVT post SCT have been published. The incidence of DVT among patients that underwent NMA allo-SCT at our hospital was 4.1% (3 of 73) over the course of last 8 years, and to the best of our knowledge this is the first study to report the incidence of DVT following NMA allo-SCT. The present findings show that NMA allo-SCT patients may have multiple risk factors for DVT. Herein we present 3 cases of DVT following NMA allo-SCT and a literature review.

CONFLICT OF INTEREST

None declared.

Epidemiology and prevention of catheter-related thrombosis in patients with cancer

Central venous catheters are extensively used in patients with cancer to secure delivery of chemotherapy and facilitate phlebotomy. Unfortunately, considerable morbidity can result from early complications or late sequelae, ranging from arterial puncture, pneumothorax and bloodstream infections to catheter-related thrombosis (CRT). Contemporary studies have shown that the incidence of symptomatic CRT is ∼5%, whereas the incidence of asymptomatic CRT is higher, at 14-18%. The significance and mechanisms of catheter design, material, insertion location and technique, position of the catheter tip and other risk factors in contributing to the development of CRT are not well understood. Efforts to reduce thrombotic complications, involving flushing the catheter with heparinized solutions, the use of heparin-bonded catheters, and systemic anticoagulant prophylaxis, have been largely ineffective. More studies are needed to understand the pathophysiology of thrombotic complications, to help identify effective interventions to reduce this adverse outcome.

Factor V Leiden thrombophilia

Factor V Leiden is a genetic disorder characterized by a poor anticoagulant response to activated Protein C and an increased risk for venous thromboembolism. Deep venous thrombosis and pulmonary embolism are the most common manifestations, but thrombosis in unusual locations also occurs. The current evidence suggests that the mutation has at most a modest effect on recurrence risk after initial treatment of a first venous thromboembolism. Factor V Leiden is also associated with a 2- to 3-fold increased relative risk for pregnancy loss and possibly other obstetric complications, although the probability of a successful pregnancy outcome is high. The clinical expression of Factor V Leiden is influenced by the number of Factor V Leiden alleles, coexisting genetic and acquired thrombophilic disorders, and circumstantial risk factors. Diagnosis requires the activated Protein C resistance assay (a coagulation screening test) or DNA analysis of the F5 gene, which encodes the Factor V protein. The first acute thrombosis is treated according to standard guidelines. Decisions regarding the optimal duration of anticoagulation are based on an individualized assessment of the risks for venous thromboembolism recurrence and anticoagulant-related bleeding. In the absence of a history of thrombosis, long-term anticoagulation is not routinely recommended for asymptomatic Factor V Leiden heterozygotes, although prophylactic anticoagulation may be considered in high-risk clinical settings. In the absence of evidence that early diagnosis reduces morbidity or mortality, decisions regarding testing at-risk family members should be made on an individual basis.

Congenital thrombophilia and central venous catheter-related thrombosis in patients with cancer

Central venous catheter (CVC)-related thrombosis is a frequently occurring complication and may cause significant morbidity in patients with cancer. The aim of this review is to discuss the main studies that examined whether a state of thrombophilia increases the risk of CVC-related thrombosis in patients with cancer. The studies were retrieved by an extensive Medline search. Patients with cancer with a CVC and a factor V Leiden mutation have a higher risk of developing CVC-related thrombosis than patients with cancer having a CVC without the mutation. The scarce information available suggests hyperhomocysteinemia to be a risk factor for CVC-related thrombosis. For other congenital thrombophilia factors, the available data are too limited to allow for any definitive conclusions to be made. Because the clinical implications of all these findings remain to be clarified, routine screening of patients with cancer having a CVC for thrombophilia cannot yet be recommended on the basis of the studies discussed.

Thrombotic complications in adult patients with lymphoma: a meta-analysis of 29 independent cohorts including 18 018 patients and 1149 events

Thrombotic complications in hematologic malignancies have important clinical implications. In this meta-analysis we sought to obtain accurate estimates of the thrombotic risk in lymphoma patients. Articles were searched in electronic databases and references. Eighteen articles were identified (29 cohorts, 18 018 patients and 1149 events). Pooled incidence rates (IRs) were calculated by the use of a method based on the exact maximum likelihood binomial distribution. The global IR of thrombosis was 6.4% (95% confidence interval [CI] 6.0%-6.8%). The global IRs of venous or arterial events were 5.3% (95% CI, 5.0%-5.7%) and 1.1% (95% CI, 0.9%-1.2%), respectively. The IR of thrombosis observed in subjects with non-Hodgkin lymphoma (NHL) was 6.5% (95% CI, 6.1%-6.9%), significantly greater than that observed for patients with Hodgkin lymphoma (4.7%; 95% CI, 3.9%-5.6%). Within NHL, patients with high-grade disease had a greater risk of events (IR 8.3%; 95% CI, 7.0%-9.9%) than low-grade disease (IR 6.3%; 95% CI, 4.5%-8.9%). This meta-analysis shows that the IR of thrombosis in lymphoma patients is quite high, especially in those with NHL at an advanced stage of the disease. These results may help better defining lymphoma populations at high thrombotic risk, to whom prophylactic approaches could be preferentially applied.

