Central venous thrombosis: an early and frequent complication in cancer patients bearing long-term silastic catheter. A prospective study

Factor XI Inhibition for the Prevention of Catheter-Associated Thrombosis in Patients With Cancer Undergoing Central Line Placement: A Phase 2 Clinical Trial

BACKGROUND

Despite the ubiquitous utilization of central venous catheters in clinical practice, their use commonly provokes thromboembolism. No prophylactic strategy has shown sufficient efficacy to justify routine use. Coagulation factors FXI (factor XI) and FXII (factor XII) represent novel targets for device-associated thrombosis, which may mitigate bleeding risk. Our objective was to evaluate the safety and efficacy of an anti-FXI mAb (monoclonal antibody), gruticibart (AB023), in a prospective, single-arm study of patients with cancer receiving central line placement.

METHODS

We enrolled ambulatory cancer patients undergoing central line placement to receive a single dose of gruticibart (2 mg/kg) administered through the venous catheter within 24 hours of placement and a follow-up surveillance ultrasound at day 14 for evaluation of catheter thrombosis. A parallel, noninterventional study was used as a comparator.

RESULTS

In total, 22 subjects (n=11 per study) were enrolled. The overall incidence of catheter-associated thrombosis was 12.5% in the interventional study and 40.0% in the control study. The anti-FXI mAb, gruticibart, significantly prolonged the activated partial thromboplastin time in all subjects on day 14 compared with baseline (P<0.001). Gruticibart was well tolerated and without infusion reactions, drug-related adverse events, or clinically relevant bleeding. Platelet flow cytometry demonstrated no difference in platelet activation following administration of gruticibart. T (thrombin)-AT (antithrombin) and activated FXI-AT complexes increased following central line placement in the control study, which was not demonstrated in our intervention study. CRP (C-reactive protein) did not significantly increase on day 14 in those who received gruticibart, but it did significantly increase in the noninterventional study.

CONCLUSIONS

FXI inhibition with gruticibart was well tolerated without any significant adverse or bleeding-related events and resulted in a lower incidence of catheter-associated thrombosis on surveillance ultrasound compared with the published literature and our internal control study. These findings suggest that targeting FXI could represent a safe intervention to prevent catheter thrombosis.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04465760.

Dual ultrasound-guided totally implantable venous access ports via the right internal jugular vein in pediatric patients with cancer: a preliminary experience in a single institution

Objective

To assess the efficacy and safety of dual ultrasound-guided (DUG) totally implantable venous access port (TIVAP) implantation (namely, using ultrasound-guided percutaneous puncture with transesophageal echocardiography-guided catheterization) via the right internal jugular vein (IJV) in pediatric patients with cancer.

Methods

Fifty-five children with cancer requiring chemotherapy underwent DUG-TIVAP implantation via the right IJV. Clinical data were recorded, including the procedure success rate, first attempt success rate, and perioperative and postoperative complications.

Results

All 55 cases were successfully operated on. The first puncture success rate was 100%. The operation time was 22-41 min, with a mean time of 30.8±5.5 min. The mean TIVAP implantation time was 253±145 days (range 42-520 days). There were no perioperative complications. The postoperative complication rate was 5.4% (3/55), including skin infections around the port in one case, catheter-related infection in one case, and fibrin sheath formation in one case. The ports were all preserved after anti-infection or thrombolytic therapy. No unplanned port withdrawal was recorded in this study.

Conclusions

DUG-TIVAP implantation is a technique with a high success rate and a low complication rate; therefore, it provides an alternative for children with cancer. Further randomized controlled studies are needed to confirm the efficacy and safety of DUG-TIVAP via the right IJV in children.

Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit

Deep vein thrombosis (DVT) is a preventable complication of critical illness, and this guideline aims to convey a pragmatic approach to the problem. Guidelines have multiplied over the last decade, and their utility has become increasingly conflicted as the reader interprets all suggestions or recommendations as something that must be followed. The nuances of grade of recommendation vs level of evidence are often ignored, and the difference between a "we suggest" vs a "we recommend" is overlooked. There is a general unease among clinicians that failure to follow the guidelines translates to poor medical practice and legal culpability. We attempt to overcome these limitations by highlighting ambiguity when it occurs and refraining from dogmatic recommendations in the absence of robust evidence. Readers and practitioners may find the lack of specific recommendations unsatisfactory, but we believe that true ambiguity is better than inaccurate certainty. We have attempted to comply with the guidelines on how to create guidelines.1 And to overcome the poor compliance with these guidelines.2 Some observers have expressed concern that DVT prophylaxis guidelines may cause more harm than good.3 We have placed greater emphasis on large randomized controlled trials (RCTs) with clinical end point and de-emphasized RCTs with surrogate end points and also de-emphasized hypothesis generating studies (observational studies, small RCTs, and meta-analysis of these studies). We have de-emphasized RCTs in non-intensive care unit populations like postoperative patients or those with cancer and stroke. We have also considered resource limitation settings and have avoided recommending costly and poorly proven therapeutic options.

How to cite this article

Jagiasi BG, Chhallani AA, Dixit SB, Kumar R, Pandit RA, Govil D, et al. Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit. Indian J Crit Care Med 2022;26(S2):S51-S65.

