Catheter-related Deep Venous Thrombosis Research Articles

Safety of non-cuffed tunneled central venous catheters in adults with cystic fibrosis

BackgroundPeripherally inserted central catheters (PICCs) are the most common route of intravenous (I.V.) access for treatment of cystic fibrosis (CF) pulmonary exacerbations, but repeated PICC placement can result in upper extremity peripheral venous stenosis. Once peripheral stenosis develops, a non-cuffed tunneled central venous catheter (NcTCVC) is an alternative route for IV access. While these are regularly used at some CF centers, the safety and complication rate compared to PICCs in adults with CF has not been reported. This study aims to describe the safety of NcTCVCs in adults with CF. MethodsA retrospective cohort study was performed at a CF Foundation accredited institution including adults with CF who received NcTCVCs in interventional radiology from 7/19/2007 to 3/09/2020. Complications analyzed included catheter related deep venous thrombosis (DVT), central line associated blood stream infection (CLABSI), and catheter related central venous stenosis. Complications were considered attributable if they occurred while the catheter was in place or within 30 days of catheter removal. ResultsDuring the study duration, 386 NcTCVCs were placed in 60 unique patients (55 % female) with a mean of 6.4 catheters per patient. Majority of NcTCVCs placed were 4 French (61.4 %). Average duration of indwelling NcTCVC was 16.2 days. No patients demonstrated catheter attributable symptomatic DVT. The incidence of DVT, CLABSI, and central venous stenosis was 0 (0 %), 4 (1 %), and 1 (0.3 %), respectively. ConclusionsMany adults with CF have required insertion of numerous PICCs for the treatment of recurrent pulmonary exacerbations. In those adults that develop PICC-associated peripheral vein stenosis precluding PICC placement, these results indicate NcTCVCs are a safe alternative.

Short-Course Versus Prolonged-Course Antimicrobial Therapy in Adults With Catheter-Related Septic Thrombosis: A Propensity-Weighted Retrospective Study

Abstract Background Optimal duration of antimicrobial therapy (AT) for catheter-related septic deep venous thrombosis (DVT) is unknown. We aimed to compare the outcomes of patients receiving short-course AT (≤21 days) versus prolonged-course AT (>21 days). Methods This was a monocentric retrospective study comparing adults with catheter-related septic DVT from 2015 to 2020 treated with short- or prolonged-course AT. A propensity score–weighted analysis was used to mitigate potential bias. The primary outcome was a composite of all-cause mortality or recurrent bloodstream infection 30 days after AT discontinuation. Results Of 172 patients with catheter-related septic DVT, 104 were treated with prolonged-course AT and 68 with short-course AT. In the propensity score analysis, we found no significant difference in 30-day all-cause mortality or relapse between the 2 groups (inverse probability of treatment weighted hazard ratio [wHR], 2.16 [95% confidence interval {CI}, .68–6.88]; P = .192). No differences in 90-day all-cause mortality and 90-day relapse were observed between the treatment groups (wHR, 1.01 [95% CI, .49–2.05], P = .987 and 1.13 [95% CI, .08–15.62], P = .928, respectively). Conclusions A 21-day AT could be an effective and safe option to treat catheter-related septic DVT. Further randomized studies are needed to establish the optimal duration of AT for patients with catheter-related septic DVT.

Risks factors and outcomes for isolated catheter-related deep venous thrombosis in patients undergoing allogeneic hematopoietic stem cell transplantation