Venous thrombosis of the upper extremity: effect of blood group and coagulation factor levels on risk

Venous thrombosis of the upper extremity is a rare form of thrombosis, accounting for around 4% of all venous thromboses, and for which only a few risk factors are known. This case-control study investigated the effect of coagulation factors on risk of venous thrombosis of the upper extremity. Patients with venous thrombosis of the arm and partner controls were selected from the Multiple Environmental and Genetic Assessment study, a large population-based case-control study. Participants with a malignancy were excluded. Odds ratios (OR) were estimated for elevated levels of factor II, VII, VIII, IX, X, XI, von Willebrand Factor (VWF), and fibrinogen, low levels of protein C, protein S, and antithrombin, and for blood group non-O. Substantially increased risks of venous thrombosis of the upper extremity were found for patients with high levels (above 90th percentile versus below) of factor VIII (OR: 4.2, 95% confidence interval (CI): 2.2-7.9), VWF (OR: 4.0, 95% CI: 2.1-7.8), fibrinogen (OR: 2.9, 95% CI, 1.5-5.7), and for blood group non-O compared to O (OR: 2.1, 95% CI, 1.3-3.6). The other factors were not associated with an increased risk. Elevated levels of several procoagulant factors are associated with a strongly increased risk of venous thrombosis of the upper extremity.

Catheter-associated thrombosis in patients with malignancy

Central venous catheters are widely used in the care of patients with cancer. Indwelling catheters are associated with upper extremity deep venous thrombosis in some patients, and recognition of this entity is an important aspect of treating patients with malignancies. This article will review the incidence, pathogenesis, clinical presentation, diagnosis, treatment, and prophylaxis of catheter-associated thrombosis in patients with malignancy. The care of pediatric patients with malignancy and catheter-associated thrombosis will also be addressed.

Risk of thrombosis and infections of central venous catheters and totally implanted access ports in patients treated for cancer

INTRODUCTION

Thrombosis and infections are well known complications of central venous catheters and totally implanted access ports. These complications lead to increased costs due to prolonged hospitalisation, increased antibiotics use and need for replacement. The objectives of the study were to document the occurrence of catheter related thrombosis and infections in patients with central venous catheters and totally implanted chest ports in cancer patients and to investigate whether factor V Leiden is a risk factor for catheter related thrombosis.

MATERIALS AND METHODS

Between February 2002 and November 2004, 43 patients with central venous catheter or totally implanted access port were followed up to document the occurrence of catheter related thrombosis and infections. Patients received chemotherapy either for haematological malignancy or for solid tumours. Factor V Leiden (R506Q) was determined by restriction fragment length polymorphism analysis. Follow-up period ended in April 2007.

RESULTS

Catheter related thrombosis occurred in 4 patients (4/43; 9.3%) with a totally implanted access port. None of the 3 patients with factor V Leiden had catheter related infection or thrombosis. Catheter related infections occurred in 15 patients: 10 patients (23.3%; 10/43) with central venous catheter and 5 patients (11.6%; 5/43) with totally implanted access ports. Time to infection was 32.5 days in the central venous catheter group compared to 88 days in the totally implanted access port group.

CONCLUSION

A higher incidence of catheter related infections was observed in patients with central venous catheters in contrast to patients with totally implanted access ports were venous thrombosis was more frequent.

The evaluation and management of postnatal thromboses

In the pediatric population, neonates have the highest risk for thromboembolism (TE), most likely due to the frequent use of intravascular catheters. This increased risk is attributed to multiple risk factors. Randomized clinical trials dealing with management of postnatal thromboses do not exist, thus, opinions differ regarding optimal diagnostic and therapeutic interventions. This review begins with an actual case study illustrating the complexity and severity of these types of cases, and then evaluates the neonatal hemostatic system with discussion of the common sites of postnatal thrombosis, perinatal and prothrombotic risk factors, and potential treatment options. A proposed step-wise evaluation of neonates with symptomatic postnatal thromboses will be suggested, as well as future research and registry directions. Owing to the complexity of ischemic perinatal stroke, this topic will not be reviewed.

Two cases of central venous catheter-related thrombosis in living liver donors: how can the risk be minimized?

