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

[Translation into French and republication of: "Central venous catheter associated upper extremity deep vein thrombosis in cancer patients: Diagnosis and therapeutic management"]

Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least 3 months, including at least 1 month after catheter removal following initiation of therapy.

Central venous catheter associated upper extremity deep vein thrombosis in cancer patients: Diagnosis and therapeutic management

Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least three months, including at least one month after catheter removal following initiation of therapy.

The clinical topography of peripherally inserted central catheter-related thrombosis in cancer patients: A prospective and longitudinal observational study based on ultrasound scans every two days

AIMS

To delineate the clinical topography of peripherally inserted central catheter (PICC)-related thrombosis in cancer patients.

BACKGROUND

Most of the clinical features of PICC-related thrombosis are based on a single follow-up, which is insufficient to reflect the full topography of a thrombosis.

DESIGN

This is an observational study conducted at West China Hospital, according to the STROBE guidelines.

METHODS

Cancer patients scheduled for PICC placement were potentially eligible; patients with contraindications to PICC placement or existing diseases affecting blood flow were excluded; and those who later withdrew or did not reply to our contact request during the follow-up period were eliminated from this study. Ultrasound was used to detect thrombosis from the insertion site, proximal insertion site, axillary vein to the subclavian vein once every two days for two weeks post insertion. The thrombosis and its involved venous segments, onset time and symptoms and signs were recorded.

RESULTS

Among the 173 included patients, 126 (72.8 %) were identified as having thrombosis. Specifically, 113 and 126 patients were identified as having thrombosis within the first three days and the first week post insertion, respectively. In the 126 patients, thrombosis occurred at the insertion site (72.8 %) concurrently with thrombosis at the proximal insertion site (n = 120, 69.4 %), thrombosis in the axillary vein (n = 94, 54.3 %), and/or thrombosis in the subclavian vein (n = 41, 23.7 %). The log-rank test demonstrated that thrombosis in these four venous segments decreased significantly from the distal to the proximal central vein (log-rank test = 117.128, P < .001). Of 31 patients (17.9 %) who presented symptomatic thrombosis, only five patients experienced obvious swelling in the upper arm, and the other 26 patients exhibited atypical symptoms, such as soreness, tightness, numbness, tingling, or other discomforts in the palm, arm, armpit, and/or shoulder. In some thrombotic cases, ultrasonic assessment of PICC-related thrombosis did not parallel clinical symptoms and signs.

CONCLUSION

PICC-related thrombosis is common and can occur very early post insertion in cancer patients, and most thromboses present atypical symptoms. More than half of the cases with thrombosis evaluated involve multiple venous segments, and the farther the venous segments are from the central vein, the higher the incidence of thrombosis tend to be and the earlier the onset time are.

RELEVANCE TO CLINICAL PRACTICE

The results highlight the importance that medical staff pay particular attention to patients with catheters in the first week post insertion and be alert to thrombosis presenting atypical symptoms while keeping in mind that clinical symptoms and signs are not reliable for diagnosing thrombosis.

CLINICAL REGESTRATION

Clinical Trials ChiCTR1900024890.

Intravascular Complications of Central Venous Catheterization by Insertion Site in Acute Leukemia during Remission Induction Chemotherapy Phase: Lower Risk with Peripherally Inserted Catheters in a Single-Center Retrospective Study

The basilic/brachial (BBV), internal jugular (IJV), and subclavian veins (SCV) are commonly used as central venous catheter (CVC) sites. A BBV approach [peripherally inserted central catheter (PICC)] is increasingly used for short- to intermediate-term CVCs for acute leukemias undergoing cytotoxic intensive regimens. In this retrospective study, the catheterization of the BBV, IJV, and SCV in patients with previously untreated acute leukemia was assessed. The primary outcome was the composite incidence of catheter-related symptomatic deep-vein thrombosis (sDVT) and bloodstream infection (BSI) from catheterization up to 30 days later. In a 10-year period, 336 CVC were inserted in the BBV (n = 115), IJV (n = 111), and SCV (n = 110) in 336 patients suffering from AML (n = 201) and ALL (n = 135) and undergoing induction chemotherapy. The primary outcome events were 8, 20, and 27 in the BBV, SCV and IJV cohorts (2.6, 6.9, and 9.6 per 1000 catheter-days, respectively; p = 0.002). The primary outcome risk was significantly higher in the IJV-cohort than in the BBV-cohort (HR, 3.6; 95% CI, 1.6 to 7.9; p = 0.001) and in the SCV-cohort than in the BBV-cohort (HR, 2.6; 95% CI, 1.2 to 5.9; p = 0.02). PICC was a valid CVC for the induction chemotherapy of acute leukemia for the lowest risk of sDVT and BSI.

Venous thromboembolism associated with central venous catheters in patients with cancer: From pathophysiology to thromboprophylaxis, areas for future studies

Symptomatic catheter related thrombosis (CRT) occurs in 4%-8% of cancer patients. The mean incidence of CRT, detected either by echography or Doppler ranges between 12 and 14% with a high negative predictive value of about 95%, allowing the subsequent occurrence of CRT (symptomatic and asymptomatic) to be safely excluded. Despite its frequency and its medico-economic consequences, no thromboprophylaxis has been validated to date. In most patients, CRT occurs immediately after catheter insertion, most often within the first week and almost all within the first month after insertion. Meta analyses show a reduction of asymptomatic and symptomatic CRT incidence by about 55%-60% using either vitamin K antagonists or low molecular weight heparins without an increased risk of major bleeding. This pharmacological prophylaxis is only effective when started before the central venous catheter insertion at prophylactic doses and thereafter continued at subtherapeutic doses. Since no population at high risk of CRT has been identified, this review focuses on pathophysiology, epidemiology and clinical supportive data that could lead to a new CRT prophylaxis strategy.

Central catheter-associated deep vein thrombosis in cancer: clinical course, prophylaxis, treatment

The adequate handling of central venous catheters is a key element in the management of patients with cancer. Catheter-associated deep vein thrombosis is frequently observed in patients with malignant diseases; however, despite being a common complication among these patients, objective information concerning its epidemiology, clinical course, prophylaxis and treatment strategies is very limited. The reported incidence of catheter-related thrombosis (CRT) is highly variable, depending on symptomatic events, or if patients are screened for asymptomatic thrombosis. Several factors have been identified as potential predisposing factors for CRT, both technical and pathological aspects. The anticoagulant of choice is still unclear; while low-molecular-weight heparin is most commonly used, recent studies assessing the role of direct oral anticoagulants in the treatment of CRT show promise as an alternative, but the evidence remains insufficient and the decision must be made on a case-by-case basis.

Invited Review: Optimal Management of Upper Extremity DVT: Is Venous Thoracic Outlet Syndrome Underrecognized?

BACKGROUND

UEDVT accounts for approximately 10% of all cases of deep vein thrombosis. In the most widely referenced general review of deep vein thrombosis (DVT the American Academy of Chest Physicians essentially recommend that upper extremity DVT (UEDVT) essentially be treated identically to that of lower extremity DVT, with anticoagulation being the default therapy. Unfortunately, the medical literature does not well differentiate between DVT in the arm and the leg, and does not emphasize the effects of the costoclavicular junction (CCJ) and the lack of effect of gravity, to the point where UEDVT due to extrinsic bony compression at the CCJ is classified as "primary."