IntroductionPatients undergoing allogenic hematopoietic stem cell transplantation (allo-HSCT) require indwelling central venous catheters. The comparative incidence, risk, and outcome of isolated catheter-related deep venous thrombosis (CR-DVT) versus pulmonary embolism/lower-extremity DVT (PE/LE-DVT) remains unclear. Materials and methodsWe conducted a retrospective cohort study for patients undergoing allo-HSCT from 2006 to 2019. CR-DVT and PE/LE-DVT outcomes were screened using ICD codes and radiology reports and confirmed by medical record reviews. Cox regression models were used to assess the association between thrombotic outcomes and pertinent baseline and time-varying covariates. The impact of thrombotic events within 1-year post-transplant (time-varying) on overall mortality was also assessed. ResultsAmong 2879 patients, the cumulative incidence of isolated CR-DVT and PE/LE-DVT at 12 months was 4.2 % and 4.8 %, respectively. The strongest time-varying predictor for onset of CR-DVT and PE/LE-DVT was hospitalization inpatient status (HR 3.71 [95 % CI 2.16–6.37] and 3.99 [95 % CI 2.00–7.99], respectively). Other overlapping variables included lymphoma diagnosis and BMI > 35 kg/m2, whereas acute GVHD grades 2–4 were found to be significantly associated with risk of PE/LE-DVT but not CR-DVT. After adjusting for baseline variables and acute GVHD, the occurrences of CR-DVT and PE/LE-DVT were both independently associated with increased overall mortality (HR 1.58 [95 % CI 1.23–2.02] and HR 1.53 [95 % CI 1.19–1.97], respectively). ConclusionsWe observed a high incidence of both CR-DVT and PE/LE-DVT with overlapping and unique risk factors. CR-DVT was also associated with increased mortality similar to PE/LE-DVT. Standardized strategies targeting high-risk hospitalization periods may help mitigate the development of thrombotic outcomes post-transplant.

A RARE CASE: CHEMOPORT TIP DISPLACEMENT FROM PERSISTENT VOMITING AND RETCHING

A RARE CASE: CHEMOPORT TIP DISPLACEMENT FROM PERSISTENT VOMITING AND RETCHING

Comparison of Central Venous Catheter Related Deep Venous Thrombosis According to Insertion Site in an Intensive Care Unit of Bangladesh

Background: Central venous catheter (CVC) is usually inserted into subclavian, internal jugular, orfemoral vein in critically ill patients. CVCs are associated with intravascular (infectious, thrombotic) andmechanical complications. CVC related deep venous thrombosis (DVT) is a common intravascularcomplication.Objectives: To see the variation in occurrence of CVC related deep venous thrombosis according todifferent insertion site. Method: It was a prospective observational study conducted in dept. of Critical Care Medicine, BIRDEMGeneral Hospital; during a period of May, 2016 to July, 2019. Purposive sampling was conducted in patientsfulfilling the selection criteria. The CVCs were percutaneously inserted using the Seldinger techniquewith standard operating procedure. After CVC insertion, patients were followed up daily to see any signof deep venous thrombosis. After catheter removal [due to any cause including suspected catheterrelated blood stream infection (CRBSI), DVT, mechanical cause], all the study patients were investigated byduplex ultrasonography (USG) within 2 days for detection of venous thrombosis. The outcome wascatheter related deep venous thrombosis (DVT). Results: A total 349 patients, of which 167 (47.9%) patients had CVC in subclavian, 88 (25.2%) in internaljugular and 94 (26.9%) in femoral vein. Total 12 patients were suspected to have catheter related DVT, but11(3.2%) patients were confirmed as DVT by duplex USG. DVT occurred significantly higher in femoralcatheter site (8.5%) than subclavian (1.8%) and internal jugular site (0%). Conclusion: The occurrence of catheter related DVT was higher in femoral site than other two sites. J MEDICINE 2022; 23: 20-23

Tunneled Femoral Vein Catheterization for Long-term Hemodialysis - Experience from a Tertiary Care Center.

Introduction:Tunneled femoral vein hemodialysis catheters are used when all other options for permanent vascular access or jugular central vein catheter are exhausted. There is little published literature on the outcome and survival of tunneled femoral vein catheters.Methods:Using a retrospective database, we identified all tunneled femoral dialysis catheters placed in the Nephrology department of our institute over a one-and-half year period. The outcomes, complications, and patency of these procedures was retrospectively evaluated.Results:Out of total 21 patients, 14 were female and 7 males with a mean age of 45 (range 17–73 years) and about one-fourth had diabetes mellitus (26%). Right-sided femoral catheter insertion was performed in 18 patients (85.7%) and 3 patients underwent left-sided insertion. Technical success of placement was 100% with no immediate complications. Median follow up period was 24 days. Primary catheter patency at 30, 60, 90, and 180 days were 81, 29, 18, and 12.5%, respectively. Three patients (15.7%) developed catheter-related deep venous thrombosis. Three catheters (14.2%) were removed for catheter-related infection and seven (33.3%) were removed because of absent blood flow.Conclusion:Our experience with tunneled femoral catheters revealed low catheter survival and significant complications (deep venous thrombosis and malfunction/occlusion).

