Central venous catheter-related thrombosis

Incidence and onset of central venous catheter-related thrombosis in critically ill surgical patients: A prospective observational single-center study

STUDY OBJECTIVE

Catheter-related thrombosis (CRT) is a major complication of central venous catheters (CVCs). However, the incidence, onset, and dependence of CRT on CVC material and/or type in critically ill surgical patients is unknown. Therefore, we here investigated the incidence, onset, and dependence of CRT on a variety of risk factors, including CVC material and type, in critically ill surgical patients.

DESIGN

Prospective, investigator-initiated, observational study.

SETTING

A surgical intensive care unit at a university hospital.

PATIENTS

All critically ill patients with CVCs (surgical: 79.8%/medical: 20.2%) who were treated in our surgical intensive care unit during a six-month period.

INTERVENTIONS

None.

MEASUREMENTS

All CVCs were examined for CRT every other day using ultrasound, starting within 24 h of placement. The primary outcome was the time of onset of CRT, depending on the type of CVC (three to five lumens, three different manufacturers). The CRT risk factors were analyzed using multiple Cox proportional hazards regression models.

MAIN RESULTS

We included 94 first-time CVCs in the internal jugular vein. The median time to CRT varied from one to five days for different types of CVCs. Within one day, 37 to 64% of CVCs and within one week, 64 to 100% of CVCs developed a CRT. All but one of the CRT observed were asymptomatic and caused no complications. Multiple regression analyses of CRT risk factors showed that beside cancer and omitting prophylactic anticoagulation, some types of CVC were also associated with a higher risk of CRT.

CONCLUSIONS

Almost all CVCs in the internal jugular vein in critically ill surgical patients developed an asymptomatic CRT in the first days after catheterization.

Comparison of Catheter Malposition Between Left and Right Ultrasound-Guided Infraclavicular Subclavian Venous Catheterizations: A Randomized Controlled Trial

OBJECTIVES

Catheter malposition after subclavian venous catheterization (SVC) is not uncommon and can lead to serious complications. This study hypothesized that the left access is superior to the right access in terms of catheter malposition after ultrasound-guided infraclavicular SVC due to the asymmetry of the bilateral brachiocephalic veins.

DESIGN

Parallel-armed randomized controlled trial.

SETTING

A tertiary referral hospital in Korea.

PATIENTS

Patients 20-79 years old who were scheduled to undergo SVC under general anesthesia.

INTERVENTIONS

Patients were randomly assigned to either the left ( n = 224) or right ( n = 225) SVC group. The primary outcome measure was the overall catheter malposition rate. The secondary outcome measures included catheter malposition rates into the ipsilateral internal jugular and contralateral brachiocephalic veins, other catheterization-related complications, and catheterization performance.

MEASUREMENTS AND MAIN RESULTS

The catheter malposition rate was lower (10 [4.5%] vs. 31 [13.8%], p = 0.001), especially in the ipsilateral internal jugular vein (9 [4.0%] vs. 24 [10.7%], p = 0.007), in the left SVC group than in the right SVC group. In the left SVC group, catheterization success rates on the first pass (88 [39.3%] vs. 65 [28.9%], p = 0.020) and first-catheterization attempt (198 [88.4%] vs. 181 [80.4%], p = 0.020) were higher whereas times for vein visualization (30 s [18-50] vs. 20 s [13-38], p < 0.001) and total catheterization (134 s [113-182] vs. 132 s [103-170], p = 0.034) were longer. There were no significant differences in other catheterization performance and catheterization-related complications between the two groups.

CONCLUSIONS

These findings strengthen the rationale for choosing the left access over the right access for ultrasound-guided infraclavicular SVC.

Catheter-related deep vein thrombosis: Where are we at and where are we going? Updates and ongoing unmet clinical needs

BACKGROUND

Catheter-related thrombosis (CRT) is one of the major complications affecting patients with indwelling venous catheters, usually involving the upper extremity deep venous system. This condition can lead to potentially life-threatening complications such as pulmonary embolism and sepsis. The risk of developing CRT varies depending on type of catheters and patient characteristics. Despite advances in materials and technologies, the actual incidence of CRT is still considerable. Available evidence on CRT management remains controversial, and clinical guidelines base their recommendations on data from non-catheter related upper extremity or lower extremity deep venous thromboses.

AIMS

This narrative review aims to describe the epidemiology of CRT, to review the available evidence on its management and to highlight the current unmet needs.

METHODS

No formal search strategy was applied for the revision of the literature. The main sources of information used were Medline and guidelines from international societies.

CONTENT

The management of CRT requires a careful balance between the risk of thrombus progression, recurrent events, and systemic embolization and the increased bleeding risk in often fragile patients. Open issues include the optimal management of the catheter and the type and duration of anticoagulant therapy. Direct oral anticoagulants are increasingly prescribed, representing an important alternative to the standard of care low molecular weight heparins in selected cases. The development of new anticoagulant drugs such as factors XI and XII inhibitors may offer further advantages in this context.

CONCLUSIONS

The management of CRT is still challenging with constant need for updated evidence to support tailored approaches.

Development of a large diameter in vitro flow loop thrombogenicity test system

BACKGROUND

To accommodate a wider range of medical device sizes, a larger in vitro flow loop thrombogenicity test system using 9.5 -mm inner diameter (ID) tubing was developed and evaluated based on our previously established 6.4 -mm ID tubing system.

METHODS

Four cardiopulmonary bypass roller pumps were used concurrently to drive four flow loops during testing. To ensure that each pump produced a consistent thrombogenic response for the same material under the same test conditions, a novel dynamic roller occlusion setting method was applied. Five materials with varying thrombogenic potentials were tested: polytetrafluoroethylene (PTFE), silicone, 3D-printed nylon, latex, and nitrile rubber (BUNA). Day-old bovine blood was heparinized to a donor-specific concentration and recirculated through the flow loops containing test materials at 20 rpm for 1 h at room temperature. Material thrombogenicity was characterized by measuring the thrombus surface coverage, thrombus weight, and platelet (PLT) count reduction.

RESULTS

The larger tubing system can differentiate thrombogenic materials (latex, BUNA) from the thromboresistant PTFE material. Additionally, silicone and the 3D-printed nylon exhibited an intermediate thrombogenic response with significantly less thrombus surface coverage and PLT count reduction than latex and BUNA but more thrombus surface coverage than PTFE (p < 0.05).

CONCLUSION

The 9.5 -mm ID test system can effectively differentiate materials of varying thrombogenic potentials when appropriate pump occlusion settings and donor-specific anticoagulation are used. This system is being assessed in an interlaboratory study to develop standardized best practices for performing in vitro dynamic thrombogenicity testing of medical devices and materials.

Development and validation of a nomogram for catheter-related thrombosis prediction in children with central venous catheter: a retrospective observational study

BACKGROUND

Catheter-related thrombosis (CRT) is a thrombotic complication associated with using central venous catheters (CVCs). Although risk factors for CRT were identified in children, no nomograms or predictive tools are available for the pediatric population with CVCs. This study aimed to develop and validate a prediction model of asymptomatic CRT in children with CVCs.

METHODS

This retrospective observational study included consecutive pediatric patients who admitted to the Children's Hospital Zhejiang University School of Medicine and received CVCs between October and December 2021.