METHODS

Comprehensive literature review, beginning with both Medline and Google Scholar searches in addition to collected references, then following relevant citations within the initial manuscripts studied. Both surgical and medical journals were explored RESULTS: It is proposed that effort thrombosis be classified as a secondary cause of UEDVT, limiting the definition of primary to that which is truly idiopathic. Other causes of secondary UEDVT include catheter- and pacemaker-related thrombosis (the most common cause, but often asymptomatic), thrombosis related to malignancy and hypercoagulable conditions, and the rare case of thrombosis due to compression of the vein by a focal malignancy or other space-occupying lesion. In true primary UEDVT and in those secondary cases where no mechanical cause is present or can be corrected, anticoagulation remains the treatment of choice, usually for three months or the duration of a needed catheter. However, evidence suggests that many cases of effort thrombosis are likely missed by a too-narrow adherence to this protocol.

CONCLUSIONS

Because proper treatment of effort thrombosis drops the long-term symptomatic status rate from 50% to almost zero and these are healthy patients with a long lifespan ahead, it is proposed that a more aggressive attitude toward thrombolysis be followed in any patient who has a reasonable degree of suspicion for venous thoracic outlet syndrome.

Jugular venous catheter-associated thrombosis and fatal pulmonary embolism: A case report

INTRODUCTION

Central venous catheters related thrombosis (CRT) insertion has been shown to increase the risk of venous thromboembolism, particularly pulmonary embolism (PE). Nevertheless, deaths cased due to PE have been rarely reported.

PATIENT CONCERNS

A central venous catheter was introduced through the right jugular vein during the operation due to severe septic shock from a 57-year-old male patient. Two days after surgery, the hemodynamics was stable. On the 7th day, and low molecular weight heparin calcium (4100 units, once a day) was added for anticoagulation to prevent venous thromboembolism. On the 15th day, during the process of central venous catheter removal, the patient suddenly lost consciousness, suffered cardiac arrest, and received emergency cardiopulmonary resuscitation.

DIAGNOSIS

Jugular venous catheter-associated thrombosis and fatal PE. An acute bedside ultrasound showed a thrombus drifting with the blood stream in the right jugular vein. The lower section of the xiphoid process by echocardiography showed decreased systolic amplitude of the right atrium and right ventricle, widened and fixed inferior vena cava, and no variation with respiration. Para-sternal left ventricular long axis section showed that the right ventricular outflow tract was significantly extended, and the contraction amplitude of the anterior and posterior walls of the left ventricle decreased. Left ventricular short axis section indicated a right ventricle enlargement and ventricular septum deviation of left ventricle, showing "D" sign. Apical 4-chamber view showed that the right ventricular ratio increased and the contractile capacity decreased.

INTERVENTIONS

One and a half million units of urokinase were immediately given trough intravenous drip.

OUTCOMES

Twenty minutes after thrombolysis, the patient's autonomic heart rhythm was recovered, but continued to suffer from hypotension and coma, followed by multiple organ failure, and died 50 hours later.

CONCLUSION

Recent clinical practice guidelines recommend against the routine use of any anticoagulant thromboprophylaxis in patients with central venous catheters, but for patients at particularly high risk for CRT, consideration can be given to using higher doses of anticoagulant as prophylaxis, although there are virtually no data to support this approach.

Comparison of outcomes of central venous catheters in patients with solid and hematologic neoplasms: an Italian real-world analysis

INTRODUCTION

Although many reports have analyzed the outcomes of central venous catheters (CVCs) in oncologic and oncohematologic patients, current guidelines do not routinely recommend a specific type of CVC over the other.

METHODS

We retrospectively evaluated the outcomes of 178 patients with CVCs referred to an Italian specialized cancer center between January 2016 and December 2018. The analysis compares midterm peripherally inserted central venous catheters (PICCs) with long-term centrally inserted catheters, including totally implanted ports and tunneled catheters with central insertion (tCVCs).

RESULTS

A total of 130 PICCs (73%) and 48 tCVCs (27%) were analyzed. The overall complication rate was significantly increased in the PICC cohort compared to the tCVC cohort (43.1% vs 25%, respectively; p = 0.037), leading to complication-related device removal in 30.8% of PICCs vs 12.5% of tCVCs (p = 0.013). No significant differences in terms of catheter-related thromboses (p = 0.676) or catheter-related infections (p = 0.140) were detected. Nonthrombotic obstructions were significantly higher in the PICC group compared to the tCVC cohort (p = 0.006). Overall complication-free survival was significantly longer for tCVCs compared to PICCs (hazard ratio [HR], 0.262; 95% confidence interval [CI], 0.128-0.536; p < 0.0001), as well as obstruction-free survival (HR, 0.082; 95% CI, 0.018-0.372; p < 0.0001). In multivariable analysis, the type of CVC was independently correlated with the occurrence of any complication (HR, 0.273; 95% CI, 0.135-0.553; p < 0.0001).

CONCLUSIONS

This Italian real-world experience suggests that PICCs are associated with a higher risk of overall complications compared with tCVCs. Catheter choice in oncologic patients should be guided by treatment type and duration, risk-benefit assessment, patient preferences, and compliance.

Venue of catheter insertion does not significantly impact the event of central line-associated bloodstream infection in patients with haematological diseases

Background

Central line-associated bloodstream infection (CLABSI) is a serious complication of central venous catheter (CVC) placement in patients with haematological diseases associated with neutropenia and immunosuppression. However, whether the venues where CVC are inserted influence CLABSI development remains unclear.

Methods

We investigated whether CVC insertion at venues with different standards of cleanliness altered the occurrence of CLABSI. We evaluated data from 279 patients (545 CVC insertions) with haematological diseases including age, sex, underlying disease, reason for insertion, insertion site, number of lumens, venue, dates of insertion and removal, complete blood counts, percentage of neutrophils and serum albumin concentrations at the time of CVC insertion.

Findings

Overall, 55 CLABSI events occurred during a period of 23,434 catheter days (2.35 per 1,000 catheter days). In total, 153 and 190 patients underwent 226 and 305 CVC insertions, respectively in a ward and in an operating room, respectively. Univariate analysis identified the operating room (P = 0.017), allogeneic haematopoietic stem cell transplantation (P < 0.001), triple lumen catheter (P = 0.002), haemoglobin (P = 0.019), white blood cell count (P = 0.012) and percentage of neutrophils (P = 0.012) as significant factors for the development of CLABSI. However, multivariate analysis adjusted for age, reason for insertion, insertion site, number of lumens, haemoglobin, percentage of neutrophils and platelet counts found no significant differences between the venue where CVC were inserted and CLABSI development (P = 0.158).

Conclusion

The venue of CVC insertion is unlikely to influence CLABSI development in patients with haematological diseases.

Apixaban for Routine Management of Upper Extremity Deep Venous Thrombosis (ARM-DVT): Methods of a prospective single-arm management study

BACKGROUND

Upper extremity deep vein thrombosis (UEDVT) constitutes approximately 10% of all deep vein thromboses (DVTs). The incidence of UEDVT is increasing in association with use of peripherally inserted central venous catheters. Treatment for UEDVT is derived largely from evidence for treatment of lower extremity DVT. Limited evidence exists for the use of a direct oral anticoagulant for the treatment of UEDVT.

POPULATION

Sequential patients identified within the Intermountain Healthcare System and University of Utah Healthcare system with symptomatic UEDVT defined as the formation of thrombus within the internal jugular, subclavian, axillary, brachial, ulnar, or radial veins of the arm.

INTERVENTION

Apixaban 10 mg PO twice daily for 7 days followed by apixaban 5 mg twice daily for 11 weeks.