Unfractionated Heparin (UFH) For Prevention of Central Venous Catheter Thrombotic Complications in Children: A systematic review and meta-analysis

Abstract Objective To determine the efficacy of unfractionated heparin in reducing central venous catheter-related deep venous thrombosis and/or catheter thrombotic occlusion in children by systematically searching the literature and conducting a meta-analysis study. Methods Four electronic databases (PubMed, Google Scholar, Elsevier’s thrombosis journal, and the Cochrane Central Register for Controlled Trials) were searched for journal peer-reviewed articles published in the period from Jan 2000 to Dec 2018. The search criteria included observational studies, and randomized controlled trials on patients aged 0–18 years with central venous catheters (CVC), which compare between the effect of UFH (flushes, lock solutions, continuous infusion, and heparin bonded catheter) and no prophylaxis (Normal saline flush or no treatment) for the prevention of CVC thrombotic complications (CVC-related deep venous thrombosis (DVT) and/or catheter thrombotic occlusion). Two authors independently reviewed and identified the eligible studies, which were assessed for study methodology including bias, and extraction of unadjusted data whenever available. To pool data from eligible studies, the meta-analysis was performed on RevMan version 5.3. Odds ratios were generated with the corresponding 95% CI through the random-effect model. Results Of the 413 articles identified, only eight studies were eligible with 1380 patients. Our results revealed that UFH was significantly superior on control group in reducing thrombotic occlusion and/or CVC-related DVT (odds ratio 0.39, 95% CI: 0.19:0.8) (p 0.01). Conclusion The published data support the hypothesis that using UFH as a thromboprophylaxis may significantly reduce catheter thrombotic complication in pediatric patients with CVC.

HIGH-2-LOW risk model to predict venous thromboembolism in allogeneic transplant patients after platelet engraftment.

Venous thromboembolism (VTE) after allogeneic hematopoietic cell transplantation (HCT) is a significant treatment-associated complication, although optimal timing of thromboprophylaxis remains uncertain when weighing concurrent risks of bleeding. We aimed to derive and internally validate a risk assessment model (RAM) using patients who underwent first allogeneic HCT from 2006 through 2015 (n = 1703). Index date was defined as the 30th day after transplant, at which point we estimated >75% of patients would have achieved platelet engraftment >50 × 109/L. Stepwise logistic regression modeling was used for model development, and internal validation was achieved by fitting a logistic regression model with 1000 bootstrapped resamples to estimate the optimism-corrected c-statistic. The final RAM, "HIGH-2-LOW," included 7 predictors obtained at 30 days after transplant: History of catheter-related deep venous thrombosis (DVT), Inpatient at day 30, Graft-versus-host disease grade 3 to 4, History of pulmonary embolism or lower-extremity DVT, Lymphoma diagnosis, Obesity with body mass index ≥35 kg/m2, and White blood cell count ≥11 × 109/L. Approximately 16% of patients were stratified as high risk, with incident VTE rate of 10.3% at 100 days compared with 1.5% for those at low risk. VTE odds ratios at 100 days were 5.87 (95% confidence interval [CI], 2.98-11.57) and 2.71 (95% CI, 1.38-5.35) in the high- and intermediate-risk vs low-risk groups, respectively. HIGH-2-LOW model serves as a novel and potentially clinically meaningful tool to identify high-risk allogeneic HCT patients who may benefit from early thromboprophylaxis after platelet engraftment.

Web Exclusive. Annals for Hospitalists Inpatient Notes - How I Treat-Catheter-Related Deep Venous Thrombosis.

Web Exclusives21 May 2019Annals for Hospitalists Inpatient Notes - How I Treat—Catheter-Related Deep Venous ThrombosisVineet Chopra, MD, MScVineet Chopra, MD, MScUniversity of Michigan Health System and Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan (V.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-1172 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail With growing use of peripherally inserted central catheters (PICCs), upper-extremity deep venous thrombosis (DVT) is becoming more common. In a study of hospitalized medical patients, upper-extremity DVT accounted for half of all hospital-onset cases and most of these events were associated with PICCs (1). In a systematic review and meta-analysis, these catheters were found to be associated with a 2.5-fold risk for thrombosis compared with other central venous catheters. Of note, risk for DVT with PICCs was greater in patients with cancer and those with critical illness (2). Because hospitalists often care for and treat patients with PICCs and because ...

