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Dam M, Lynggaard LS, Jónsson ÓG, Saulyte Trakymiene S, Palk K, Jarvis K, Andrés-Jensen L, Tuckuviene R, Albertsen BK. Sequelae and post-thrombotic syndrome after venous thromboembolism in acute lymphoblastic leukemia survivors treated on the NOPHO ALL2008 protocol. Pediatr Blood Cancer 2024; 71:e30937. [PMID: 38480517 DOI: 10.1002/pbc.30937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/09/2024] [Accepted: 02/22/2024] [Indexed: 04/24/2024]
Abstract
The treatment of acute lymphoblastic leukemia (ALL) is frequently complicated by toxicity, including venous thromboembolism (VTE) affecting roughly 8% of patients. VTE can lead to post-thrombotic syndrome (PTS), a group of signs and symptoms developed as a complication to deep venous thrombosis (DVT), imposing risk of permanent disability and reduced quality of life (QoL). PTS prevalence ranges from 0% to 70%, reflecting very heterogenous cohorts and assessment tools. We aimed to estimate sequelae, including PTS and QoL in children and adults (<45 years old) who had a DVT during ALL treatment. PTS and QoL scores were obtained through use of Villalta and Modified Villalta Scale, PedsQL, and Short Form-36 questionnaires. The cohort comprised 20 children (<18 years) and seven adults (median age: 12.9 years, range: 2-44 years) at the time of DVT diagnosis. In total, 25 ALL survivors underwent PTS examination. The examination took place when survivors were 7-48 years (median age: 20.3 years, median follow-up time 6.8 years). QoL was assessed correlating cases with three matching ALL survivors without VTE. Two adults (15.4%) showed mild or moderate PTS. Eight children (66.7%) were diagnosed with mild PTS, while three cases had collaterals as sole symptoms. Pain or symptoms affecting daily life were reported by 16%. No difference in QoL was found (p = .9). This study underscores the need for comprehensive population-based investigations with validation of PTS instruments in ALL survivors.
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Affiliation(s)
- Merete Dam
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Line Stensig Lynggaard
- Department of Hematology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Sonata Saulyte Trakymiene
- Clinic of Children's Diseases, Faculty of Medicine, Vilnius University, Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Katrin Palk
- The North Estonia Medical Centre, Tallinn, Estonia
| | - Kirsten Jarvis
- Department of Paediatric Haematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Liv Andrés-Jensen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ruta Tuckuviene
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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O'Brien SH, Rodriguez V, Lew G, Newburger JW, Schultz CL, Orgel E, Derr K, Ranalli MA, Esbenshade AJ, Hochberg J, Kang HJ, Dinikina Y, Mills D, Donovan M, Dyme JL, Favatella NA, Mitchell LG. Apixaban versus no anticoagulation for the prevention of venous thromboembolism in children with newly diagnosed acute lymphoblastic leukaemia or lymphoma (PREVAPIX-ALL): a phase 3, open-label, randomised, controlled trial. Lancet Haematol 2024; 11:e27-e37. [PMID: 37980924 DOI: 10.1016/s2352-3026(23)00314-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Paediatric patients with acute lymphoblastic leukaemia or lymphoma are at increased risk of venous thromboembolism resulting in increased mortality and morbidity. We hypothesised that apixaban, a direct oral anticoagulant, would safely reduce venous thromboembolism in this patient population. METHODS PREVAPIX-ALL was a phase 3, open-label, randomised, controlled trial conducted in 74 paediatric hospitals in 9 countries. Participants aged 1 year or older to younger than 18 years with newly diagnosed acute lymphoblastic leukaemia (pre-B cell or T cell) or lymphoblastic lymphoma (B cell or T cell immunophenotype) and a central venous line in place throughout induction were randomly assigned 1:1 to standard of care (SOC, ie, no systemic anticoagulation) or weight-adjusted twice-daily apixaban during induction. Randomisation was performed centrally and stratified by age (those <10 years or those ≥10 years). Participants weighing 35 kg or less were administered 2·5 mg twice daily of apixaban as a 2·5 mg tablet, 0·5 mg tablets, or 0·4 mg/mL oral solution, while those weighing more than 35 kg were administered weight-adjusted prophylactic doses using 0·5 mg tablets or the 0·4 mg/mL oral solution twice daily. Primary outcomes were assessed by a blinded central adjudication committee. The primary efficacy outcome for the intention to treat population was the composite of symptomatic or clinically unsuspected venous thromboembolism, the primary safety outcome was major bleeding, and secondary safety outcomes included clinically relevant non-major (CRNM) bleeding. Patients were screened for venous thromboembolism by ultrasound and echocardiogram at the end of induction. The trial was registered with ClinicalTrials.gov (NCT02369653) and is now complete. FINDINGS Between Oct 22, 2015, and June 4, 2021, 512 participants were randomly assigned and included in analyses (222 [43%] female and 290 [57%] male; 388 [76%] White, 52 [10%] Asian, 24 [5%] Black or African American, and 48 [9%] other races; and 122 [24%] Hispanic or Latino ethnicity). During a median follow-up period of 27 days (IQR 26-28), 31 (12%) of 256 patients on apixaban had a composite venous thromboembolism compared with 45 (18%) of 256 participants receiving SOC (relative risk [RR] 0·69, 95% CI 0·45-1·05; p=0·080). Two major bleeding events occurred in each group (RR 1·0, 95% CI 0·14-7·01; p=1·0). A higher incidence of CRNM bleeding, primarily grade 1 or 2 epistaxis, occurred in the apixaban group (11 [4%] of 256 participants) compared with the SOC group (3 [1%] of 256; RR 3·67, 95% CI 1·04-12·97, p=0·030). The most frequent grade 3-5 adverse events in both groups were thrombocytopenia (n=28 for the apixaban group and n=20 for the SOC group) or platelet count decreased (n=49 and n=45), anaemia (n=77 and n=74), febrile neutropenia (n=27 and n=20), and neutropenia (n=16 and n=17) or neutrophil count decreased (n=22 and n=25). Five deaths occurred, which were due to infection (n=3 in the SOC group), cardiac arrest (n=1 in apixaban group), and haemorrhagic cerebral sinus vein thrombosis (n=1 in the SOC group). There was one apixaban-related death (coagulopathy and haemorrhage after cardiac arrest of unknown cause). INTERPRETATION PREVAPIX-ALL is, to our knowledge, the first trial assessing primary thromboprophylaxis using a direct oral anticoagulant in paediatric patients with acute lymphoblastic leukaemia or lymphoma. No statistically significant treatment benefit was identified in participants receiving apixaban. Major and CRNM bleeding were infrequent overall, but a higher incidence of CRNM bleeding (primarily epistaxis in younger children) occurred in participants receiving apixaban. For patients deemed to be at particularly high risk of thrombosis, PREVAPIX-ALL provides encouraging safety data for the use of apixaban in clinical settings in which the potential benefits are thought to outweigh the risk of bleeding. FUNDING Bristol Myers Squibb-Pfizer Alliance.
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology and Oncology, Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University, Columbus, OH, USA.