A central venous catheter (CVC) is commonly used for intraoperative management by anesthetists and surgeons during major operations, including donor operations for living donor liver transplantation (LDLT), in which donor safety is of utmost importance. Reasons for use of CVC for donors include measurement of central venous pressure and drug infusion when necessary. A potentially serious complication of a major operation is pulmonary thromboembolism. We report two cases of LDLT donors complicated by catheter related thrombosis (CRT) of the jugular vein, who were eventually discharged without long-term complications. To the best of our knowledge, there has been no report of CRT among LDLT donor population. In this report, in order to minimize the risks related to CRT in LDLT donors, we propose thorough screening for thrombophilic disorders, use of a silicone or polyurethane double-lumen CVC as thin as possible, placement of the tip of the CVC at the superior vena cava via the right jugular vein using ultrasonography as a guide for puncture, and removal of the catheter at the end of the operation based on our experience of CRT among LDLT donors.

Current perspective of venous thrombosis in the upper extremity

Venous thrombosis of the upper extremity is a rare disease. Therefore, not as much is known about risk factors, treatment and the risk of recurrence as for venous thrombosis of the leg. Only central venous catheters and strenuous exercise are commonly known risk factors for an upper extremity venous thrombosis. In this review an overview of the different risk factors, possible treatments and the complications for patients with a venous thrombosis of the upper extremity is given.

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

Increased incidence of cancers and the development of totally implanted venous access devices that contain their own port to deliver chemotherapy will lead to a greater than before numbers of central venous catheter-related thrombosis (CVCT). Medical consequences include catheter dysfunction and pulmonary embolism. Vessel injury caused by the procedure of CVC insertion is the most important risk factor for development of CVCT. This event could cause the formation of a fresh thrombus, which is reversible in the large majority of patients. In some cases, thrombus formation is not related to catheter insertion. The incidence of CVC-related DVT assessed by venography has been reported to vary from 30 to 60% but catheter-related DVT in adult patients is symptomatic in only 5% of cases. The majority of patients with CVC-related DVT is asymptomatic or has nonspecific symptoms: arm or neck swelling or pain, distal paresthesias, headache, congestion of subcutaneous collateral veins. In the case of clinical suspicion of CVC-related deep venous thrombosis (DVT), compressive ultrasonography (US), especially with doppler and color imaging, currently is first used to confirm the diagnosis. Consequently, contrast venography is reserved for clinical trials and difficult diagnostic situations. There is no consensus on the optimal management of patients with CVC-related DVT. Treatment of CVC-related VTE requires a five- to seven-day course of adjusted-dose unfractionated heparin or low molecular weight heparin (LMWH) followed by oral anticoagulants. Long-term LMWH that has been shown to be more effective than oral anticoagulant in cancer patients with lower limb DVT, could be used in these patients. The efficacy and safety of pharmacologic prophylaxis for CVC related thrombosis is not established and the last recommendations suggest that clinicians not routinely use prophylaxis to try to prevent thrombosis related to long-term indwelling CVCs in cancer patients. Additional studies performed in high risk populations with appropriate dosage and timing will help to define which patients could benefit from prophylaxis.

Thrombophilia and risk of venous thrombosis in patients with cancer

Venous thrombosis is a common and severe complication in patients with cancer. We reviewed studies assessing whether a state of acquired or congenital thrombophilia influenced the risk of thrombosis in patients with cancer. The results are equivocal. However, the majority of studies were of limited size. The influence of thrombophilia in patients with cancer may be more difficult to demonstrate than in the general population, the risk of thrombosis due to cancer per se possibly outweighing the contribution of thrombophilic factors. Moreover, the results may depend on the genetic background of the population, the type of cancer, the type of thrombosis, and the chemotherapeutic treatment. Nevertheless, it appears that factor V Leiden or G20210A prothrombin gene mutation increases the risk of venous thromboembolism about 2- to 4-fold, compared with patients with cancer without either of these mutations. Similar results were observed for the occurrence of central venous catheter-associated thrombosis. Antiphospholipid antibodies and acquired resistance to activated protein C were frequently observed in patients with cancer and appeared to favor the occurrence of thrombosis. The role of hyperhomocysteinemia deserves further investigation. Since the clinical implications of these findings remain to be clarified, routine screening of cancer patients for thrombophilia cannot yet be recommended on the basis of these studies. Studies designed to assess the value of thromboprophylaxis in high-risk patients, including thrombophilic patients, with long-term central venous catheters may be valuable.

Association between inherited thrombophilic abnormalities and central venous catheter thrombosis in patients with cancer: a meta-analysis

BACKGROUND

The risk of deep vein thrombosis (DVT) is increased in cancer patients with central venous catheters (CVC). Factor (F)V Leiden and the G20210A prothrombin mutation (PTM) may play a role in causing catheter-related DVT in patients with cancer. However, information on the association between these thrombophilic abnormalities and CVC-related thrombosis are scarce.