RESULTS

This study included 669 patients, 553 (314 males, aged 22.00 [0.36, 180.00] months, 62 with CRT) were in the training set, and 116 (62 males, aged 15.00 [1.13, 156.00] months, 16 with CRT) were in the validation set. Multivariate logistic regression showed that a catheter time of 0-3 days (OR = 0.201, 95%CI: 0.081-0.497, P = 0.001), catheter time of 4-7 days (OR = 0.412, 95%CI: 0.176-0.964, P = 0.041), male (OR = 3.976, 95%CI: 1.864-4.483, P < 0.001), congenital heart diseases (OR = 0.277, 95%CI: 0.078-0.987, P = 0.048), postoperative (OR = 0.161, 95%CI: 0.072-0.360, P < 0.001), and femoral CVC (OR = 2.451, 95%CI: 1.129-5.318, P = 0.002) were independently associated with CRT. The nomogram incorporating these variables showed relatively good discrimination (AUC = 0.77, 95%CI: [0.65, 0.90]) and calibration abilities in the validation set, and the decision curve analysis (DCA) yielded a clinical net benefit.

CONCLUSION

A prediction model for CRT in children with CVC was established based on catheter time, sex, diseases, postoperative, and catheter vein. The nomogram based on logistic regression model showed favorable predictive performance.

Prevention of complications for hospitalized patients receiving parenteral nutrition: A narrative review

Hospitalized patients may benefit from parenteral nutrition to address their compromised nutrition status attributed to limited oral/enteral intake and increased nutrient/energy requirement during acute illness. Parenteral nutrition, however, can be associated with many complications that can negatively impact patient outcomes. In this review, we focus on potential metabolic and catheter-related complications associated with parenteral nutrition use. We report on potential risk factors for such complications and highlight strategies for prevention and early recognition. To optimize outcomes, key findings include the creation and implementation of evidence-based protocols with proven efficacy. For each hospital unit delivering parenteral nutrition to patients, tracking compliance with established protocols and patient outcomes is crucial for ongoing improvement through identification of gaps, proper reeducation and training, and ongoing refinement of care protocols. Establishment of specialized inpatient nutrition support teams should be considered.

Central Venous Catheter Misplacement Presenting With Parotid Gland Swelling: A Case Report

Central venous catheter (CVC) placement is a routine procedure in ICUs but can be associated with various complications, including misplacement and thrombosis. We present a rare case of parotid gland enlargement due to catheter-related thrombosis of the external jugular vein following ultrasound-guided placement through the subclavian vein in an 84-year-old woman. This case was managed with systemic anticoagulation and catheter removal. It emphasizes the importance of confirming correct CVC tip positioning and highlights the need for a post-procedure chest X-ray.

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Edema of the upper extremity on the unaffected side in unilateral breast cancer patients

Breast cancer-related lymphedema (BCRL) occurs usually on the affected side, and its cause and pathophysiology are well known. However, the cause of edema of the upper extremity on the unaffected side is barely known. It is often considered to be chemotherapy-induced general edema, and clinical evaluation is rarely performed in these patients. This study aimed to present the clinical characteristics of unilateral breast cancer patients with edema of upper extremity on the unaffected side, and to emphasize the importance of early diagnosis and medical interventions. This study retrospectively analyzed the medical records of unilateral breast cancer patients complaining edema of upper extremity on the unaffected side, from January 2020 to May 2021. Lymphoscintigraphy was used to assist in confirming the diagnosis of lymphedema, and Doppler ultrasonography or 3D computed tomography angiography were performed to differentiate vascular problems. Fourteen patients were enrolled in the study. Seven, 3, and 4 patients had edema of both upper extremities, edema of the upper extremity on the unaffected side only, and edema of all extremities, respectively. None of the 4 patients with edema of all extremities showed abnormal findings on examination. In patients with edema in the upper extremity on the unaffected side alone, lymphatic flow dysfunction was seen in 2 patients, and deep vein thrombosis (DVT) was diagnosed in 1. In patients with edema of both upper extremities, lymphatic flow dysfunction was seen in 2 patients, and DVT was diagnosed in 3. One patient had DVT and accompanying lymphatic flow dysfunction. Lymphedema and DVT were diagnosed in a number of patients with edema of the upper extremity on the unaffected side, and lymphedema can occur without direct injury to the lymphatic flow system. Therefore, clinicians should not overlook the fact that diseases that require early diagnosis and treatment can occur in patients with edema of the unaffected upper extremity.

Active Dual-Protein Coating Assisted by Stepwise Protein-Protein Interactions Assembly Reduces Thrombosis and Infection

Universal protein coatings have recently gained wide interest in medical applications due to their biocompatibility and ease of fabrication. However, the challenge persists in protein activity preservation, significantly complicating the functional design of these coatings. Herein, an active dual-protein surface engineering strategy assisted by a facile stepwise protein-protein interactions assembly (SPPIA) method for catheters to reduce clot formation and infection is proposed. This strategy is realized first by the partial oxidation of bovine serum albumin (BSA) and lysozyme (LZM) for creating stable nucleation platforms via hydrophobic interaction, followed by the assembly of nonoxidized BSA (pI, the isoelectric point, ≈4.7) and LZM (pI ≈11) through electrostatic interaction owing to their opposite charge under neutral conditions. The SPPIA method effectively preserves the conformation and functionality of both BSA and LZM, thus endowing the resultant coating with potent antithrombotic and bactericidal properties. Furthermore, the stable nucleation platform ensures the adhesion and durability of the coating, resisting thrombosis and bacterial proliferation even after 15 days of PBS immersion. Overall, the SPPIA approach not only provides a new strategy for the fabrication of active protein coatings but also shows promise for the surface engineering technology of catheters.

Should ultrasound evaluation for catheter-related thrombosis always be required before PICC removal?

Despite several effective preventive strategies peripherally inserted central catheters (PICCs)-as much as centrally inserted central catheters and femorally inserted central catheters-are inevitably associated with the potential development of catheter-related thrombosis. This complication may be symptomatic or-more often-asymptomatic. Even if remote, the chance that PICC removal may mobilize an asymptomatic thrombus and cause pulmonary embolism, is theoretically possible. On the other hand, the diffuse adoption of an ultrasound scan aiming at detecting an asymptomatic catheter-related thrombosis may be logistically difficult and expensive. No clear evidence-based recommendations exist on this issue and whether perform an ultrasound scan before PICC removal in asymptomatic patients remains a matter of debate. For these reasons, the authors propose few common sense recommendations that may help clinicians in weighing the clinical advantages of the exam (optimal safety for the patient) versus its practical disadvantages (logistic cost).

Design, manufacturing and testing of a green non-isocyanate polyurethane prosthetic heart valve

The sole effective treatment for most patients with heart valve disease is valve replacement by implantation of mechanical or biological prostheses. However, mechanical valves represent high risk of thromboembolism, and biological prostheses are prone to early degeneration. In this work, we aim to determine the potential of novel environmentally-friendly non-isocyanate polyurethanes (NIPUs) for manufacturing synthetic prosthetic heart valves. Polyhydroxyurethane (PHU) NIPUs are synthesized via an isocyanate-free route, tested in vitro, and used to produce aortic valves. PHU elastomers reinforced with a polyester mesh show mechanical properties similar to native valve leaflets. These NIPUs do not cause hemolysis. Interestingly, both platelet adhesion and contact activation-induced coagulation are strongly reduced on NIPU surfaces, indicating low thrombogenicity. Fibroblasts and endothelial cells maintain normal growth and shape after indirect contact with NIPUs. Fluid-structure interaction (FSI) allows modeling of the ideal valve design, with minimal shear stress on the leaflets. Injection-molded valves are tested in a pulse duplicator and show ISO-compliant hydrodynamic performance, comparable to clinically-used bioprostheses. Poly(tetrahydrofuran) (PTHF)-NIPU patches do not show any evidence of calcification over a period of 8 weeks. NIPUs are promising sustainable biomaterials for the manufacturing of improved prosthetic valves with low thrombogenicity.