Central venous catheters-related-thrombosis and risk factors in oncological patients: a retrospective evaluation of recent risk scores

BACKGROUND

Insertions of central venous catheters (CVC) has become a common practice in Onco-Hematologic Units to administer systemic treatments. Unfortunately they can cause complications influencing patient's care-pathway significantly. Oncological patients have a higher thrombotic risk than the general population, therefore specific recent risk scores are spreading through the clinical practice, such as Khorana, Protecht, COMPASS-CAT, and Michigan scores.

METHODS

A retrospective cohort of 177 out of a total of 3046 outpatients accessing the Medical Day Hospital of Istituto Nazionale Tumori di Milano from March 2019 to February 2021 aged ⩾ 18 years who developed CVC complications was analyzed extracting clinical data from their medical records. Focusing on the risk factors, especially through recent risk scores to estimate the thrombotic risk we used Wilcoxon-test for continuous variables and the Pearson-Chi-Square test for categorical variables.

RESULTS

Anticoagulants resulted a protective factor mostly for partial CVC occlusion (p = 0.0001), preventing CVC occlusions. CVC occlusions were significantly associated with epitelial tumor histotype, (p = 0.0061). Complete CVC occlusions were significantly associated with peripherical inserted central venous catheters (PICC) (p < 0.0001). Catheter-related-thrombosis (CRT) was significantly associated with peripherical-inserted-central-venous-catheter, both when it was diagnosed clinically (p = 0.0121) and radiographically (p = 0.0168).There was a strong association between CRT and a high grade of Khorana Score (p = 0.0195), Protecht Score (p = 0.0412), COMPASS-CAT Score (p = 0.0027). A positive statistical trend was observed between the Michigan Score and CRT in patients carrying PICC (p = 0.053).

CONCLUSIONS

There are many different and various factors associated with higher or lower risk of CVC thrombotic complications, so it could be useful to test the recent risk scores to estimate thrombotic risk in oncological patients in clinical practice.

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

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

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

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

Durability of tunneled catheters in children is associated with catheter tip depth: A single-center report

The aim of this study was to examine the impact of different catheter tip positions on catheter duration and dysfunction of tunneled catheters in children. Catheters were evaluated for place of insertion, time of insertion, catheter tip depth and position, duration of use, and reason for removal. The mean duration of implanted catheters with tips placed in cavo-atrial junction/right atrium was significantly longer with significantly lower percentage of complications than tips placed in superior vena cava. Only catheter tips placed in cavo-atrial junction/right atrium was a predictor of catheter functionality and survival. Shorter catheter survival in children with tunneled catheters is a consequence of a catheter tip depth proximal of CAJ and RA. Our results showed that the main factor responsible for better catheter functionality was not laterality but the depth of the catheter tip, which reduces need for future catheter insertions with increased catheter durability.

Saddle pulmonary embolism with fluorouracil: A case report

INTRODUCTION

As a single agent, fluorouracil has been documented to have a small but present chance of causing extravasation of the port when not properly administered. It has also been shown that cancer patients receiving chemotherapy are at increased risk of deep vein thrombosis, symptomatic or silent.

CASE REPORT

A 43-year-old male patient with stage III colon cancer receiving FOLFOX developed a saddle pulmonary embolism involving possible extravasation that was discovered following cycle 3 of chemotherapy. CT scan and lower extremity Doppler confirmed non-occlusive deep vein thrombosis along with saddle pulmonary embolism.Management and outcome: For acute management, patient underwent bilateral pulmonary artery thrombolysis. Following this, the patient was initiated on rivaroxaban indefinitely. The right subclavian port was removed, and a new port was placed in the left subclavian. Patient went on to receive three more cycles of chemotherapy.

DISCUSSION

Fluorouracil, an inflammitant, has been shown to have damaging potential, especially in terms of the integrity of the endothelium. Over time, this can lead to serious complications such as cardiotoxicity, including deep vein thrombosis formation. Based on how and when the thrombi were discovered, it is not possible to deduce whether the port, the 5-FU, extravasation or other factors were the precipitators of the formation of the thrombi. The combination of chemotherapy treatment along with CVC placement appears to have an additive risk to the formation of a thrombus. Practitioners should take caution when evaluating for extravasation and CVC integrity and note other potential differentials for causes, including deep vein thrombosis/saddle pulmonary embolism formation.

Methods of Hydration in Palliative Care Patients

A strong and often polarized debate has taken place during recent years concerning the consequences of dehydration in the terminally ill patient. When a patient has a severely restricted oral intake or is found to be dehydrated, the decision to administer fluids should be individualized and made on the basis of a careful assessment that considers problems related to dehydration, potential risks and benefits of fluid replacement, and patients’ and families’ wishes. This review discusses the assessment of hydration status in the terminal cancer patient and the options for fluid administration in the cases where evaluation of the patients’ condition has led to this indication. These include different modes of hypodermoclysis, intravenous hydration, use of the nasogastric route, and proctoclysis. Arguments for and against rehydration have been previously addressed by other authors and fall outside the scope of this review.

Unsuccessful removal of a totally implantable venous access port caused by thrombosis in the left brachiocephalic vein: A case report

RATIONALE

Thrombosis is a common complication associated with implantable venous access ports (IVAPs) and often results in loss of catheter function but is rarely associated with difficulty in IVAP removal.

PATIENT CONCERNS

A 53-year-old woman presented to the hospital due to difficulty in IVAP removal. The patient had been diagnosed with breast cancer and received modified radical mastectomy. After that, she underwent IVAP implantation. Four and half years later, the IVAP catheter had become stuck while the catheter remained unobstructed. The patient had no special chief complaints.

