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Élias A, Debourdeau P, Espitia O, Sevestre MA, Girard P, Mahé I, Sanchez O. [Translation into French and republication of: "Central venous catheter associated upper extremity deep vein thrombosis in cancer patients: Diagnosis and therapeutic management"]. Rev Med Interne 2024; 45:354-365. [PMID: 38823999 DOI: 10.1016/j.revmed.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 06/03/2024]
Abstract
Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least 3 months, including at least 1 month after catheter removal following initiation of therapy.
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Affiliation(s)
- A Élias
- Département de cardiologie et de médecine vasculaire, délégation recherche clinique et innovation, hôpital Sainte-Musse, centre hospitalier intercommunal de Toulon La Seyne-sur-Mer, 83000 Toulon, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - P Debourdeau
- F-CRIN INNOVTE network, Saint-Étienne, France; Équipe mobile territoriale soins palliatifs, hôpital Joseph-Imbert, Arles, France
| | - O Espitia
- Service de médecine interne et vasculaire, Team III Vascular & Pulmonary Diseases, institut du thorax, CHU de Nantes, Nantes université, Inserm UMR 1087, CNRS UMR 6291, Nantes, France
| | - M-A Sevestre
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire, EA Chimère 7516, CHU d'Amiens, 80054 Amiens, France
| | - P Girard
- F-CRIN INNOVTE network, Saint-Étienne, France; Institut du thorax Curie-Montsouris, institut mutualiste Montsouris, 75014 Paris, France
| | - I Mahé
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France
| | - O Sanchez
- F-CRIN INNOVTE network, Saint-Étienne, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France
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Riess H, Beyer-Westendorf J, Pelzer U, Klamroth R, Linnemann B. Cancer-Associated Venous Thromboembolism-Diagnostic and Therapeutic Considerations: An Update Based on the Revised AWMF S2k Guideline. Hamostaseologie 2024; 44:143-149. [PMID: 37992730 DOI: 10.1055/a-2178-6508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Abstract
Patients with cancer are prone to develop venous thromboembolism (VTE) with negative impact on quality of life, morbidity, and mortality. Treatment of established VTE is often complex in patients with cancer. Treatment of cancer-associated VTE (CAT) basically comprises initial and maintenance treatment, for 3 to 6 months, secondary preventions, and treatment in special situations. Therapeutic anticoagulation is the treatment of choice in CAT. In addition to the efficacy and safety of low-molecular-weight heparin (LMWH) that had been recommended for decades, direct oral anti-factor Xa inhibitors, a subgroup of direct oral anticoagulants (DOACs), demonstrated their advantages along with the accompanying concerns in several randomized controlled treatment trials of CAT. The latest guidelines, such as the German AWMF-S2k Guideline "Diagnostics and Therapy of Venous Thrombosis and Pulmonary Embolism," agree with each other on most aspects with respect to the treatment of CAT. Encompassing recent clinical studies, and meta-analyses, as well as the focus on some special management aspects of CAT, the objective of this review is to present a current overview and recommendations for the treatment of CAT.
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Affiliation(s)
- Hanno Riess
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jan Beyer-Westendorf
- Department of Hematology, Medical Faculty, University Hospital Carl Gustav-Carus, Dresden, Germany
| | - Uwe Pelzer
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Robert Klamroth
- Department of Internal Medicine and Vascular Medicine, Vivantes Hospital in Friedrichshain, Berlin, Germany
| | - Birgit Linnemann
- Cardiology III - Angiology, Department of Cardiology, University Hospital of the Johannes-Gutenberg University, Mainz, Germany
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3
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Wang TF, Kou R, Carrier M, Delluc A. Management of catheter-related upper extremity deep vein thrombosis in patients with cancer: a systematic review and meta-analysis. J Thromb Haemost 2024; 22:749-764. [PMID: 38065528 DOI: 10.1016/j.jtha.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Patients with cancer commonly require a central venous catheter, which is associated with an increased risk of venous thromboembolism (VTE). Despite the frequent occurrence, the optimal anticoagulation management and outcomes for patients with cancer and catheter-related upper extremity deep vein thrombosis (DVT) are unclear. OBJECTIVE We performed a systematic review and meta-analysis to evaluate the rates of recurrent VTE and bleeding in patients with cancer and catheter-related upper extremity DVT. METHODS We searched MEDLINE, Embase, Scopus, and CENTRAL from inception to June 2, 2023. The primary efficacy outcome was recurrent VTE, and the primary safety outcome was major bleeding. The incidence rates (with 95% CI) of outcomes were pooled using random effects model. RESULTS We included 29 studies (N = 2,836), among which 5 were prospective. The duration of follow-up and anticoagulation varied considerably. The main long-term anticoagulant used was low molecular weight heparin, followed by direct oral anticoagulants. The pooled 3-month recurrent VTE rate from 14 studies (N = 1,128) was 0.56% (95% CI, 0.10%-3.01%; I2 = 0%). The pooled 3-month major bleeding rate from 10 studies (N = 834) was 2.34% (95% CI, 1.14%-4.76%; I2 = 0%). We were unable to pool event rates beyond 3 months, given high heterogeneity. All studies had serious risk of bias. CONCLUSIONS Our study demonstrated a relatively low rate of recurrent VTE and moderate rate of major bleeding events within the first 3 months in patients with cancer and catheter-related upper extremity DVT. However, there was significant heterogeneity in the management and reporting after 3 months.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Roger Kou
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada. https://twitter.com/MarcCarrier1
| | - Aurélien Delluc
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada. https://twitter.com/DellucAurelien
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Espitia O, Raimbeau A, Planquette B, Katsahian S, Sanchez O, Espinasse B, Bénichou A, Murris J. A systematic review and meta-analysis of the incidence of post-thrombotic syndrome, recurrent thromboembolism, and bleeding after upper extremity vein thrombosis. J Vasc Surg Venous Lymphat Disord 2024; 12:101688. [PMID: 37717788 DOI: 10.1016/j.jvsv.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/26/2023] [Accepted: 09/04/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Data on complications after upper extremity vein thrombosis (UEVT) are limited and heterogeneous. METHODS The aim of the present study was to evaluate the pooled proportions of venous thromboembolism (VTE) recurrence, bleeding, and post-thrombotic syndrome (PTS) in patients with UEVT. A systematic literature review was conducted of PubMed, Embase, and the Cochrane Library databases from January 2000 to April 2023 in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. All studies included patients with UEVT and were published in English. Meta-analyses of VTE recurrence, bleeding, and of PTS after UEVT were performed to compute pooled estimates and associated 95% confidence intervals (CIs). Subgroup analyses of cancer-associated UEVT and catheter-associated venous thrombosis were conducted. Patients with Paget-Schroetter syndrome or effort thrombosis were excluded. RESULTS A total of 55 studies with 15,694 patients were included. The pooled proportions for VTE recurrence, major bleeding, and PTS were 4.8% (95% CI, 3.8%-6.2%), 3.0% (95% CI, 2.2%-4.0%), and 23.8% (95% CI, 17.0%-32.3%), respectively. The pooled proportion of VTE recurrence was 2.7% (95% CI, 1.6%-4.6%) for patients treated with direct oral anticoagulants (DOACs), 1.7% (95% CI, 0.8%-3.7%) for patients treated with low-molecular-weight heparin (LMWH), and 4.4% (95% CI, 1.5%-11.8%) for vitamin K antagonists (VKAs; P = .36). The pooled proportion was 6.3% (95% CI, 4.3%-9.1%) for cancer patients compared with 3.1% (95% CI, 2.1%-4.6%) for patients without cancer (P = .01). The pooled proportion of major bleeding for patients treated with DOACs, LMWH, and VKAs, was 2.1% (95% CI, 0.9%-5.1%), 3.2% (95% CI, 1.4%-7.2%), and 3.4% (95% CI, 1.4%-8.4%), respectively (P = .72). The pooled proportion of PTS for patients treated with DOACs, LMWH, and VKAs was 11.8% (95% CI, 6.5%-20.6%), 27.9% (95% CI, 20.9%-36.2%), and 24.5% (95% CI, 17.6%-33.1%), respectively (P = .02). CONCLUSIONS The results from this study suggest that UEVT is associated with significant rates of PTS and VTE recurrence. Treatment with DOACs might be associated with lower PTS rates than treatment with other anticoagulants.