PURPOSE

To assess the risk of CVC-related thrombosis associated with these two thrombophilic disorders.

METHODS

MEDLINE and EMBASE databases (up to March 2007); reference lists of retrieved articles. Studies comparing the prevalence of prothrombotic abnormalities in cancer patients with CVC-related thrombosis and in a control group of cancer subjects with CVC without thrombosis. Two reviewers independently selected studies and extracted study characteristics, quality and outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each trial and pooled.

RESULTS

Ten studies involving 1000 patients were included. The pooled OR for CVC-related thrombosis was 4.6 (95% CI: 2.6, 8.1) in patients with FV Leiden. The pooled OR for CVC-related thrombosis was 4.9 (95% CI: 1.7, 14.3) in patients with PTM. The estimated attributable risk of CVC-related thrombosis was 13.1% for FV Leiden and 4.5% for PTM.

CONCLUSION

Our meta-analysis suggests that the presence of FV Leiden and PTM is associated with CVC-related thrombosis.

Thrombotic and infectious complications of central venous catheters in patients with hematological malignancies

Central venous catheters (CVCs) have considerably improved the management of patients with hematological malignancies, by facilitating chemotherapy, supportive therapy and blood sampling. Complications of insertion of CVCs include mechanical (arterial puncture, pneumothorax), thrombotic and infectious complications. CVC-related thrombosis and infections are frequently occurring complications and may cause significant morbidity in patients with hematological malignancies. CVC-related thrombosis and infections are related and can therefore not be seen as separate entities. The incidence of symptomatic CVC-related thrombosis had been reported to vary between 1.2 and 13.0% of patients with hematological malignancy. The incidence of CVC-related bloodstream infections varies between 0.0 and 20.8%. There is need for a specific approach regarding diagnosis and treatment of CVC-related thrombosis and infection with specific attention to the preservation of the catheter. Since data on CVC-related infections and thrombosis in hematological patients have been obtained mainly from retrospective studies of small sample size, prospective, randomized studies of prophylactic measures concerning CVC-related thrombosis and infection are warranted.

Genetic prothrombotic mutations are common in neonates but are not associated with umbilical catheter-associated thrombosis

OBJECTIVE

To evaluate the prevalence of hereditary prothrombotic mutations, and their effect on the incidence and severity of umbilical arterial or venous catheter (UAC or UVC)-associated thrombosis.

STUDY DESIGN

All neonates with a UAC or UVC were studied prospectively for the presence, severity and timing of thrombosis with duplex Doppler ultrasound scan. Genetic testing for factor V Leiden (FVL), prothrombin mutation (PTm) and methylene-tetrahydrofolate reductase (MTHFR) mutations was performed using PCR and restriction fragment length polymorphism assays.

RESULT

Umbilical catheter (UC)-associated thrombosis developed in 16/53 (31%) neonates; 23% of UACs and 22% of UVCs were associated with thrombosis. The prevalence of a significant prothrombotic mutation was present in 10/51 (20%) of infants: FVL (8%), MTHFR667 homozygosity (10%), MTHFR1298 homozygosity (2%) and PTm (0%). There was no increase in the risk of UC-associated thrombus in patients carrying these prothrombotic mutations; our study had the power to detect a 2.5-fold increased risk of thrombosis for any of these significant mutations. In addition, MTHFR667 heterozygosity was found in 41% of infants and MTHFR1298 heterozygosity in 52% and also were not associated with increased risk of UC-associated thrombus. The risk of MTHFR double heterozygosity (db het) was 14%, the risk of a significant or db het was 17/51 (33%) and the risk of any mutation was 90%.

CONCLUSION

Prothrombotic genetic mutations are common in our Neonatal Intensive Care Unit population but do not appear to increase the risk of UC-associated thrombosis.

Thromboses sur cathéter central chez le patient cancéreux

OBJECTIVES

Increased incidence of cancers and the development of totally implanted venous access devices that contain their own port to deliver chemotherapy will lead to a greater than before numbers of central venous catheter related thrombosis (CVCT). Medical consequences include catheter dysfunction and pulmonary embolism. Compared with lower extremity deep venous thrombosis (DVT) (3 d) and with non CVC associated thrombosis (5 d), CVCT is associated with an increased duration of hospitalisation (9 d). CVCT oftentimes leads to the need to replace such ports at an average cost of 4500 euros.