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology and Oncology, Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University, Columbus, OH, USA
| | - Glen Lew
- Bristol Myers Squibb, Lawrenceville, NJ, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Corinna L Schultz
- Nemours Center for Cancer and Blood Disorders, Nemours Children's Health, Wilmington, DE, USA
| | - Etan Orgel
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kimberly Derr
- Department of Pediatric Oncology, Geisinger, Danville, PA, USA
| | - Mark A Ranalli
- Division of Pediatric Hematology and Oncology, Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University, Columbus, OH, USA
| | - Adam J Esbenshade
- Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jessica Hochberg
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Cancer Research Institute, Wide River Institute of Immunology, Seoul National University Children's Hospital, Seoul, South Korea
| | - Yulia Dinikina
- Department of Chemotherapy for Oncohematological Diseases and Bone Marrow Transplantation for Children, Almazov National Medical Research Centre, Saint Petersburg, Russian
| | - Donna Mills
- Bristol Myers Squibb, Lawrenceville, NJ, USA
| | | | | | | | - Lesley G Mitchell
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Lan Y, Wu L, Guo J, Wang J, Guan H, Li B, Liu L, Zhang L, Hong Y, Deng J, Zhu J, Lu S, Sun F, Huang J, Sun X, Zhang Y, Wang J, Cai R. Risk factors for totally implantable access ports-associated thrombosis in pediatric oncology patients. Sci Rep 2023; 13:3553. [PMID: 36864082 PMCID: PMC9981621 DOI: 10.1038/s41598-023-30763-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 02/28/2023] [Indexed: 03/04/2023] Open
Abstract
The application of totally implantable access ports (TIAPs) reduces treatment-related discomfort; however, the existence of catheter may cause side effects, with the most common one being the occurrence of TIAPs-associated thrombosis. The risk factors for TIAPs-associated thrombosis in pediatric oncology patients have not been fully described. A total of 587 pediatric oncology patients undergoing TIAPs implantation at a single center over a 5-year period were retrospectively analyzed in the present study. We investigated the risk factors for thrombosis, emphasizing the internal jugular vein distance, by measuring the vertical distance from the highest point of the catheter to the upper border of the left and right extremitas sternalis claviculae on chest X-ray images. Among 587 patients, 143 (24.4%) had thrombosis. Platelet count, C-reactive protein, and the vertical distance from the highest point of the catheter to the upper border of the left and right extremitas sternalis claviculae were demonstrated to be the main risk factors for the development of TIAPs-associated thrombosis. TIAPs-associated thrombosis, especially asymptomatic events, is common in pediatric cancer patients. The vertical distance from the highest point of the catheter to the upper border of the left and right extremitas sternalis claviculae was a risk factor for TIAPs-associated thrombosis, which deserved additional attention.
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Affiliation(s)
- Yingxia Lan
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Liuhong Wu
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Jin Guo
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Anesthesiology and Operating Theatre, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Juan Wang
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Huijie Guan
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Baihui Li
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Longzhen Liu
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Lian Zhang
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Ye Hong
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Jun Deng
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Jia Zhu
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Suying Lu
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Feifei Sun
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Junting Huang
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Xiaofei Sun
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Yizhuo Zhang
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Jian Wang
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China
- Department of Anesthesiology and Operating Theatre, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Ruiqing Cai
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, People's Republic of China.
- Department of Pediatric Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, Guangdong, People's Republic of China.
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Rodriguez V. Thrombosis Complications in Pediatric Acute Lymphoblastic Leukemia: Risk Factors, Management, and Prevention: Is There Any Role for Pharmacologic Prophylaxis? Front Pediatr 2022; 10:828702. [PMID: 35359904 PMCID: PMC8960248 DOI: 10.3389/fped.2022.828702] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/26/2022] [Indexed: 01/19/2023] Open
Abstract
Pediatric acute lymphoblastic leukemia (ALL) has achieved close to 90% cure rates through extensive collaborative and integrative molecular research, clinical studies, and advances in supportive care. Despite this high achievement, venous thromboembolic complications (VTE) remain one of the most common and potentially preventable therapy-associated adverse events in ALL. The majority of thromboses events involve the upper central venous system which is related to the use and location of central venous catheters (CVC). The reported rates of symptomatic and asymptomatic CVC-related VTE range from 2.6 to 36.7% and 5.9 to 43%, respectively. Thrombosis can negatively impact not only disease-free survival [e.g., therapy delays and/or interruption, omission of chemotherapy agents (e.g., asparaginase therapy)] but also can result in long-term adverse effects that can impair the quality of life of ALL survivors (e.g., post-thrombotic syndrome, central nervous system (CNS)-thrombosis related complications: seizures, neurocognitive deficits). In this review, will discuss thrombosis pathophysiology in pediatric ALL, risk factors, treatment, and prevention strategies. In addition, the recently published clinical efficacy and safety of direct oral anticoagulants (DOACs) use in thrombosis treatment, and their potential role in primary/secondary thrombosis prevention in pediatric patients with ALL will be discussed. Future clinical trials involving the use of these novel oral anticoagulants should be studied in ALL not only for primary thrombosis prevention but also in the treatment of thrombosis and its secondary prevention. These future research findings could potentially extrapolate to VTE prevention strategies in other pediatric cancer diagnoses and children considered at high risk for VTE.
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Augustin AM, Kertels O, Wiegering V, Thurner A, Kickuth R. Percutaneous implantation of peripherally inserted totally implantable venous access systems in the forearm in adolescent patients. Pediatr Radiol 2022; 52:1550-1558. [PMID: 35368211 PMCID: PMC9271099 DOI: 10.1007/s00247-022-05321-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 01/14/2022] [Accepted: 02/11/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Children with different underlying malignant diseases require long-term central venous access. As for port systems in a pectoral position, peripherally implanted port systems in the forearm revealed high levels of technical and clinical success in adult cohorts. OBJECTIVE To investigate the technical and clinical outcomes of percutaneous central venous port implantation in the forearm in adolescents. MATERIALS AND METHODS Between April 2010 and August 2020, 32 children ages 9 to 17 years with underlying malignancy received 35 totally implantable venous access ports (TIVAPs) in the forearm. All venous port systems were peripherally inserted under ultrasound guidance. Correct catheter placement was controlled by fluoroscopy. As primary endpoints, the technical success, rate of complications and catheter maintenance were analyzed. Secondary endpoints were the side of implantation, vein of catheter access, laboratory results on the day of the procedure, procedural radiation exposure, amount of contrast agent and reasons for port device removal. RESULTS Percutaneous TIVAP placement under sonographic guidance was technically successful in 34 of 35 procedures (97.1%). Procedure-related complications did not occur. During the follow-up, 13,684 catheter days were analyzed, revealing 11 complications (0.8 per 1,000 catheter-duration days), Of these 11 complications, 7 were major and 10 occurred late. In seven cases, the port device had to be removed; removal-related complications did not occur. CONCLUSION Peripheral TIVAP placement in the forearms of children is a feasible, effective and safe technique with good midterm outcome. As results are comparable with standard access routes, this technique may be offered as an alternative when intermittent venous access is required.