DIAGNOSIS

Postoperative breast cancer; difficulty in removal of IVAP (caused by thrombus in the left brachiocephalic vein).

INTERVENTIONS

We injected urokinase 5 ml 1000U/L into the catheter once a day for three days but failed to remove the IVAP. Vasography showed a thrombus in the left brachiocephalic vein. Removal of the thrombus would have been very dangerous, so we decided to leave both thrombus and catheter in the body and used heparin and warfarin as anticoagulants.

OUTCOMES

The general situation of the patient, followed-up for 20 months, was good and there was no psychological impact or other special chief complaints.

LESSONS

It is best to remove the IVAP in a timely manner once all treatments are finished.

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

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

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

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

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

INTRODUCTION

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

METHODS

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

FINDINGS

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

DISCUSSION

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

ACR Appropriateness Criteria® Radiologic Management of Central Venous Access

Obtaining central venous access is one of the most commonly performed procedures in hospital settings. Multiple devices such as peripherally inserted central venous catheters, tunneled central venous catheters (eg, Hohn catheter, Hickman catheter, C. R. Bard, Inc, Salt Lake City UT), and implantable ports are available for this purpose. The device selected for central venous access depends on the clinical indication, duration of the treatment, and associated comorbidities. It is important for health care providers to familiarize themselves with the types of central venous catheters available, including information about their indications, contraindications, and potential complications, especially the management of catheters in the setting of catheter-related bloodstream infections. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Vascular Screening Prior to Placement of Tunnelled and Cuffed Hemodialysis Catheters

Purpose

To demonstrate the importance of venous vascular screening before the placement of tunneled and cuffed hemodialysis catheters in patients requiring hemodialysis prior to placement and/or maturation of an arteriovenous fistula (AVF) or graft (AVG).

Methods

Between October 1998 and March 2000, all patients requiring hemodialysis access placement were prospectively evaluated with duplex ultrasound for status of upper extremity vessels and central veins prior to selection of a permanent access site. When interim tunneled and cuffed hemodialysis catheters were required, they were placed on the side contralateral to proposed AVF/AVG placement. No catheters were placed without initial vascular screening. The study group was compared to historical controls during a similar period (April 1997 through September 1998) when no vascular screening was performed.

Results

During the study period, 234 screening duplex ultrasound examinations were performed in 244 patients. Ten patients required no screening prior to access site placement. Overall, 353 catheters were placed, 243 (69%) on the right side and 110 (31%) on the left side. During the control period, 394 catheters were placed in 255 patients, 306 (78%) right-sided and 88 (22%) left-sided. The increase in left-sided catheters with ultrasound screening and careful planning for future access sites was significant (p<0.01).

Conclusion

Vascular-screening-directed catheter placement significantly alters the side of catheter placement when compared to a management protocol without prior screening. Such screening helps identify the side of permanent access placement, while directing interim catheters to the contralateral side such that central veins may be preserved for permanent access.

Home Parenteral Nutrition in Adult Patients With Chronic Intestinal Failure: Catheter-Related Complications Over 4 Decades at the Main Danish Tertiary Referral Center

BACKGROUND/AIMS

Catheter-related complications (CRCs) cause mortality and morbidity in patients dependent on parenteral support at home (HPN) due to intestinal failure (IF). This study describes the incidences of CRCs in an adult IF cohort over 40 years. It illustrates the evolution and consequences of CRCs, their association to demographic characteristics, and potential risk factors in an effort to provide the rationale for preventive precautions to the relevant patients with IF at risk.

METHODS

All patients with IF discharged with HPN from 1970-2010 were included. Patient and treatment characteristics were extracted from the Copenhagen IF database. The incidences were given per 1000 central venous catheter (CVC) days.

RESULTS

The 1715 CRCs occurred in 70% of the 508 patients with IF (56% of the 2191 CVCs). The incidence of catheter-related bloodstream infections (CRBSIs) was 1.43. Higher age, HPN administration by community home nurses, and prior CRBSIs significantly raised the hazard for CRBSIs. In the 1970s, catheters were generally replaced following CRBSIs, whereas catheter salvage was the norm in the 2000s. The incidences of mechanical complications, tunnel infections, and catheter-related venous thromboses were 0.80, 0.25, and 0.11, respectively. The overall CRC incidence was 2.58, decreasing the first 3 decades but peaking in the last (2.84). The deaths related to CRCs were low (0.018).

CONCLUSION

Even in an experienced IF center of excellence, the incidence of CRCs increased over the 4 decades. This increase could be explained by the expansion of the indication of HPN to a more elderly and frail patient population.

Diagnosis and management of upper extremity deep-vein thrombosis in adults

Upper extremity deep-vein thrombosis (UEDVT) is common and can cause important complications, including pulmonary embolism and post-thrombotic syndrome. An increase in the use of central venous catheters, particularly peripherally inserted central catheters has been associated with an increasing rate of disease. Accurate diagnosis is essential to guide management, but there are limitations to the available evidence for available diagnostic tests. Anticoagulation is the mainstay of therapy, but interventional treatments may be considered in select situations. The risk of UEDVT may be reduced by more careful selection of patients who receive central venous catheters and by use of smaller catheters. Herein we review the diagnosis, management and prevention of UEDVT. Due to paucity of research, some principles are drawn from studies of lower extremity DVT. We present a practical approach to diagnosing the patient with suspected deep-vein thrombosis of the upper extremity.