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Affiliation(s)
- Olivier Espitia
- Department of Vascular Medicine, Nantes Université, CHU Nantes, l'institut du Thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France; UNAV, Nantes Vascular Access Unit, Nantes Université, CHU Nantes, Nantes, France.
| | - Alizée Raimbeau
- Department of Vascular Medicine, Nantes Université, CHU Nantes, l'institut du Thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France; UNAV, Nantes Vascular Access Unit, Nantes Université, CHU Nantes, Nantes, France
| | - Benjamin Planquette
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Centre - Université Paris Cité, INSERM UMR S1140, Innovative Therapies in Hemostasis, Paris, France, F-CRIN INNOVTE, Université Paris Cité, St-Etienne, France
| | - Sandrine Katsahian
- INSERM, Centre d'Investigation Clinique 1418 (CIC1418) Epidémiologie Clinique, AP-HP, Hôpital Européen Georges Pompidou, Unité de Recherche Clinique, Service d'Informatique Médicale, Biostatistiques et Santé Publique, AP-HP Centre, Paris, France; Inserm, Centre de Recherche des Cordeliers, Université de Paris, Sorbonne Université, Paris, France; HeKA, Inria, Paris, France
| | - Olivier Sanchez
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Centre - Université Paris Cité, INSERM UMR S1140, Innovative Therapies in Hemostasis, Paris, France, F-CRIN INNOVTE, Université Paris Cité, St-Etienne, France
| | | | - Antoine Bénichou
- Department of Vascular Medicine, Nantes Université, CHU Nantes, l'institut du Thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France; UNAV, Nantes Vascular Access Unit, Nantes Université, CHU Nantes, Nantes, France
| | - Juliette Murris
- Inserm, Centre de Recherche des Cordeliers, Université de Paris, Sorbonne Université, Paris, France; HeKA, Inria, Paris, France; RWE and Data, Pierre Fabre, Boulogne-Billancourt, France
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Elias A, Debourdeau P, Espitia O, Sevestre MA, Girard P, Mahé I, Sanchez O. Central venous catheter associated upper extremity deep vein thrombosis in cancer patients: Diagnosis and therapeutic management. Arch Cardiovasc Dis 2024; 117:72-83. [PMID: 38065755 DOI: 10.1016/j.acvd.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least three months, including at least one month after catheter removal following initiation of therapy.
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Affiliation(s)
- Antoine Elias
- Département de Cardiologie et de Médecine Vasculaire, Délégation Recherche Clinique et Innovation, Centre Hospitalier Intercommunal Toulon La Seyne-sur-Mer, Toulon, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - Philippe Debourdeau
- Équipe Mobile Territoriale Soins Palliatifs, Hôpital Joseph-Imbert d'Arles, Arles, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Olivier Espitia
- Service de Médecine Interne et Vasculaire, Nantes Université, CHU de Nantes, Institut du thorax, Inserm UMR 1087, CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France
| | - Marie-Antoinette Sevestre
- Service de Médecine Vasculaire, EA Chimère 7516, CHU Amiens, 80054, Amiens, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Philippe Girard
- Institut du Thorax Curie-Montsouris, Institut Mutualiste Montsouris, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Isabelle Mahé
- Service de Médecine Interne, Hôpital Louis-Mourier, AP-HP, Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Olivier Sanchez
- Service de Pneumologie et de Soins Intensifs, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
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Yin Q, Zheng X, Han L, Huang X, Wang Y, Song Y, Zhang Y, Bian Y. Outcome of antithrombotic therapy in cancer patients with catheter-related thrombosis: a systematic review. Front Cardiovasc Med 2023; 10:1290822. [PMID: 38162134 PMCID: PMC10756912 DOI: 10.3389/fcvm.2023.1290822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction The guidelines' recommendations for anticoagulation in cancer patients with catheter-related thrombosis are unclear. The aim of this systematic review was to assess anticoagulation management in cancer patients with catheter-related thrombosis (CRT) based on previously published studies. Methods As of June 10, 2023,we searched databases including PubMed, Embase, and Cochrane and included 11 observational studies that met the criteria. We evaluated 770 adults with active cancer and objectively confirmed patients with CRT who were using drugs including warfarin, LMWH, and new oral anticoagulants as antithrombotic therapy. Results We extracted outcome data, including thrombosis recurrence, catheter dysfunction, major bleeding, and death, and performed a meta-analysis. Discussion In this study we found that the risk of VTE recurrence was higher with rivaroxaban, the risk of bleeding and death appeared to be greater with warfarin, and although the risk of catheter dysfunction due to LMWH is a concern, it is still a more reasonable option for cancer patients with catheter-related thrombosis. Systematic Review Registration http://www.clinicaltrials.gov, identifier (CRD42022367979).
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Affiliation(s)
- Qinan Yin
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xingyue Zheng
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lizhu Han
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xuefei Huang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yueyuan Wang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yujie Song
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuan Zhang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuan Bian
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Mahé I, Meyer G, Girard P, Bertoletti L, Laporte S, Couturaud F, Mismetti P, Sanchez O. French guidelines for the treatment of cancer-associated venous thromboembolism - 2023 update. Respir Med Res 2023; 84:101056. [PMID: 37922776 DOI: 10.1016/j.resmer.2023.101056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND In recent years, knowledge about cancer associated thrombosis has evolved considerably. METHODS Practical guidelines were drafted on the initiative of the INNOVTE FCRIN Network, led by the French Speaking Society of Respiratory Diseases (SPLF), by a coordinating group, a writing group, and a review group, with the involvement of different scientific societies practicing in various settings. The method followed the "Clinical Practice Guidelines" process of the French National Authority for Health (HAS). RESULTS After a literature review, guidelines were formulated, improved, and then validated by the working groups. These guidelines addressed multiple aspects of the disease and management from the data of available clinical trials and observational studies : epidemiology, initial treatment, treatment duration, extended treatment, recurrent thrombosis, central venous catheter thrombosis, incidental thrombosis, treatment in case of thrombocytopenia. CONCLUSION These evidence-based guidelines are intended to guide the practical management of patients with cancer associated thrombosis.
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Affiliation(s)
- Isabelle Mahé
- Paris Cité University; Internal Medicine Department - Louis Mourier Hospital, Assistance Publique des Hôpitaux de Paris, Colombes; Inserm UMR_S1140, Paris; F-CRIN INNOVTE, St-Etienne.
| | - Guy Meyer
- Paris Cité University; Pulmonology and Intensive Care Department, Georges Pompidou European Hospital, Assistance Publique des Hôpitaux de Paris; INSERM UMRS 970; INSERM CIC 1418, Paris; F-CRIN INNOVTE, St-Etienne
| | - Philippe Girard
- Curie-Montsouris Thorax Institute, Montsouris Mutualist Institute, Paris; F-CRIN INNOVTE, St-Etienne
| | - Laurent Bertoletti
- Vascular and Therapeutic Medicine Department, St-Etienne University Hospital; INSERM UMR1059, Vascular Dysfunction and Hemostasis Team, Jean-Monnet University, Saint-Etienne; INSERM, CIC-1408, Saint-Etienne; F-CRIN INNOVTE, Saint-Etienne, France
| | - Silvy Laporte
- SAINBOIS U1059 DVH team, Jean Monnet University, Lyon University, INSERM; Clinical Research, Innovation, Pharmacology Unit, Saint-Etienne University Hospital, Hôpital Nord; Saint-Etienne; F-CRIN INNOVTE, St-Etienne
| | - Francis Couturaud
- Internal Medicine and Pulmonology Department, EA3878-GETBO, CIC_INSERM1412, Western Brittany University, Brest University Hospital, F-CRIN INNOVTE, St-Etienne
| | - Patrick Mismetti
- Vascular and Therapeutic Medicine Department, St-Etienne University Hospital; INSERM UMR1059, Vascular Dysfunction and Hemostasis Team, Jean-Monnet University, Saint-Etienne; INSERM, CIC-1408, Saint-Etienne; F-CRIN INNOVTE, Saint-Etienne, France
| | - Olivier Sanchez
- Paris Cité University; Pulmonology and Intensive Care Department, Georges Pompidou European Hospital, Assistance Publique des Hôpitaux de Paris; INSERM UMRS 1140, Paris; F-CRIN INNOVTE, St-Etienne
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8
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Giustozzi M, Franco L, Agnelli G, Verso M. Unmet clinical needs in the prevention and treatment of cancer-associated venous thromboembolism. Trends Cardiovasc Med 2023; 33:336-343. [PMID: 35150850 DOI: 10.1016/j.tcm.2022.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 12/11/2022]
Abstract
Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, is a leading cause of morbidity and mortality in patients with cancer. Based on accumulating evidence, the prophylaxis and treatment of cancer-associated VTE have been changed over the years. Recently, the introduction in clinical practice of the direct oral anticoagulants has radically changed the management of cancer-associated VTE for their easier use and non-inferior efficacy-safety profile compared to low-molecular-weight heparins. However, the heterogeneity of the cancer population in terms of site, type and stage of the malignancy, the presence of comorbidities, and the variability in cancer treatment and prognosis represent major challenges in the management of VTE in patients with cancer. In the present review, we will discuss clinical questions that represent unsolved issues in the setting of cancer-associated VTE and provide an overview on recent evidence on this topic: primary prophylaxis in ambulatory cancer patients treated with chemotherapy and in cancer surgical patients, need of long-term anticoagulation in cancer patients, treatment of VTE in cancer patients at increased bleeding risk and in special categories such as incidental VTE, splanchnic vein thrombosis or catheter-related thrombosis.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy.