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Affiliation(s)
- Anne Marie Augustin
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Oberdürrbacher Strasse 6, DE 97080, Würzburg, Germany.
| | - Olivia Kertels
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Oberdürrbacher Strasse 6, DE 97080 Würzburg, Germany
| | - Verena Wiegering
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Annette Thurner
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Oberdürrbacher Strasse 6, DE 97080 Würzburg, Germany
| | - Ralph Kickuth
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Oberdürrbacher Strasse 6, DE 97080 Würzburg, Germany
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Samji N, Bhatt MD, Kulkarni K. Challenges in Management of VTE in Children With Cancer: Risk Factors and Treatment Options. Front Pediatr 2022; 10:855162. [PMID: 35463883 PMCID: PMC9021605 DOI: 10.3389/fped.2022.855162] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/11/2022] [Indexed: 01/19/2023] Open
Abstract
Venous thromboembolism (VTE) occurs in 2.1 to up to 50% of children with cancer and contributes to long term morbidity as well as early mortality in this population. Pediatric patients with malignancy are predisposed to VTE due to the prothrombotic nature of cancer and its associated coagulopathies as well as chemotherapeutic agents, use of central venous catheters, surgery, radiotherapy, and concomitant thrombophilia. Management of thrombosis in this population is challenging due to concomitant thrombocytopenia, associated bleeding risks, concurrent co-morbidities, and toxicities of therapy. The aim of this paper is to highlight clinically relevant issues and management dilemmas using clinical vignettes. We review the clinical significance of asymptomatic and symptomatic thrombosis, examine the various options for asparaginase-associated thrombosis, address the role and controversies of direct oral anticoagulants, and describe our approach to managing anticoagulation therapy in the context of chemotherapy-induced thrombocytopenia.
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Affiliation(s)
- Nasrin Samji
- Department of Pediatrics, Division of Hematology Oncology, McMaster University, Hamilton, ON, Canada
| | - Mihir D Bhatt
- Department of Pediatrics, Division of Hematology Oncology, McMaster University, Hamilton, ON, Canada
| | - Ketan Kulkarni
- Department of Pediatrics, Division of Hematology Oncology, Dalhousie University and Izaak Walton Killam (IWK) Health Centre, Halifax, NS, Canada
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Georgeades C, Rothstein AE, Plunk MR, Arendonk KV. Iatrogenic vascular trauma and complications of vascular access in children. Semin Pediatr Surg 2021; 30:151122. [PMID: 34930587 DOI: 10.1016/j.sempedsurg.2021.151122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.
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Affiliation(s)
- Christina Georgeades
- Division of Pediatric Surgery, Children's Wisconsin and Medical College of Wisconsin, 999N 92nd Street, Suite 320, Milwaukee, WI 53226, United States.
| | - Abby E Rothstein
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, 8701W. Watertown Plank Road, Milwaukee, WI 53226, United States
| | - Matthew R Plunk
- Department of Radiology, Children's Wisconsin and Medical College of Wisconsin, 9000W. Wisconsin Avenue, MS-721, Milwaukee, WI 53226, United States
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Children's Wisconsin and Medical College of Wisconsin, 999N 92nd Street, Suite 320, Milwaukee, WI 53226, United States
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8
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Hansen RS, Nybo M, Hvas AM. Venous Thromboembolism in Pediatric Cancer Patients with Central Venous Catheter-A Systematic Review and Meta-analysis. Semin Thromb Hemost 2021; 47:920-930. [PMID: 34474495 DOI: 10.1055/s-0041-1729886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pediatric cancer patients hold an increased risk of venous thromboembolism (VTE) due to their cancer. Central venous catheters (CVCs) further increase the VTE risk. This systematic literature review elucidates the VTE incidence in pediatric cancer patients with CVC. MEDLINE and EMBASE were searched in August 2020 without time limits. We included studies reporting original data on patients ≤18 years with any CVC type and any cancer type, who were examined for VTE with ≥7 days follow-up. In total, 682 unique records were identified, whereof 189 studies were assessed in full text. Altogether, 25 studies were included, containing 2,318 pediatric cancer patients with CVC, of which 17% suffered VTE. Fifteen studies (n = 1,551) described CVC-related VTE and reported 11% CVC-related VTE. Concerning cancer type, 991 children suffered from acute lymphoblastic leukemia (ALL) and 616 from solid tumors. Meta-analysis revealed VTE incidence (95% confidence interval) of 21% (8-37) for ALL and 7% (0.1-17) for solid tumors. Additionally, 20% of children with tunneled or nontunneled CVC and 12% of children with implantable ports suffered VTE. In conclusion, pediatric cancer patients with CVC have substantial VTE risk. Children with ALL and CVC have higher VTE incidence than children with solid tumors and CVC. Implantable port catheter should be preferred over tunneled or nontunneled CVC to reduce VTE risk. Thrombophilia investigation does not seem relevant in pediatric cancer patients with CVC and VTE. To prevent VTE, intensified catheter care is recommended, especially in children with ALL.
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Affiliation(s)
- Rasmus Søgaard Hansen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Neverova IN, Borisenko DV, Perevalova NG, Tarasov RS. [Thrombosis of the inferior vena cava and right atrium in a neonate with thrombophilia: diagnosis, treatment, result]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:169-174. [PMID: 33825745 DOI: 10.33529/angio2021115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Hereditary thrombophilia is rare pathology giving rise to a ninefold increase in the risk for the development of thromboembolism in infants. The problem is multifactorial and characterized by high mortality, especially in neonates. Infants who develop thrombosis, particularly those with no family history, are often subjected to testing for hereditary thrombophilia. However, genetic testing for thrombophilia does not change the plan of treatment but makes it possible to perform prevention of thrombosis within the risk periods for the patient. Poor awareness of paediatricians, the complexity of carrying out genetic testing, the absence of approaches supported by evidence-based medicine due to shortage of high-quality clinical trials and no guidelines on prevention of thromboembolism in infants, as well as the frequent occurrence of diversified causes and diseases in different age groups make the problem significant for modern medicine. Further studies are needed to address many unanswered as yet questions.
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Affiliation(s)
- Iu N Neverova
- Cardiosurgical Department, Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - D V Borisenko
- Department of Anaesthesiology and Resuscitation, Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - N G Perevalova
- Department of Paediatric Cardiology, Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - R S Tarasov
- Cardiosurgical Department, Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
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10
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Sharathkumar AA, Biss T, Kulkarni K, Ahuja S, Regan M, Male C, Revel-Vilk S. Epidemiology and outcomes of clinically unsuspected venous thromboembolism in children: A systematic review. J Thromb Haemost 2020; 18:1100-1112. [PMID: 31984669 PMCID: PMC7192773 DOI: 10.1111/jth.14739] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 12/27/2019] [Accepted: 01/21/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Clinically unsuspected venous thromboembolic events (uVTE) detected during routine imaging pose a management challenge due to limited knowledge about their clinical significance. Unsuspected VTE are often referred as "asymptomatic," "incidental," or "clinically silent/occult" VTE. OBJECTIVE To understand the epidemiology, management, and outcomes of uVTE in children. METHODS A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search criteria included controlled vocabulary and keywords for VTE, incidental findings, and children (ages ≤ 21 years). RESULTS Among 10 875 articles, 51 studies (8354 children with 758 uVTE) were selected. The studies were heterogeneous, I2 96%; P < .0001. Unsuspected VTE were diagnosed in two settings: first, asymptomatic VTE (aVTE) diagnosed through surveillance imaging for VTE (46 studies; n = 5894; aVTE: 715, pooled frequency: 19%, 95% confidence interval [CI]: 13%-24%); second, incidental VTE (iVTE) diagnosed during imaging performed for indications without primary suspicion for VTE (6 studies; n = 2460; iVTE: 43). The majority (94%) of aVTE were associated with central venous lines (CVL). Non-CVL settings included post-spinal surgery, post-splenectomy, trauma, nephrotic syndrome, and newborns. In general, aVTE were reported to have a benign clinical course, were mostly transient, and resolved without intervention and with few immediate or long-term functional complications. Incidental VTE were primarily detected in children with cancer and ranged from tumor-associated thrombi to pulmonary embolism (PE) with insufficient evidence to draw meaningful conclusions about their management. CONCLUSION Clinically uVTE were predominantly diagnosed with CVL and their outcomes were generally favorable implying limited benefit of routine surveillance and thromboprophylaxis. Prospective research is needed to clarify the optimal management of iVTE.