CURRENT KNOWLEDGE AND KEY POINTS

Vessel injury caused by the procedure of CVC insertion is the most important risk factor for development of CVCT. This event could cause the formation of a fresh thrombus, which is reversible in the large majority of patients. The incidence of CVC-related DVT assessed by venography has been reported to vary from 30 to 60% but catheter-related DVT in adult patients is symptomatic in only 5% of cases. The majority of patients with CVC-related DVT is asymptomatic or has non-specific symptoms: arm or neck swelling or pain, distal paresthesias, headache, congestion of subcutaneous collateral veins. In the case of clinical suspicion of CVC-related DVT, compressive ultrasonography (US), especially with Doppler and color imaging, currently is first used to confirm the diagnosis. The main criteria of color-Doppler US are visualization of mural thrombi or incompressibility of the veins. Consequently, contrast venography is reserved for clinical trials and difficult diagnostic situations. There is no consensus on the optimal management of patients with CVC-related DVT. Treatment of CVC-related VTE requires a 5- to 7-day course of adjusted-dose unfractionated heparin or LMWH followed by oral anticoagulants. Long-term LMWH that has been shown to be more effective than oral anticoagulant in cancer patients with lower limb DVT could be used in these patients. The optimal duration of oral anticoagulation treatment for CVC-related DVT is unknown, but patients with active cancer should be treated for at least 6 months or indefinitely.

FUTURE PROSPECTS AND PROJECTS

The efficacy and safety of pharmacologic prophylaxis for CVC related thrombosis is not established. Additional studies performed in high risk populations are needed to define if LMWH or oral anticoagulation is indicated in this clinical setting.

Therapy Insight: venous-catheter-related thrombosis in cancer patients

Central venous catheters (CVCs) have improved the management of patients with cancer substantially, by facilitating chemotherapy and supportive therapy. The use of CVCs is associated with complications such as infection and upper-limb deep vein thrombosis (UL-DVT). The incidence of clinically overt UL-DVT related to the use of CVCs ranges between 2% and 4%. In the most recent study, the incidence of CVC-related thrombosis, as screened by venography, was approximately 18% in the absence of prophylaxis. In cancer patients with CVC-related UL-DVT, the incidence of clinically overt pulmonary embolism was between 15% and 25%, and the incidence of autopsy-proven pulmonary embolism was up to 50%. Pathogenic factors for CVC-related thrombosis include vessel injury caused by the CVC insertion procedure, venous stasis because of the indwelling CVC, and hypercoagulability associated with cancer. Recent studies have not confirmed a benefit for prophylaxis with antithrombotic agents for CVC-related thrombosis. The recommended treatment for CVC-related thrombosis is based on long-term anticoagulant therapy, with or without catheter removal.

Prophylaxis of central venous catheter-related thrombosis with minidose warfarin in patients treated with high-dose chemotherapy and peripheral-blood stem-cell transplantation: retrospective analysis of 228 cancer patients

Patients with a central venous catheter (CVC) undergoing high-dose chemotherapy (HDC) followed by peripheral-blood stem-cell transplantation (PBSCT) for malignancies are at high risk of thrombosis, but the use of anti-coagulant prophylaxis remains debatable in this setting of patients. We analyzed the efficacy and the safety of minidose warfarin in 228 patients in whom CVCs had been placed and who had received 292 HDC courses of therapy. The catheters remained in place for a mean of 173 (range 40-298) days. All patients received prophylactic oral warfarin in the fixed dose of 1 mg/day starting on the day of CVC insertion. Prophylaxis was interrupted during aplasia when platelet counts fell below 50,000/dL. There were no toxic deaths related to the prophylaxis. Overall there were 4 thrombotic events. Three occurrences were directly related to the catheter, while the remaining event was a deep saphenous-vein thrombosis. A number of potential predictive factors were analyzed for their impact on thrombotic events without finding any significant correlation. Four episodes of bleeding occurred, with each of these individuals having a normal INR but a platelet count below 50,000/dL. Minidose warfarin is effective and safe to use for preventing thrombotic events in this setting of patients.

Prevalence of inherited prothrombotic abnormalities and central venous catheter-related thrombosis in haematopoietic stem cell transplants recipients