| | - Laura Franco
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy
| | - Melina Verso
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy
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9
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Jenab Y, Tofighi S, Ayati A, Rezvanimehr A, Moosavi NS, Jalaie H, Barbati ME. Single-center experience with catheter-directed thrombolysis and balloon angioplasty for acute upper-extremity deep vein thrombosis: a case series study. BMC Cardiovasc Disord 2023; 23:351. [PMID: 37460994 DOI: 10.1186/s12872-023-03389-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Effective treatment of upper extremity deep vein thrombosis (UEDVT) is crucial to prevent further complications. Various treatments, including percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), decompression surgery, and venoplasty are suggested for UEDVT. However, no prospective study has yet favored any of these treatments. This study presents a review of our experience with CDT followed by balloon venoplasty in patients with acute primary UEDVT. METHODS We enrolled all patients diagnosed with acute UEDVT from January 2020 to June 2021. Subjects with UEDVT due to secondary causes like malignancies, indwelling catheters, or leads were excluded. CDT was performed through brachial vein access, using a perfusion catheter, and rt-PA administration. Balloon venoplasty was performed if the treated segment had remaining stenosis after CDT. Patients were followed up at the vein clinic for any signs and symptoms in the upper extremity and lifestyle changes. Follow-up ultrasonography was done 12 months after discharge. RESULTS Twelve patients with a mean age of 41.08 ± 14.0 years were included in the study. The mean duration of CDT was 25.00 ± 10.56 h. After CDT, all patients had remaining occlusions, with seven having more than 50% remaining stenosis. However, after balloon venoplasty, no patient had significant (more than 50%) stenosis. There was no serious complication after both procedures. Patients were followed up for a mean duration of twelve months after their admission, with a mean time of maintenance anticoagulation was 10.73 ± 5.77 months. Only one patient had recurrent symptoms in his target limb which required a decompression surgery, while the rest were free of symptoms in their treated extremity. No subject developed pulmonary emboli (PE) during admission or the follow-up period. There was no evidence of hospital readmission for any reason. Upper extremity color-doppler sonography of the patients at twelve months after their procedure showed normal venous flow without any significant stenosis in 8 (66.7%), and partially normal flow with patent target vein in 4 (33.3%) patients. CONCLUSIONS CDT followed by balloon venoplasty may be an effective treatment for selected patients with acute primary UEDVT, providing desirable long-term results and potentially avoiding the need for decompression surgery in the short or long term.
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Affiliation(s)
- Yaser Jenab
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Tofighi
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Aryan Ayati
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Rezvanimehr
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Najme-Sadat Moosavi
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Houman Jalaie
- Department of Vascular and Endovascular Surgery, University Hospital Aachen, Aachen, Germany
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10
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Hussain RN, Mandal AKJ, Li N, Kafsi JE, Sioftanos A, Missouris CG. Right heart thrombus in transit and peripherally inserted central catheters. Thromb J 2023; 21:68. [PMID: 37349797 DOI: 10.1186/s12959-023-00513-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023] Open
Abstract
Right heart thrombus in transit or "free-floating right heart thrombus" is defined as thrombus(i) arising from the deep veins that embolises to the right atrium or right ventricle before reaching the pulmonary vasculature. It is almost always associated with pulmonary thromboembolism and is a medical emergency with reported mortality rates of over 40%. We present two cases of right heart thrombus in transit with pulmonary thromboembolism resulting from venous thrombosis associated with peripherally inserted central catheters that were managed with different approaches. The cases highlight that clinicians should have a low threshold to utilise imaging modalities such as computerised tomography and transthoracic echocardiography when there is an untoward change in physiological parameters among patients with peripherally inserted central catheters, particularly those with risk factors for peripherally inserted central catheter associated venous thrombosis. Furthermore, procedural optimisation surrounding peripherally inserted central catheters, such as insertion technique and choice of lumen size, is underscored.
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Affiliation(s)
- Rezwan N Hussain
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Amit K J Mandal
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK.
| | - Nick Li
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- The Queen's College, University of Oxford, Oxford, UK
| | - Jihène El Kafsi
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | | | - Constantinos G Missouris
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- University of Nicosia Medical School, Nicosia, Cyprus
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11
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Falanga A, Ay C, Di Nisio M, Gerotziafas G, Jara-Palomares L, Langer F, Lecumberri R, Mandala M, Maraveyas A, Pabinger I, Sinn M, Syrigos K, Young A, Jordan K. Venous thromboembolism in cancer patients: ESMO Clinical Practice Guideline. Ann Oncol 2023; 34:452-467. [PMID: 36638869 DOI: 10.1016/j.annonc.2022.12.014] [Citation(s) in RCA: 64] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 12/09/2022] [Accepted: 12/11/2022] [Indexed: 01/11/2023] Open
Affiliation(s)
- A Falanga
- Division of Immunohaematology and Transfusion Medicine, Haemostasis and Thrombosis Center, Department of Oncology and Haematology, Hospital Papa Giovanni XXIII, Bergamo, Italy; University of Milan Bicocca, Department of Medicine and Surgery, Monza, Italy
| | - C Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - M Di Nisio
- Department of Medicine and Ageing Sciences, G. d'Annunzio University, Chieti, Italy
| | - G Gerotziafas
- Sorbonne University, INSERM UMRS-938, Team "Cancer Vessels, Biology and Therapeutics", Group "Cancer-Hemostasis-Angiogenesis", Institut Universitaire de Cancérologie, Consultation Thrombosis in Oncology (COTHON), Tenon-Saint Antoine Hospital, AP-HP, Paris, France
| | - L Jara-Palomares
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - F Langer
- Centre for Oncology, University Cancer Centre Hamburg (UCCH), II Medical Clinic and Polyclinic, University Medical Centre Eppendorf, Hamburg, Germany
| | - R Lecumberri
- Servicio de Hematología, Clínica Universidad de Navarra, Pamplona (Navarra); CIBER-CV, Instituto de Salud Carlos III, Madrid, Spain
| | - M Mandala
- University of Perugia, Unit of Medical Oncology, Santa Maria Misericordia Hospital, Perugia, Italy
| | - A Maraveyas
- Queen's Centre for Oncology and Haematology, Faculty of Health Sciences, Hull York Medical School and Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - I Pabinger
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - M Sinn
- Centre for Oncology, University Cancer Centre Hamburg (UCCH), II Medical Clinic and Polyclinic, University Medical Centre Eppendorf, Hamburg, Germany
| | - K Syrigos
- Oncology Unit, 3rd Department of Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - A Young
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - K Jordan
- Department of Hematology, Oncology and Palliative Medicine, Ernst von Bergmann Hospital, Potsdam, Germany; Department of Rheumatology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
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12
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Chiu J, Lazo-Langner A. Venous thromboembolism in hematopoietic stem cell transplantation: A narrative review. Thromb Res 2023; 226:141-149. [PMID: 37150028 DOI: 10.1016/j.thromres.2023.04.019] [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: 02/07/2023] [Revised: 03/28/2023] [Accepted: 04/21/2023] [Indexed: 05/09/2023]
Abstract
Venous thromboembolism (VTE) is a common complication of hematopoietic stem cell transplantation (HSCT) and its treatment has significant effects on morbidity and non-relapse mortality. There is a complex interplay on balancing the risk for thrombosis and bleeding in these patients, making treatment decisions particularly challenging. Despite this, there are currently no validated risk assessment models or guidelines to aid clinical decision making on thromboprophylaxis and VTE treatment in this population of patients. Herein, we review the many risk factors for VTE in HSCT patients, categorized into patient, disease, catheter, treatment, laboratory, and transplant-related variables. This review also discusses current thromboprophylaxis and VTE management strategies in HSCT patients, with scope into the development of risk assessment models that allow for identification of high-risk subgroups who may benefit from targeted intervention.
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Affiliation(s)
- Jodi Chiu
- Department of Medicine, Division of Hematology, Western University, London, ON, Canada
| | - Alejandro Lazo-Langner
- Department of Medicine, Division of Hematology, Western University, London, ON, Canada; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
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13
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Xu J, Wang G, Chen X, Shen Y, Wang X, Wang H. Efficacy and safety of rivaroxaban for the treatment of PICC-related upper extremity deep vein thrombosis in cancer patients: a retrospective study. Thromb J 2023; 21:15. [PMID: 36726149 PMCID: PMC9890768 DOI: 10.1186/s12959-023-00456-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The optimal duration and choice of anticoagulant for the treatment of Peripherally inserted central catheters (PICC)-related upper extremity deep vein thrombosis (UEDVT) in cancer patients are still undetermined. OBJECTIVES The aim of this study was to assess the efficacy and safety of rivaroxaban for the treatment of PICC-related UEDVT in cancer patients. METHODS We conducted a retrospective cohort study including consecutive cancer patients for the management of acute symptomatic PICC-related UEDVT. The efficacy outcome of the study was the 180-day recurrence of any venous thromboembolism (VTE), while the safety outcome was the 180-day incidence of all bleeding events. The Kaplan‒Meier method was used to estimate the overall incidence. Hazard ratios (HRs) were obtained with a Cox proportional hazards model to estimate the risk of the outcome events. RESULTS A total of 217 patients were included in the final analysis with a median age of 56 years old, 41.5% of whom had metastases. After the initial 3-5 days of nadroparin, patients received sequential anticoagulation, either with nadroparin (118 patients) or with rivaroxaban (99 patients). Four patients with recurrent VTE were observed (nadroparin, n = 2; rivaroxaban, n = 2). The 180-day cumulative VTE recurrence rates were 1.7% and 2.0% (p = 0.777) in patients receiving nadroparin and rivaroxaban, respectively. The overall bleeding rate at 180 days was 8.8%. Although no major bleeding events were observed, nineteen patients with clinically relevant nonmajor bleeding (CRNMB) were observed. The 180-day cumulative rate of CRNMB was 5.1% for nadroparin and 13.1% for rivaroxaban (HR = 3.303, 95% CI 1.149-9.497, p = 0.027). CONCLUSION Our study supported the efficacy of rivaroxaban for treating PICC-related UEDVT in cancer patients. However, data on anticoagulation therapy for PICC-related UEDVT presented with a low risk of VTE recurrence and a relatively high risk of CRNMB bleeding events. Considering the risk-benefit ratio, further well-designed trials are required to optimize the drug selection and duration for the treatment of PICC-related UEDVT in cancer patients.