Clinical impact of peripherally inserted central catheters vs implanted port catheters in patients with cancer: an open-label, randomised, two-centre trial

BackgroundCentrally inserted totally implanted vascular access ports (PORTs) and peripherally inserted central catheters (PICCs) are widely used for the administration of chemotherapy. Our aim was to study the incidence of catheter-related deep venous thrombosis in patients with cancer receiving chemotherapy through either a PICC or a PORT. MethodsAdults with non-haematological cancer (mainly breast and colorectal) from two Swedish oncology centres were included and followed for up to 1 yr. Patients were randomly assigned to receive a single-lumen PICC or PORT. The primary end point was the occurrence of a clinically significant catheter-related deep venous thrombosis, and the secondary end point was a composite of adverse events related to the catheter: insertion complication, thrombosis, occlusion, infection, and mechanical problems. ResultsThe trial recruited 399 participants (PICC, n=201; PORT, n=198) between March 2013 and February 2017. The PICCs were associated with 16 (8%) deep venous thromboses compared with two (1%) in the PORT group (HR=10.2; 95% confidence interval, 2.3–44.6; P=0.002). The overall incidence of composite adverse events was higher for patients with a PICC compared with those with a PORT (HR=2.7; 95% confidence interval, 1.6–4.6; P<0.001). ConclusionsPICCs are associated with higher risk for catheter-related deep venous thrombosis and other adverse events when compared with PORTs. This increased risk should be considered when choosing a vascular access device for chemotherapy, especially in patients with solid malignancy. Clinical trial registrationNCT01971021.

Outcomes in a nurse-led peripherally inserted central catheter program: a retrospective cohort study.

Peripherally inserted central catheters (PICCs) provide enormous benefit to patients. However, recent publications have highlighted relatively high PICC-associated complication rates. We report on patient and device outcomes from a nurse-led program. We performed a retrospective analysis of a prospective cohort of consecutive patients undergoing PICC insertion at The Ottawa Hospital between Jan. 1, 2013 and Dec. 31, 2014. Of the 8314 BioFlo PASV PICCs inserted, we randomly selected a sample of 700 and obtained a complete data set for 656. We measured the cumulative incidence of major complications (catheter-related bloodstream infections and deep vein thrombosis) and use of a thrombolytic to alleviate occlusions. The total number of catheter days was 58 486, and the median dwell time 45 days. We observed 4 cases of catheter-related bloodstream infection (0.6% [95% CI 0.17%-1.55%]) (0.07/1000 catheter days). Ten patients (1.5% [95% CI 0.83%-2.78%]) (0.17/1000 catheter days) had catheter-related deep venous thrombosis. At least 1 dose of thrombolytic was required in 75 catheters (11.4% [95% CI 8.61%-13.39]), 31 (7.1%) of the 436 single-lumen catheters and 113 (25.7%) of the 440 lumina of dual-lumen catheters (p < 0.001). We attribute our low rates of major complications to a nurse-led expert insertion team, standardized care and maintenance protocols, high insertion volumes, novel catheter material and continuous quality-improvement initiatives that are implemented and evaluated regularly. We conclude that the considerable benefits PICCs provide to patients are attained with a low risk of major complications.

口腔がん再建術後に中心静脈カテーテル関連深部静脈血栓症を生じた2例

口腔がん再建術後に中心静脈カテーテル関連深部静脈血栓症を生じた2例

MRI after removal of central venous access device reveals a high number of asymptomatic thromboses in children with haemophilia

Central venous access devices (CVADs) are often required in children with haemophilia to secure venous access for prophylactic treatment or immune tolerance therapy. Complications of CVADs include infections, thrombosis and mechanical problems. This study sought to determine the outcome of the vessels by magnetic resonance imaging (MRI) in children with haemophilia and to assess risk factors for development of catheter-related deep venous thrombosis (DVT). After the removal of CVAD an MRI of the chest and neck was performed to 20 boys with haemophilia who each had 1-3 (total number 27) CVADs placed. MRI revealed DVT in five children (25%). As their CVADs were functional at the time of the removal, the DVTs were clinically silent. However, there had been suspicion of DVT leading to replacement of the CVAD in one case. All the children with DVT had their CVADs inserted initially below the age of 1 year. The clinical signs of mild post-thrombotic syndrome (PTS) were common: dilated chest wall veins were observed in 11 (55%) children and were associated with DVT in three cases. Arm circumference discrepancy was observed in one child with DVT. No correlation between the duration or number of CVADs and DVT was detected. None of the patients had subjective symptoms of PTS. Silent DVT is a common complication of CVAD. Catheter insertion at a young age seems to predispose to thrombosis. The long-term consequences of the DVTs remain unknown.

