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

Cancer-associated venous thrombosis in adults (second edition): A British Society for Haematology Guideline

A shared decision on the most appropriate agent for the treatment of cancer-associated thrombosis should consider the following factors, which should be reassessed as patients continue along their cancer care pathway: risk of bleeding; tumour site; suitability of oral medications; potential for drug-drug interactions; and patient preference and values regarding choice of drug. Continuing anticoagulation beyond 6 months in patients with cancer-associated venous thromboembolism and active cancer is recommended.

Comparison of outcomes from tunnelled femorally inserted central catheters and peripherally inserted central catheters: a propensity score-matched cohort study

OBJECTIVES

To compare catheter-related outcomes of individuals who received a tunnelled femorally inserted central catheter (tFICC) with those who received a peripherally inserted central catheter (PICC) in the upper extremities.

DESIGN

A propensity-score matched cohort study.

SETTING

A 980-bed tertiary referral hospital in South West Sydney, Australia.

PARTICIPANTS

In-patients referred to the hospital central venous access service for the insertion of a central venous access device.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome of interest was the incidence of all-cause catheter failure. Secondary outcomes included the rates of catheters removed because of suspected or confirmed catheter-associated infection, catheter dwell and confirmed upper or lower extremity deep vein thrombosis (DVT).

RESULTS

The overall rate of all-cause catheter failure in the matched tFICC and PICC cohort was 2.4/1000 catheter days (95% CI 1.1 to 4.4) and 3.0/1000 catheter days (95% CI 2.3 to 3.9), respectively, and when compared, no difference was observed (difference -0.63/1000 catheter days, 95% CI -2.32 to 1.06). We found no differences in catheter dwell (mean difference of 14.2 days, 95% CI -6.6 to 35.0, p=0.910); or in the cumulative probability of failure between the two groups within the first month of dwell (p=0.358). No significant differences were observed in the rate of catheters requiring removal for confirmed central line-associated bloodstream infection (difference 0.13/1000 catheter day, 95% CI -0.36 to 0.63, p=0.896). Similarly, no significant differences were found between the groups for confirmed catheter-related DVT (difference -0.11 per 1000 catheter days, 95% CI -0.26 to 0.04, p=1.00).

CONCLUSION

There were no differences in catheter-related outcomes between the matched cohort of tFICC and PICC patients, suggesting that tFICCs are a possible alternative for vascular access when the veins of the upper extremities or thoracic region are not viable for catheterisation.

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.

Rivaroxaban and apixaban are less effective than enoxaparin for the prevention of catheter-induced clotting in vitro

BACKGROUND

Central venous catheters are prone to clotting, particularly in patients with cancer. Although low-molecular-weight heparin and direct oral anticoagulants, such as apixaban and rivaroxaban, have been evaluated for the prevention of catheter thrombosis, their efficacy remains uncertain.

OBJECTIVES

Compare apixaban and rivaroxaban with enoxaparin for the prevention of catheter-induced clotting in vitro.

METHODS

To address this uncertainty, we used a well-established microplate-based assay to compare the effects of enoxaparin, apixaban, and rivaroxaban on catheter-induced thrombosis and thrombin generation in human plasma.

RESULTS

Consistent with our previous findings, catheter segments shortened the clotting time and promoted thrombin generation. When compared at concentrations with similar anti-factor Xa activity as enoxaparin, apixaban and rivaroxaban were >20-fold less potent than enoxaparin for the prevention of catheter-induced clotting and thrombin generation.

CONCLUSION

The prevention of catheter thrombosis in patients with cancer is challenging. Clinical trials are needed to compare the efficacy of low-molecular-weight heparin with that of direct oral anticoagulants both for the prevention and treatment of catheter thrombosis.

Edoxaban: front-line treatment for brachiocephalic vein thrombosis in primitive mediastinal seminoma: A case report and literature review

RATIONALE

Venous thromboembolism is a feared frequent complication of cancer with a 2-way relationship. Low molecular weight heparin is the mainstay of treatment. The use of direct oral anticoagulants is supported by established evidence for the treatment of deep vein thrombosis also in active cancer and they are prioritized over low molecular weight heparin for cancer-associated thrombosis according to current guidelines. However, upper limb deep vein thrombosis is poorly studied with scant data on the use of direct oral anticoagulants in noncatheter-related deep vein thrombosis. We report the case of a patient with noncatheter-related deep vein thrombosis and a rare tumor site effectively and safely treated with a direct oral anticoagulant, edoxaban, after lack of efficacy with low molecular weight heparin.

PATIENT CONCERNS

A 35-year-old man with primitive mediastinal seminoma presented at our Cardio-Oncology Unit for prechemotherapy assessment.

DIAGNOSIS

Persistent brachiocephalic deep vein thrombosis, despite full-dose enoxaparin, was detected at ultrasonography.

INTERVENTION

We decided to switch the anticoagulant treatment from enoxaparin to edoxaban.

OUTCOME

The 3-month ultrasonography showed almost total regression of the deep vein thrombosis without any adverse effects and a good patient compliance.

LESSONS

We conducted a literature review on upper limb deep vein thrombosis, since its management is challenging due to inconsistency of evidence. This report highlights the benefits of direct oral anticoagulants compared to low molecular weight heparins in cancer-associated thrombosis therapy in terms of efficacy, safety and ease of use.