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Affiliation(s)
- Anjali A. Sharathkumar
- Stead Family Department of Pediatrics, University of Iowa Carver School of Medicine, Iowa City, IA
| | - Tina Biss
- Department of Pediatrics, Royal Victoria Infirmary, UK
| | | | - Sanjay Ahuja
- Division of Hematology/Oncology, Department of Pediatrics, IWK Health Centre and Dalhousie University, Canada
| | | | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Austria
| | - Shoshana Revel-Vilk
- Pediatric Hematology/Oncology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
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11
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Jones S, Monagle P, Newall F. Do asymptomatic clots in children matter? Thromb Res 2020; 189:24-34. [DOI: 10.1016/j.thromres.2020.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 01/28/2023]
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12
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Tailored Optimization of Pediatric Body MR Angiography for Successful Outcomes in Thoracic Applications. AJR Am J Roentgenol 2020; 214:1031-1041. [DOI: 10.2214/ajr.19.22253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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13
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Central venous catheter-related thrombosis in children and adults. Thromb Res 2020; 187:103-112. [DOI: 10.1016/j.thromres.2020.01.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/03/2020] [Accepted: 01/14/2020] [Indexed: 02/06/2023]
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14
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Mandel-Shorer N, Tzvi-Behr S, Harvey E, Revel-Vilk S. Central venous catheter-related venous thrombosis in children with end-stage renal disease undergoing hemodialysis. Thromb Res 2018; 172:150-157. [DOI: 10.1016/j.thromres.2018.10.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/01/2018] [Accepted: 10/29/2018] [Indexed: 10/28/2022]
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15
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16
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Dolmatch BL, Gurley JC, Baskin KM, Nikolic B, Lawson JH, Shenoy S, Saad TF, Davidson I, Baerlocher MO, Cohen EI, Dariushnia SR, Faintuch S, d’Othee BJ, Kinney TB, Midia M, Clifton J. Society of Interventional Radiology Reporting Standards for Thoracic Central Vein Obstruction: Endorsed by the American Society of Diagnostic and Interventional Nephrology (ASDIN), British Society of Interventional Radiology (BSIR), Canadian Interventional Radiology Association (CIRA), Heart Rhythm Society (HRS), Indian Society of Vascular and Interventional Radiology (ISVIR), Vascular Access Society of the Americas (VASA), and Vascular Access Society of Britain and Ireland (VASBI). J Vasc Access 2018; 20:114-122. [DOI: 10.1177/1129729818791409] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Bart L Dolmatch
- Department of Interventional Radiology, Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - John C Gurley
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Kevin M Baskin
- Department of Radiology, Advanced Interventional Institute, Pittsburgh, PA, USA
| | - Boris Nikolic
- Department of Radiology, Stratton Medical Center, Albany, NY, USA
| | - Jeffrey H Lawson
- Division of Vascular and Endovascular Surgery, Duke University, Durham, NC, USA
| | - Surendra Shenoy
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Theodore F Saad
- Department of Radiology, St. Francis Hospital, Nephrology Associates, Wilmington, DE, USA
| | - Ingemar Davidson
- Department of Radiology, Tulane University, New Orleans, LA, USA
| | - Mark O Baerlocher
- Department of Interventional Radiology, Royal Victoria Hospital, Barrie, ON, Canada
| | - Emil I Cohen
- Department of Radiology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sean R Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University School of Medicine, GA, USA
| | - Salomão Faintuch
- Division of Interventional Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Thomas B Kinney
- Department of Radiology, University of California, San Diego Medical Center, San Diego, CA, USA
| | - Mehran Midia
- Department of Interventional Radiology, McMaster University, Hamilton, ON, Canada
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17
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The association of venous thromboembolism with survival in pediatric cancer patients: a population-based cohort study. Ann Hematol 2018; 97:1903-1908. [PMID: 29846760 DOI: 10.1007/s00277-018-3371-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/08/2018] [Indexed: 01/19/2023]
Abstract
Venous thromboembolism (VTE) is a well-recognized complication in pediatric oncology patients. Studies in adult oncology patients have suggested a potential negative association between VTE and survival, but this association has not been examined in pediatric patients yet. The aim of this study was to assess the association of VTE with survival in pediatric oncology patients. Data from all pediatric oncology patients treated at the two tertiary care centers in Atlantic Canada were pooled to create a population-based cohort. The association between VTE and survival was analyzed using a Cox proportional hazards model stratified by diagnosis group (leukemia, lymphoma, and other; sarcoma) and adjusted for age at diagnosis and sex. Out of 939 patients included in this study, 73 had a VTE (8%) and 131 (14%) patients died during the study period. Children in the leukemia/lymphoma/other group with a VTE had significantly poorer survival relative to children in the same group who did not have a VTE. Although children with sarcoma and VTE had poorer survival compared to children with sarcoma with no VTE, this association was not statistically significant. In this population-based study, we found a negative association between VTE and survival in pediatric oncology patients. If future studies confirm this association, this finding may have prognostic implications and potentially offer new avenues for the management of pediatric patients with cancer.
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18
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Dolmatch BL, Gurley JC, Baskin KM, Nikolic B, Lawson JH, Shenoy S, Saad TF, Davidson I, Baerlocher MO, Cohen EI, Dariushnia SR, Faintuch S, Janne d’Othee B, Kinney TB, Midia M, Clifton J, Baerlocher MO, Baskin K, Clifton J, Dalley A, Dariushnia S, Davidson I, Dolmatch B, Gurley J, Haskal Z, Journeycake J, Lawson J, McLennan G, Nikolic B, Ramsburg D, Ross J, Saad T, Shenoy S, Spencer B, Thompson D, Walker TG, Walser E. Society of Interventional Radiology Reporting Standards for Thoracic Central Vein Obstruction. J Vasc Interv Radiol 2018; 29:454-460.e3. [DOI: 10.1016/j.jvir.2017.12.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 12/14/2017] [Accepted: 12/14/2017] [Indexed: 10/17/2022] Open
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19
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Celkan T, Dikme G. Thrombosis in children: Which test to whom, when and how much necessary? Turk Arch Pediatr 2018; 53:1-9. [PMID: 30083068 DOI: 10.5152/turkpediatriars.2018.2586] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/24/2017] [Indexed: 11/22/2022]
Abstract
Pediatric thrombosis is multifactorial, and usually risk factors either congenital or acquired are present. After 2000, systematic reviews and meta-analysis on pediatric venous thromboembolic disease and inherited thrombophilia revealed elevated thrombotic risks in these children. In this review, we discuss thrombosis and new literature in various pediatric patient groups and the usefulness of thrombophilia testing.