Right or left? Side selection for a totally implantable vascular access device: a randomised observational study

BACKGROUND

Totally implantable vascular access device (TIVAD)-related complications interfere in the anticancer treatment and increase medical expenses. We examined whether the implantation side of central line TIVADs is associated with the occurrence of thrombotic or occlusion events.

METHODS

We enrolled patients with cancer who required central line TIVADs and randomised them to receive the TIVAD implantation on either the left or right side. The primary endpoint was the occurrence of catheter-related thrombotic or occlusion events.

RESULTS

We randomised 240 patients, of which 235 received TIVAD implantation according to the protocol. In the per-protocol cohort, 117 and 118 patients received implantation on the left and right sides, respectively. Catheter-related thrombotic or occlusion events occurred in 9 (4%) patients, accounting for 0.065 events per 1000 catheter-days. Between the patients with left- and right-sided implantations, the occurrence rates (P=0.333) and the time from catheter implantation to the occurrence of thrombotic or occlusion events (P=0.328) were both similar. In the multivariate analysis, the side of implantation remained unassociated with the occurrence of thrombotic or occlusion events.

CONCLUSIONS

The side of central line TIVAD implantation was not associated with the occurrence of catheter-related thrombotic or occlusion events in patients with cancer.

Tip Position of Long-Term Central Venous Access Devices Used for Parenteral Nutrition

BACKGROUND

Venous thrombosis is a potential postplacement complication of a central venous access device (VAD). Improper catheter tip position is a predisposing factor, especially when the device is used to administer parenteral nutrition (PN). American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines recommend that a central VAD used for PN be placed with its tip in the superior vena cava (SVC) adjacent to the right atrium (RA). The purpose of this study is to determine the prevalence of improper central VAD tip position and factors associated with malpositioning.

METHODS

All adult patients with a longterm VAD (ie, tunneled central venous catheter, peripherally inserted central catheter [PICC], or implanted port) placed before the current admission who were scheduled to receive PN also received chest x-rays to evaluate position of the catheter tip. Position was determined by a staff radiologist. A catheter with its tip ranging from the middle third of the SVC to the RA was considered acceptable; a catheter with its tip in any other position was considered malpositioned. Subjects with multiple VADs or multiple evaluations for the same catheter had the first placement and last evaluation considered. A logistic regression analysis was used to study the univariable and multivariable associations of these factors with tip malposition.

RESULTS

Data were collected for catheters in 124 patients, including 74 tunneled catheters (71 Hickman, 2 Broviac, 1 Groshong), 38 PICCs, and implanted ports. Most of the catheters were placed for (81.9%) or chemotherapy (14.5%). Median catheter duration was 1.6 months at time of evaluation. Of 138 catheters studied, 15.9% (95% confidence interval, 10.2-23.1) were malpositioned at time of evaluation. According to univariable analysis, factors associated with malpositioned catheters included shorter catheter duration (p = .001), greater number of lumens (p = .029), venous entry site on the arm (p <.001) and catheters placed at institutions other than Cleveland Clinic (p = .007). Additionally, PICCs were likely to be malpositioned at time of evaluation compared with other long-term VADs combined (34.2% vs 9.0%; p < .001).

CONCLUSIONS

A high percentage of long-term VADs improperly positioned for PN in the present study. were more likely to be malpositioned at time of evaluation compared with tunneled catheters and implanted These findings suggest the tip position of long-term should be confirmed before infusing PN.

A systematic review of patient-related risk factors for catheter-related thrombosis

To identify patient-related risk factors for venous thrombosis in patients with central venous catheters (CVC) or peripherally inserted central catheters (PICC). We performed a systematic review of the literature assessing patient-related risk factors for thrombosis related to CVC or PICC. The databases PubMed, Ovid and the Cochrane library were searched for observational studies pertaining to patient-related risk factors for CVC and PICC-related thrombosis. The initial search through PubMed, Ovid and the Cochrane library yielded 516 results. After 71 duplicates were removed, 445 articles were assessed for eligibility based on title and abstract. Four hundred and eleven articles were then excluded and 33 full text articles were manually assessed for eligibility. Eight articles were eliminated as they did not contain content relevant to the review. Twenty-five studies were then selected to assess 20 risk factors. There were no consistent significant associations for catheter-related thrombosis across the twenty-five studies. Multiple studies identified age, malignancy, diabetes, obesity, chemotherapy, thrombophilia and a history of thrombosis as significant risk factors for catheter-related thrombosis. Inconsistent findings among studies make it difficult to establish which patient-related risk factors are associated with catheter-related thrombosis. Future studies could include larger sample sizes and more cases of catheter-related thrombosis to produce more significant results. Identification of patient-related risk factors could lead to early recognition of upper limb deep vein thrombosis in patients with catheters, thereby preventing complications.

Poor Prognostic Factors in Patients with Parenteral Nutrition-Dependent Pediatric Intestinal Failure

PURPOSE

Parenteral nutrition (PN) not only provides nutritional support but also plays a crucial role in the treatment of children with intestinal failure. The aim of this study was to evaluate the clinical significance and clinical outcomes of long-term PN.

METHODS

Retrospective cohort study was conducted using the medical records of patients treated at Seoul National University Children's Hospital. This study included 19 patients who received PN for over six months. Most patients received home PN.