A Spectrum of Chemoport-Associated Complications and Their Management in Cancer Patients

INTRODUCTION

Chemotherapy is part and parcel of the multimodality approach to cancer treatment. Chemoports are frequently used to administer chemotherapy, preventing complications associated with the use of peripheral lines. However, chemoports have their own set of complications and can be very debilitating at times. Accurate knowledge and correct technique can help prevent and manage these complications properly.

METHODS

We retrospectively analyzed all patients who underwent chemoport insertion for chemotherapy infusion over three years between July 2020 and June 2023. The patient's profile, type of cancer, the technique of chemoport insertion, complications related to chemoport, and its management were recorded retrospectively from patient records.

RESULTS

The total number of patients in our study was 119. The age group of patients ranged from 13 years to 76 years. Of the 119 patients, 55 had breast cancer, 23 had ovarian cancers, 29 had GI cancers including gastroesophageal junction (GEJ)/ stomach/periampullary/colorectal, and 12 had leukemias. The most common intraoperative complication was catheter tip malposition (9.2%). The most common postoperative complications were infection (7.5%), followed by drug extravasation (5.0%), thrombosis (3.3%), wound dehiscence (2.5%), and skin necrosis (0.8%) in decreasing order of frequency. Serious complications such as hemothorax, pneumothorax, air emboli, brachial plexus injury, and pericardial tamponade, commonly reported in the literature, were not seen in any of our cases.

CONCLUSION

 Totally implanted venous access devices (TIVAD)/chemoports are indispensable in the management of cancer patients, especially in patients requiring long duration of infusion and prolonged treatment. Although chemoports are associated with a spectrum of complications, proper technique of implantation and use makes it a safe and reliable tool.

Central venous catheter tip misplacement: A multicentre cohort study of 8556 thoracocervical central venous catheterisations

BACKGROUND

There is a paucity of data on the incidence of central venous catheter tip misplacements after the implementation of ultrasound guidance during insertion. The aims of the present study were to determine the incidence of tip misplacements and to identify independent variables associated with tip misplacement.

METHODS

All jugular and subclavian central venous catheter insertions in patients ≥16 years with a post-procedural chest radiography at four hospitals were included. Each case was reviewed for relevant catheter data and radiologic evaluations of chest radiographies. Tip misplacements were classified as 'any tip misplacement', 'minor tip misplacement' or 'major tip misplacement'. Multivariable logistic regression analyses were used to investigate associations between predefined independent variables and tip misplacements.

RESULTS

A total of 8556 central venous catheter insertions in 5587 patients were included. Real-time ultrasound guidance was used in 91% of all insertions. Any tip misplacement occurred (95% confidence interval) in 3.7 (3.3-4.1)% of the catheterisations, and 2.1 (1.8-2.4)% were classified as major tip misplacements. The multivariable logistic regression analyses showed that female patient gender, subclavian vein insertions, number of skin punctures and limited operator experience were associated with a higher risk of major tip misplacement, whereas increasing age and height were associated with a lower risk.

CONCLUSIONS

In this large prospective multicentre cohort study, performed in the ultrasound-guided era, we demonstrated the incidence of tip misplacements to be 3.7 (3.3-4.1)%. Right internal jugular vein catheterisation had the lowest incidence of both minor and major tip misplacement.

Clinical Outcomes of Standardized Central Venous Catheterization Simulation Training: A Comparative Analysis

OBJECTIVE

A standardized ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) using online- and simulation-based training was first designed and then large-scale deployed at a teaching hospital institution to improve CVC surgical education. To understand the impact that the standardized training might have on patient complications, this study focuses on identifying the impact of the integration of an iteratively designed US-IJCVC training on clinical complications at a teaching hospital.

DESIGN AND PARTICIPANTS

A comparative study was conducted using TriNetX, a global health research network. Using Current Procedural Terminology (CPT) codes and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes, we identified the total number of patients with a CVC and mechanical, infectious, and thrombosis complications with and without billable ultrasound between July 1 to June 30 in 2016, 2017, and 2022.

SETTING

A teaching hospital institution in Pennsylvania.

RESULTS

Results showed a correlation between years and complications indicating, (1) mechanical complications billable ultrasound, (2) infectious complications billable ultrasound, and (3) thrombosis complications billable ultrasound were significantly lower with the large-scale deployment. Results also showed that (4) mechanical, infectious, and thrombosis complications with and without billable ultrasound are within the range that prior work has reported.

CONCLUSION

These results indicate that there has been a decrease in mechanical, infectious, and thrombosis complications, which correlates with the US-IJCVC training large-scale deployment.

Risk factors for peripherally inserted central catheter-related venous thrombosis in adult patients with cancer

PURPOSE

The purpose of this study was to understand and analyze the risk factors of peripherally inserted central catheter (PICC)-related venous thrombosis in adult patients with cancer.

METHODS

This observational cohort study included adult patients with cancer who underwent color Doppler ultrasound at the Xiangya Hospital of Central South University, Hunan Provincial Maternal and Child Healthcare Hospital, and Xiangya Changde Hospital, Hunan Province, from January 1, 2017 to December 31, 2021. Univariate and multivariate logistic regression analyses were performed to determine the risk factors of PICC-related venous thrombosis.

RESULTS

After risk adjustment, multivariate logistic regression analysis revealed statistically significant associations between PICC-related venous thrombosis and age > 65 years old (OR: 1.791, CI: 1.343-2.389), male sex (OR: 1.398, CI: 1.057-1.849), white blood cell count > 9.5 × 109 /L (OR: 1.422, CI: 1.041-1.942), APTT < 25 s (OR: 2.006, CI: 1.431-2.811), gastrointestinal tumor (OR: 2.191, CI: 1.406-3.414), infection (OR:7.619, CI: 5.783-10.037), the use of cisplatin (OR: 2.374, CI: 1.714-3.214), vincristine (OR: 2.329, CI: 1.447-3.749), the use of polyurethane (OR: 2.449, CI: 1.863-3.219) and open-ended catheters (OR:1.660, CI: 1.131-2.439), keeping time of the catheter (days) (OR: 1.003, CI: 1.001-1.005) were associated with PICC-related venous thrombosis.

CONCLUSION

We identified that the presence of age > 65 years old, male sex, white blood cell count > 9.5 × 109 /L, APTT < 25 s, gastrointestinal tumor, infection, the use of cisplatin and vincristine, the use of polyurethane, open-ended catheters and keeping time of the catheter (days), were associated with PICC-related venous thrombosis.

Patterns of interventions for central venous catheter-associated deep vein thrombosis and outcomes in cancer patients

PURPOSE

This letter evaluated the impact of different management strategies, specifically the presence or absence of therapeutic anticoagulation, on clinical outcomes for central venous catheter (CVC)-associated deep vein thrombosis (DVT) in cancer patients.