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Affiliation(s)
- Jiaxuan Xu
- grid.412474.00000 0001 0027 0586Department of Critical Care Medicine, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Guodong Wang
- grid.412474.00000 0001 0027 0586Department of Critical Care Medicine, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Xiaojie Chen
- grid.412474.00000 0001 0027 0586Department of Critical Care Medicine, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Yanfen Shen
- grid.412474.00000 0001 0027 0586Department of Critical Care Medicine, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Xinpeng Wang
- grid.412474.00000 0001 0027 0586Department of Critical Care Medicine, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Hongzhi Wang
- grid.412474.00000 0001 0027 0586Department of Critical Care Medicine, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
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14
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Wang TF. The 5 most frequently asked questions about factor Xa inhibitors. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:515-521. [PMID: 36485108 PMCID: PMC9821165 DOI: 10.1182/hematology.2022000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Direct oral anticoagulants (DOACs) are commonly used oral factor Xa inhibitors in recent years. However, in some special clinical situations, the appropriate use of these anticoagulants may be of concern. In this article, we address the 5 commonly asked questions regarding their use for the treatment of venous thromboembolism, including in the setting of obesity, renal impairment, gastrointestinal (GI) malignancy, catheter-related thrombosis, and drug-drug interactions. Data on the use of DOACs in the presence of significant obesity or renal failure are mainly observational. Some DOACs are shown to have an increased risk of bleeding in patients with unresected luminal GI malignancy but not others, so selection of appropriate patients is the key. Furthermore, literature on the use of DOACs for catheter-related thrombosis or when drug-drug interactions are of concern is limited, and more research is welcome.
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Affiliation(s)
- Tzu-Fei Wang
- Correspondence Tzu-Fei Wang, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 201A, Ottawa, ON K1H 8L6, Canada; e-mail:
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15
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Fu J, Cai W, Zeng B, He L, Bao L, Lin Z, Lin F, Hu W, Lin L, Huang H, Zheng S, Chen L, Zhou W, Lin Y, Fu F. Development and validation of a predictive model for peripherally inserted central catheter-related thrombosis in breast cancer patients based on artificial neural network: A prospective cohort study. Int J Nurs Stud 2022; 135:104341. [DOI: 10.1016/j.ijnurstu.2022.104341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 04/21/2022] [Accepted: 08/02/2022] [Indexed: 10/31/2022]
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16
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Lipe DN, Qdaisat A, Rajha E, Al-Breiki A, Cruz Carreras MT, Chaftari P, Yeung SCJ, Rice TW. Characteristics and predictors of venous thrombosis recurrence in patients with cancer and catheter-related thrombosis. Res Pract Thromb Haemost 2022; 6:e12761. [PMID: 36000091 PMCID: PMC9391569 DOI: 10.1002/rth2.12761] [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] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 05/23/2022] [Accepted: 06/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background Central venous catheters raise the risk of catheter‐related thrombosis (CRT) in patients with cancer, typically affecting the upper extremity. Management of CRT involves catheter removal and anticoagulation. However, robust evidence is lacking on the optimal timing of anticoagulation relative to catheter removal. Objectives Our goal is to provide a better understanding of the factors that increase the risk of recurrent venous thromboembolism (VTE) in these patients. Patients and Methods We conducted a retrospective chart review of all consecutive patients with cancer in our hospital affected by CRT between January 1, 2015, and December 31, 2017. We measured recurrence of VTE as thrombosis in any vascular bed or pulmonary embolism, for up to 2 years after diagnosis. Logistic and competing risk regression analyses were used to determine the association between different clinical factors and any VTE recurrence in patients with cancer and CRT. Results Of the 257 individuals meeting the inclusion criteria, 80.2% had their catheter removed; of these, 50.5% did not receive anticoagulation before the removal. Patients who did not receive anticoagulation before the removal had increased 3‐month and 1‐year risks of recurrent VTE (odds ratio, 5.07 [95% confidence interval [CI], 1.53–23.18]; and hazard ratio, 3.47 [95% CI, 1.34–9.01]), respectively. Conclusions Our study supports the use of anticoagulants before catheter removal in patients with CRT. Randomized clinical trials are recommended to establish stronger evidence pertaining to the long‐term risk of VTE recurrence and the effect of catheter reinsertion.
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Affiliation(s)
- Demis N Lipe
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Aiham Qdaisat
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Eva Rajha
- Department of Emergency Medicine Baylor College of Medicine Houston Texas USA
| | - Aisha Al-Breiki
- Department of Emergency Medicine Sultan Qaboos University Hospital Muscat Oman
| | - Maria T Cruz Carreras
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Patrick Chaftari
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Sai-Ching J Yeung
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
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17
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Best practice & research: Clinical hematology review on thrombosis and bleeding in hematological malignancy. Best Pract Res Clin Haematol 2022; 35:101353. [DOI: 10.1016/j.beha.2022.101353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 01/19/2023]
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18
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19
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[Chinese expert consensus on the diagnosis and treatment of venous thromboembolism after hematopoietic stem cell transplantation (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:184-196. [PMID: 35405775 PMCID: PMC9072068 DOI: 10.3760/cma.j.issn.0253-2727.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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20
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Valeriani E, Di Nisio M, Porceddu E, Agostini F, Pola R, Spoto S, Donadini MP, Ageno W, Porfidia A. Anticoagulant treatment for upper extremity deep vein thrombosis: A systematic review and meta-analysis. J Thromb Haemost 2022; 20:661-670. [PMID: 34846783 DOI: 10.1111/jth.15614] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data on anticoagulant treatment for upper extremity deep vein thrombosis (UEDVT) are largely derived from studies on usual site venous thromboembolism (VTE). OBJECTIVES The objective of this meta-analysis was to evaluate the efficacy and safety of anticoagulant therapy for UEDVT. PATIENTS/METHODS A systematic search of MEDLINE and EMBASE was conducted for studies including patients with UEDVT. Primary outcomes were recurrent VTE and major bleeding. Secondary outcomes included clinically-relevant non-major bleeding and all-cause mortality. Summary estimates with 95% confidence intervals (CIs) were calculated by random-effect meta-analysis. RESULTS A total of 1473 patients from 11 prospective and nine retrospective studies were included. Sixty percent of patients had an indwelling catheter and 56.1% had cancer. Anticoagulant treatment consisted of direct oral anticoagulants, low molecular weight heparin followed by vitamin K antagonists, and low molecular weight heparin alone in 45.1%, 35.0%, and 19.9% of patients, respectively. During a median follow-up of 13 months, recurrent VTE occurred in 3% of patients (95% CI: 2-4; 21/1334 patients), major bleeding in 3% (95% CI: 2%-5%; 29/1235 patients), clinically-relevant non-major bleeding in 4% (95% CI: 3-6; 40/1075 patients), and all-cause mortality in 9% (95% CI: 5-15; 108/1084 patients). Rates of these outcomes were not significantly different between patients with or without cancer, patients with or without an indwelling catheter, and among those receiving different anticoagulant treatments. CONCLUSIONS In patients with UEDVT, anticoagulant treatment is associated with a low risk of recurrent VTE and a nonnegligible risk of major bleeding.
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Affiliation(s)
- Emanuele Valeriani
- Diagnostic and Therapeutic Medicine Department, University Campus Bio-Medico of Rome, Rome, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Enrica Porceddu
- Department of Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - Fabiana Agostini
- Department of Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - Roberto Pola
- Department of Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
| | - Silvia Spoto
- Diagnostic and Therapeutic Medicine Department, University Campus Bio-Medico of Rome, Rome, Italy
| | | | - Walter Ageno
- Department of Clinical Medicine, University of Insubria, Varese, Italy
| | - Angelo Porfidia
- Department of Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore School of Medicine, Rome, Italy
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21
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Ageno W. Treatment of Atypical Clots. Hamostaseologie 2022; 42:10-18. [PMID: 35196729 DOI: 10.1055/a-1669-3336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
The term unusual site thrombosis refers to the occurrence of venous thromboembolism outside of the lower limbs and the pulmonary arteries. Unusual site thrombosis can virtually affect any venous segment, with the most common and/or clinically relevant sites including the upper limbs veins, the retinal veins, the splanchnic veins and the cerebral veins. Clinical features are obviously heterogeneous, while many predisposing factors are common, though with different prevalence among the various disorders. Antithrombotic therapy is prescribed to most patients, but the type, intensity, and duration of treatment vary both within and among patient groups. Increasing evidence is supporting the use of the direct oral anticoagulants in patients with upper limb deep vein thrombosis, cerebral vein thrombosis, and with splanchnic vein thrombosis. This article will review available evidence on the treatment of venous thrombosis occurring in unusual sites.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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22
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Carrier M, Blais N, Crowther M, Kavan P, Le Gal G, Moodley O, Shivakumar S, Suryanarayan D, Tagalakis V, Wu C, Lee AYY. Treatment Algorithm in Cancer-Associated Thrombosis: Updated Canadian Expert Consensus. Curr Oncol 2021; 28:5434-5451. [PMID: 34940092 DOI: 10.3390/curroncol28060453] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/02/2021] [Accepted: 12/13/2021] [Indexed: 12/20/2022] Open
Abstract
Patients with cancer-associated thrombosis (CAT) are at high risk of recurrent venous thromboembolism (VTE) and major bleeding complications. Risks vary significantly between individuals based on cancer status, treatment, and other characteristics. To facilitate the evidence-based management of anticoagulant therapy in this patient population, a committee of 11 Canadian clinical experts updated a consensus-based algorithm for the acute and extended treatment of symptomatic and incidental CAT that was developed in 2018. Following a systematic review of the literature, updates to the algorithm were discussed during an online teleconference, and the algorithm was subsequently refined based on feedback from committee members. Clinicians using this treatment algorithm should consider bleeding risk, type of cancer, and drug-drug interactions, as well as patient and clinician preferences, in tailoring anticoagulation for patients with CAT. Anticoagulant therapy should be adapted as the patient's cancer status and management change over time.