RESULTS

The indications for PN included short bowel syndrome, chronic intestinal pseudo-obstruction, and intractable diarrhea of infancy. The median age of PN initiation was 1.3 years, and the median treatment duration was 2.9 years. Two patients were weaned from PN; 14 continued to receive PN with enteral feedings; and 3 patients died. The overall survival rates at 2 and 5 years were 93.3% and 84.0%, respectively. The incidence of catheter-related bloodstream infections was 2.7/1,000 catheter-days and was associated with younger age at PN initiation and lower initial height Z-score. Six patients developed catheter-related central vein thrombosis, with an incidence of 0.25/1,000 catheter-days. Eleven patients experienced PN-associated liver disease (PNALD), and one patient underwent multi-visceral transplant. The patients with PNALD exhibited lower final heights and body weight Z-scores. All patients experienced micronutrient deficiencies transiently while receiving PN.

CONCLUSION

PN is an important and safe treatment for pediatric intestinal failure. PNALD was linked to final anthropometric poor outcomes. Micronutrient deficiencies were common. Anthropometric measurements and micronutrient levels must be monitored for successful PN completion.

Femoral Placement of Totally Implantable Venous Access Ports in Patients with Bilateral Breast Cancer

Purpose: Aim of this study was to determine the rate of complications following femoral placement of totally implantable venous access ports (f-TIVAP) in women with bilateral breast cancer, with a special focus on long-term function, deep vein thrombosis (DVT), and port infection. Methods: 73 patients with bilateral breast cancer treated between October 2000 and January 2013 with placement of an f-TIVAP using a transfemoral approach were retrospectively reviewed. All patients were followed up, and all complications of f-TIVAP were recorded. Results: The median age was 62.5 years (range: 35-86 years). Four patients received f-TIVAP under local anesthesia, and 69 underwent placement under general anesthesia. Mean follow-up was 33.7 months (SD 25.9; range: 0.2-93.5 months). Complications over the entire period of observation included infections in 21 %, DVT in 19 % and catheter occlusion in 12 %. Patients receiving chemotherapy who developed leukopenia were more likely to experience DVT at the access site (p = 0.037). There was a trend towards a higher infection rate when the device was used more often (p = 0.084). Conclusion: Although the rates of complications in the longer term, especially device infections and DVTs, appeared to be relatively high, TIVAP implantation using femoral vein access is recommended in patients with bilateral breast cancer not suitable for cephalic vein cut-down.

Totally Implantable Venous Access Devices in Children Requiring Long-Term Chemotherapy: Analysis of Outcome in 122 Children from a Single Institution

Children with malignancy require venous access that is reliable, safe and compliant on a long-term basis. There is little data available on utilization of totally implantable venous access devices (TIVAD) for long term chemotherapy in children in an Indian setting [1]. We report our long-term follow-up results of utilization of totally implantable venous access devices for long-term chemotherapy in children. This was a retrospective analysis of 122 children requiring long-term chemotherapy done between January 2008 and December 2013. Data collected included primary disease process, type of port, site of insertion, intraoperative events, early and late postoperative complications, and issues with utilization, maintenance and removal. 127 ports were placed in 122 children. The follow up ranged from 16 to 50 months. Internal jugular vein was accessed in 96.8 % of cases (123/127). Majority of children (61 %) had hematological malignancy. Early complications occurred in 5 children. Late complications occurred in 18 children which included port pocket infection in 3, port site skin issues in 5, catheter related issues in 3, venous thrombosis in 2 and catheter related bacteremia in 5 children respectively. Only 10 children have been lost to follow-up either due to death or discontinuation of treatment and rest are on follow up. Totally implantable venous access devices usage is safe and reliable for access needs in children for long-term chemotherapy. Their low complication and low cost maintenance should increase their utilization in children requiring long-term chemotherapy. Chemoport placement in children with hematological malignancy can be carried out safely without much impact on complication rates. Though management and compliance of children with malignancy has improved; critical analysis and standardization of port system care through prospective trials are necessary to reduce the morbidity and for cost analysis in these children.

A retrospective evaluation of polyurethane, long-stay, peripheral venous cannulae in dogs undergoing radiotherapy

OBJECTIVES

The aim of this retrospective study was to review placement duration and associated complications of long-stay, peripheral venous cannulae in dogs undergoing a radiotherapy protocol. Factors affecting duration of stay of the cannulae were evaluated.

METHODS

The records of patients which had a single-lumen, 16-gauge, 16-cm polyurethane cannulae inserted into a peripheral vein between 2010 and 2014 were reviewed.

RESULTS

Forty-one cannulae were placed in 41 patients. Median duration of cannula stay was 14 days (range 2 to 26). In 14 cases (~34%) the cannula was removed at the end of the radiotherapy course. In 13 (~32%) cases, cannula-related complications resulted in premature removal. Use of steroids and antibiotics appeared to be associated with a longer median duration of stay.

CLINICAL SIGNIFICANCE

No life-threatening complications were encountered. Indwelling, polyurethane, saphenous cannulae were an effective and safe way to maintain venous access in this group of patients. Prednisolone and antibiotics were typically commenced for acute radiation side effects -midway through the protocol; therefore their association with length of stay may not be a direct result of their administration.