METHODS

One-hundred ninety-eight adult cancer patients with a confirmed CVC-associated DVT diagnosis from February 2013 and February 2021 were included.

RESULTS

Incidence of symptomatic recurrent venous thromboembolism (VTE) was similar between patients who received therapeutic anticoagulation and those who did not (14% vs 16%, p = 0.807). In addition, therapeutic anticoagulation did not significantly alter the incidence of grade 3 and above bleeding events despite most patients having hematologic malignancies (9% vs 8%, p = 0.826).

CONCLUSION AND RELEVANCE

Therapeutic anticoagulation was not associated with a reduction in the incidence of recurrent VTE or increase the incidence of bleeding in adult cancer patients following a CVC-associated DVT diagnosis.

Catheter and Non-Catheter-Related Venous Thromboembolism in Cancer Patients: Survival, Anticoagulation Efficacy, and Safety

PURPOSE

To investigate the differences in survival after venous thromboembolism (VTE) and anticoagulation efficacy and safety between catheter (CRVTE) and non-catheter-related VTE (NCRVTE) in cancer patients.

METHODS

A retrospective research was conducted, and consecutive cancer (digestive, respiratory, genitourinary, blood and lymphatic, and the other cancers) patients with VTE were enrolled. The anticoagulation therapies included low-molecular-weight heparin (LMWH), warfarin, new type of direct oral anticoagulants (NDOACs), LMWH combined with warfarin, and LMWH combined with NDOACs. Data were collected from the electronic medical record database of our hospital and were analyzed accordingly by Kruskal-Wallis H Test, Chi-square test, Fisher's exact test, Logistic regressions, Kaplan-Meier analysis, and Cox regressions.

RESULTS

263 patients were included, median age in years (interquartile range) was 64(56-71) and 60.5% were male. VTE recurrence rate was 16.7% in CRVTE group which was significantly lower than 34.8% in NCRVTE group (P = .032). Heart diseases were independently associated with VTE recurrence (P = .025). Kaplan-Meier survival estimates at 1, 2, and 3 years for CRVTE group were 62.5%, 60.0%, and 47.5%, respectively, compared with 47.9% (P = .130), 38.7% (P = .028), and 30.1% (P = .046), respectively, for NCRVTE group. Cox regression showed surgery (P = .003), anticoagulation therapy types (P = .009), VTE types (P = .006) and cancer types (P = .039) were independent prognostic factors for 3-year survival after VTE. Nonmajor and major bleeding were not significantly different (P = .417). Anticoagulation therapy types were independently associated with the bleeding events (P = .030).

CONCLUSIONS

Cancer patients with CRVTE potentially have a better anticoagulation efficacy and survival compared to NCRVTE, and the anticoagulation safety seems no significant difference.

Vertebral Venous Congestion That May Mimic Vertebral Metastasis on Contrast-Enhanced Chest Computed Tomography in Chemoport Inserted Patients

OBJECTIVE

This study aimed to determine the prevalence of vertebral venous congestion (VVC) in patients with chemoport insertion, evaluate the imaging characteristics of nodular VVC, and identify the factors associated with VVC.

MATERIALS AND METHODS

This retrospective single-center study was based on follow-up contrast-enhanced chest computed tomography (CT) of 1412 adult patients who underwent chemoport insertion between January 2016 and December 2016. The prevalence of venous stenosis, reflux, and VVC were evaluated. The imaging features of nodular VVC, including specific locations within the vertebral body, were analyzed. To identify the factors associated with VVC, patients with VVC were compared with a subset of patients without VVC who had been followed up for > 3 years without developing VVC after chemoport insertion. Toward this, a multivariable logistic regression analysis was performed.

RESULTS

After excluding 333 patients, 1079 were analyzed (mean age ± standard deviation, 62.3 ± 11.6 years; 540 females). The prevalence of VVC was 5.8% (63/1079), with all patients (63/63) demonstrating vertebral venous reflux and 67% (42/63) with innominate vein stenosis. The median interval between chemoport insertion and VVC was 515 days (interquartile range, 204-881 days). The prevalence of nodular VVC was 1.5% (16/1079), with a mean size of 5.9 ± 3.1 mm and attenuation of 784 ± 162 HU. Nodular VVC tended to be located subcortically. Forty-four patients with VVC underwent CT examinations with contrast injections in both arms; the VVC disappeared in 70% (31/44) when the contrast was injected in the arm contralateral to the chemoport site. Bevacizumab use was independently associated with VVC (odds ratio, 3.45; P < 0.001).

CONCLUSION

The prevalence of VVC and nodular VVC was low in patients who underwent chemoport insertion. Nodular VVC was always accompanied by vertebral venous reflux and tended to be located subcortically. To avoid VVC, contrast injection in the arm contralateral to the chemoport site is preferred.

Central vein stenosis in hemodialysis vascular access: clinical manifestations and contemporary management strategies

Central venous stenosis is a significant and frequently encountered problem in managing hemodialysis (HD) patients. Venous hypertension, often accompanied by severe symptoms, undermines the integrity of the hemodialysis access circuit. In central venous stenosis, dialysis through an arteriovenous fistula is usually inefficient, with high recirculation rates and prolonged bleeding after dialysis. Central vein stenosis is a known complication of indwelling intravascular and cardiac devices, such as peripherally inserted central catheters, long-term cuffed hemodialysis catheters, and pacemaker wires. Hence, preventing this challenging condition requires minimization of central venous catheter use. Endovascular interventions are the primary approach for treating central vein stenosis. Percutaneous angioplasty and stent placement may reestablish vascular function in cases of elastic and recurrent lesions. Currently, there is no consensus on the optimal treatment, as existing management approaches have a wide range of patency rates.

Emphysematous thrombophlebitis caused by a misplaced central venous catheter: A case report

BACKGROUND

Central venous catheters (CVCs) often cause life-threatening complications, especially CVC-related bloodstream infection (CVC-BSI) and catheter-related thrombosis (CRT). Here, we report an unusual case of misplaced CVC-induced emphysematous thrombophlebitis, a rare but potentially lethal form of CRT and CVC-BSI characterized by both thrombosis and gas formation.

CASE SUMMARY

A 48-year-old male presented to the emergency room of a local hospital with sudden-onset headache and coma for 4 h. Computed tomography (CT) revealed right basal ganglia hemorrhage, so emergency decompressive craniotomy was performed and a CVC was inserted through the right subclavian vein for fluid resuscitation during anesthesia. Two days later, the patient was transferred to the intensive care unit of our hospital for further critical care. On day 9 after CVC insertion, the patient suddenly developed fever and hypotension. Point-of-care ultrasound (POCUS) demonstrated thrombosis and dilatation of the right internal jugular vein (IJV) filled with thrombosis. Ultrasonography also revealed that the CVC tip had been misplaced into the IJV and was surrounded by gas bubbles, which manifested as hyperechoic lines with dirty shadowing and comet-tail artifacts. Further CT scan confirmed air bubbles surrounding the CVC in the right neck. The final diagnosis was septic emphysematous thrombophlebitis induced by a misplaced CVC and ensuing septic shock. The responsible CVC was removed immediately. The patient received fluid resuscitation, intravenous noradrenaline, and a 10-d ultra-broad spectrum antibiotic treatment to combat septic shock. Both CVC and peripheral venous blood cultures yielded methicillin-resistant Staphylococcus cohnii. The patient was gradually weaned off vasopressors and the symptoms of redness and swelling in the right neck subsided within 7 d.