In this prospective study, we assessed the incidence of central venous catheter (CVC)-related thrombosis in haematopoietic stem cell transplant (HSCT) recipients. We determined the contribution of inherited prothrombotic abnormalities in blood coagulation to CVC-related thrombosis in these patients. The study was conducted between May 2002 and September 2004. CVCs were externalized, nontunneled, polyurethane double lumen catheters. Before catheter insertion, laboratory prothrombotic markers included factor V Leiden, the prothrombin gene Gly20210A mutation, plasma antithrombin levels, and protein C and S activity. All patients were systematically examined by ultrasonography just before, or <24 h after, catheter removal, and in case of clinical signs of thrombosis. A total of 171 patients were included during the 28-month study period. Five (2.9%) and three (1.7%) patients had evidence of protein C and protein S deficiency, respectively. Only one patient had an antithrombin deficiency (0.6%). In total, 10 patients (5.8%) were heterozygous for the factor V Leiden mutation, and one patient had heterozygous prothrombin G20210A mutation (0.6%). We observed a CVC-related thrombosis in 13 patients (7.6%). Thrombosis was diagnosed in four out of 20 patients (20%) with a inherited prothrombotic abnormality compared to nine of 151 patients (6%) who did not have a thrombophilic marker (relative risk 3.3 CI 95% 1.1-9.9). Our results suggest that inherited prothrombotic abnormalities contribute substantially to CVC-related thrombosis in HSCT recipients. In view of physicians' reluctance to prescribe prophylactic anticoagulant treatment in these patients, a priori determination of inherited prothrombotic abnormalities may form a basis to guide these treatment decisions.

Infectious Complications of Central Venous Catheters Increase the Risk of Catheter-Related Thrombosis in Hematology Patients: A Prospective Study

Purpose

We studied whether the risk of central venous catheter (CVC) -related thrombosis increased after an episode of CVC-related infection in patients undergoing intensive chemotherapy. Secondly, we determined whether thrombosis can be predicted or excluded by CVC lock fluid surveillance cultures.

Patients and Methods

In a prospective setting, 105 consecutive patients were carefully examined for CVC-related infection and thrombosis. In all patients, microbial surveillance cultures of CVC lock fluid were taken every other day. All patients with clinical suspicion of CVC-related thrombosis underwent Doppler ultrasound or additional venography.

Results

The cumulative incidence of CVC-related infection was 24% (25 of 105 patients). Clinically manifest thrombosis occurred in 13 (12%) of 105 patients. In patients with CVC-related infection, the risk of thrombosis increased markedly in comparison to those without infection (relative risk, 17.6; 95% CI, 4.1 to 74.1). In patients having two or more positive subsequent CVC lock fluid cultures with identical micro-organisms, 71.4% developed thrombosis, as compared with 3.3% in patients with negative or a single positive culture.

Conclusion

The risk of clinically manifest thrombosis is increased after an episode of CVC-related infection in patients undergoing intensive chemotherapy. Surveillance culturing of CVC lock fluid may be clinically useful in estimating the risk for thrombosis and the instigation of focused early intervention.

Safety of low-dose low-molecular-weight-heparins in thrombocytopenic stem cell transplantation patients: a case series and review of the literature

Few attempts have been made to examine the feasibility of safely administering low-molecular-weight-heparins (LMWHs) in the presence of concurrent thrombocytopenia. We retrospectively investigated the safety of low-dose LMWH in BMT patients, a population at risk of bleeding. In total, 26 patients received at least one dose of low-dose enoxaparin (ie <1 mg/kg/day) during thrombocytopenia. s.c. enoxaparin 40 mg once daily was given in 85% of the cohort. The mean number of platelet days <55 x 10(9) and <20 x 10(9)/l were 16.5 days (95% CI=8.04-24.96) and 4.14 days (95% CI=2.35-5.93), respectively. The mean number of low-dose enoxaparin administration days when platelet <55 x 10(9) and 20 x 10(9)/l were 9.89 days (95% CI=3.26-16.53) and 2.25 days (95% CI=0.57-3.93), respectively. Minor bleeding occurred in four patients (15%) whereas major episodes developed in two patients (8%). The latter two events occurred during the transition between full therapeutic (ie 1.5-2 mg/kg/day) and low-dose enoxaparin close to the onset of thrombocytopenia. The present case series, along with the discussed literature, descriptively suggests that low-dose enoxaparin may be safely administered at a platelet count in the range of 20 and 55 x 10(9)/l in BMT patients who weigh >55 kg.

Risk factors for catheter-related thrombosis in cancer patients

We investigated the risk factors for venous thrombosis in cancer patients with implantable ports undergoing chemotherapy. One hundred and seventy one ports were placed in a central ("chest ports") and 84 in a peripheral vein ("arm ports"), 181 received prophylactic nadroparin and 10 coumarin. Clinically overt thrombosis was confirmed by ultrasound or angiography. Catheter-related thrombosis incidence without anticoagulants was 28% in arm and 33% in chest ports, but with anticoagulants this was 32% in arm and only 1% in chest ports (odds ratio (OR) 34.8 95% confidence interval (CI) 7.3-165). Left-sided placement compared with right-sided and catheter tip position in the superior vena cava compared with right atrium were associated with a 3.5 respectively 2.6-fold increased risk. Thrombosis was associated with elevated homocysteine levels (OR=3.8, 95% CI 1.3-11.3), but not with factor V Leiden or prothrombin 20210A gene mutations, or high concentration of factor VIII, IX or XI. Prophylaxis with anticoagulants is recommended for chest, but not for arm ports. Determination of plasma homocysteine levels may identify patients at an increased risk for thrombosis.