A prediction model for central venous catheter-related thrombosis in patients with newly-diagnosed acute myeloid leukemia: A derivation cohort analysis

BACKGROUND

Catheter-related thrombosis (CRT) is a common complication in cancer patients, that may lead to chemotherapy deferral, elevated risk for systemic infections and pulmonary embolism. This study aimed to assess CRT incidence and risk factors in newly-diagnosed acute myeloid leukemia (AML) patients and create predictive models potentially allowing to decrease CRT occurrence in this population.

METHODS

This retrospective single-center analysis included all AML patients treated at the Rambam Health Care Campus between 2006 and 2019. Patient clinical and laboratory data were collected to evaluate thrombosis occurrence and time from AML diagnosis to CRT development. Multivariate classification models were created using logistic regression (LR) and competing risk analyzes.

RESULTS

The final analysis included 632 newly-diagnosed AML patients (mean age 54 ± 15 years). CRT incidence was 10.1% [confidence interval (CI) 7.7-12.9%], median time from AML diagnosis to CRT was 12.5 days [interquartile range 6-30]. In an LR multivariate model, prior history of venous thromboembolism [adjusted odds ratio (AOR) 12.046, p < 0.0001], acute promyelocytic leukemia (APL) (AOR 2.824, p = 0.015), a high body mass index and initial platelet counts <100 × 10E9/L (AOR 1.059 and 0.546; p = 0.011 and 0.040, respectively) were significantly associated with high CRT risk. Analysis of 587 non-APL patients demonstrated comparable results, with CRT incidence of 9.3% (CI 7.0%-12.1%) and emergence of chronic obstructive pulmonary disease (COPD) as a novel significant co-factor (AOR 34.491, p = 0.004). In both models, the area under curve (AUC) was ≥70%.

CONCLUSIONS

Significant CRT risk factors defined using the created model could be used for identification of high-risk newly-diagnosed AML patients requiring CRT prophylaxis.

Conditional catheter-related thrombosis free probability and risk-adapted choices of catheter for lung cancer

Background

Current predictive tools assess catheter‐related thrombosis (CRT) in patients with lung cancer in a static manner at a single time point of catheterization. The subsequent hazard changes over time are unknown. The conditional catheter‐related thrombosis‐free probability (CCFP) can provide dynamic information on continual CRT‐free expectations. This study aimed to assess the CCFP and hazard rates based on risk categories and various venous access devices (VADs).

Methods

This retrospective study reviewed 939 patients with lung cancer with peripherally inserted central venous catheters (PICCs) or central venous catheters (CVCs) identified at the National Clinical Research Center for Cancer between January 1, 2015 and December 31, 2018. The incidence of CRT has also been reported. Patients were stratified into low‐ and high‐risk groups according to multivariate Cox regression analyses. CCFP is defined as the CRT‐free probability given that patients have no CRT for a definite time.

Results

A total of 507 patients with PICCs and 432 patients with CVCs were included in this study. The 3‐month CCFP increased from 74.2% at catheter insertion to 93.6% at 3 months. The hazards of CRT in the first month were highest (16.4%) and slightly thereafter. The high‐risk group initially had a higher (21.4%) but significantly decreased CRT hazard after 2 months (8.3%), whereas the low‐risk group maintained a comparable lower risk hazard of less than 5% after 1 month. In the overall cohort, patients with CVCs had lower CRT probability than those with PICCs (HR, 1.76; 95% CI: 1.28–2.41; p < 0.01). Further analysis demonstrated that compared with PICCs, CVCs provided a CRT‐free benefit in low‐risk patients (p = 0.02) but not in high‐risk patients (p = 0.06).

Conclusions

CCFP increased, and the hazards of CRT decreased over time in a risk‐dependent manner in patients with lung cancer. These valuable dynamic data may help optimize risk‐adjusted choices of VADs and risk‐adjusted prophylactic anticoagulation strategies for patients.

Incidence of venous thromboembolism and discriminating capacity of Khorana score in lung cancer patients treated with immune checkpoint inhibitors

Venous-thromboembolism (VTE) is increased in lung cancer patients (LCP) treated with immune-checkpoint inhibitors (ICIs) but risk factors are not identified and the Khorana Score (KS) is not validated. To assess VTE incidence and its clinical impact, to investigate potential clinical risk factors and KS performance in LCP. Retrospective analysis of LCP initiating ICIs treatment between June 2015 and November 2020 in a for-profit cancer center. 481 patients were included: 62% adenocarcinoma, 70% PDL1 + , 86% stage-IV-disease. Over a median follow-up of 9.8 months, 47 VTE were observed: 28 pulmonary embolisms, 15 deep venous thromboses (distal n = 9, proximal n = 6), 3 inferior vena cava thromboses, 1 other VTE, no superficial or digestive vein thrombosis. Median time from ICIs' initiation to VTE was 180 (11-1277) days. Overall survival was significantly lower in patients who experienced VTE (42.5 vs. 86.8 months, p = 0.006). In univariate analysis patients VTE was more frequent in metastatic patients (11.1% vs. 1.5%, p = 0.015) and lower in those treated with durvalumab (1.9% vs. 9.6%, p = 0.046). Logistic regression analysis showed that non-metastatic status (OR 0.13; 0.02-0.95, p = 0.04) and BMI (OR 1.07; 1.01-1.14, p = 0.028) were associated with VTE. The rate of VTE was the same in patients with a KS < or ≥ 2 (10.2% vs. 9.3%, p = 0.87). ICIs-treated LCP are at high risk of thromboembolism. VTE has a negative impact on survival. KS does not perform well in LCP. It is important to identify which VTE prediction models are available to be used in adult ambulatory lung cancer patients.