CONCLUSION

Emphysematous thrombophlebitis is a fulminant and life-threatening CVC-BSI associated with thrombosis and gas formation in the vein. A misplaced CVC may facilitate the development of emphysematous thrombophlebitis. POCUS can easily identify the artifacts produced by gas and thrombosis, facilitating rapid diagnosis at the bedside.

Eustachian Valve-Enhanced Paradoxical Cerebral Embolism: A Case Report

Cryptogenic stroke includes many suspicious embolic causes that do not fulfill the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification criteria. Atrial fibrillation (AF) is one of the major hidden causes of cryptogenic stroke, and an implantable loop recorder (ILR) is widely used for detecting AF. Herein, we report a case of paradoxical cerebral embolism due to a large Eustachian valve with large PFO under no molecular complete remission (CR) of acute monocytic leukemia (AMoL). A 75-year-old man arrived at our emergency room because of aphasia and right hemiparesis. He had a history of two cryptogenic strokes and implanted ILR. Magnetic resonance imaging showed left middle cerebral artery occlusion with slight acute ischemic lesion. The red clot was retrieved by mechanical thrombectomy, and complete recanalization was achieved. We checked ILR, but there was no AF. Transesophageal echocardiography revealed a large patent foramen ovale (PFO) and the large Eustachian valve in the right atrium. Although obvious deep vein thrombosis (DVT) was not detected in venous ultrasonography of the lower extremities, Wilms' tumor 1 messenger ribonucleic acid (WT1mRNA) expression level was high, and AMoL was considered to be not in molecular CR, suggesting a high risk of thrombosis to the large Eustachian valve. From large PFO and no molecular CR of AMoL, we diagnosed him with paradoxical cerebral embolism. Ruling out of AF by ILR and other etiologies, such as aortic or carotid atherosclerosis and pulmonary shunt, also supported the diagnosis of paradoxical cerebral embolism. Even in the absence of obvious DVT, paradoxical cerebral embolism should be considered in cases of a large Eustachian valve and PFO with a hypercoagulable state.

Establishment of risk nomogram prediction model for venous catheter thrombosis

BACKGROUND

Venous catheters are widely used in clinical practice, but a drawback of their usage is the increased risk of thrombosis.

AIMS

The current study explored the risk factors affecting the formation of thrombosis following venous catheterization and establishes a risk nomogram prediction model for catheter-related thrombosis.

METHODS

Univariate and multivariate logistic regression analyses were carried out to identify the independent factors involved in venous catheter thrombosis. These factors were included in the construction of a nomogram. Finally, the C-index and calibration curves were used to validate the nomogram.

RESULT

A total of 146 cases were included in the sample, of which 36 were cases of thrombosis. The results of the univariate logistic regression analysis showed that the following were significant factors: age, Acute Physiology and Chronic Health Evaluation scoring system (APACHE II) score, white blood cell (WBC), hematocrit (HCT), international normalized ratio (INR), fibrinogen (FIB), and D-dimer. Multivariate logistic regression analysis was performed, which confirmed that the factors of age (AUC: 0.677, 95% CI: 0.564-0.790), APACHE II score (AUC: 0.746, 95% CI: 0.656-0.837), INR (AUC: 0.743, 95% CI: 0.636-0.849), and D-dimer (AUC: 0.826, 95% CI: 0.750-0.902) were independent variables. Next, a nomogram was constructed using these independent variables for predicting venous catheter thrombosis. Favorable results with C-indexes (0.816; 95% CI: 0.780-0.882) and calibration curves closer to ideal curves indicated the accurate predictive ability of this nomogram.

CONCLUSION

The individualized nomogram demonstrated effective prognostic prediction for patients with venous thrombosis.

Development and validation of machine learning models for venous thromboembolism risk assessment at admission: a retrospective study

Introduction

Venous thromboembolism (VTE) risk assessment at admission is of great importance for early screening and timely prophylaxis and management during hospitalization. The purpose of this study is to develop and validate novel risk assessment models at admission based on machine learning (ML) methods.

Methods

In this retrospective study, a total of 3078 individuals were included with their Caprini variables within 24 hours at admission. Then several ML models were built, including logistic regression (LR), random forest (RF), and extreme gradient boosting (XGB). The prediction performance of ML models and the Caprini risk score (CRS) was then validated and compared through a series of evaluation metrics.

Results

The values of AUROC and AUPRC were 0.798 and 0.303 for LR, 0.804 and 0.360 for RF, and 0.796 and 0.352 for XGB, respectively, which outperformed CRS significantly (0.714 and 0.180, P < 0.001). When prediction scores were stratified into three risk levels for application, RF could obtain more reasonable results than CRS, including smaller false positive alerts and larger lower-risk proportions. The boosting results of stratification were further verified by the net-reclassification-improvement (NRI) analysis.

Discussion

This study indicated that machine learning models could improve VTE risk prediction at admission compared with CRS. Among the ML models, RF was found to have superior performance and great potential in clinical practice.

Peripherally inserted central catheters versus implantable port catheters for cancer patients: a meta-analysis

Background

The implanted vascular access ports (PORTs) were compared with peripherally inserted central catheters (PICCs) as the administration of chemotherapy regarding different clinical effects and adverse effects. Which is better is debatable. Hence, the current study was conducted to assess the safety and efficacy of these two optimal vascular access strategies.

Methods

The following electronic databases were searched: PubMed, Embase, and the Cochrane Library updated in May 2023. Studies on the differences in complication rates in patients with cancer using either PICC or PORT for chemotherapy were included. Meta-analysis Revman 5.3 software was used for statistical analysis.

Results

A total of 22 articles were retrieved. The results suggested that PORT has a superior safety profile, with lower incidences of overall adverse effects (OR=2.72, 95% CI=1.56-4.72 P=0.0004), catheter-related thrombosis (OR=2.84, 95% CI=1.97-4.11, P<0.00001), and allergic reactions (OR=6.26, 95% CI=1.86-21.09, P=0.003) than typically expected with PICC. Moreover, PICC was non-inferior to the PORT group with respect to DVT (OR=2.00, 95% CI=0.86-4.65, P=0.11) and infection (OR=1.55, 95% CI=0.75-3.22, P=0.24).

Conclusion

PORT achieved safety benefits compared with chemotherapy through PICC. Therefore, PORT is regarded as safe and effective vascular access for the administration of chemotherapy. When considering economic factors and some key elements, more high-quality research would help verify these clinical benefits.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identififier CRD42023421690.

The association of vitamin-D level with catheter-related-thrombosis in hemodialysis patients: A data mining model

PURPOSE

This study aims to investigate the association of different risk factors including vitamin-D level with catheter-related-thrombosis in hemodialysis patients by applying data mining techniques.

METHODS

This study used the retrospectively approach and was done based on the CRISP-DM framework. The data of 1048 hemodialysis patients of Hasheminejad Kidney Center whose first catheterization was between 2014 and 2019 was used for analysis. In this study, patients with a previous history of deep venous thrombosis, thrombophilic condition, and undergone anticoagulant therapy were excluded. The decision tree J48 in WEKA software was used for modeling. The K-fold cross-validation method was also used to evaluate the classification performance. Finally, the model was evaluated by using Confusion Matrix and F-Measure.