COMPARISON

The historical literature review rate of venous thrombosis reported for recurrent clinically overt objective venous thromboembolism (VTE) and VTE-related death. If the confidence interval for the observed rate excludes the threshold event rate of 4%, we will conclude that treatment with apixaban is noninferior and therefore a clinically valid approach to treat UEDVT.

SAMPLE SIZE

We elected a sample size of 375 patients so that an exact 95% confidence interval would exclude an event rate of VTE in the observation cohort of 4%.

OUTCOME

Ninety-day rate of new or recurrent objectively confirmed symptomatic venous thrombosis and VTE-related death. The primary safety outcome is the composite of major and clinically relevant nonmajor bleeding.

The role of hemostatic markers as venous stenosis or occlusion predictors following first transvenous cardiac device implantation

BACKGROUND

Among patients with an implanted cardiac implantable electronic device (CIED), ipsilateral upper extremity vein stenosis or occlusion (VSO) is observed more frequently than in the general population. However, there are no data available concerning the relationship between hemostatic markers (and their dynamics) and the occurrence of VSO. The aim of this study was to assess the predictive value of beta-thromboglobulin, the von Willebrand factor (vWF), fibrynogen and D-dimer for VSO development among first time CIED recipients.

METHODS

This is a single-center, prospective study of consecutive first time CIED recipients without upper extremity VSO in baseline ultrasound examination. Biochemical data were collected from all the patients before CIED implantation (first measuring), up to 7 days subsequent (second measuring) and 6 months after the operation (third measuring). Primary endpoint was defined as the presence of upper extremity VSO at the implantation site during the ultrasound examination 6 months after the operation.

RESULTS

The study included 71 patients (mean age 73.1 ± 10.5 years; 39 [55%] male). The incidence of VSO within 6-months follow up was 21.1%. Average concentrations of hemostatic markers increased significantly in all patients immediately after CIED implantation. Serial hemostatic marker concentrations were similar in patients who met or did not meet the primary endpoint, apart from vWF. The mean concentration was significantly elevated in the group of 15 patients who reached the primary endpoint (p = 0.032).

CONCLUSIONS

A significant increase in vWF concentration at 6 months post implantation may be a marker for VSO occurrence.

Etiology and Management of Upper-Extremity Catheter-Related Thrombosis in Cancer Patients

Central venous access devices are a critical instrument in the treatment and supportive care delivery for oncology patients. Catheter-related thrombosis (CRT) is a common complication of central venous access devices in oncology patients. Risk factors for CRT include patient-, device-, and treatment-related risk factors. Treatment of CRT is indicated to reduce symptoms, prevent catheter malfunction, prevent recurrent DVT or thromboembolic pulmonary embolism, and minimize the risk of post-thrombotic syndrome. Minimal prospective data exist on the prevention and treatment of catheter-related thromboses in cancer patients. As such recommendations largely are derived from data in the lower-extremity DVT and PE studies in cancer and non-cancer patients. Based on the available literature, primary pharmacologic prophylaxis against CRT is not recommended in cancer patients. Treatment options for CRT include catheter removal, anticoagulation, catheter-directed thrombolysis, or surgical thrombectomy. Current evidence-based guidelines recommend LMWH as the anticoagulant of choice. However, recent data showing efficacy and safety of DOACs in cancer-related VTE may be extrapolated to treatment of CRT in cancer patients. In patients with CRT, catheter removal should be pursued if continued vascular access is no longer needed, the catheter is dysfunctional, a catheter-associated infection is present, or if CRT symptoms do not resolve with anticoagulation alone. Catheter-directed thrombolysis is reserved for rare severe cases of CRT. Herein we discuss the pathophysiology, clinical presentation, diagnosis, and general management of CRT in cancer patients.

Predictors of venous stenosis or occlusion following first transvenous cardiac device implantation: Prospective observational study

INTRODUCTION

Venous stenosis or occlusion related to an intracardiac device is a well-known complication of that procedure. There are numerous studies tried to determine predictors of venous stenosis or occlusion; however, most of them investigate the venous system prior to device upgrade, generator replacement, or transvenous lead extraction. Therefore, we aimed to assess the prevalence and determine the predictors of venous stenosis or occlusion following first transevnous cardiac device implantation.

METHODS

Observational, prospective study included 71 consecutive patients admitted for first transvenous cardiac device implantation. All patients were followed up for 6 months after operation.

RESULTS

Implanted device systems comprised cardioverter defibrillator (n = 26), single-chamber or dual-chamber pacemakers (n = 34), and biventricular pacemakers (n = 11); 88.5% of implantable cardioverter defibrillator leads were single-coils and 11.5% were dual-coils. The incidence of venous stenosis or occlusion within 6-month follow-up was 21.1%. Multivariate logistic regression showed that only diabetes or prediabetes (p = 0.033, odds ratio: 0.17, 95% confidence interval: 0.04-0.87), prolonged procedure time (p = 0.046, odds ratio: 4.54, 95% confidence interval: 1.01-20.12), and perioperative complications (p = 0.021, odds ratio: 7.04, 95% confidence interval: 1.35-36.85) were predictors of venous stenosis or occlusion.

CONCLUSION

Prolonged implantation time (>60 min) and perioperative complications are associated with an increased risk of venous stenosis or occlusion, whereas diabetes and prediabetes significantly reduce the risk of venous stenosis or occlusion.

Incidence and outcomes of catheter related thrombosis (CRT) in patients with acute leukemia using a platelet-adjusted low molecular weight heparin regimen

Patients with acute leukemia frequently develop catheter-related thrombosis (CRT) despite concurrent thrombocytopenia. The incidence, treatment and outcomes of this complication are poorly documented. We undertook this study to determine the incidence of CRT in patients with acute leukemia and assess the safety and effectiveness of a treatment strategy using a platelet-adjusted low molecular weight heparin (LMWH) dosing protocol. Patients (18 years and older) with newly diagnosed acute leukemia from January 2014 to December 2015 who received central venous catheters were included. The clinical data were reviewed up to 12 months from acute leukemia diagnosis to capture objectively documented CRT events. The outcome events including recurrent venous thromboembolism (VTE), bleeding events, infectious or mechanical complications, and death were reported up to 3 months from the time of CRT diagnosis. The incidence of CRT among 214 patients was 10.7% (23 patients) in the first 12 months after acute leukemia diagnosis. Among 18 patients who were treated with anticoagulation, 14 (78%) received reduced LMWH dosing due to concurrent thrombocytopenia. There were no recurrent VTE episodes, but 3 patients experienced bleeding events while on anticoagulation. Fifteen patients (83%) completed a minimum of 3 months anticoagulation. Twelve patients (52%) experienced an infectious complication, which was the main reason for catheter removal. Deaths occurred in 2 patients, related to underlying acute leukemia during 3 months period following CRT. Symptomatic CRT is frequent in patients with acute leukemia. Platelet-adjusted LMWH dosing may be effective and well tolerated despite thrombocytopenia.

Anticoagulation for people with cancer and central venous catheters

BACKGROUND

Central venous catheter (CVC) placement increases the risk of thrombosis in people with cancer. Thrombosis often necessitates the removal of the CVC, resulting in treatment delays and thrombosis-related morbidity and mortality. This is an update of the Cochrane Review published in 2014.

OBJECTIVES

To evaluate the efficacy and safety of anticoagulation for thromboprophylaxis in people with cancer with a CVC.