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Affiliation(s)
- Tiraje Celkan
- İstanbul University Cerrahpaşa Medical Faculty, Department of Pediatrics, Division of Pediatric Hematology-Oncology, Istanbul, Turkey
| | - Gürcan Dikme
- İstanbul University Cerrahpaşa Medical Faculty, Department of Pediatrics, Division of Pediatric Hematology-Oncology, Istanbul, Turkey
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20
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Sibson KR, Biss TT, Furness CL, Grainger JD, Hough RE, Macartney C, Payne JH, Chalmers EA. BSH Guideline: management of thrombotic and haemostatic issues in paediatric malignancy. Br J Haematol 2018; 180:511-525. [DOI: 10.1111/bjh.15112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/28/2017] [Accepted: 11/07/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Keith R. Sibson
- Department of Haematology; Great Ormond Street Hospital; London UK
| | - Tina T. Biss
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust; Newcastle Upon Tyne UK
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21
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Acord M, Cahill AM, Krishnamurthy G, Vatsky S, Keller M, Srinivasan A. Venous Ports in Infants. J Vasc Interv Radiol 2018; 29:492-496. [PMID: 29352697 DOI: 10.1016/j.jvir.2017.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/25/2017] [Accepted: 10/15/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To evaluate technical success and the incidences of, and risk factors for, mechanical and infectious complications of venous port placement in infants. MATERIALS AND METHODS This was a retrospective single-institution cohort study of port placement in infants (age < 1 y) from January 2006 through June 2016 (mean age, 7.5 mo ± 3.3; mean weight, 8.1 kg ± 1.9). Age, weight, sex, side of placement, tip position, and indication for placement (chemotherapy vs other) were recorded. Total catheter-days (CDs), mechanical complications, and central catheter-associated bloodstream infections (CCABSIs) were identified. RESULTS During the study years, 64 ports were placed in 64 infants, with a technical success rate of 100%. The mean catheter life was 321 days (total range, 4-1,917 d; interquartile range [IQR], 107-421 d). There were 13 CCABSI events (0.63 per 1,000 CDs); of these, 8 (12.5% among 64 patients) required port removal for infection. There was an increase in CCABSIs in patients with left-sided port placement (relative risk [RR], 3.22; 95% confidence interval [CI], 1.02-10.14; P = .05). There were 8 mechanical complications of the port reservoir or catheter (0.39 per 1,000 CDs). Of these, 2 (3.1%) required removal. Patients in the lowest weight quartile were at an increased risk of mechanical complications (RR, 4.37; 95% CI, 1.09-17.48; P = .04). CONCLUSIONS Venous ports can be placed with a high rate of technical success in infants. Left-sided ports and low weight are associated with increased infectious and mechanical complications, respectively.
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Affiliation(s)
- Michael Acord
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19014.
| | - Anne Marie Cahill
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19014
| | - Ganesh Krishnamurthy
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19014
| | - Seth Vatsky
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19014
| | - Marc Keller
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19014
| | - Abhay Srinivasan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19014
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22
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Theron A, Biron-Andreani C, Haouy S, Saumet L, Saguintah M, Jeziorski E, Sirvent N. [Thromboembolic disease in pediatric oncology]. Arch Pediatr 2018; 25:139-144. [PMID: 29325825 DOI: 10.1016/j.arcped.2017.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 08/20/2017] [Accepted: 10/26/2017] [Indexed: 11/30/2022]
Abstract
The survival rate of children with cancer is now close to 80 %, as a result of continuous improvement in diagnostic and treatment procedures. Prevention and treatment of treatment-associated complications is now a major challenge. Thromboembolic venous disease, due to multifactorial pathogenesis, is a frequent complication (up to 40 % asymptomatic thrombosis in children with cancer), responsible for significant morbidity. Predominantly in children with acute lymphoblastic leukemia, lymphoma, or sarcoma, thromboembolic disease justifies primary prophylaxis in certain populations at risk, whether genetic or environmental. The curative treatment, well codified, is based on the administration of low-molecular-weight heparin. In the absence of robust pediatric prospective studies, this article proposes a concise decision tree summarizing the preventive and curative strategy.
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Affiliation(s)
- A Theron
- Département d'onco-hématologie pédiatrique, CHU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France; Département d'hématologie biologie, centre régional de traitement de l'hémophilie, CHU de Montpellier, 80, avenue Augustin-Fliche, 34090 Montpellier, France.
| | - C Biron-Andreani
- Département d'hématologie biologie, centre régional de traitement de l'hémophilie, CHU de Montpellier, 80, avenue Augustin-Fliche, 34090 Montpellier, France
| | - S Haouy
- Département d'onco-hématologie pédiatrique, CHU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - L Saumet
- Département d'onco-hématologie pédiatrique, CHU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - M Saguintah
- Département de radiologie pédiatrique, CHRU de Montpellier, 371, avenue du Doyen-Gaston Giraud, 34090 Montpellier, France
| | - E Jeziorski
- Département de pédiatrie générale, CHU de Montpellier, 371, avenue du Doyen-Gaston Giraud, 34090 Montpellier, France
| | - N Sirvent
- Département d'onco-hématologie pédiatrique, CHU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
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23
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Baumann Kreuziger L, Jaffray J, Carrier M. Epidemiology, diagnosis, prevention and treatment of catheter-related thrombosis in children and adults. Thromb Res 2017; 157:64-71. [DOI: 10.1016/j.thromres.2017.07.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 06/09/2017] [Accepted: 07/03/2017] [Indexed: 12/21/2022]
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24
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van Ommen CH, Nowak-Göttl U. Inherited Thrombophilia in Pediatric Venous Thromboembolic Disease: Why and Who to Test. Front Pediatr 2017; 5:50. [PMID: 28352625 PMCID: PMC5348488 DOI: 10.3389/fped.2017.00050] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/27/2017] [Indexed: 11/16/2022] Open
Abstract
Venous thromboembolic disease in childhood is a multifactorial disease. Risk factors include acquired clinical risk factors such as a central venous catheter and underlying disease and inherited thrombophilia. Inherited thrombophilia is defined as a genetically determined tendency to develop venous thromboembolism. In contrast to adults, acquired clinical risk factors play a larger role than inherited thrombophilia in the development of thrombotic disease in children. The contributing role of inherited thrombophilia is not clear in many pediatric thrombotic events, especially catheter-related thrombosis. Furthermore, identification of inherited thrombophilia will not often influence acute management of the thrombotic event as well as the duration of anticoagulation. In some patients, however, detection of inherited thrombophilia may lead to identification of other family members who can be counseled for their thrombotic risk. This article discusses the potential arguments for testing of inherited thrombophilia, including factor V Leiden mutation, prothrombin mutation, and deficiencies of antithrombin, protein C, or protein S and suggests some patient groups in childhood, which may be tested.