Characterizing the Risk Factors Associated With Venous Thromboembolism in Pediatric Patients After Central Venous Line Placement

OBJECTIVES

With the apparent increase in venous thromboembolism noted in the pediatric population, it is important to define which children are at risk for clots and to determine optimal preventative therapy. The purpose of this study was to determine the risk factors for venous thromboembolism in pediatric patients with central venous line placement.

METHODS

This was an observational, retrospective, case-control study. Control subjects were patients aged 0 to 18 years who had a central venous line placed. Case subjects had a central line and a radiographically confirmed diagnosis of venous thromboembolism.

RESULTS

A total of 150 patients were included in the study. Presence of multiple comorbidities, particularly the presence of a congenital heart defect (34.7% case vs. 14.7% control; p < 0.005), was found to put pediatric patients at increased risk for thrombosis. Additionally, the administration of parenteral nutrition through the central line (34.7% case vs. 18.7% control; p = 0.03) and location of the line increased the risk for clot formation.

CONCLUSIONS

With increased awareness of central venous line-related thromboembolism, measures should be taken to reduce the number and duration of central line placements, and further studies addressing the need for thromboprophylaxis should be conducted.

Medical management of tumor lysis syndrome, postprocedural pain, and venous thromboembolism following interventional radiology procedures

The rapid expansion of minimally invasive image-guided procedures has led to their extensive use in the interdisciplinary management of patients with vascular, hepatobiliary, genitourinary, and oncologic diseases. Given the increased availability and breadth of these procedures, it is important for physicians to be aware of common complications and their management. In this article, the authors describe management of select common complications from interventional radiology procedures including tumor lysis syndrome, acute on chronic postprocedural pain, and venous thromboembolism. These complications are discussed in detail and their medical management is outlined according to generally accepted practice and evidence from the literature.

Tunnelled central venous catheter–induced thrombosis: a rare case of superior vena cava syndrome

Thrombotic venous obstruction in patients with a tunnelled central venous catheter is a cause of superior vena cava syndrome that is not routinely encountered by emergency physicians. Diagnosis requires identifying patients at risk (e.g., those under treatment for cancer and those who have a tunnelled central venous catheter), recognizing the signs and symptoms of superior vena cava syndrome, usually dyspnea and dilated neck or thoracic veins, and imaging the venous obstruction using computer tomography or sonography. Management involves anticoagulation and local thrombolytic administration. We report the case of a 28-year-old woman who presented with a 2-day history of face, chest and bilateral arm swelling who had been receiving maintenance chemotherapy for acute lymphoblastic leukemia through a Hickman® catheter. This case demonstrates the need to be vigilant for thrombus formation in patients with long-term, indwelling central venous catheters.

Prospective monitoring of cytomegalovirus, Epstein-Barr virus, BK virus, and JC virus infections on belatacept therapy after a kidney transplant

OBJECTIVES

Few data regarding viral replication in patients receiving belatacept are available. The aim of this single-center study was to compare the incidence of viral infections (cytomegalovirus, Epstein Barr virus, BK virus, and JC virus), in 62 de novo kidney transplant patients enrolled in the BENEFIT studies, receiving either belatacept (n=42) or cyclosporine (n=20).

MATERIALS AND METHODS

By means of polymerase chain reaction, belatacept-treated patients were tested for cytomegalovirus, Epstein-Barr virus, BK virus, and JC virus infections monthly for 36 months, monthly for the first 6 months, and then quarterly for 36 months in cyclosporine-treated patients. Additional samples were obtained when a viral infection was suspected.

RESULTS

The number of positive cytomegalovirus, BK virus, or JC virus viremias over the number of polymerase chain reactions performed through all 3 years was similar in both groups. Conversely, over the 3-year study, the number of positive Epstein-Barr virus viremias over the number of Epstein-Barr virus polymerase chain reactions performed was significantly higher in the belatacept group (76% vs 50%; P = .047). The number of Epstein-Barr virus primary infection was similar in both groups, while the number of Epstein-Barr virus reactivation was higher in the belatacept group.

CONCLUSIONS

Epstein-Barr virus replication occurs more often in patients receiving belatacept, than it does in those receiving cyclosporine.

Short-term and long-term outcome of radiological-guided insertion of central venous access port devices implanted at the forearm: a retrospective monocenter analysis in 1704 patients

OBJECTIVES

The objectives are to analyze the technical success rate as well as the short-term and long-term complications of totally implantable venous access ports (TIVAPs) at the forearm.

METHODS

Retrospective analysis of 1,704 consecutively implanted TIVAPs was performed. Primary endpoints were defined as technical success rate, clinical outcome, device service interval, and rates of major complications. Minor complications not requiring port explantation were defined as secondary endpoints.

RESULTS

The technical success rate was 99.2 % with no major complications. During follow-up, a total of 643,200 catheter-days were documented, the mean device service interval was 380.6 days/patient. A total of 243 complications (14.4 %) in 226 patients were observed (0.4/1000 catheter-days), in 140 patients (8.3 %) the port device had to be explanted. Disconnection between the port device and the catheter (1.6 %) was more frequent than fracture (0.8 %) and leakage (0.6 %) of the catheter, which occurred more frequently when the catheter was inserted via the cephalic versus the brachial vein.

CONCLUSION

TIVAP implantation at the forearm is a simple and safe procedure with a low rate of early and late complications.

Risk factors for subclavian vein thrombosis in cancer patients with total parenteral nutrition

Background

There are few reports on total parenteral nutrition (TPN) and its possible prothrombotic effect. The purpose of this study was to identify risk factors for subclavian vein thrombosis (SVT) in patients receiving TPN.