SEARCH METHODS

We conducted a comprehensive literature search in May 2018 that included a major electronic search of Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), and Embase (Ovid); handsearching of conference proceedings; checking of references of included studies; searching for ongoing studies; and using the 'related citation' feature in PubMed. This update of the systematic review was based on the findings of a literature search conducted on 14 May 2018.

SELECTION CRITERIA

Randomized controlled trials (RCTs) assessing the benefits and harms of unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), vitamin K antagonists (VKA), or fondaparinux or comparing the effects of two of these anticoagulants in people with cancer and a CVC.

DATA COLLECTION AND ANALYSIS

Using a standardized form, we extracted data and assessed risk of bias. Outcomes included all-cause mortality, symptomatic catheter-related venous thromboembolism (VTE), pulmonary embolism (PE), major bleeding, minor bleeding, catheter-related infection, thrombocytopenia, and health-related quality of life (HRQoL). We assessed the certainty of evidence for each outcome using the GRADE approach (Balshem 2011).

MAIN RESULTS

Thirteen RCTs (23 papers) fulfilled the inclusion criteria. These trials enrolled 3420 participants. Seven RCTs compared LMWH to no LMWH (six in adults and one in children), six RCTs compared VKA to no VKA (five in adults and one in children), and three RCTs compared LMWH to VKA in adults.LMWH versus no LMWHSix RCTs (1537 participants) compared LMWH to no LMWH in adults. The meta-analyses showed that LMWH probably decreased the incidence of symptomatic catheter-related VTE up to three months of follow-up compared to no LMWH (risk ratio (RR) 0.43, 95% confidence interval (CI) 0.22 to 0.81; risk difference (RD) 38 fewer per 1000, 95% CI 13 fewer to 52 fewer; moderate-certainty evidence). However, the analysis did not confirm or exclude a beneficial or detrimental effect of LMWH on mortality at three months of follow-up (RR 0.82, 95% CI 0.53 to 1.26; RD 14 fewer per 1000, 95% CI 36 fewer to 20 more; low-certainty evidence), major bleeding (RR 1.49, 95% CI 0.06 to 36.28; RD 0 more per 1000, 95% CI 1 fewer to 35 more; very low-certainty evidence), minor bleeding (RR 1.35, 95% CI 0.62 to 2.92; RD 14 more per 1000, 95% CI 16 fewer to 79 more; low-certainty evidence), and thrombocytopenia (RR 1.03, 95% CI 0.80 to 1.33; RD 5 more per 1000, 95% CI 35 fewer to 58 more; low-certainty evidence).VKA versus no VKAFive RCTs (1599 participants) compared low-dose VKA to no VKA in adults. The meta-analyses did not confirm or exclude a beneficial or detrimental effect of low-dose VKA compared to no VKA on mortality (RR 0.99, 95% CI 0.64 to 1.55; RD 1 fewer per 1000, 95% CI 34 fewer to 52 more; low-certainty evidence), symptomatic catheter-related VTE (RR 0.61, 95% CI 0.23 to 1.64; RD 31 fewer per 1000, 95% CI 62 fewer to 51 more; low-certainty evidence), major bleeding (RR 7.14, 95% CI 0.88 to 57.78; RD 12 more per 1000, 95% CI 0 fewer to 110 more; low-certainty evidence), minor bleeding (RR 0.69, 95% CI 0.38 to 1.26; RD 15 fewer per 1000, 95% CI 30 fewer to 13 more; low-certainty evidence), premature catheter removal (RR 0.82, 95% CI 0.30 to 2.24; RD 29 fewer per 1000, 95% CI 114 fewer to 202 more; low-certainty evidence), and catheter-related infection (RR 1.17, 95% CI 0.74 to 1.85; RD 71 more per 1000, 95% CI 109 fewer to 356; low-certainty evidence).LMWH versus VKAThree RCTs (641 participants) compared LMWH to VKA in adults. The available evidence did not confirm or exclude a beneficial or detrimental effect of LMWH relative to VKA on mortality (RR 0.94, 95% CI 0.56 to 1.59; RD 6 fewer per 1000, 95% CI 41 fewer to 56 more; low-certainty evidence), symptomatic catheter-related VTE (RR 1.83, 95% CI 0.44 to 7.61; RD 15 more per 1000, 95% CI 10 fewer to 122 more; very low-certainty evidence), PE (RR 1.70, 95% CI 0.74 to 3.92; RD 35 more per 1000, 95% CI 13 fewer to 144 more; low-certainty evidence), major bleeding (RR 3.11, 95% CI 0.13 to 73.11; RD 2 more per 1000, 95% CI 1 fewer to 72 more; very low-certainty evidence), or minor bleeding (RR 0.95, 95% CI 0.20 to 4.61; RD 1 fewer per 1000, 95% CI 21 fewer to 95 more; very low-certainty evidence). The meta-analyses showed that LMWH probably increased the risk of thrombocytopenia compared to VKA at three months of follow-up (RR 1.69, 95% CI 1.20 to 2.39; RD 149 more per 1000, 95% CI 43 fewer to 300 more; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence was not conclusive for the effect of LMWH on mortality, the effect of VKA on mortality and catheter-related VTE, and the effect of LMWH compared to VKA on mortality and catheter-related VTE. We found moderate-certainty evidence that LMWH reduces catheter-related VTE compared to no LMWH. People with cancer with CVCs considering anticoagulation should balance the possible benefit of reduced thromboembolic complications with the possible harms and burden of anticoagulants.

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.

How I treat central venous access device-related upper extremity deep vein thrombosis

Central venous access device (CVAD)-related thrombosis (CRT) is a common complication among patients requiring central venous access as part of their medical care. Complications of CRT include pulmonary embolism, recurrent deep venous thrombosis, loss of central venous access, and postthrombotic syndrome. Patient-, device-, and treatment-related factors can influence the risk of CRT. Despite numerous randomized controlled trials, the clinical benefit of pharmacologic thromboprophylaxis for the prevention of CRT remains to be established. Therefore, minimizing patient exposure to known risk factors is the best available approach to prevent CRT. Venous duplex is recommended for the diagnosis of CRT. Anticoagulation for at least 3 months or the duration of the indwelling CVAD is recommended for treatment of CRT. Thrombolysis should be considered for patients at low risk for bleeding who have limb-threatening thrombosis or whose symptoms fail to resolve with adequate anticoagulation. CVAD removal should be consider for patients with bacteremia, persistent symptoms despite anticoagulation, and if the CVAD is no longer needed. Superior vena cava filters should be avoided. Prospective studies are needed to define the optimal management of patients with or at risk for CRT.

Assessment of thrombosis in right internal jugular vein after percutaneous superior vena cava catheter insertion during cardiovascular surgery with cardiopulmonary bypass

OBJECTIVE

We evaluated the incidence of percutaneous superior vena cava catheter-related thrombosis and identified risk factors for developing the condition in patients undergoing cardiovascular surgery with cardiopulmonary bypass.

METHODS

A total of 121 patients were evaluated. A percutaneous superior vena cava catheter was inserted into the right internal jugular vein during cardiovascular surgery with cardiopulmonary bypass. The right internal jugular vein was evaluated using ultrasonography, including cross-sectional area and velocity just before insertion of the percutaneous superior vena cava catheter (preoperative) and 24 hours and 48 hours after its insertion. If an echogenic mass was detected in the right internal jugular vein, the size was measured.