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Affiliation(s)
- C Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital Erasmus MC , Rotterdam , Netherlands
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Department of Clinical Chemistry, University Hospital of Kiel and Lübeck , Kiel , Germany
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25
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Jaffray J, Bauman M, Massicotte P. The Impact of Central Venous Catheters on Pediatric Venous Thromboembolism. Front Pediatr 2017; 5:5. [PMID: 28168186 PMCID: PMC5253371 DOI: 10.3389/fped.2017.00005] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/09/2017] [Indexed: 12/12/2022] Open
Abstract
The use of central venous catheters (CVCs) in children is escalating, which is likely linked to the increased incidence of pediatric venous thromboembolism (VTE). In order to better understand the specific risk factors associated with CVC-VTE in children, as well as available prevention methods, a literature review was performed. The overall incidence of CVC-VTE was found to range from 0 to 74%, depending on the patient population, CVC type, imaging modality, and study design. Throughout the available literature, there was not a consistent determination regarding whether a particular type of central line (tunneled vs. non-tunneled vs. peripherally inserted vs. implanted), catheter material, insertion technique, or insertion location lead to an increased VTE risk. The patient populations who were found to be most at risk for CVC-VTE were those with cancer, congenital heart disease, gastrointestinal failure, systemic infection, intensive care unit admission, or involved in a trauma. Both mechanical and pharmacological prophylactic techniques have been shown to be successful in preventing VTE in adult patients, but studies in children have yet to be performed or are underpowered. In order to better determine true CVC-VTE risk factors and best preventative techniques, an increase in large, prospective pediatric trials needs to be performed.
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Affiliation(s)
- Julie Jaffray
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine , Los Angeles, CA , USA
| | - Mary Bauman
- University of Alberta, Stollery Children's Hospital , Edmonton, AB , Canada
| | - Patti Massicotte
- University of Alberta, Stollery Children's Hospital , Edmonton, AB , Canada
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26
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Wasserman RL. The Nuts and Bolts of Immunoglobulin Treatment for Antibody Deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:1076-1081.e3. [DOI: 10.1016/j.jaip.2016.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/14/2016] [Accepted: 09/21/2016] [Indexed: 01/09/2023]
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Neshat-Vahid S, Pierce R, Hersey D, Raffini LJ, Faustino EVS. Association of thrombophilia and catheter-associated thrombosis in children: a systematic review and meta-analysis. J Thromb Haemost 2016; 14:1749-58. [PMID: 27306795 PMCID: PMC5035642 DOI: 10.1111/jth.13388] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Indexed: 12/17/2022]
Abstract
UNLABELLED Essentials It is unclear if thrombophilia increases the risk of catheter-associated thrombosis in children. We conducted a meta-analysis on thrombophilia and pediatric catheter-associated thrombosis. Presence of ≥1 trait confers additional risk of venous thrombosis in children with catheters. Limitations of included studies preclude us from recommending routine thrombophilia testing. SUMMARY Background The association between thrombophilia and deep vein thrombosis (DVT) associated with central venous catheter (CVC) use, the most important pediatric risk factor for thrombosis, is unclear in children. Pediatric studies with small sample sizes have reported conflicting results. We sought to evaluate whether, among children with CVCs, thrombophilia increases the risk of CVC-associated DVT (CADVT). Materials and methods We systematically searched MEDLINE, EMBASE, the Web of Science, the Cochrane Central Register for Controlled Trials, PubMed and reference lists for controlled studies published from the inception of the database until September 2015. Included were studies of children aged <21 years with CVCs who were systematically tested for thrombophilic traits that are commonly screened for in clinical practice. Pooled prevalence rates and pooled odds ratios (pORs) of CADVT with thrombophilia were estimated by use of a random effects model. Results We analyzed 16 cohort studies with 1279 children, 277 of whom had CADVT, and with 12 traits tested. There was significant heterogeneity in the included studies. The presence of one or more traits was associated with CADVT (pOR 3.20; 95% confidence interval [CI] 1.56-6.54). Although the prevalence of most traits was < 0.10, children with protein C deficiency, elevated factor VIII levels and the FV Leiden mutation had an increased prevalence of CADVT. The association with thrombophilia seemed to be stronger for symptomatic CADVT (pOR 6.71; 95% CI 1.93-23.37) than for asymptomatic CADVT (pOR 2.14; 95% CI 1.10-4.18). Conclusions On the basis of the low prevalence of specific traits, the relatively weak association with CADVT, and the limitations of the included studies, we cannot recommend routine testing of thrombophilias in children with CADVT.
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Affiliation(s)
- S Neshat-Vahid
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - R Pierce
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - D Hersey
- Medical Library, Yale School of Medicine, New Haven, CT, USA
| | - L J Raffini
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - E V S Faustino
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA.
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28
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Cousin VL, Wildhaber BE, Verolet CM, Belli DC, Posfay-Barbe KM, McLin VA. Complications of indwelling central venous catheters in pediatric liver transplant recipients. Pediatr Transplant 2016; 20:798-806. [PMID: 27346183 DOI: 10.1111/petr.12745] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2016] [Indexed: 11/30/2022]
Abstract
In pLT recipients, the advantages of ICVCs need to be weighed against the risk of complications. This single-center retrospective study aimed to review ICVC complications in our cohort of pLT recipients. We performed chart reviews of pLT patients having undergone transplant between 01/2000 and 03/2014 and who underwent ICVC placement either before or after LT. We identified 100 ICVC in 85 patients. Overall observation time was 90 470 catheter-days. There was no difference in catheter lifespan between those inserted pre- or post-transplant; 46% of ICVC presented a complication. Most frequent complications were MD and infection. The infection rate was 0.09 per 1000 catheter-days, and MD rate was 0.36 per 1000 catheter-days. Patients having received technical variant grafts were more at risk of complications. To the best of our knowledge, this is the first study examining ICVC complications in pLT recipients. We conclude that ICVC have a high rate of MD. Children receiving technical variants may be more at risk of complications. By removing ICVC in a select number of patients at six months post-insertion, we might avoid as much as 60% of complications.
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Affiliation(s)
- Vladimir L Cousin
- Pediatric Gastroenterology Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Barbara E Wildhaber
- Division of Pediatric Surgery, University Hospitals Geneva, Geneva, Switzerland
| | | | - Dominique C Belli
- Pediatric Gastroenterology Unit, University Hospitals Geneva, Geneva, Switzerland.,Department of Pediatrics, University Hospitals Geneva, Geneva, Switzerland
| | | | - Valérie A McLin
- Pediatric Gastroenterology Unit, University Hospitals Geneva, Geneva, Switzerland
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Schoot RA, van de Wetering MD, Stijnen T, Tissing WJE, Michiels E, Abbink FCH, Raphael MF, Heij HA, Zwaan M, Lieverst JA, Caron HN, van Ommen H. Prevalence of Symptomatic and Asymptomatic Thrombosis in Pediatric Oncology Patients With Tunneled Central Venous Catheters. Pediatr Blood Cancer 2016; 63:1438-44. [PMID: 27128820 DOI: 10.1002/pbc.26036] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 04/01/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pediatric oncology patients with tunneled central venous catheters (CVCs) are at increased risk to develop venous thromboembolic events (VTEs), but the true prevalence of (a)symptomatic VTE is unknown. Aim of this study was to evaluate the prevalence of (a)symptomatic VTE in pediatric oncology patients with tunneled CVCs. PROCEDURE All patients were included in the Aristocaths study: a randomized controlled multicenter trial investigating the prophylactic effect of 70% ethanol locks on CVC-associated bloodstream infections (CABSIs) were eligible for this study. We assessed the following outcomes: (i) symptomatic VTE and (ii) asymptomatic CVC-related VTE (using ultrasound [US]). Follow-up was 6 months, unless patients developed one of the following events: VTE, CABSI, CVC removal, or death. RESULTS We included 305 patients (hematologic malignancy, n = 148; solid tumor, n = 157), median age 9 years (range, 1-18 years). Symptomatic VTE was detected in 8 of 305 patients (2.6%; 95% confidence interval [CI]: 1.1-5.1%), which was related to the CVC in three patients. Patients (185/305) were evaluated with US: 11 of 185 (5.9%; 95% CI: 3.0-10.4%) patients had asymptomatic CVC-related VTE. CONCLUSIONS Prevalence of both symptomatic VTE and asymptomatic CVC-related VTE was low compared to other studies, which may be explained by the inclusion of patients with solid tumors, reduction of CABSI by ethanol, use of tunneled CVCs, and use of US.