Method

Cancer patients with indwelling subclavian catheters and TPN were followed in a cohort study. Doppler ultrasound examination was performed 8 and 30 days after catheter placement.

Results

One hundred twenty-one patients were included, with a mean of 61 (± 11.8) years of age. We detected 36 SVT events at day 8 (29.8%) and 47 (38.8%) at day 30 after central catheter placement. Mean length of subclavian catheterization was 17.2 (± 8.2) days. Fifty-three point three percent of patients receiving ≥ 3,050 mOsm TPN in 24 hours developed SVT (relative risk (RR) = 2.01, 95% CI, 1.14 - 3.57; P = 0.016) at day 8 and 60% (RR = 1.67, 95% CI, 1.30 - 2.71; P = 0.038) at day 30 post-catheter placement. Protein administration of > 97.5 g/day was shown to be a risk factor for early thrombosis with a mean of 16.88 days for the development of SVT (95% CI, 10 - 23.7) versus 27.8 days (95% CI, 25.8 - 29.9) in the group with nutritional protein content < 97.5 g/day (P = 0.000).

Conclusion

High-osmolarity and high-protein nutrition formulas were shown to be risk factors for SVT in cancer patients receiving TPN.

Central venous thrombosis and thrombophilia in cystic fibrosis: A prospective study

BACKGROUND AND AIMS

Catheter venous thrombosis may result in life-threatening embolic complications. Recently, a thrombophilic tendency was described in cystic fibrosis (CF), the significance of which remains unclear. The aims of this study were to (1) document the frequency of catheter venous thrombosis detected by colour-Doppler-ultrasound (Doppler-US), (2) assess genetic and acquired thrombophilia risk factors for catheter venous thrombosis and hypercoagulability status and (3) provide recommendations on laboratory screening when considering insertion of a totally implantable vascular access device (TIVAD) in CF patients.

METHODS

We designed a multicentre prospective study in patients selected at the time of catheter insertion. Doppler-US was scheduled at 1 and 6months after insertion and before insertion in case of a previous central line. Blood samplings were drawn at insertion and at 1 and 6months later.

RESULTS

One-hundred patients received a TIVAD and 90 completed the 6-month study. Prevalence of thrombophilia abnormalities and hypercoagulability was found in 50% of the cohorts. Conversely, catheter venous thrombosis frequency was low (6.6%).

CONCLUSION

Our data do not support biological screening at the time of a TIVAD insertion. We emphasise the contribution of a medical history of venous thromboembolism and prospective Doppler-US for identifying asymptomatic catheter venous thrombosis to select patients who may benefit from biological screening and possible anticoagulant therapy.

Patency of neck veins following ultrasound-guided percutaneous Hickman line insertion

PURPOSE

Venous occlusion following permanent central venous catheter (CVC) insertion by open cutdown or the landmark percutaneous technique has been reported between up to 25 %. However, there are no published data on the equivalent rate following ultrasound-guided percutaneous CVC insertion. The purpose of this study was to document the rate of venous occlusion associated with ultrasound-guided percutaneous CVC insertion in children.

METHOD

From 1 April 2010 to 1 December 2011, all children having elective or emergency removal of a Hickman line by the vascular access team had a Doppler ultrasound of their neck veins. Only Hickman lines inserted by the ultrasound-guided percutaneous route were included. Internal jugular, innominate and subclavian veins were scanned and recorded as patent, reduced or absent.

RESULTS

We identified 100 consecutive children. Median age was 6 years (range 21 days to 16 years). Indication for insertion was chemotherapy (60), parenteral nutrition (15), blood products (12), renal replacement (3) and other indications (10). Three children had absent flow at the time of line removal (median age 4 months, range 3-6 months), with 2 out of 3 requiring removal for infection. The venous occlusion rate following ultrasound-guided insertion of CVC is 3 % in our study.

CONCLUSIONS

We conclude that (1) complete venous occlusion is associated with younger age and CVC infection. (2) In our study, the venous occlusion rate of 3 % is significantly lower than the published series of either open cutdown or the landmark technique.

Totally implantable central venous catheters for chemotherapy: experience with 793 patients

OBJECTIVE

To retrospectively study the results obtained with the implementation of totally implantable catheters in patients undergoing chemotherapy.

METHODS

815 totally implantable catheters placed in 793 patients undergoing chemotherapy regimen, preferably using the right cephalic vein. We evaluated early and late complications.

RESULTS

The retrospective analysis showed an average duration of 339 days of the catheters. In 733 (90%) catheters there was no observe complication. Among early complications we observed one pneumothorax, one bad positioning of the catheter, one arterial puncture, one bleeding, one hemothorax and hemomediastinum and six hematomas in the implantation site. As for late complications, there were 35 catheter-related infections ten, infections in the surgical site, six obstructions and 20 thromboses. We removed 236 catheters, 35 due to complications and 201 by the end of treatment.

CONCLUSION

totally implantable catheters for chemotherapy are a safe means for the administration of substances, in view of the low number of complications observed in this study.