RESULTS

The incidence of thrombosis in the right internal jugular vein was 56.2%. Change in the right internal jugular vein cross-sectional area and velocity had no clinical implications. Multiple logistic regression analysis identified age (odds ratio, 1.061; 95% confidence interval, 1.022-1.101; P = .002), superior vena cava catheter indwelling duration (odds ratio, 1.015; 95% confidence interval, 1.008-1.023; P < .001), and amount of transfusion platelet concentrate (odds ratio, 1.155; 95% confidence interval, 1.030-1.295; P = .013) as risk factors for percutaneous superior vena cava catheter-related thrombosis in the right internal jugular vein.

CONCLUSIONS

The incidence of percutaneous superior vena cava catheter-related thrombosis was higher than conventional central venous catheter-related thrombosis. Risk factors were age, superior vena cava catheter indwelling duration, and amount of transfusion platelet concentrate.

The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities

BACKGROUND

Peripherally inserted central catheters are associated with upper-extremity deep vein thrombosis. Whether they also are associated with lower-extremity deep vein thrombosis or pulmonary embolism is unknown. We examined the risk of venous thromboembolism in deep veins of the arm, leg, and chest after peripherally inserted central catheter placement.

METHODS

We conducted a multicenter, retrospective cohort study of 76,242 hospitalized medical patients from 48 Michigan hospitals. Peripherally inserted central catheter presence, comorbidities, venous thrombosis risk factors, and thrombotic events within 90 days from hospital admission were ascertained by phone and record review. Cox proportional hazards models were fit to examine the association between peripherally inserted central catheter placement and 90-day hazard of upper- and lower-extremity deep vein thrombosis or pulmonary embolism, adjusting for patient-level characteristics and natural clustering within hospitals.

RESULTS

A total of 3790 patients received a peripherally inserted central catheter during hospitalization. From hospital admission to 90 days, 876 thromboembolic events (208 upper-extremity deep vein thromboses, 372 lower-extremity deep vein thromboses, and 296 pulmonary emboli) were identified. After risk adjustment, peripherally inserted central catheter use was independently associated with all-cause venous thromboembolism (hazard ratio [HR], 3.16; 95% confidence interval [CI], 2.59-3.85), upper-extremity deep vein thrombosis (HR, 10.49; 95% CI, 7.79-14.11), and lower-extremity deep vein thrombosis (HR, 1.48; 95% CI, 1.02-2.15). Peripherally inserted central catheter use was not associated with pulmonary embolism (HR, 1.34; 95% CI, 0.86-2.06). Results were robust to sensitivity analyses incorporating receipt of pharmacologic prophylaxis during hospitalization.

CONCLUSIONS

Peripherally inserted central catheter use is associated with upper- and lower-extremity deep vein thrombosis. Weighing the thrombotic risks conferred by peripherally inserted central catheters against clinical benefits seems necessary.

Anticoagulation for people with cancer and central venous catheters

BACKGROUND

Central venous catheter (CVC) placement increases the risk of thrombosis in people with cancer. Thrombosis often necessitates the removal of the CVC, resulting in treatment delays and thrombosis-related morbidity and mortality.

OBJECTIVES

To evaluate the relative efficacy and safety of anticoagulation for thromboprophylaxis in people with cancer with a CVC.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2012), MEDLINE Ovid (January 1966 to February 2013), and EMBASE Ovid (1980 to February 2013). We handsearched conference proceedings, checked references of included studies, used the 'related citations' feature within PubMed, and searched clinicaltrials.gov for ongoing studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing the effects of any dose of unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), vitamin K antagonists (VKA), or fondaparinux with no intervention or placebo or comparing the effects of two different anticoagulants in people with cancer and a CVC.

DATA COLLECTION AND ANALYSIS

Teams of two review authors independently used a standardized form to extract data in duplicate. They resolved any disagreements by discussion. They extracted data on risk of bias, participants, interventions, and outcomes. Outcomes of interest included mortality, symptomatic deep venous thrombosis (DVT), asymptomatic DVT, major bleeding, minor bleeding, infection, and thrombocytopenia. Where possible, we conducted meta-analyses using the random-effects model.

MAIN RESULTS

Of 9559 identified citations, we included 12 RCTs (17 publications) reporting follow-up data on 2823 participants. Two of the RCTs included children. Of the 10 RCTs including 2564 adults, one compared prophylactic dose heparin with low-dose VKA. Three RCTs compared VKA with no VKA and four RCTs compared heparin with no heparin. Two additional trials had three separate arms comparing heparin, VKA, and no intervention. Prophylactic-dose heparin, compared with no heparin, was associated with a statistically significant reduction in symptomatic DVT (risk ratio (RR) 0.48; 95% confidence interval (CI) 0.27 to 0.86; moderate-quality evidence). However, results did not confirm or exclude a beneficial or detrimental effect of heparin on mortality (RR 0.82; 95% CI 0.53 to 1.26; moderate-quality evidence), major bleeding (RR 0.49; 95% CI 0.03 to 7.84; low-quality evidence), infection (RR 1.00; 95% CI 0.54 to 1.85; moderate-quality evidence); thrombocytopenia (RR 1.03; 95% CI 0.80 to 1.33; moderate-quality evidence), or minor bleeding (RR 1.35; 95% CI: 0.62 to 2.92). Low-dose VKAs, compared with no VKAs, were associated with a statistically significant reduction in asymptomatic DVT (RR 0.43; 95% CI 0.30 to 0.62). Results did not confirm or exclude a beneficial or detrimental effect of VKAs on mortality (RR 1.04; 95% CI 0.89 to 1.22; low-quality evidence), symptomatic DVT (RR 0.51; 95% CI 0.21 to 1.22; low-quality evidence), major bleeding (RR 7.60; 95% CI 0.94 to 61.49; very-low-quality evidence), or minor bleeding (RR 3.14; 95% CI 0.14 to 71.51). The use of heparin, compared with VKA was associated with a statistically significant increase in thrombocytopenia (RR 3.73; 95% CI 2.26 to 6.16; low-quality evidence) and asymptomatic DVT (RR 1.74; 95% CI 1.20 to 2.52). However, results did not show or exclude a beneficial or detrimental effect on any of the other outcomes of interest (very-low-quality evidence).

AUTHORS' CONCLUSIONS

Compared with no anticoagulation, we found a statistically significant reduction of symptomatic DVT with heparin and asymptomatic DVT with VKA. Heparin was associated with a higher risk of thrombocytopenia and asymptomatic DVT when compared with VKA. However, the findings did not rule out other clinically important benefits and harms. People with cancer with CVCs considering anticoagulation should balance the possible benefit of reduced thromboembolic complications with the possible harms and burden of anticoagulants.

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.