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Affiliation(s)
- Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | - Normand Blais
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC H2L 4M1, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON L8N 4A6, Canada
| | - Petr Kavan
- Department of Oncology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | - Otto Moodley
- Department of Hematology, Royal University Hospital, Saskatoon, SK S7N 0W8, Canada
| | - Sudeep Shivakumar
- Department of Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax, NS B3H 3A7, Canada
| | - Deepa Suryanarayan
- Department of Medicine, University of Calgary, Foothills Hospital, Calgary, AB T2N 2T9, Canada
| | - Vicky Tagalakis
- Department of Medicine, Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, QC H3T 1E2, Canada
| | - Cynthia Wu
- Department of Medicine, University of Alberta, Edmonton, AB T5J 2J7, Canada
| | - Agnes Y Y Lee
- Department of Medicine, University of British Columbia, British Columbia Cancer Agency, Vancouver, BC V5Z 4E6, Canada
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Debourdeau P, Lamblin A, Debourdeau T, Marcy PY, Vazquez L. Venous thromboembolism associated with central venous catheters in patients with cancer: From pathophysiology to thromboprophylaxis, areas for future studies. J Thromb Haemost 2021; 19:2659-2673. [PMID: 34363736 DOI: 10.1111/jth.15487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/02/2021] [Accepted: 08/05/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Pierre Yves Marcy
- Department of Diagnosis & Interventional Imaging, Polyclinics Les Fleurs, Ollioules, France
| | - Léa Vazquez
- Supportive Care Unit, Sainte Catherine Institute, Avignon, France
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24
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Marin A, Bull L, Kinzie M, Andresen M. Central catheter-associated deep vein thrombosis in cancer: clinical course, prophylaxis, treatment. BMJ Support Palliat Care 2021; 11:371-380. [PMID: 34413028 PMCID: PMC8606430 DOI: 10.1136/bmjspcare-2019-002106] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/07/2021] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Arnaldo Marin
- Department of Basic and Clinical Oncology, University of Chile Faculty of Medicine, Santiago, 8380453, Chile
| | - Leonardo Bull
- School of Medicine, University of Chile, Santiago, 8380453, Chile
| | - Matthew Kinzie
- Neurosciences, University of Texas Health, Houston, Texas, USA
| | - Max Andresen
- Intensive Care Department, Facultad de Medicina . Pontificia Universidad Catolica de Chile, Santiago, 8330077, Chile
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25
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LeBlanc R, Bergstrom DJ, Côté J, Kotb R, Louzada ML, Sutherland HJ. Management of Myeloma Manifestations and Complications: The Cornerstone of Supportive Care: Recommendation of the Canadian Myeloma Research Group (formerly Myeloma Canada Research Network) Consensus Guideline Consortium. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:e41-e56. [PMID: 34456159 DOI: 10.1016/j.clml.2021.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/14/2021] [Accepted: 07/29/2021] [Indexed: 11/18/2022]
Abstract
Multiple myeloma (MM) is a hematological cancer associated with significant symptomatic burden. Bone disease, renal insufficiency, cytopenias, infection, and peripheral neuropathy, among other disease manifestations and complications, impair patients' quality of life. The Canadian Myeloma Research Group Consensus Guideline Consortium, formerly Myeloma Canada Research Network Consensus Guideline Consortium, proposes national consensus recommendations for the management of MM-related manifestations and complications. To address the needs of Canadian physicians and people living with MM across the country, this document focuses on the improvement and maintenance of patient care by clarifying best-practice approaches for the prevention, detection and management of disease manifestations and complications. The Canadian Myeloma Research Group Consensus Guideline Consortium will periodically review the recommendations herein and update as necessary.
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Affiliation(s)
- Richard LeBlanc
- Hôpital Maisonneuve-Rosemont, University of Montreal, Montreal, QC, Canada.
| | | | - Julie Côté
- Centre hospitalier universitaire de Québec, Quebec, QC, Canada
| | - Rami Kotb
- CancerCare Manitoba, University of Manitoba, Winnipeg, MB, Canada
| | - Martha L Louzada
- London Health Sciences Centre, Western University, London, ON, Canada
| | - Heather J Sutherland
- Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, BC Cancer, University of British Columbia, Vancouver, BC, Canada
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26
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Current Recommendations for the Management of Cancer-Associated Venous Thromboembolism. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2021. [DOI: 10.2478/jce-2021-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Cancer-associated thrombosis (CAT) is a major cause of death in oncological patients. The mechanisms of thrombogenesis in cancer patients are not fully established, and it seems to be multifactorial in origin. Also, several risk factors for venous thromboembolism (VTE) are present in these patients such as tumor site, stage, histology of cancer, chemotherapy, surgery, and immobilization. Anticoagulant treatment in CAT is challenging because of high bleeding risk during treatment and recurrence of VTE. Current major guidelines recommend low molecular weight heparins (LMWHs) for early and long-term treatment of VTE in cancer patients. In the past years, direct oral anticoagulants (DOACs) are recommended as potential treatment option for VTE and have recently been proposed as a new option for treating CAT. This manuscript will give a short overview of risk factors involved in the development of CAT and a summary on the recent recommendations and guidelines for treatment of VTE in patients with malignancies, discussing also some special clinical situations (e.g. renal impairment, catheter-related thrombosis, and thrombocytopenia).
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Potere N, Candeloro M, Porreca E, DI Nisio M. Management of upper extremity deep vein thrombosis: an updated review of the literature. Minerva Med 2021; 112:746-754. [PMID: 33969964 DOI: 10.23736/s0026-4806.21.07578-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Upper extremity deep vein thrombosis (UEDVT) represents about 5-10% of all cases of deep vein thrombosis (DVT) with a steadily increasing incidence mostly due to the high prevalence of cancer and frequent use of intravascular devices such as central venous catheters and pacemaker. In primary UEDVT, the venous outflow obstruction and subsequent thrombosis are related to congenital or acquired anatomical abnormalities, whereas secondary UEDVT is often associated with malignancy or indwelling lines. A considerable proportion of patients with UEDVT develops serious complications such as recurrent thrombosis, post-thrombotic syndrome, and pulmonary embolism, therefore timely diagnosis and adequate treatment are of crucial importance. Despite sharing many similarities with lower extremity DVT, UEDVT has distinctive features requiring specific diagnostic and therapeutic approaches. The present review discusses the latest evidence on the epidemiology, diagnosis, and treatment of UEDVT, and provides management indications which may help guide clinical decision making.
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Affiliation(s)
- Nicola Potere
- Department of Innovative Technologies in Medicine and Dentistry, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Matteo Candeloro
- Department of Medicine and Ageing Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Ettore Porreca
- Department of Innovative Technologies in Medicine and Dentistry, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Marcello DI Nisio
- Department of Medicine and Ageing Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy -
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Mahé I, Meyer G, Girard P, Bertoletti L, Laporte S, Couturaud F, Mismetti P, Sanchez O. [Treatment of cancer associated thrombosis. 2019 update of the French guidelines]. Rev Mal Respir 2021; 38:427-437. [PMID: 33858733 DOI: 10.1016/j.rmr.2021.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/11/2021] [Indexed: 11/28/2022]
Affiliation(s)
- I Mahé
- Service de Médecine Interne-Hôpital Louis Mourier, Assistance publique des Hôpitaux de Paris, Colombes, Université de Paris, Inserm UMR_S1140, Paris, F-CRIN INNOVTE, St-Etienne, France
| | - G Meyer
- Service de Pneumologie et de soins intensifs, Hôpital Européen Georges-Pompidou, Assistance publique des Hôpitaux de Paris, Inserm UMRS 970, Université de Paris, Inserm CIC 1418, Paris, F-CRIN INNOVTE, St-Etienne, France
| | - P Girard
- Institut du Thorax Curie-Montsouris, l'Institut mutualiste Montsouris, Paris, F-CRIN INNOVTE, St-Etienne, France
| | - L Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Inserm UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, Inserm, CIC-1408, Saint-Etienne, F-CRIN INNOVTE, Saint-Etienne, France
| | - S Laporte
- SAINBOIS U1059 équipe DVH, Université Jean-Monnet, Université de Lyon, Inserm, Unité de recherche clinique, Innovation, Pharmacologie, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, F-CRIN INNOVTE, St-Etienne, France
| | - F Couturaud
- Département de médecine interne et pneumologie, EA3878-GETBO, CIC_INSERM1412, université de Bretagne occidentale, centre hospitalo-universitaire de Brest, F-CRIN INNOVTE, St-Etienne, France
| | - P Mismetti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Inserm UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, Inserm, CIC-1408, Saint-Etienne, F-CRIN INNOVTE, Saint-Etienne, France
| | - O Sanchez
- Service de Pneumologie et de soins intensifs, Hôpital européen Georges-Pompidou, Assistance publique des Hôpitaux de Paris, Université de Paris, Inserm UMRS 1140, Paris, F-CRIN INNOVTE, St-Etienne, France.