Catheter-related thrombosis in cancer patients

Central venous catheters are commonly used in haematology departments for the administration of chemotherapy, blood products and parenteral nutrition in patients with haematological malignancy. Thrombosis is a recognized complication of such devices especially in oncology patients. Catheter-related thrombi (CRT) may lead to pulmonary embolism and infection, as well as catheter failure and potential delays in treatment. The vast majority of CRT are asymptomatic, thus a high index of suspicion is required in making the diagnosis. Doppler ultrasound or venography may be employed to identify CRT. Once confirmed, the initiation of treatment is a balance between the risks of anticoagulation against potential complications of CRT. A number of risk factors for CRT are discussed along with an overview of catheter types, their appropriate choice and intravascular positioning.

Venous access catheter-related thrombosis in patients with cancer

Patients with cancer are at high risk for developing venous thromboembolism (VTE), and the presence of a central venous catheter (CVC) further increases this risk. CVC-related VTE has serious implications related to the loss of vascular access, development of pulmonary embolism, recurrent VTE, infections and post-thrombotic syndrome. The pathogenesis of CVC-related VTE is complex and multifactorial, with risk factors associated with the catheter, the vessel selected for insertion and the underlying cancer as well as the anti-cancer therapy. Clinical presentation of CVC-related VTEs is often non-specific, and ultrasonography is the most commonly used radiological diagnostic test. Management of CVC-related VTE in patients with cancer requires a balance between the need for venous access, the risk of VTE recurrence and the risk of bleeding from treatment-induced thrombocytopenia. Effective VTE prophylaxis methods have yet to be defined. Ongoing studies are evaluating the role of newer oral antithrombotic agents and alternative interventional strategies for the prevention and treatment of CVC-related VTE in patients with cancer.

Prophylaxis of catheter-related deep vein thrombosis in cancer patients with low-dose warfarin, low molecular weight heparin, or control: a randomized, controlled, phase III study

PURPOSE

Whether an anticoagulant prophylaxis is needed for patients with cancer with a central venous catheter is a highly controversial subject. We designed a study to compare different prophylactic strategies over 3 months of treatment.

METHODS

We performed a phase III prospective, open-label randomized trial. After the insertion of a central venous access device, consecutive patients with planned chemotherapy for cancer were randomized to no anticoagulant prophylaxis, low molecular weight heparin [low molecular weight heparin (LMWH); with isocoagulation doses], or warfarin 1 mg/day. Treatments were given over the first 3 months. Doppler ultrasound and venographies were performed on days 1 and 90, respectively, or sooner in case of clinical presumption of thrombosis.

RESULTS

A total of 420 patients were randomized, and 407 were evaluable. Forty-two catheter-related deep vein thrombosis (DVT) occurred (10.3 %), 20 in those with no anticoagulation, 8 in those receiving warfarin, and 14 in those receiving LMWH. Nine additional non-related catheter deep vein thrombosis (CDVT) occurred. Anticoagulation significantly reduced the incidence of catheter-related DVT (p = 0.035) and catheter non-related DVT (p = 0.007), with no difference between warfarin and LMWH. Safety was good (3.4 % of attributable events) but compliance with randomized prophylaxis was lower than expected.

CONCLUSIONS

Prophylaxis showed a benefit regarding catheter-related and non-catheter-related DVT with no increase in serious side effects.

Imaging and management of complications of central venous catheters

Central venous catheters (CVCs) provide valuable vascular access. Complications associated with the insertion and maintenance of CVCs includes pneumothorax, arterial puncture, arrhythmias, line fracture, malposition, migration, infection, thrombosis, and fibrin sheath formation. Image-guided CVC placement is now standard practice and reduces the risk of complications compared to the blind landmark insertion technique. This review demonstrates the imaging of a range of complications associated with CVCs and discusses their management with catheter salvage techniques.

Thrombosis and acute leukemia

Thrombosis is a common complication in patients with acute leukemia. While the presence of central venous lines, concomitant steroids, the use of Escherichia coli asparaginase and hereditary thrombophilic abnormalities are known risk factors for thrombosis in children, information on the pathogenesis, risk factors, and clinical outcome of thrombosis in adult patients with acute lymphoid leukemia (ALL) or acute myeloid leukemia (AML) is still scarce. Expert consensus and guidelines regarding leukemia-specific risk factors, thrombosis prevention, and treatment strategies, as well as optimal type of central venous catheter in acute leukemia patients are required. It is likely that each subtype of acute leukemia represents a different setting for the development of thrombosis and the risk of bleeding. This is perhaps due to a combination of different disease-specific pathogenic mechanisms of thrombosis, including the type of chemotherapy protocol chosen, the underlying patients health, associated risk factors, as well as the biology of the disease itself. The risk of thrombosis may also vary according to ethnicity and prevalence of hereditary risk factors for thrombosis; thus, it is advisable for Latin American, Asian, and African countries to report on their specific patient population.

Thromboembolic and bleeding complications in acute leukemia

The risk of both thromboembolic and bleeding complications is high in acute leukemia. This double hazard has a significant negative impact on the morbidity and mortality of patients with this disease. The clinical manifestations of both complications show special features specific to the form of acute leukemia. Recognition of these characteristics is important in the diagnosis and management of acute leukemia. In this article, several additional issues are addressed, including the features of bleeding and thrombosis in acute promyelocytic leukemia, the current understanding of the leukostasis syndrome and the iatrogenic complications including catheter-associated thrombosis, and the adverse effects of therapeutic agents used in acute leukemia. As regards the bleeding complications, thrombocytopenia is a major cause. Corrective measures, including recent guidelines on platelet transfusions, are provided.