RESULTS

The approved model was accurate in 70.3% of the predictions, and it demonstrated an association between patients' vitamin-D range and catheter-related-thrombosis.

CONCLUSION

The results indicated that in hemodialysis patients without the history of cancer or high blood pressure, vitamin-D had a significant impact on catheter related thrombosis.

Postoperative intermittent pneumatic compression for preventing venous thromboembolism in Chinese lung cancer patients: a randomized clinical trial

BACKGROUND

Postoperative lung cancer patients belong to the high-risk group for venous thromboembolism (VTE). The standardized preventive measures for perioperative VTE in lung cancer are not perfect, especially for the prevention and treatment of catheter-related thrombosis (CRT) caused by carried central venous catheters (CVCs) in lung cancer surgery.

PATIENTS AND METHODS

This study included 460 patients with lung cancer undergoing video-assisted thoracic surgery (VATS) in our center from July 2020 to June 2021. Patients were randomized into two groups, and intraoperatively-placed CVCs would be carried to discharge. During hospitalization, the control group was treated with low-molecular-weight heparin (LMWH), and the experimental group with LMWH + intermittent pneumatic compression (IPC). Vascular ultrasound was performed at three time points which included before surgery, before discharge, and one month after discharge. The incidence of VTE between the two groups was studied by the Log-binomial regression model.

RESULTS

CRT occurred in 71.7% of the experimental group and 79.7% of the control group. The multivariate regression showed that the risk of developing CRT in the experimental group was lower than in the control group (Adjusted RR = 0.889 [95%CI0.799-0.989], p = 0.031), with no heterogeneity in subgroups (P for Interaction > 0.05). Moreover, the fibrinogen of patients in the experimental group was lower than control group at follow-up (P = 0.019).

CONCLUSION

IPC reduced the incidence of CRT during hospitalization in lung cancer patients after surgery.

TRIAL REGISTRATION

No. ChiCTR2000034511.

Diagnosis of the right atrial myxoma after treatment of COVID-19: A case report

Key Clinical Message

Atrial myxoma is a rare disease but has a broad clinical presentation and complication that involves several systems- heart, lungs, brain, and systemic. An interdisciplinary approach is very important to optimize the outcome in patients with atrial myxomas. A thorough examination by primary care providers is crucial. Then radiologists or cardiologists can help with imaging modalities that can help diagnose and characterize the tumor. Prior to surgical resection by cardiothoracic surgeons, patients need to be evaluated by pulmonologists, cardiologists, and anesthesiologists for preoperative risk stratifications. In patients with neurological complications, pulmonary complications, or infectious endocarditis, input from neurologists, hematologists, infectious disease specialists is essential for patient care. In case antiplatelet/anticoagulation therapy or antibiotic treatment is warranted, pharmacists can provide valuable recommendations.

Abstract

Myxoma is the most common benign cardiac primary tumor, occurring in the right atrium in only 15%-20% of cases. This disease is asymptomatic initially depending upon size of the tumor, and symptoms develop as the tumor spreads. Atrial myxomas are associated with a triad of complications, including obstruction, emboli, and constitutional symptoms (such as fever and weight loss). This regard, embolization of the pulmonary circulation system is a complication of right myxoma. The patient was a 40-year-old male who presented to the emergency department complaining of fever and confusion. He had been previously hospitalized due to COVID-19 and treated with Remdesivir and plasmapheresis. He had tachycardia, tachypnea, thrombocytopenia, and increased liver enzymes. Chest imaging showed nodular lesions with necrotic areas and cavitary lesions in both lungs and the right atrium infected clot was seen in echocardiography. He was treated with intravenous antibiotics and finally underwent heart surgery due to the diagnosis of pulmonary septic embolism. The patient was finally diagnosed with right atrial myxoma according to heart mass histopathology. It is worth noting that the patient's thrombosis had already developed on the right atrial myxoma, which delayed the diagnosis in this patient. This thrombus formation was due to the hypercoagulability state of COVID-19 and following the insertion of a central venous catheter to perform plasmapheresis as a complication of treatment. Special attention should be paid to thromboprophylaxis and the early diagnosis of intravascular and intracardiac thrombosis in COVID-19 patients. Furthermore, the use of imaging modalities is recommended to differentiate thrombus from myxoma.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Central catheter tip migration in critically ill patients

OBJECTIVES

Chest X-ray (CXR) is routinely required for assessing Central Venous Catheter (CVC) tip position after insertion, but there is limited data as to the movement of the tip location during hospitalization. We aimed to assess the migration of Central Venous Catheter (CVC) position, as a significant movement of catheter tip location may challenge some of the daily practice after insertion.

DESIGN AND SETTINGS

Retrospective, single-center study, conducted in the Intensive Care and Cardiovascular Intensive Care Units in Tel Aviv Sourasky Medical Center 'Ichilov', Israel, between January and June 2019.

PATIENTS

We identified 101 patients with a CVC in the Right Internal Jugular (RIJ) with at least two CXRs during hospitalization.

MEASUREMENTS AND RESULTS

For each patient, we measured the CVC tip position below the carina level in the first and all consecutive CXRs. The average initial tip position was 1.52 (±1.9) cm (mean±SD) below the carina. The maximal migration distance from the initial insertion position was 1.9 (±1) cm (mean±SD). During follow-up of 2 to 5 days, 92% of all subject's CVCs remained within the range of the Superior Vena Cava to the top of the right atrium, regardless of the initial positioning.

CONCLUSIONS

CVC tip position can migrate significantly during a patient's early hospitalization period regardless of primary location, although for most patients it will remain within a wide range of the top of the right atrium and the middle of the Superior Vena Cava (SVC), if accepted as well-positioned.

Incidence of Venous Thromboembolism in Adults Receiving Extracorporeal Membrane Oxygenation: A Systematic Review

Extracorporeal membrane oxygenation (ECMO) has become an increasingly used tool for cardiorespiratory support. Thrombosis is a well-recognized complication of ECMO, yet the burden of disease remains unclear. We undertook a systematic review to investigate the incidence of venous thromboembolism (VTE) during ECMO or soon after decannulation, in patients screened for VTE. We retrieved all studies that evaluated VTE incidence in ECMO patients in EMBASE, MEDLINE, Web of Science, and Cochrane Library from inception to April 2, 2021. Studies reporting incidence of VTE diagnosed on systematic screening tests during ECMO or within 7 days of decannulation in adult patients were included. A total of 18 studies were included in the systematic review. These studies screened a total of 1095 ECMO patients. Most studies screened for cannula-associated deep vein thrombosis (CaDVT) after decannulation. The overall incidence of DVT was 52.8% (95% CI, 49.8-55.8%). Incidence of DVT was 53.5% (95% CI, 50.0-57.0%) for venovenous ECMO vs. 34.0% (95% CI, 26.5-42.2%) for venoarterial ECMO. No studies screened for pulmonary embolism. Our systematic review found a very high incidence of DVT among patients treated with ECMO. Routine screening for DVT after decannulation for all ECMO patients may be warranted.