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Affiliation(s)
- Reineke A Schoot
- Department of Pediatric Oncology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Marianne D van de Wetering
- Department of Pediatric Oncology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Theo Stijnen
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Wim J E Tissing
- Department of Pediatric Oncology, Beatrix Children's Hospital, University of Groningen, Groningen, The Netherlands
| | - Erna Michiels
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Floor C H Abbink
- Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Martine F Raphael
- Department of Pediatric Oncology/Hematology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Hugo A Heij
- Pediatric Surgical Center Amsterdam, Academic Medical Center & VU University Medical Center, Amsterdam, The Netherlands
| | - Michel Zwaan
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jan A Lieverst
- Dutch Childhood Oncology Group, The Hague, The Netherlands
| | - Hubert N Caron
- Department of Pediatric Oncology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Heleen van Ommen
- Department of Pediatric Hematology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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Concepcion NDP, Laya BF, Lee EY. Current updates in catheters, tubes and drains in the pediatric chest: A practical evaluation approach. Eur J Radiol 2016; 95:409-417. [PMID: 27377573 DOI: 10.1016/j.ejrad.2016.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/20/2016] [Indexed: 12/31/2022]
Abstract
Chest radiographs are very helpful tool not only in the evaluation of respiratory and/or cardiac pathologies, but also to help clinicians in the assessment of various tubes and catheters inserted in pediatric patients. This review article focuses on the indications, contraindications, ideal locations of the tips of these tubes and catheters, as well as the consequences of malpositioning. Clinical outcomes of pediatric patients can be affected by the placement of these medical devices. The radiologist therefore has a critical role in detecting and relaying such malpositioned devices for prompt revisions or removal.
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Affiliation(s)
- Nathan David P Concepcion
- Institute of Radiology, St. Luke's Medical Center, 32(nd) Avenue corner 5(th) Street, Bonifacio Global City, Taguig City 1634, Philippines.
| | - Bernard F Laya
- Institute of Radiology, St. Luke's Medical Center, 32(nd) Avenue corner 5(th) Street, Bonifacio Global City, Taguig City 1634, Philippines.
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
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Venous Thromboembolic Disease in Children and Adolescents. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:149-165. [DOI: 10.1007/5584_2016_113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Ullman AJ, Marsh N, Mihala G, Cooke M, Rickard CM. Complications of Central Venous Access Devices: A Systematic Review. Pediatrics 2015; 136:e1331-44. [PMID: 26459655 DOI: 10.1542/peds.2015-1507] [Citation(s) in RCA: 193] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 11/24/2022] Open
Abstract
CONTEXT The failure and complications of central venous access devices (CVADs) result in interrupted medical treatment, morbidity, and mortality for the patient. The resulting insertion of a new CVAD further contributes to risk and consumes extra resources. OBJECTIVE To systematically review existing evidence of the incidence of CVAD failure and complications across CVAD types within pediatrics. DATA SOURCES Central Register of Controlled Trials, PubMed, and Cumulative Index to Nursing and Allied Health databases were systematically searched up to January 2015. STUDY SELECTION Included studies were of cohort design and examined the incidence of CVAD failure and complications across CVAD type in pediatrics within the last 10 years. CVAD failure was defined as CVAD loss of function before the completion of necessary treatment, and complications were defined as CVAD-associated bloodstream infection, CVAD local infection, dislodgement, occlusion, thrombosis, and breakage. DATA EXTRACTION Data were independently extracted and critiqued for quality by 2 authors. RESULTS Seventy-four cohort studies met the inclusion criteria, with mixed quality of reporting and methods. Overall, 25% of CVADs failed before completion of therapy (95% confidence interval [CI] 20.9%-29.2%) at a rate of 1.97 per 1000 catheter days (95% CI 1.71-2.23). The failure per CVAD device was highest proportionally in hemodialysis catheters (46.4% [95% CI 29.6%-63.6%]) and per 1000 catheter days in umbilical catheters (28.6 per 1000 catheter days [95% CI 17.4-39.8]). Totally implanted devices had the lowest rate of failure per 1000 catheter days (0.15 [95% CI 0.09-0.20]). LIMITATIONS The inclusion of nonrandomized and noncomparator studies may have affected the robustness of the research. CONCLUSIONS CVAD failure and complications in pediatrics are a significant burden on the health care system internationally.
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Affiliation(s)
- Amanda J Ullman
- School of Nursing and Midwifery, and National Health and Medical Research Council, Centre of Research Excellence in Nursing, and Centre for Health Practice Innovation, Alliance for Vascular Access Teaching and Research Group, and
| | - Nicole Marsh
- National Health and Medical Research Council, Centre of Research Excellence in Nursing, and Centre for Health Practice Innovation, Alliance for Vascular Access Teaching and Research Group, and Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Gabor Mihala
- Alliance for Vascular Access Teaching and Research Group, and School of Medicine, Griffith University, Queensland, Australia; Centre for Applied Health Economics, Menzies Health Institute, Queensland, Australia; and
| | - Marie Cooke
- School of Nursing and Midwifery, and National Health and Medical Research Council, Centre of Research Excellence in Nursing, and Centre for Health Practice Innovation, Alliance for Vascular Access Teaching and Research Group, and
| | - Claire M Rickard
- School of Nursing and Midwifery, and National Health and Medical Research Council, Centre of Research Excellence in Nursing, and Centre for Health Practice Innovation, Alliance for Vascular Access Teaching and Research Group, and
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Radulescu VC. Management of venous thrombosis in the pediatric patient. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2015; 6:111-119. [PMID: 29388593 PMCID: PMC5683259 DOI: 10.2147/phmt.s65697] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The incidence of venous thromboembolism in children has increased significantly over the past decade. The evaluation and management of the child with venous thromboembolism, while based on the adult experience, has its own particularities dictated by the differences in the hemostatic system of the newborn and child. The current review addresses the evaluation of pediatric patient with thrombosis as well as the established and emerging treatment interventions.