Thromboembolic complications in burn patients and associated risk factors

Early mobilization and deep venous thrombosis (DVT) prophylaxis have been shown to reduce the incidence of DVT and pulmonary embolism among hospitalized patients, yet thromboembolic complications remain a great concern, especially to those who remain immobilized for an extended period of time. There are many risk factors associated with the development of thromboembolism, especially DVT. The main objective of this retrospective study is to estimate the occurrence of DVT in burn patients and to investigate some burn-related risk factors. A retrospective examination of DVT cases was conducted among the acute burn patients admitted to our Regional Burn Center during 2008. The analysis included the demographic factors, preexisting medical conditions, ventilator support, number of surgeries and blood transfusions, and use of central line. There was a total of 97 diagnosed patients with DVT and among them 86 were adult acute burn patients. There were 113 diagnosed with DVTs in 86 burn patients, including 22 patients diagnosed with DVT at multiple sites either in one screening or in subsequent screenings. Incidence of DVT at the center was 5.92 per 100 adult acute burn admissions. Men had more DVT than women (6.87 vs. 3.34%, relative risk 2.05, P < .05). The average percentage of %TBSA was smaller in the patients who were more than 50 years of age compared with the patients who were 49 years or younger (21.97 vs. 34.77%, P < .05). Among the patients with DVT, 80 (93%) had a central venous catheter before DVT developed and the other six never had a central venous catheter. The most common site for DVT development was common femoral vein site 89%. The average number of procedures before DVT was 7.84 ± 8.36, and blood transfusions were 39.55 ± 108.37 units. Six patients (7%) died in the hospital within these study cohorts and there was no indication that pulmonary embolism was the cause of the deaths. The study showed that the incidence of DVT in the burn center was comparable with the incidences reported in the literature. Being of male sex, a smoker, an alcoholic, high-age group, high %TBSA, use of central line, increased number of surgeries, and increased number of blood transfusions are identified as possible predisposing factors for DVTs. Further meaningful evaluation to determine the incidence of DVT in burn patients and its associated risk factors will require large multicenter, well-controlled, prospective designed study.

Acute promyelocytic leukemia-associated thrombosis

Patients with acute promyelocytic leukemia (APL) are prone to both bleeding and thrombosis. The bleeding complications are well known. In contrast, APL-associated thrombosis is relatively underappreciated. We aimed to explore the issue of APL-associated thrombosis events. In the past 20 years, 127 cases with APL were found in our hospital database. We collected their coagulation laboratory profiles, including leukemia burdens, white blood cell and platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen levels, and disseminated intravascular coagulation scores. Data were compared between patients with or without thrombosis. Clinical outcomes and potential risk factors were obtained for analysis. Ten cases with APL-associated thrombosis were found. The incidence of thrombosis was 7.9% in our cohort. Five patients had cerebral infarction, 5 had catheter-related thrombosis and 1 had acute myocardial infarction. No laboratory data were associated with clinical thrombosis. Three patients died during the induction phase but thrombosis was not the direct cause of death for any of them. We conclude that patients with APL are susceptible to thrombosis in addition to bleeding. Laboratory coagulation parameters did not predict thrombosis in our series. Ischemic stroke and catheter-related thrombosis were the most common events in our Taiwanese cohort. Such a thrombosis pattern is unique and worth further investigation.

Early ultrasonographic finding of septic thrombophlebitis is the main indicator of central venous catheter removal to reduce infection-related mortality in neutropenic patients with bloodstream infection

BACKGROUND

Septic thrombophlebitis increases patient morbidity and mortality following metastatic infections, pulmonary emboli, and/or septic shock. Central venous catheter (CVC) removal for occult septic thrombophlebitis challenges current strategy in neutropenic patients.

PATIENTS AND METHODS

We prospectively evaluated infection-related mortality in 100 acute leukemia patients, with CVC-related bloodstream infection (CRBSI) after chemotherapy, who systematically underwent ultrasonography to identify the need for catheter removal. Their infection-related mortality was compared with that of a historical cohort of 100 acute leukemia patients, with CRBSI after chemotherapy, managed with a clinically driven strategy. Appropriate antimicrobial therapy was administered in all patients analyzed.

RESULTS

In the prospective series, 30/100 patients required catheter removal for ultrasonography-detected septic thrombophlebitis after 1 median day from BSI onset; 70/100 patients without septic thrombophlebitis retained their CVC. In the historical cohort, 60/100 patients removed the catheter (persistent fever, 40 patients; persistent BSI, 10 patients; or clinically manifest septic thrombophlebitis, 10 patients) after 8 median days from BSI onset; 40/100 patients retained the CVC because they had not clinical findings of complicated infection. At 30 days median follow-up, one patient died for infection in the ultrasonography-assisted group versus 17 patients in the historical cohort (P<0.01). With the ultrasonography-driven strategy, early septic thrombophlebitis detection and prompt CVC removal decrease infection-related mortality, whereas clinically driven strategy leads to inappropriate number, reasons, and timeliness of CVC removal.

CONCLUSION

Ultrasonography is an easy imaging diagnostic tool enabling effective and safe management of patients with acute leukemia and CRBSI.

Thrombophilia - how far and how much to investigate?

Thrombohemorrhagic balance is maintained by complicated interactions between the coagulation and fibrinolytic system, platelets, and the vessel wall. Dr. Virchow provided approach for investigating and managing thrombotic disorders. He proposed stasis, vascular injury, and hypercoagulability as causes for thrombosis. In 1965, antithrombin deficiency was described. After two decades, protein C and protein S deficiencies, mutations of factor V Leiden, and factor II were described. If we distinguish patients at high risk and low risk of thrombosis, we can optimize therapeutic decisions. There is currently no evidence to say that laboratory abnormality should influence intensity of anticoagulation. In this article we reviewed the risk factors and need for thrombophilia screening in patients. Screening general population for thrombophilia is not justified or recommended at this time.

Anticoagulation for patients with cancer and central venous catheters

BACKGROUND

Central venous catheter (CVC) placement increases the risk of thrombosis in cancer patients. Thrombosis often necessitates the removal of the CVC, resulting in treatment delays and thrombosis related morbidity and mortality.

OBJECTIVES

To evaluate the efficacy and safety of anticoagulation in cancer patients with a CVC.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (January 1966 to February 2010; accessed via OVID), EMBASE (January 1980 to February 2010; accessed via OVID) and ISI the Web of Science (1975 to February 2010). We handsearched conference proceedings, checked references of included studies and used the "related article" feature within PubMed.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing any dose of unfractionated heparin (UFH), low molecular weight heparin (LMWH), vitamin K antagonists (VKA), or fondaparinux to no intervention or placebo or comparing two different anticoagulants in cancer patients with a CVC.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from each included study and resolved their disagreements by discussion.

MAIN RESULTS

Of 8187 identified citations, we included 12 RCTs enrolling 3611 patients and assessing either prophylactic dose heparin or low dose VKAs. Prophylactic dose heparin was not associated with a statistically significant effect on death (relative risk (RR) = 0.85; 95% confidence interval (CI): 0.53 to 1.37), symptomatic deep venous thrombosis (DVT) (RR = 0.54; 95% CI: 0.28 to 1.05) asymptomatic DVT (RR = 0.81; 95% CI: 0.64 to 1.02), major bleeding (RR = 0.68; 95% CI: 0.10 to 4.78), thrombocytopenia (RR = 0.85; 95% CI: 0.49 to 1.46), or infection (RR = 0.91; 95% CI: 0.49 to 1.68). Similarly, low dose VKAs were not associated with a statistically significant effect on death (RR = 0.97; 95% CI: 0.82 to 1.15), symptomatic DVT (RR = 0.63; 95% CI: 0.35 to 1.11) or major bleeding (RR = 6.93; 95% CI: 0.86 to 56.08). However, they were associated with a statistically significant reduction in asymptomatic DVT (RR = 0.42; 95% CI: 0.28 to 0.61). Studies comparing heparin to VKA found no effects on any of the outcomes of interest.

AUTHORS' CONCLUSIONS

We found no statistically significant effect of heparin or VKA on the outcomes of interest. However, the findings did not rule out clinically important benefits and harms. Patients with cancer with CVCs considering anticoagulation should balance the possible benefit of reduced thromboembolic complications with the possible harms and burden of anticoagulants.