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Treatment of venous thromboembolism in cancer patients: The dark side of the moon. Cancer Treat Rev 2021; 96:102190. [PMID: 33812338 DOI: 10.1016/j.ctrv.2021.102190] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 02/08/2023]
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer. The risk of emergent VTE is four- to seven-fold higher in cancer patients compared to non-cancer patients. Although the therapeutic armamentarium for cancer-associated VTE has been recently implemented, anticoagulant treatment remains challenging because of the increased risk of recurrent VTE and bleeding. Several international societies and expert panels released clinical practice guidelines on VTE treatment which are mostly focused on the general cancer population. Nevertheless, recommendations for the management of VTE in patients with peculiar clinical presentations are inconsistent and remain elusive due to the lack of pertinent evidence. The challenging clinical scenarios include, among others, patients with thrombocytopenia, renal impairment, gastrointestinal cancer, primary or metastatic brain cancer, distal thrombosis of the lower extremities, catheter-related VTE, splanchnic thrombosis, incidental VTE, extreme body weight, recurrent VTE during treatment, as well as the optimal duration of anticoagulant treatment in patients with active disease who have received 3 to 6 months of anticoagulation. Herein, we present a critical overview on VTE management in these challenging clinical settings, discuss potential approaches, and include some calls to action for future clinical research.
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Abstract
This review aims to describe the epidemiology, pathophysiology, risk factors, presentation, complications, evaluation/diagnosis, and treatment of upper extremity deep vein thrombosis (UEDVT). Upper extremity deep vein thrombosis (UEDVT) accounts for 6% of cases of deep vein thrombosis (DVT). It can lead to swelling and discomfort in that extremity and can be complicated by pulmonary embolism, post-thrombotic syndrome, and recurrence of DVT. Evaluation can begin with a dichotomized Constans score and fibrin degradation product testing. Diagnosis is typically made with compression ultrasound. Anticoagulation is the mainstay of therapy. Primary UEDVT is known as Paget Schroetter Syndrome (PSS) which occurs due to venous thoracic outlet syndrome (vTOS). Anticoagulation, thrombolysis, and decompression of the venous thoracic outlet are used for treatment but the optimal strategy remains to be elucidated. Secondary UEDVT are most commonly caused by indwelling catheters and malignancy. There is an ongoing realization that UEDVT are more than simply 'leg clots in the arm.' Given the increasing incidence, research needs to be done to further our understanding of this disease state, its evaluation, and its treatment.
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Affiliation(s)
- Oneib Khan
- Lankenau Medical Center - Internal Medicine, Wynnewood, PA, USA
| | - Ashley Marmaro
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - David A Cohen
- Mainline Healthcare Internal Medicine at Lankenau Medical Center, Sidney Kimmel Medical College, Wynnewood, PA, USA
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Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv 2021; 5:927-974. [PMID: 33570602 PMCID: PMC7903232 DOI: 10.1182/bloodadvances.2020003442] [Citation(s) in RCA: 384] [Impact Index Per Article: 128.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. RESULTS Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. CONCLUSIONS Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.
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Affiliation(s)
- Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH
| | - Andrew D Leavitt
- Department of Laboratory Medicine and
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Oncology, BC Cancer, Vancouver site, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- American University of Beirut (AUB) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Center, American University of Beirut, Beirut, Lebanon; and
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
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32
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Wang TF, Billett HH, Connors JM, Soff GA. Approach to Cancer-Associated Thrombosis: Challenging Situations and Knowledge Gaps. Oncologist 2020; 26:e17-e23. [PMID: 33275323 DOI: 10.1002/onco.13570] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/21/2020] [Indexed: 11/10/2022] Open
Abstract
Malignancy is a significant risk factor for venous thromboembolism (VTE). It is estimated that up to 20% of patients with cancer may develop VTE at some time in their cancer journey. Cancer-associated VTE can lead to hospitalizations, morbidity, delayed cancer treatment, and mortality. The optimal prevention and management of cancer-associated thrombosis (CAT) is of utmost importance. Direct oral anticoagulants have been recommended as first-line therapy for VTE treatment in the general population and their efficacy has recently been demonstrated in the cancer population, leading to increased use. However, patients with cancer have unique challenges and comorbidities that can lead to increased risks and concerns with anticoagulation. Herein we will discuss commonly encountered challenges in patients with CAT, review available literature, and provide practice suggestions. IMPLICATIONS FOR PRACTICE: This article aims to specifically address cancer-associated thrombosis issues for which there is limited or absent evidence to guide best practice, for circumstances that pose unique challenges for clinicians, and for directions when the literature is conflicting. It reviews pertinent data for each selected topic and provides guidance for patient management based on the best available evidence and experiences from the panel.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Henny H Billett
- Division of Hematology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gerald A Soff
- Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Bosch FTM, Nisio MD, Büller HR, van Es N. Diagnostic and Therapeutic Management of Upper Extremity Deep Vein Thrombosis. J Clin Med 2020; 9:jcm9072069. [PMID: 32630244 PMCID: PMC7408847 DOI: 10.3390/jcm9072069] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 12/21/2022] Open
Abstract
Upper extremity deep vein thrombosis (UEDVT) accounts for 5% of all deep vein thromboses (DVTs). UEDVT may be complicated by post thrombotic syndrome and pulmonary embolism, and early recognition and prompt start of anticoagulant treatment are key. Primary UEDVT, also known as Paget-von Schrötter syndrome, is associated with repeated or sudden physical activity of the upper arm and venous outflow obstruction due to anatomical variations. Secondary UEDVT is often associated with malignancy or use of intravenous devices, such as central venous catheters or pacemaker leads. Although the diagnosis and treatment of UEDVT have many similarities with DVT of the lower extremities, knowledge of specific aspects regarding UEDVT is important to guide optimal management. In this review, we will discuss the epidemiology, diagnosis, and treatment of UEDVT based on the current literature.
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Affiliation(s)
- Floris T. M. Bosch
- Department of Internal Medicine, Tergooi Hospitals, 1213 XZ Hilversum, The Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.R.B.); (N.v.E.)
- Correspondence: ; Tel.: +31-20-566-8791
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, Gabriele D′Annunzio University, Via dei Vestini 31, 66100 Chieti, Italy;
| | - Harry R. Büller
- Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.R.B.); (N.v.E.)
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.R.B.); (N.v.E.)
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Beiswenger AC, Quereshy HA, Rouabhi M, Harth KC, Azim AA, Janko MR, Shevitz AJ, Bose S, Cho JSS, Kashyap VS. Midterm outcomes in patients with upper extremity deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2020; 8:930-938.e2. [PMID: 32457023 DOI: 10.1016/j.jvsv.2020.02.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 02/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Outcomes and the necessity for anticoagulation in patients with upper extremity deep vein thrombosis (UE DVT) are unclear. The purpose of this study was to determine the incidence of UE DVT, the outcomes of patients stratified by anticoagulation treatment, and which factors were significantly associated with mortality. METHODS This study was a single-center, retrospective review of all patients undergoing UE venous duplex imaging in 2016. Information on patients' demographics, relevant comorbidities, use of anticoagulation at the time of diagnosis, characteristics of the UE DVT, treatment regimen(s), and outcomes was collected. Data were analyzed using descriptive and univariate statistics; multivariate logistic regression and Cox proportional hazard models were used to identify which of the aforementioned covariates are significantly associated with mortality rates at 30 days and 6 months, respectively, at a 95% confidence level. RESULTS Of the 911 patients undergoing UE venous duplex imaging, 182 (20.0%) were positive for UE DVT. Within the first 30 days, 30 patients (16.5%) died, 13 (7.1%) had pulmonary emboli, 42 (23.1%) had either pulmonary emboli or died, and 3 (1.6%) had ischemic strokes. Within the first 6 months, 50 patients (27.5%) died. The mortality rate at 30 days was found to be significantly increased in patients who were older (odds ratio [OR], 1.06; P < .01), had high-risk contraindications to anticoagulation (OR, 5.14; P < .01), were on dialysis (OR, 3.03; P = .04), had centrally located UE DVTs (OR, 2.72; P < .05), and had a stroke (OR, 20.34; P = .03). Mortality was significantly decreased in patients who were treated with anticoagulation (OR, 0.16; P < .05). At 6 months, however, age (hazard ratio [HR], 1.05; P < .001), male sex (HR, 2.16; P = .02), dialysis (HR, 2.90; P = .01), high-risk contraindications to anticoagulation (HR, 2.67; P = .02), UE DVTs in both central and peripheral veins (HR, 4.55; P = .03), and ischemic stroke in the first 30 days (HR, 71.63; P < .001) were associated with significant increases in mortality. CONCLUSIONS These data suggest that mortality rates among patients with UE DVT are relatively high and that treatment with anticoagulation is associated with a decrease in mortality at 30 days. Mortality was also associated with multiple comorbid conditions and demographics and not necessarily venous thromboembolism.