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Affiliation(s)
- Vlad C Radulescu
- Department of Pediatrics, University of Kentucky, Lexington, KY, USA
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Abstract
Abstract
The etiology of pediatric venous thromboembolic disease (VTE) is multifactorial, and in most children, 1 or more clinical risk factors are present. In addition, inherited thrombophilic disorders contribute to the development of pediatric VTE. In this review, the role of inherited thrombophilic disorders in the development of pediatric VTE, as well as the benefits and limitations of thrombophilia testing, will be discussed.
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Gonzales F, Abou Chahla W, Pagniez J, Nelken B. [Superior vena cava thrombosis in patients with mediastinal large B-cell lymphoma: two pediatric cases]. Arch Pediatr 2014; 22:66-70. [PMID: 25267192 DOI: 10.1016/j.arcped.2014.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/20/2014] [Indexed: 11/26/2022]
Abstract
We report two pediatric cases of superior vena cava thrombosis (VTE) in patients treated for primary mediastinal large B-cell lymphoma (PMBCL). PMBCL is a rare entity in children and adolescents and no thrombosis has been described in this population. Thrombosis in lymphoma is frequently asymptomatic, detected as an incidental finding in the first months following diagnosis. The thrombosis mechanisms are often multifactorial based on veinous compression by the mass, elevated risk of thrombosis in neoplasia, and/or presence of a central catheter. The risk factors of venous thromboembolism (VTE) in lymphoma are high-grade lymphoma, comorbidities, central nervous system lymphoma, and mediastinal mass. Because thrombosis has an impact on prognosis and treatment, it seems important to improve knowledge in order to improve the diagnosis and prevention of thrombosis in lymphoma.
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Affiliation(s)
- F Gonzales
- Université Lille Nord de France, 59000 Lille, France; Unité d'hématologie pédiatrique, CHU de Lille, 59000 Lille, France.
| | - W Abou Chahla
- Université Lille Nord de France, 59000 Lille, France; Unité d'hématologie pédiatrique, CHU de Lille, 59000 Lille, France
| | - J Pagniez
- Service de radiologie thoracique, CHU de Lille, 59000 Lille, France
| | - B Nelken
- Unité d'hématologie pédiatrique, CHU de Lille, 59000 Lille, France
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Wiegering V, Schmid S, Andres O, Wirth C, Wiegering A, Meyer T, Winkler B, Schlegel PG, Eyrich M. Thrombosis as a complication of central venous access in pediatric patients with malignancies: a 5-year single-center experience. BMC HEMATOLOGY 2014; 14:18. [PMID: 25317335 PMCID: PMC4195887 DOI: 10.1186/2052-1839-14-18] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 09/22/2014] [Indexed: 12/23/2022]
Abstract
Background Reliable central venous access (CVC) is essential for hematology–oncology patients since frequent puncture of peripheral veins—e.g., for chemotherapy, antibiotic administration, repeated blood sampling, and monitoring—can cause unacceptable pain and psychological trauma, as well as severe side effects in cases of extravasation of chemotherapy drugs. However, CVC lines still carry major risk factors, including thrombosis, infection (e.g., entry site, tunnel, and luminal infections), and catheter dislocation, leakage, or breakage. Methods Here we performed a retrospective database analysis to determine the incidence of CVC-associated thrombosis in a single-center cohort of 448 pediatric oncologic patients, and to analyze whether any subgroup of patients was at increased risk and thus might benefit from prophylactic anticoagulation. Results Of the 448 patients, 269 consecutive patients received a CVC, and 55 of these 269 patients (20%) also had a thrombosis. Of these 55 patients, 43 had at least one CVC-associated thrombosis (total number of CVC-associated thrombosis: n = 52). Among all patients, the median duration of CVC exposure was 464 days. Regarding exposure time, no significant difference was found between patients with and without CVC-associated thrombosis. Subclavia catheters and advanced tumor stages seem to be the main risk factors for the development of CVC-associated thrombosis, whereas pharmacologic prophylaxis did not seem to have a relevant impact on the rate of thrombosis. Conclusions We conclude that pediatric surgeons and oncologists should pay close attention to ensuring optimal and accurate CVC placement, as this appears the most effective tool to minimize CVC-associated complications.
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Affiliation(s)
- Verena Wiegering
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, University Children's Hospital, D31, Josef-Schneider-Straße 2, D-97080 Würzburg, Germany
| | - Sophie Schmid
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, University Children's Hospital, D31, Josef-Schneider-Straße 2, D-97080 Würzburg, Germany
| | - Oliver Andres
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, University Children's Hospital, D31, Josef-Schneider-Straße 2, D-97080 Würzburg, Germany
| | - Clemens Wirth
- Division of Pediatric Radiology, University Department of Radiology, Würzburg, Germany
| | - Armin Wiegering
- Division of Pediatric Surgery, University Medical Center ZOM, Würzburg, Germany
| | - Thomas Meyer
- Division of Pediatric Surgery, University Medical Center ZOM, Würzburg, Germany
| | - Beate Winkler
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, University Children's Hospital, D31, Josef-Schneider-Straße 2, D-97080 Würzburg, Germany
| | - Paul G Schlegel
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, University Children's Hospital, D31, Josef-Schneider-Straße 2, D-97080 Würzburg, Germany
| | - Matthias Eyrich
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, University Children's Hospital, D31, Josef-Schneider-Straße 2, D-97080 Würzburg, Germany
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Vidal E, Sharathkumar A, Glover J, Faustino EVS. Central venous catheter-related thrombosis and thromboprophylaxis in children: a systematic review and meta-analysis. J Thromb Haemost 2014; 12:1096-109. [PMID: 24801495 PMCID: PMC4107177 DOI: 10.1111/jth.12598] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 04/29/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVES In preparation for a pediatric randomized controlled trial on thromboprophylaxis, we determined the frequency of catheter-related thrombosis in children. We also systematically reviewed the pediatric trials on thromboprophylaxis to evaluate its efficacy and to identify possible pitfalls in the conduct of these trials. PATIENTS/METHODS We searched MEDLINE, EMBASE, Web of Science and the Cochrane Central Register for Controlled Trials for articles published until December 2013. We included cohort studies and trials on patients aged 0-18 years with central venous catheters who underwent active surveillance for thrombosis with radiologic imaging. We estimated the pooled frequency of thrombosis and the pooled risk ratio (RR) with thromboprophylaxis by using a random effects model. RESULTS From 2651 articles identified, we analyzed 37 articles with 3128 patients. The pooled frequency of thrombosis was 0.20 (95% confidence interval [CI] 0.16-0.24). In 10 trials, we did not find evidence that heparin-bonded catheters (RR 0.34; 95%CI 0.01-7.68), unfractionated heparin (RR 0.93; 95% CI 0.57-1.51), low molecular weight heparin (RR 1.13; 95% CI 0.51-2.50), warfarin (RR 0.85; 95%CI 0.34-2.17), antithrombin concentrate (RR 0.76; 95% CI 0.38-1.55) or nitroglycerin (RR 1.53; 95%CI 0.57-4.10) reduced the risk of thrombosis. Most of the trials were either not powered for thrombosis or were powered to detect large, probably unachievable, reductions in thrombosis. Missing data on thrombosis also limited these trials. CONCLUSIONS Catheter-related thrombosis is common in children. An adequately powered multicenter trial that can detect a modest, clinically significant reduction in thrombosis is critically needed. Missing outcome data should be minimized in this trial.
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Affiliation(s)
- E Vidal
- Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
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