Predictors of Early Thrombotic Events in Adult Patients with Acute Myeloid Leukemia: A Real-World Experience

Information regarding the incidence and the prognostic impact of thrombotic events (TE) in non-promyelocytic acute myeloid leukemia (AML) is sparse. Although several risk factors associated with an increased risk of TE development have been recognized, we still lack universally approved guidelines for identification and management of these complications. We retrospectively analyzed 300 consecutive patients with newly diagnosed AML. Reporting the incidence of venous TE (VTE) and arterial TE (ATE) was the primary endpoint. Secondarily, we evaluated baseline patient- and disease-related characteristics with a possible influence of VTE-occurrence probability. Finally, we evaluated the impact of TE on survival. Overall, the VTE incidence was 12.3% and ATE incidence was 2.3%. We identified three independent predictors associated with early-VTE: comorbidities (p = 0.006), platelets count >50 × 109/L (p = 0.006), and a previous history of VTE (p = 0.003). Assigning 1 point to each variable, we observed an overall cumulative incidence of VTE of 18.4% in the high-risk group (≥2 points) versus 6.4% in the low-risk group (0−1 point), log-rank = 0.002. Overall, ATE, but not VTE, was associated with poor prognosis (p < 0.001). In conclusion, TE incidence in AML patients is not negligible. We proposed an early-VTE risk score that could be useful for a proper management of VTE prophylaxis.

Pathology of catheter-related complications: what we need to know and what should be discovered

Despite the considerable efforts made to increase the prevalence of autogenous fistula in patients on hemodialysis, tunneled cuffed catheters are still an important access modality and used in a high percentage of the hemodialysis population. However, because of the conundrum posed by tunneled cuffed catheters, patients can develop a multitude of complications, including thrombosis, infections, formation of a fibrin sheath, and central vein stenosis, resulting in increased morbidity and mortality as well as placing a heavy burden on the healthcare system. However, with an increasing number of studies now focusing on how to manage these catheter-related complications, there has been less translational research on the pathology of these complications. This review of the most recent literature provides an update on the pathological aspects of catheter-related complications, highlighting what we need to know and what is yet to be discovered. The future research strategies and innovations needed to prevent these complications are also addressed.

Secondary arteriovenous malformation due to subclavian vein occlusion

An 80-year-old man underwent rectal resection and insertion of a central venous catheter through the left subclavian vein 16 years earlier. Following surgery, he developed edema of his left upper limb that became exacerbated and infected. Computed tomography showed occlusion of the subclavian vein and multiple arteriovenous shunts from the branches of the axillary artery to the venous sac of the axillary vein. Angiography confirmed numerous shunts between the branches of the axillary artery and vein and dilated collateral veins. Embolization of the venous sac was performed using coils, alcohol, and glue. Postprocedural angiography showed complete eradication of the nidus.

Benefits of an online multimodal nursing program among patients with peripherally inserted central catheter-related thrombosis

Background

Asymptomatic peripherally inserted central catheter-related thrombosis (PICC-RT) is one of the most common and dangerous complications caused by peripherally inserted central catheter (PICC) insertion. A variety of factors might lead to huge psychological pressures on patients and markedly affect their quality of life. The aim of this study was to evaluate the benefits of an online multimodal nursing program on the quality of life and psychological resilience of asymptomatic PICC-RT patients with ovarian cancer.

Methods

This was a prospective cohort study on patients with asymptomatic PICC-RT. Patients in the control group received routine nursing care, while patients in the intervention group obtained extra assistance through an online multimodal nursing program. Individual guidance, psychological support, and real-time consultation were provided to patients in the intervention group. All participants were followed for 3 months. The health-related quality of life and psychological resilience of patients were evaluated by using the 36-item Short Form Health Survey (SF-36) and Connor-Davidson Resilience Scale (CD-RISC), respectively.

Results

Compared to baseline, most of the items in the SF-36 scores were significantly increased in both intervention and control groups after 3 months (all p < 0.05), except for the role emotional domain (p = 0.085 in control group). However, the SF-36 scores of the intervention group were significantly higher than those of the control group in All health domains, including physical functioning (p = 0.001), role physical (p = 0.004), bodily pain (p = 0.003), general health (p < 0.001), vitality (p < 0.001), social functioning (p < 0.001), role emotional (p = 0.002), mental health (p < 0.001) and health transition (p < 0.001). For CD-RISC scores, the mean value of the control group was 42.03 ± 4.42 at baseline and increased to 50.36 ± 4.70 after 3 months (p < 0.001), while the intervention group was 40.00 ± 6.61 at baseline and increased to 65.12 ± 5.21 after 3 months (p < 0.001). Moreover, the CD-RISC score in the intervention group was significantly higher than that in the control group after 3 months (p < 0.001).

Conclusion

The application of an online multimodal nursing program could significantly improve the health-related quality of life and psychological resilience of asymptomatic PICC-RT patients. These findings provide evidence to support the necessity of an online multimodal nursing program in routine long-term follow-up, especially in the era of COVID-19.

Complications Associated with Continuous RRT

Continuous renal replacement therapy (CRRT) is a form of renal replacement therapy that is used in modern intensive care units (ICUs) to help manage acute kidney injury (AKI), end stage kidney disease (ESKD), poisonings, and some electrolyte disorders. CRRT has transformed the care of patients in the ICU over the past several decades. In this setting, it is important to recognize CRRT-associated complications but also up-to-date management of these complications. Some of these complications are minor, but others may be more significant and even life-threatening. Some CRRT complications may be related to dialysis factors and others to specific patient factors. Our overarching goal in this article is to review and discuss the most significant CRRT-related complications at the different stage of management of CRRT. With the advent of newer solutions, there have been newer complications as well.

The ICU-venous thromboembolism score and tumor grade can predict inhospital venous thromboembolism occurrence in critical patients with tumors

Background

Venous thromboembolism (VTE) is a threat to the prognosis of tumor patients, especially for critically ill patients. No uniform standard model of VTE risk for critically ill patients with tumors was formatted by now. We thus analyzed risk factors of VTE from the perspectives of patient, tumor, and treatment and assessed the predictive value of the ICU-VTE score, which consisted of six independent risk factors (central venous catheterization, 5 points; immobilization ≥ 4 days, 4 points; prior VTE, 4 points; mechanical ventilation, 2 points; lowest hemoglobin during hospitalization ≥ 90 g/L, 2 points; and baseline platelet count > 250,000/μL, 1 points).

Methods

We evaluated the data of tumor patients admitted to the intensive care unit of the Peking University Cancer Hospital between November 2011 and January 2022; 560 cases who received VTE-related screening during hospitalization were chosen for this retrospective study.

Results

The inhospital VTE occurrence rate in our cohort was 55.7% (312/560), with a median interval from ICU admission to VTE diagnosis of 8.0 days. After the multivariate logistic regression analysis, several factors were proved to be significantly associated with inhospital VTE: age ≥ 65 years, high tumor grade (G3–4), medical diseases, fresh frozen plasma transfusion, and anticoagulant prophylaxis. The medium-high risk group according to the ICU-VTE score was positively correlated with VTE when compared with the low-risk group (9–18 points vs. 0–8 points; OR, 3.13; 95% CI, 2.01–4.85, P < 0.001). The AUC of the ICU-VTE scores according to the ROC curve was 0.714 (95% CI, 0.67–0.75, P < 0.001).

Conclusions

The ICU-VTE score, as well as tumor grade, might assist in the assessment of inhospital VTE risk for critically ill patients with tumors. The predictive accuracy might be improved when combining two of them; further follow-up researches are needed to confirm it.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02705-z.