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Affiliation(s)
| | | | - Mohamed Rouabhi
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Karem C Harth
- The Vascular Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Anas Abdel Azim
- The Vascular Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Matthew R Janko
- The Vascular Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Andrew J Shevitz
- William Carey University College of Osteopathic Medicine, Hattiesburg, Miss
| | - Saideep Bose
- The Vascular Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jae-Sung S Cho
- The Vascular Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Vikram S Kashyap
- The Vascular Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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35
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Rokosh RS, Ranganath N, Yau P, Rockman C, Sadek M, Berland T, Jacobowitz G, Berger J, Maldonado TS. High Prevalence and Mortality Associated with Upper Extremity Deep Venous Thrombosis in Hospitalized Patients at a Tertiary Care Center. Ann Vasc Surg 2020; 65:55-65. [DOI: 10.1016/j.avsg.2019.10.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 12/18/2022]
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36
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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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Muñoz Martín AJ, Gallardo Díaz E, García Escobar I, Macías Montero R, Martínez-Marín V, Pachón Olmos V, Pérez Segura P, Quintanar Verdúguez T, Salgado Fernández M. SEOM clinical guideline of venous thromboembolism (VTE) and cancer (2019). Clin Transl Oncol 2020; 22:171-186. [PMID: 31981080 DOI: 10.1007/s12094-019-02263-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Abstract
In 2011, the Spanish Society of Medical Oncology (SEOM) first published a clinical guideline of venous thromboembolism (VTE) and cancer. This guideline was updated in 2014, and since then, multiple studies and clinical trials have changed the landscape of the treatment and prophylaxis of VTE in cancer patients. To incorporate the most recent evidence, including data from direct oral anticoagulants (DOACs) randomized clinical trials, SEOM presents a new update of the guideline.
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Affiliation(s)
- A J Muñoz Martín
- Medical Oncology Department, Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo, 46, 28007, Madrid, Spain.
| | - E Gallardo Díaz
- Medical Oncology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - I García Escobar
- Medical Oncology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - R Macías Montero
- Medical Oncology Department, Complejo H. Universitario, Badajoz, Spain
| | - V Martínez-Marín
- Medical Oncology Department, Hospital Universitario la Paz, Madrid, Spain
| | - V Pachón Olmos
- Medical Oncology Department, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERONC, Madrid, Spain
| | - P Pérez Segura
- Medical Oncology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | - M Salgado Fernández
- Medical Oncology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
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Norris AH, Shrestha NK, Allison GM, Keller SC, Bhavan KP, Zurlo JJ, Hersh AL, Gorski LA, Bosso JA, Rathore MH, Arrieta A, Petrak RM, Shah A, Brown RB, Knight SL, Umscheid CA. 2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis 2020; 68:e1-e35. [PMID: 30423035 DOI: 10.1093/cid/ciy745] [Citation(s) in RCA: 161] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Indexed: 12/16/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.
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Affiliation(s)
- Anne H Norris
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Genève M Allison
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Sara C Keller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kavita P Bhavan
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - John J Zurlo
- Division of Infectious Diseases, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City
| | - Lisa A Gorski
- Wheaton Franciscan Home Health & Hospice, Part of Ascension at Home, Milwaukee, Wisconsin
| | - John A Bosso
- Departments of Clinical Pharmacy and Outcome Sciences and Medicine, Colleges of Pharmacy and Medicine, Medical University of South Carolina, Charleston
| | - Mobeen H Rathore
- University of Florida Center for HIV/AIDS Research, Education and Service and Wolfson Children's Hospital, Jacksonville
| | - Antonio Arrieta
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County Division of Pediatrics, University of California-Irvine School of Medicine
| | | | - Akshay Shah
- Metro Infectious Disease Consultants, Northville, Michigan
| | - Richard B Brown
- Division of Infectious Disease Medical Center, University of Massachusetts School of Medicine, Worcester
| | - Shandra L Knight
- Library & Knowledge Services, National Jewish Health, Denver, Colorado
| | - Craig A Umscheid
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia
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Prabhash K, Munot P, Noronha V, Patil V, Joshi A, Menon N. Cancer thrombosis: Narrative review. CANCER RESEARCH, STATISTICS, AND TREATMENT 2020. [DOI: 10.4103/crst.crst_18_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Mahé I, Meyer G, Sanchez O. [What are the special features of the treatment of venous thromboembolic disease in the course of cancer?]. Rev Mal Respir 2019; 38 Suppl 1:e138-e144. [PMID: 31703829 DOI: 10.1016/j.rmr.2019.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- I Mahé
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Université de Paris, Service de médecine interne, AH-HP, hôpital Louis-Mourier, 92700 Colombes, France; Innovations Thérapeutiques en Hémostase, INSERM UMRS 1140, 75006 Paris, France
| | - G Meyer
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Université de Paris, Service de pneumologie et soins intensifs, AH-HP, Hôpital Européen Georges-Pompidou, 75015 Paris, France; INSERM UMRS 970, INSERM CIC 1418, 75015 Paris, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Innovations Thérapeutiques en Hémostase, INSERM UMRS 1140, 75006 Paris, France; Université de Paris, Service de pneumologie et soins intensifs, AH-HP, Hôpital Européen Georges-Pompidou, 75015 Paris, France.
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41
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Cires-Drouet R, Sharma J, McDonald T, Sorkin JD, Lal BK. Variability in the management of line-related upper extremity deep vein thrombosis. Phlebology 2019; 34:552-558. [PMID: 30704347 PMCID: PMC7012441 DOI: 10.1177/0268355519827155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Central-venous devices are risk-factors for upper extremity deep vein thrombosis. We surveyed physicians to identify practice-patterns and adherence to American College of Chest Physicians guidelines. Methods: The 13-question survey obtained physician-demographics and treatment-choices. Respondents were grouped into surgical and medical specialists. Data were reported as ratios and percentages, and compared using Fisher’s exact test. Results: We received 143 responses from physicians; 65% treated one-to-two new cases/month. Most physicians (69.2%) used anticoagulation; 36.4% retained the catheter and 32.9% removed it. Medical-specialists retained catheters more often than surgeons (p = 0.027). For recurrences, 84% repeated anticoagulation; 50.3% retained the catheter. A majority anticoagulated upper-extremity deep-vein thrombosis in long-term catheters for three months only (55.1%). Direct oral anticoagulants were used frequently (43.6%). Only 10% believed that existing guidelines were appropriate and only 2.8% followed all guidelines. Conclusion: There is great variability in treatment-decisions for upper-extremity deep-vein thrombosis. The existing guidelines are considered inadequate and not followed by most physicians.
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Affiliation(s)
- Rafael Cires-Drouet
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Jashank Sharma
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tara McDonald
- Claude D. Pepper Older Americans Independence Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - John D Sorkin
- Claude D. Pepper Older Americans Independence Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Baltimore VA Medical Center Geriatric Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
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Shatzel JJ, Mart D, Bien JY, Maniar A, Olson S, Liem TK, DeLoughery TG. The efficacy and safety of a catheter removal only strategy for the treatment of PICC line thrombosis versus standard of care anticoagulation: a retrospective review. J Thromb Thrombolysis 2019; 47:585-589. [PMID: 30673943 DOI: 10.1007/s11239-019-01807-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Peripherally-inserted central catheters (PICCs) are commonly used during hospitalization. Unfortunately, their use can be complicated by catheter-related thrombosis (CRT). Current guidelines recommend 3-6 months of anticoagulation for patients with CRT after catheter removal. This recommendation is based on extrapolation of data on lower extremity thrombosis, as data is lacking regarding the efficacy and safety of more specific management strategies. Many providers feel catheter removal alone is a reasonable treatment option, particularly for patients at risk for bleeding. We performed a retrospective analysis of hospitalized adult patients diagnosed with CRT at our center. We determined rates of progressive thrombosis and bleeding in cohorts of patients who underwent catheter removal vs those who had catheters removed and received anticoagulation. Among 83 total patients, 62 were treated with PICC removal alone, while 21 underwent PICC removal followed by therapeutic anticoagulation. Patients treated with PICC removal alone were more likely to have hematologic malignancy, receive chemotherapy, develop thrombocytopenia, and have brachial vein thrombosis. No patients in the PICC removal plus anticoagulation arm developed progressive thrombosis, while 6.4% of patients treated with catheter removal alone developed a secondary VTE event, including one PE, three DVTs, and five patients (8%) who developed progressive symptoms leading to initiation of anticoagulation. Major bleeding was significantly more common in the PICC removal + anticoagulation arm (28.5% vs. 4.8% p = 0.007). Catheter-removal alone results in significantly reduced major bleeding compared with catheter-removal plus anticoagulation. In select patients, catheter removal alone may be an option for CRT.