Internal jugular vein thrombosis: outcome and risk factors

INTRODUCTION

The aims of this study were to analyse the characteristics of patients with internal jugular venous thrombosis. We compared the characteristics of patients with internal jugular venous thrombosis with those of patients exhibiting upper extremity deep venous thrombosis (UEDVT) without internal jugular vein involvement.

PATIENTS

From 1998 to 2007, 1948 consecutive patients were referred to our Department of Internal Medicine for deep venous thrombosis.

RESULTS

Sixty-four patients exhibited UEDVT. Internal jugular venous thrombosis was diagnosed in 29 patients. Twenty-three patients had secondary thrombosis mainly due to cancer, central venous catheter and ovarian hyperstimulation syndrome; three of the four patients with bilateral DVT exhibited cancer. Six patients had primary internal jugular vein thrombosis. Complications of internal jugular vein thrombosis were pulmonary embolism (10.3%) and post-thrombotic syndrome (41.4%). Under multivariate analysis, significant factors for internal jugular vein thrombosis were older patients (P = 0.0008), female gender (P = 0.0035) and ovarian hyperstimulation syndrome (P = 0.0093).

CONCLUSION

Our study underscores that the most common causes of internal jugular vein thrombosis are cancer, central venous catheter and ovarian hyperstimulation syndrome; it also underlines that bilateral internal jugular vein thrombosis is a significant risk indicator of malignancy Thrombosis led to high morbidity related to pulmonary embolism and post-thrombotic syndrome, principally in patients with secondary DVT. The knowledge of predictive factors of internal jugular vein thrombosis seems to be of utmost importance to improve patients' management.

Upper extremity deep venous thrombosis

Upper extremity deep venous thrombosis is a serious disease entity which, based on the pathogenesis and in view of the individual patient’s prognosis, must be divided into a primary and a secondary form. Primary upper extremity deep venous thrombosis is, when related to effort, a rather benign disease with excellent prognosis quoad vitam, carrying only a minor potential of developing disabling post-thrombotic syndrome. If primary upper extremity deep venous thrombosis occurs without any obvious cause, screening for underlying malignancy is recommended. Secondary upper extremity deep venous thrombosis typically occurs in older patients with severe comorbidities, mainly related to indwelling central venous catheters and cancer. As a consequence of the underlying diseases, prognosis of secondary upper extremity deep venous thrombosis is poor. Despite a lack of high-quality validation data, ultrasonography is regarded the first-line imaging technique, since it is a non-invasive method without exposure to radiation. In case of a non-diagnostic result of ultrasonography, other imaging modalities such as magnetic resonance imaging and computed tomography may be applied. Regardless of the etiology, the cornerstone of therapy is anticoagulant treatment with low molecular weight heparin or unfractionated heparin and vitamin K antagonists in order to prevent thrombus progression and pulmonary embolism. Owing to a lack of evidence, the optimal duration of anticoagulant treatment remains unclear. The additional benefit of compression therapy as well as of more aggressive therapeutic approaches such as thrombolysis, angioplasty and surgical decompression of the thoracic outlet needs to be investigated in randomized trials.

Anticoagulation for patients with cancer and central venous catheters

BACKGROUND

Central venous catheter (CVC) placement increases the risk of thrombosis in cancer patients. Thrombosis often necessitates the removal of the CVC, resulting in treatment delays and thrombosis related morbidity and mortality.

OBJECTIVES

To evaluate the efficacy and safety of anticoagulation in cancer patients with a CVC.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (January 1966 to February 2010; accessed via OVID), EMBASE (January 1980 to February 2010; accessed via OVID) and ISI the Web of Science (1975 to February 2010). We handsearched conference proceedings, checked references of included studies and used the "related article" feature within PubMed.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing any dose of unfractionated heparin (UFH), low molecular weight heparin (LMWH), vitamin K antagonists (VKA), or fondaparinux to no intervention or placebo or comparing two different anticoagulants in cancer patients with a CVC.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from each included study and resolved their disagreements by discussion.

MAIN RESULTS

Of 8187 identified citations, we included 12 RCTs enrolling 3611 patients and assessing either prophylactic dose heparin or low dose VKAs. Prophylactic dose heparin was not associated with a statistically significant effect on death (relative risk (RR) = 0.85; 95% confidence interval (CI): 0.53 to 1.37), symptomatic deep venous thrombosis (DVT) (RR = 0.54; 95% CI: 0.28 to 1.05) asymptomatic DVT (RR = 0.81; 95% CI: 0.64 to 1.02), major bleeding (RR = 0.68; 95% CI: 0.10 to 4.78), thrombocytopenia (RR = 0.85; 95% CI: 0.49 to 1.46), or infection (RR = 0.91; 95% CI: 0.49 to 1.68). Similarly, low dose VKAs were not associated with a statistically significant effect on death (RR = 0.97; 95% CI: 0.82 to 1.15), symptomatic DVT (RR = 0.63; 95% CI: 0.35 to 1.11) or major bleeding (RR = 6.93; 95% CI: 0.86 to 56.08). However, they were associated with a statistically significant reduction in asymptomatic DVT (RR = 0.42; 95% CI: 0.28 to 0.61). Studies comparing heparin to VKA found no effects on any of the outcomes of interest.

AUTHORS' CONCLUSIONS

We found no statistically significant effect of heparin or VKA on the outcomes of interest. However, the findings did not rule out clinically important benefits and harms. Patients with cancer with CVCs considering anticoagulation should balance the possible benefit of reduced thromboembolic complications with the possible harms and burden of anticoagulants.

Venous thromboembolism following vigorous deep tissue massage

Venous thromboembolism (VTE) is an increasing public health concern, in part because of lack of awareness among patients and physicians. Nonpenetrating trauma to the legs may be an under-recognized potential risk factor for VTE. We report a case of VTE following vigorous deep tissue massage in a previously healthy 67-year-old man with no other identifiable risk factors. The etiology, risk factors, and implications for the prevention and detection of VTE are reviewed. There are few other published reports of VTE associated with massage, but under-reporting seems likely. Vigorous massage or any equivalent trauma to the legs should be considered and evaluated as a possible risk factor for VTE, especially in older adults. Additional research is needed to clarify the risks associated with nonpenetrating trauma to the legs in older adults and other susceptible groups. Improved awareness of VTE, including its risk factors and symptoms, is an urgent priority for more effective prevention, detection, and treatment.

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.

Internal jugular vein deformities after central venous catheterisation in neonates: evaluation by Doppler ultrasound

AIM

The use of a central venous catheter (CVC) through the internal jugular vein (IJV) in neonates is associated with various complications. We postulated that the risk of vein deformity after removing the CVC is underestimated. This study aimed to evaluate, using Doppler ultrasound, morphological changes in the IJV that had undergone CVC insertion during the neonatal period.

METHODS

The study consisted of 23 cases, in which 2.7 Fr Broviac (Bard Access Systems, Salt Lake City, Utah, USA) CVCs were inserted through the IJVs of newborns over a 2-year period. After the removal of the CVCs, the IJVs were examined by Doppler ultrasound.