Catheter-related thrombosis (CRT) in patients with solid tumors: a narrative review and clinical guidance for daily care

Central venous access devices (CVADs) including central venous catheters and peripherally inserted central catheters (PICCs) are essential in the treatment of cancer. Catheter-related thrombosis (CRT) is the most frequent non-infectious complication associated with the use of central lines. The development of CRT may cause to delays in oncologic treatment and increase morbidity leading to potentially life-threatening complications. Several local and systemic risk factors are associated with the development of CRT and should be taken into account to prevent CRT by standardizing appropriate catheter placement and maintenance. The use of primary pharmacological thromboprophylaxis in order to avoid CRT is not routinely recommended, although it can be considered in selected cases. Recommendations for the management of established CRT are based on the extrapolation of anticoagulation for lower limb venous thrombosis. The present review summarizes the current evidence and recommendations for the prevention and management of CRT and identifies areas that require further research.

Characteristics and predictors of venous thrombosis recurrence in patients with cancer and catheter-related thrombosis

Background

Central venous catheters raise the risk of catheter-related thrombosis (CRT) in patients with cancer, typically affecting the upper extremity. Management of CRT involves catheter removal and anticoagulation. However, robust evidence is lacking on the optimal timing of anticoagulation relative to catheter removal.

Objectives

Our goal is to provide a better understanding of the factors that increase the risk of recurrent venous thromboembolism (VTE) in these patients.

Patients and Methods

We conducted a retrospective chart review of all consecutive patients with cancer in our hospital affected by CRT between January 1, 2015, and December 31, 2017. We measured recurrence of VTE as thrombosis in any vascular bed or pulmonary embolism, for up to 2 years after diagnosis. Logistic and competing risk regression analyses were used to determine the association between different clinical factors and any VTE recurrence in patients with cancer and CRT.

Results

Of the 257 individuals meeting the inclusion criteria, 80.2% had their catheter removed; of these, 50.5% did not receive anticoagulation before the removal. Patients who did not receive anticoagulation before the removal had increased 3-month and 1-year risks of recurrent VTE (odds ratio, 5.07 [95% confidence interval [CI], 1.53-23.18]; and hazard ratio, 3.47 [95% CI, 1.34-9.01]), respectively.

Conclusions

Our study supports the use of anticoagulants before catheter removal in patients with CRT. Randomized clinical trials are recommended to establish stronger evidence pertaining to the long-term risk of VTE recurrence and the effect of catheter reinsertion.

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.

Home Parenteral and Enteral Nutrition

While the history of nutrition support dates to the ancient world, modern home parenteral and enteral nutrition (HPEN) has been available since the 1960s. Home enteral nutrition is primarily for patients in whom there is a reduction in oral intake below the amount needed to maintain nutrition or hydration (i.e., oral failure), whereas home parenteral nutrition is used for patients when oral-enteral nutrition is temporarily or permanently impossible or absorption insufficient to maintain nutrition or hydration (i.e., intestinal failure). The development of home delivery of these therapies has revolutionized the field of clinical nutrition. The use of HPEN appears to be increasing on a global scale, and because of this, it is important for healthcare providers to understand all that HPEN entails to provide safe, efficacious, and cost-effective support to the HPEN patient. In this article, we provide a comprehensive review of the indications, patient requirements, monitoring, complications, and overall process of managing these therapies at home. Whereas some of the information in this article may be applicable to the pediatric patient, the focus is on the adult population.

Management of Central Venous Catheters in Children and Adults on Home Parenteral Nutrition: A French Survey of Current Practice

Although central venous catheter (CVC)-related thrombosis (CRT) is a severe complication of home parenteral nutrition (HPN), the amount and quality of data in the diagnosis and management of CRT remain low. We aimed to describe current practices regarding CVC management in French adult and pediatric HPN centers, with a focus on CVC obstruction and CRT. Current practices regarding CVC management in patients on HPN were collected by an online-based cross-sectional survey sent to expert physicians of French HPN centers. We compared these practices to published guidelines and searched for differences between pediatric and adult HPN centers’ practices. Finally, we examined the heterogeneity of practices in both pediatric and adult HPN centers. The survey was completed by 34 centers, including 21 pediatric and 13 adult centers. We found a considerable heterogeneity, especially in the responses of pediatric centers. On some points, the centers’ responses differed from the current guidelines. We also found significant differences between practices in adult and pediatric centers. We conclude that the management of CVC and CRT in patients on HPN is a serious and complex situation for which there is significant heterogeneity between HPN centers. These findings highlight the need for more well-designed clinical trials in this field.

A Readily Scalable, Clinically Demonstrated, Antibiofouling Zwitterionic Surface Treatment for Implantable Medical Devices

Unlike growth on tissue, microbes can grow freely on implantable devices with minimal immune system intervention and often form resilient biofilms that continuously pump out pathogenic cells. The efficacy of antibiotics used to treat infection is declining due to increased rates of pathogenic resistance. A simple, one-step zwitterionic surface modification is developed to significantly reduce protein and microbial adhesion to synthetic materials and demonstrate the successful modification of several clinically relevant materials, including recalcitrant materials such as elastomeric polydimethylsiloxane. The treated surfaces exhibit robust adhesion resistance against proteins and microorganisms in both static and flow conditions. Furthermore, the surface treatment prevents the adhesion of mammalian fibroblast cells while displaying no cytotoxicity. To demonstrate the clinical efficacy of the novel technology in the real-world, a surface-treated, commercial silicone foley catheter is developed that is cleared for use by the U.S. Food and Drug Administration (K192034). 16 long-term catheterized patients received surface-treated catheters and completed a Patient Global Impression of Improvement (PGI-I) questionnaire. 10 out of 16 patients described their urinary tract condition post implantation as "much better" or "very much better" and 72% (n = 13) of patients desire to continue using the surface-treated catheter over conventional latex or silicone catheters.

Central venous catheters are associated with thrombosis among adult inpatients undergoing therapeutic plasma exchange

BACKGROUND

For inpatients undergoing therapeutic plasma exchange (TPE) in the United States, the primary mode of venous access is the central venous catheter (CVC). To evaluate the impact of CVC on thrombosis outcomes of patients undergoing TPE, we analyzed the National Inpatient Sample (NIS) database.

STUDY DESIGN AND METHODS

In a cross-sectional analysis of the NIS, we identified hospital discharges of adult patients treated with TPE. Cases were classified into two groups based on CVC status. The primary outcome was thrombosis. Secondary outcomes were major bleeding, packed red blood cell (PRBC) transfusion, in-hospital mortality, hospital length of stay (LOS), and charges.

RESULTS

Among 9863 TPE-treated discharges, CVC was used in 5988 (60%). These numbers correspond to weighted national estimates of 49 315 and 29 940, respectively. There was a positive and significant association between CVC and thrombosis (OR = 1.23, 95% 1.04-1.46, P = 0.0174), PRBC transfusion (OR = 1.15, 95% 1.03-1.29, P = 0.0121), in-hospital mortality (OR = 1.36, 95% 1.10-1.68, P = 0.0043), hospital LOS (15.63 vs 12.45 days, P < 0.0001) and hospital charges ($166 387 vs. $132 655, P < 0.0001).

CONCLUSION

In hospitalized patients undergoing TPE, CVC use is associated with increased rates of thrombosis. Future studies are needed to investigate strategies to decrease CVC use and/or prevent CVC-associated complications in TPE-treated inpatients.