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Affiliation(s)
- Joseph J Shatzel
- Department of Hematology & Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
| | - Dylan Mart
- Department of Hematology & Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Jeffrey Y Bien
- Department of Hematology & Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Ashray Maniar
- Department of Hematology & Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Sven Olson
- Department of Hematology & Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Timothy K Liem
- Department of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Thomas G DeLoughery
- Department of Hematology & Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
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43
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Innovative application of an implantable venous access system in the portal vein: technique, results and complications in three dogs. BMC Vet Res 2019; 15:240. [PMID: 31296216 PMCID: PMC6621995 DOI: 10.1186/s12917-019-1986-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/30/2019] [Indexed: 11/22/2022] Open
Abstract
Background Vascular access port (VAP) systems are widely used in human medicine to provide long-term venous access. However, in veterinary medicine the use of VAP systems is not common practice and publications on their potential applications have been limited. A VAP system was used as part of an experimental study on liver regeneration and implanted in the canine portal vein to create direct access to the portal venous circulation of the liver. The aim of the present study is to describe the surgical technique, its use, and the complications of a VAP system in three research dogs. Results The VAP system was successfully used for the intraoperative measurement of portal blood pressure, the administration of cell suspensions, and the collection of portal venous blood samples. Long-term complications consisted of dislocation of the VAP system in one dog (2 months after implantation) and thrombus formation at the catheter tip in two dogs (3 months after implantation). Both complications prevented further use of the VAP but had no adverse clinical implications. Conclusions This pilot study suggests that the VAP system is an effective and safe technique to obtain long term access to the portal venous system in dogs. However, complications with port detachment and thrombosis may limit long term use of VAPs in the portal system of dogs.
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Woller SC, Stevens SM, Johnson SA, Bledsoe JR, Galovic B, Lloyd JF, Wilson EL, Armbruster B, Evans RS. Apixaban for Routine Management of Upper Extremity Deep Venous Thrombosis (ARM-DVT): Methods of a prospective single-arm management study. Res Pract Thromb Haemost 2019; 3:340-348. [PMID: 31294320 PMCID: PMC6611360 DOI: 10.1002/rth2.12208] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/05/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Upper extremity deep vein thrombosis (UEDVT) constitutes approximately 10% of all deep vein thromboses (DVTs). The incidence of UEDVT is increasing in association with use of peripherally inserted central venous catheters. Treatment for UEDVT is derived largely from evidence for treatment of lower extremity DVT. Limited evidence exists for the use of a direct oral anticoagulant for the treatment of UEDVT. POPULATION Sequential patients identified within the Intermountain Healthcare System and University of Utah Healthcare system with symptomatic UEDVT defined as the formation of thrombus within the internal jugular, subclavian, axillary, brachial, ulnar, or radial veins of the arm. INTERVENTION Apixaban 10 mg PO twice daily for 7 days followed by apixaban 5 mg twice daily for 11 weeks. COMPARISON The historical literature review rate of venous thrombosis reported for recurrent clinically overt objective venous thromboembolism (VTE) and VTE-related death. If the confidence interval for the observed rate excludes the threshold event rate of 4%, we will conclude that treatment with apixaban is noninferior and therefore a clinically valid approach to treat UEDVT. SAMPLE SIZE We elected a sample size of 375 patients so that an exact 95% confidence interval would exclude an event rate of VTE in the observation cohort of 4%. OUTCOME Ninety-day rate of new or recurrent objectively confirmed symptomatic venous thrombosis and VTE-related death. The primary safety outcome is the composite of major and clinically relevant nonmajor bleeding.
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Affiliation(s)
- Scott C. Woller
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Scott M. Stevens
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Stacy A. Johnson
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Joseph R. Bledsoe
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Brian Galovic
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - James F. Lloyd
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Emily L. Wilson
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - Brent Armbruster
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
| | - R. Scott Evans
- Intermountain Medical CenterUniversity of Utah School of MedicineEccles Outpatient Care CenterMurrayUtah
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45
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Lazo‐Langner A. Studies in upper extremity deep vein thrombosis: Addressing the knowledge gaps. Res Pract Thromb Haemost 2019; 3:312-314. [PMID: 31294317 PMCID: PMC6611369 DOI: 10.1002/rth2.12210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 11/26/2022] Open
Affiliation(s)
- Alejandro Lazo‐Langner
- Department of MedicineDivision of HematologyWestern UniversityLondonONCanada
- Department of Epidemiology and BiostatisticsWestern UniversityLondonONCanada
- Department of OncologyWestern UniversityLondonONCanada
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46
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Thiyagarajah K, Ellingwood L, Endres K, Hegazi A, Radford J, Iansavitchene A, Lazo-Langner A. Post-thrombotic syndrome and recurrent thromboembolism in patients with upper extremity deep vein thrombosis: A systematic review and meta-analysis. Thromb Res 2019; 174:34-39. [DOI: 10.1016/j.thromres.2018.12.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/13/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
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Rajasekhar A, Streiff MB. Etiology and Management of Upper-Extremity Catheter-Related Thrombosis in Cancer Patients. Cancer Treat Res 2019; 179:117-137. [PMID: 31317484 DOI: 10.1007/978-3-030-20315-3_8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Anita Rajasekhar
- Division of Hematology/Oncology, Department of Medicine, University of Florida, PO Box 100278, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7300, Baltimore, MD, 21205, USA
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48
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How I treat cancer-associated venous thromboembolism. Blood 2018; 133:291-298. [PMID: 30478093 DOI: 10.1182/blood-2018-08-835595] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/18/2018] [Indexed: 12/17/2022] Open
Abstract
Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a common complication of cancer and is associated with significant morbidity and mortality. Several cancer-related risk factors contribute to the development of VTE including cancer type and stage, chemotherapy, surgery, and patient-related factors such as advanced age and immobilization. Patients with cancer frequently undergo diagnostic imaging scans for cancer staging and treatment response evaluation, which is increasing the underlying risk of VTE detection. The management of cancer-associated VTE is challenging. Over the years, important advances have been made and, recently, randomized controlled trials have been published helping clinicians' management of this patient population. In this review, we will discuss common cancer-associated VTE scenarios and critically review available evidence to guide treatment decisions.
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Htun KT, Ma MJY, Lee AYY. Incidence and outcomes of catheter related thrombosis (CRT) in patients with acute leukemia using a platelet-adjusted low molecular weight heparin regimen. J Thromb Thrombolysis 2018; 46:386-392. [PMID: 30014300 DOI: 10.1007/s11239-018-1711-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Kay T Htun
- Department of Haematology, Peninsula Health, Frankston, VIC, Australia
| | - Mabel J Y Ma
- University of British Columbia, Vancouver, Canada
| | - Agnes Y Y Lee
- Department of Medicine, University of British Columbia, British Columbia Cancer Agency, Vancouver, Canada. .,Gordon and Leslie Diamond Health Care Centre, 2775 Laurel Street, 10th Fl, Vancouver, BC, V5Z 1M9, Canada.
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50
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Carrier M, Blais N, Crowther M, Kavan P, Le Gal G, Moodley O, Shivakumar S, Tagalakis V, Wu C, Lee AYY. Treatment algorithm in cancer-associated thrombosis: Canadian expert consensus. ACTA ACUST UNITED AC 2018; 25:329-337. [PMID: 30464682 DOI: 10.3747/co.25.4266] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Management of anticoagulant therapy for the treatment of venous thromboembolism (vte) in cancer patients is complex because of an increased risk of recurrent vte and major bleeding complications in those patients relative to the general population. Subgroups of patients with cancer also show variation in their risk for recurrent vte and adverse bleeding events. Accordingly, a committee of 10 Canadian clinical experts developed the consensus risk- stratification treatment algorithm presented here to provide guidance on tailoring anticoagulant treatment choices for the acute and extended treatment of symptomatic and incidental vte, to prevent recurrent vte, and to minimize the bleeding risk in patients with cancer. During a 1-day live meeting, a systematic review of the literature was performed, and a draft treatment algorithm was developed. The treatment algorithm was refined through the use of a Web-based platform and a series of online teleconferences. Clinicians using this treatment algorithm should consider the bleeding risk, the type of cancer, and the potential for drug-drug interactions in addition to informed patient preference in determining the most appropriate treatment for patients with cancer-associated thrombosis. Anticoagulant therapy should be regularly reassessed as the patient's cancer status and management change over time.
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Affiliation(s)
- M Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - N Blais
- Department of Medicine, Centre hospitalier de l'Université de Montréal, Montreal, QC
| | - M Crowther
- Department of Medicine, McMaster University, Hamilton, ON
| | - P Kavan
- Department of Oncology, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, QC
| | - G Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - O Moodley
- Department of Hematology, Royal University Hospital, Saskatoon, SK
| | - S Shivakumar
- Department of Medicine, qeii Health Sciences Centre, Dalhousie University, Halifax, NS
| | - V Tagalakis
- Department of Medicine, Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, QC
| | - C Wu
- Department of Medicine, University of Alberta, Edmonton, AB
| | - A Y Y Lee
- Department of Medicine, University of British Columbia, BC Cancer, Vancouver, BC
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