RESULTS

Seventeen cases had normal appearances, but six (26%) cases had deformities. One case had a completely obstructed IJV, and five had abnormal compressibility, echogenic intravascular masses or monophasic waveforms of blood flow. On follow-up, IJV deformities were not improved but tended to be aggravated. There were significant differences in gestational age (36.6 +/- 3.2 weeks vs. 30.0 +/- 3.9 weeks, P= 0.002), body weight at time of CVC insertion (2.60 +/- 0.72 kg vs. 1.32 +/- 0.47 kg, P= 0.001) and duration of catheter use (25.9 +/- 13.6 days vs. 49.0 +/- 22.0 days, P= 0.016) between the normal and deformity groups, respectively.

CONCLUSIONS

IJV deformities after central venous catheterisation in neonates are common. A lower gestational age, a lower body weight, and more catheter indwelling days are significant factors affecting the incidence of IJV deformities.

Upper-extremity deep vein thrombosis related to central venous port systems implanted in cancer patients

The purpose of the current study was to evaluate the incidence and course of upper-extremity deep vein thrombosis (UEDVT) related to an implanted central venous port (CV-port) system in cancer patients. From July 2007 to July 2008, 92 consecutive patients who underwent implantation of a CV-port for chemotherapy for colorectal cancer were prospectively enrolled in the study. All patients were examined at prescribed intervals by ultrasonography (US) to estimate the incidence of catheter-related venous thrombosis. We categorised ultrasound diagnosis into three types: Type 0, no thrombus; Type I, thrombi around catheter without obstruction of venous flow; Type II: thrombi with obstruction of venous flow. Upon initial ultrasound examination, 25 cases (27%) were categorised as Type 0, 64 (70%) as Type I and III (3%) as Type II. Of the 64 Type-I cases, 4 cases worsened to Type II within a month, and 3 others (including 1 patient who developed pulmonary embolism) became Type II after 1 month. Of the other Type-I cases, 12 cases improved to Type 0 and 45 cases remained Type I. All 10 patients categorised as Type II underwent anticoagulant therapy and resumed their chemotherapy without exacerbations of thrombosis. In cancer patients undergoing long-term chemotherapy, there is an unexpectedly high prevalence of catheter-related UEDVT, which can be detected by ultrasound at an early stage after implantation of a CV-port. Given that cancer patients with UEDVT may have worse outcomes than those without, clinicians should consider careful monitoring for UEDVT and introducing anticoagulant therapy.

[Role of low molecular weight heparins in prophylaxis of thromboembolic events on oncological patients with indwelling central venous catheter]

BACKGROUND AND OBJECTIVE

Our study was designed to assess the incidence of thrombosis in the upper limbs and of pulmonary embolism in oncological patients with indwelling central venous catheters, and to evaluate, also, the potential role of LMWH to prevent these events.

PATIENTS AND METHODS

Oncological patients undergoing placement of a central venous acccess (port-a-cath type) were treated with or without bemiparin in a non-randomized fashion. Assessment included clinical and radiological follow-up. A phlebography on the first day and ecodoppler on days 1th, 45th and 90th were performed. Patients received or not prophylactic bemiparin (3500UI/day) in a non-randomized way. The incidence of thrombosis in both groups was assessed as well as its relation with some risk factors.

RESULTS

One hundred and forty eight patients were eligible; 19 thrombotic events were found. The incidence of symptomatic upper extremity thrombosis was 5.41%, asymptomatic thrombosis in 2.03% ; there was one case of pulmonary embolism ( 0,68%); catheter failure occurred in 2.70%; incidence of lower extremities deep venous thrombosis was 2.03%. There was a higher percentage of events in the group of patients treated with bemiparin than in the not treated individuals (9.4%), although the difference did not reach statistical significance (p=0.27). The only risk factors reaching statistical significance were the prothrombin time, high blood pressure and overweight.

CONCLUSIONS

Central venous catheters are very useful in oncology. The procedure was related with a low percentage of thrombotic complications. Sodic bemiparin does not reduce the thrombotic risk in these patients.

Management of occlusion and thrombosis associated with long-term indwelling central venous catheters

Long-term central venous catheters (CVCs) are important instruments in the care of patients with chronic illnesses, but catheter occlusions and catheter-related thromboses are common complications that can result from their use. In this Review, we summarise management of these complications. Mechanical CVC occlusions need cause-specific treatment, whereas thrombotic occlusions usually resolve with thrombolytic treatment, such as alteplase. Prophylaxis with thrombolytic flushes might prevent CVC infections and catheter-related thromboses, but confirmatory studies and cost-effectiveness analysis of this approach are needed. Risk factors for catheter-related thromboses include previous catheter infections, malposition of the catheter tip, and prothrombotic states. Catheter-related thromboses can lead to catheter infection, pulmonary embolism, and post-thrombotic syndrome. Catheter-related thromboses are usually diagnosed by Doppler ultrasonography or venography and treated with anticoagulation therapy for 6 weeks to a year, dependent on the extent of the thrombus, response to initial therapy, and whether thrombophilic factors persist. Prevention of catheter-related thromboses includes proper positioning of the CVC and prevention of infections; anticoagulation prophylaxis is not currently recommended.

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.

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.

Anticoagulation for thrombosis prophylaxis in cancer patients with central venous catheters

BACKGROUND

Central venous catheter (CVC) placement increases the risk of thrombosis in cancer patients. Thrombosis often necessitates the removal of the CVC, resulting in treatment delays and thrombosis related morbidity and mortality.

OBJECTIVES

To evaluate the efficacy and safety of anticoagulation in reducing venous thromboembolic (VTE) events in cancer patients with CVC.

SEARCH STRATEGY

A comprehensive search for studies of anticoagulation in cancer patients up to January 2006 was conducted in the following databases: The Cochrane Central Register of Controlled Trials ( CENTRAL), MEDLINE, EMBASE and ISI the Web of Science.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing unfractionated heparin (UFH), low molecular weight heparin (LMWH), vitamin K antagonists (VKA), fondaparinux or ximelagatran to no intervention or placebo in cancer patients with a CVC or comparing two different anticoagulants.

DATA COLLECTION AND ANALYSIS

Data was extracted on methodological quality, patients, interventions and outcomes including all cause mortality (primary outcome), premature CVC removal, catheter-related infections, CVC site and non CVC site deep venous thrombosis (DVT), pulmonary embolism (PE), major and minor bleeding and thrombocytopenia.

MAIN RESULTS

Of 3986 identified citations nine RCTs were included in the meta-analysis including one published as an abstract and one focusing on paediatric patients not included in the meta-analysis. None of these RCTs tested fondaparinux or ximelagatran. The use of heparin in cancer patients with CVC was associated with a trend towards a reduction in symptomatic DVT (Relative Risk (RR) = 0.43; 95% Confidence Interval (CI): 0.18 to 1.06), but the data did not show any statistically significant effect on mortality (RR = 0.74; 95% CI: 0.40 to 1.36), infection (RR = 0.91; 95% CI: 0.36 to 2.28), major bleeding (RR = 0.68; 95% CI: 0.10 to 4.78) or thrombocytopenia (RR = 0.85; 95% CI: 0.49 to 1.46). The effect warfarin on symptomatic DVT was not statistically significant (RR = 0.62; 95% CI: 0.30 to 1.27). When studies assessing different types of anticoagulants were pooled, symptomatic DVT rates were significantly reduced (RR = 0.56; 95% CI: 0.34 to 0.92).

AUTHORS' CONCLUSIONS

Cancer patients with CVC considering anticoagulation, should consider the possible benefit of reduced incidence of thromboembolic complications with the burden and harms of anticoagulation. Future studies should be adequately powered and evaluate the effects of newer anticoagulants such as fondaparinux and ximelagatran in cancer patients with CVC.

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.