Consensus recommendations for use of central venous access devices in haemophilia

Venous access is essential for delivery of haemophilia factor concentrate. Wherever possible, peripheral veins remain the route of choice, and the use of central venous access devices (CVADs) should be limited to cases of clear need in patients with caregivers able to exercise diligence in CVAD care and should continue no longer than necessary. CVADs are of recognized value for repeated administration of coagulation factors in haemophilia, particularly for prophylaxis and immune tolerance therapy and in young children. Evidence to guide best practices has been fragmentary, and standardized methods for CVAD usage have yet to be established. We have developed management recommendations based upon available published evidence as well as extensive clinical experience. These recommendations address patient and CVAD selection; CVAD placement, care and removal; caregiver/patient guidance; and complications, including infection and thrombosis. In the absence of inhibitors, ports are recommended, primarily because of fewer associated infections than with external catheters. For patients with inhibitors, ports also appear to be associated with fewer infections. Infection is the most frequent complication, and recommendations to prevent and treat infections are supported by extensive clinical data and experience. Strict adherence to handwashing and aseptic technique are essential elements of catheter care. Evidence-based data regarding the detection and treatment of CVAD-related thrombotic complications are limited. Caregiver education is an integral part of CVAD use and the procedural practices of users should be regularly re-assessed. These recommendations provide a basis for sound current CVAD practice and are expected to undergo further refinements as new evidence is compiled and clinical experience is gained.

Factor V Leiden and G20210A prothrombin mutation and the risk of subclavian vein thrombosis in patients with breast cancer and a central venous catheter

BACKGROUND

To analyze the influence of the prothrombotic gene mutation factor V G1691A (factor V Leiden) and prothrombin G20210A on the risk of a first episode of catheter-related deep venous thrombosis (DVT) in a group of patients with breast cancer treated with chemotherapy.

PATIENTS AND METHODS

Between January 1999 and February 2001, the occurrence of a first symptomatic DVT was investigated in a cohort of 300 consecutive patients with locally advanced or metastatic breast cancer treated at a single institution with fluorouracil-based chemotherapy, administered continuously through a totally implanted access port. A nested case-control study included 25 women (cases) with catheter-related DVT and 50 controls without DVT matched with cases for age, identical chemotherapy, stage of disease and prognostic features. The G1691A factor V and G20210A prothrombin mutation genotypes were analyzed.

RESULTS

Five cases [20%; 95% confidence interval (CI) 9% to 39%)] and two controls (4%; 95% CI 1% to 14%) were heterozygous carriers of G1691A factor V (P = 0.04). The age-adjusted odds ratio for catheter-related DVT was 6.1 (95% CI 1.1-34.3). Only one patient (case) had the G20210A prothrombin gene mutation. Time from start of chemotherapy infusion to DVT was not significantly different between patients with (median 31 days) and without (median 43 days) G1691A factor V mutation (P = 0.6).

CONCLUSIONS

Factor V Leiden carriers with locally advanced or metastatic breast cancer have an increased risk of developing catheter-related DVT during chemotherapy.

Central venous catheter related thrombosis in haematology patients and prediction of risk by screening with Doppler-ultrasound

Patients with a central venous catheter (CVC) who receive intensive chemotherapy or a stem cell transplantation for haematological disease are at risk for developing CVC-related thrombosis. To study the incidence of thrombosis, 105 consecutive patients underwent serial Doppler-ultrasound and we evaluated whether clinically manifest thrombosis could be predicted by screening with Doppler-ultrasound. Patients with subclavian or jugular inserted CVCs were clinically assessed each day for signs and symptoms of thrombosis. Additional Doppler-ultrasound screens were performed weekly by an independent physician in all patients until CVC removal. Doppler-ultrasound recordings were assessed by two blinded observers. In cases of clinically suspected thrombosis, the attending physicians followed routine diagnostic and therapeutic procedures. The overall cumulative incidence of CVC-related thrombosis was 28.6% (30 of 105 patients). Of the 30 patients with thrombosis, 26 had subclinical thrombosis by Doppler-ultrasound, nine of whom developed clinically manifest thrombosis later. Four patients had clinically manifest thrombosis without prior abnormal Doppler-ultrasound. In cases of subclinical thrombosis the risk of developing symptomatic disease increased sevenfold (34.6% vs. 5.1%). Doppler-ultrasound screening may be useful to identify those patients that are at high and low risk for clinically manifest CVC-related thrombosis.

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

Long-term central venous catheters (CVCs) have considerably improved the management of cancer patients because they facilitate chemotherapy, transfusions, parenteral nutrition, and blood sampling. However, the use of long-term CVCs, especially for chemotherapy, has been associated with the occurrence of upper-limb deep venous thrombosis (UL-DVT). The incidence of clinically overt UL-DVT related to CVCs has been reported to vary between 0.3% and 28.3%. The incidence of CVC-related UL-DVT screened by venography reportedly varies between 27% and 66%. The incidence of clinically overt pulmonary embolism (PE) in patients with CVC-related UL-DVT ranges from 15% to 25%, but an autopsy-proven PE rate of up to 50% has been reported. Vessel injury caused by the procedure of CVC insertion, venous stasis caused by the indwelling CVC, and cancer-related hypercoagulability are the main pathogenetic factors for CVC-related venous thromboembolism (VTE). Several studies have assessed the benefit of the prophylaxis of UL-DVT after CVC insertion in cancer patients. According to the results of these studies, prophylaxis with low molecular weight heparin or a low fixed dose of warfarin has been recently proposed. However, the limitations of the experimental design of the prophylactic studies do not allow definitive recommendations. The recommended therapy for UL-DVT associated with CVC is based on anticoagulant therapy with or without catheter removal. This review focuses on the epidemiology, pathogenesis, diagnosis, prevention, and treatment of VTE in cancer patients with long-term CVC.

Fatal pulmonary thromboembolism after a second course of high-dose chemotherapy with autologous peripheral blood stem cell transplantation

We describe a 4-yr-old boy with an occult primitive neuroectodermal tumor, who suffered fatal PTE after a second course of HDC with autologous PBSCT. On day + 52 after a second PBSCT, he was admitted because of respiratory distress. Respiratory failure rapidly progressed and he died within 4 days. The diagnosis of PTE was confirmed by a lung perfusion study with technetium-99m macroaggregated albumin, but too late to allow treatment. Although rare, PTE must be recognized as an important differential diagnosis when respiratory symptoms are observed after HDC with PBSCT.

Venous thromboembolism associated with the management of acute thrombotic thrombocytopenic purpura

Venous thromboembolism (VTE) is not a feature of thrombotic thrombocytopenic purpura (TTP), but there has been a recent report of VTE in association with plasma exchange (PEX) treatment for TTP using the solvent detergent (SD) plasma, PLAS+SD. We reviewed the occurrence of VTE in 68 consecutive patients with TTP (25 men, 43 women). Eight documented VTE events [six deep venous thromboses (DVTs), three pulmonary emboli] were identified in seven patients (all female) during PEX therapy. All six DVTs were associated with central lines at the site of thrombosis. Other known precipitating factors included pregnancy, immobility, obesity and factor V Leiden heterozygosity. VTE occurred at a mean of 53 d following the first PEX. The European SD plasma, Octaplas was the last plasma to be used in PEX prior to the VTE in 7/8 events. This is the first report of VTE following Octaplas infusion. VTE is a multifactorial disease and, although several known precipitating factors were present in all patients in this study, the use of large volumes of SD plasma in PEX may be an additional risk factor. We recommend prevention of VTE with graduated elastic compression stockings (class I) at diagnosis and prophylactic low-molecular-weight heparin once the platelet count rises above 50 x 10(9)/l.

Central venous catheter techniques in infants and children

PURPOSE OF REVIEW

The placement of central venous catheters is often necessary to facilitate optimal anaesthetic and perioperative management or for the long-term management of chronic underlying diseases. Insertion may be a challenge in selected patients, and the risk of infection, thrombosis, and other complications may result in significant risk factors.

RECENT FINDINGS

Ultrasound visualization of the cervical veins with Valsalva manoeuvres significantly increases the rate and safety of central venous cannulation, and decreases needle passes in paediatric patients even with experienced operators. Pericardial effusion with tamponade is a more frequent phenomenon than generally realized, and accurate location of the catheter-tip position is essential. The femoral venous approach has proved to be safe even in premature babies. Clear guidelines for infection control and the prevention of intravascular catheter-related infections in children have been established; however, the high incidence of nosocomial catheter-related infections requires effective prevention strategies. The impact of antimicrobial-impregnated central venous catheters on the prevention of bloodstream infections in children is not yet clear. Routine use of prophylactic antibiosis (i.e. vancomycin) to prevent catheter-related infection cannot be recommended. Thrombolytic therapy with recombinant tissue plasminogen activator is safe, efficient, well tolerated and effective for lysis of catheter-induced intravascular and intracardiac thrombi even in neonates. Embolized catheter fragments can be retrieved in neonates and children by non-surgical interventions using standard procedures applied by paediatric cardiologists.

SUMMARY

Despite a variety of new techniques, the major problem of central venous catheterization in neonates and children remains the prevention of catheter-related infection and infection control.