The impact of early thromboembolic event on prognosis in cancer patients: A single-center analysis of 1,838 patients.

e19694 Background: Thromboembolic events (TE) are common complication of cancer, may lead to mortality and detoriate quality of life. “Initial period”, (first 3 months) after the diagnosis of cancer holds the highest risk for development of cancer-associated TE. Methods: Between 2007 to 2010, we retrospectively evaluated the occurence of TE in patients with histologically confirmed solid tumors. The diagnosis of TE is confirmed by radiology and patients were treated accordingly. One hundred five of 1838 patients (5.7%) were diagnosed as TE. Twenty nine of 105 patients (28%) had TE at initial period and 76 (72%) had TE at delayed (later than three months) period. Results: There was no statistical significant relationship for age and gender between TE and non-TE groups. Forty three (41%) had distal lower extremity (DLE) deep venous thrombosis (DVT), 33 (31%) had PE and the rest includes 15 central/proximal DVT (14%), 8 PE with DLE DVT (8%), 4 central venous catheter-related DVT (4%) and 2 upper extremity DVT (2%). Frequencies for TE according to histopathology were; Non Hodgkin’s lymphoma (6/36=16.7%), pancreatic cancer (13/79=16.5%), gastric cancer (17/152=11.2%), NSCL (adenocarcinoma) (9/82=11%), GBM (4/53=7.5%) and colorectal cancer (21/312=6.7%). Median survival was 30.5 months for TE group and 127 months for non-TE group (log-rank, p=0.0001). Median time from diagnosis to TE was 7.25 months. Median overall survival was 15 months and 34.25 months for patients with TE at initial period and with delayed TE (log-rank, p=0.011), respectively.The diagnosis of TE were more frequent in advanced stage (stage I-II vs stage III-IV, 13/105=12% vs 92/105=88% respectively, p=0.0001) and with histology of adenocarcinoma (84/105=80% vs 21/105=20% respectively, p=0.016). Odds ratio (OR) for TE in patients with adenocarcinoma histology was 1.8 [ 95% confidence interval (CI):1.1-2.9], and with advanced stage, OR was 4.35 [95% CI:2.42-7.84]. OR for TE in patients with adenocarcinoma at advanced stage was 2.54 [95% CI:1.44-4.49] Conclusions: In our patient cohort, having TE at initial period, histology of adenocarcinoma and advanced stage emerged as independent prognostic factors for poor survival in cancer patients.

Thromboses sur cathéter central chez le patient cancéreux

Increased incidence of cancers and the development of totally implanted venous access devices that contain their own port to deliver chemotherapy will lead to a greater than before numbers of central venous catheter-related thrombosis (CVCT). Medical consequences include catheter dysfunction and pulmonary embolism. Vessel injury caused by the procedure of CVC insertion is the most important risk factor for development of CVCT. This event could cause the formation of a fresh thrombus, which is reversible in the large majority of patients. In some cases, thrombus formation is not related to catheter insertion. The incidence of CVC-related DVT assessed by venography has been reported to vary from 30 to 60% but catheter-related DVT in adult patients is symptomatic in only 5% of cases. The majority of patients with CVC-related DVT is asymptomatic or has nonspecific symptoms: arm or neck swelling or pain, distal paresthesias, headache, congestion of subcutaneous collateral veins. In the case of clinical suspicion of CVC-related deep venous thrombosis (DVT), compressive ultrasonography (US), especially with doppler and color imaging, currently is first used to confirm the diagnosis. Consequently, contrast venography is reserved for clinical trials and difficult diagnostic situations. There is no consensus on the optimal management of patients with CVC-related DVT. Treatment of CVC-related VTE requires a five- to seven-day course of adjusted-dose unfractionated heparin or low molecular weight heparin (LMWH) followed by oral anticoagulants. Long-term LMWH that has been shown to be more effective than oral anticoagulant in cancer patients with lower limb DVT, could be used in these patients. The efficacy and safety of pharmacologic prophylaxis for CVC related thrombosis is not established and the last recommendations suggest that clinicians not routinely use prophylaxis to try to prevent thrombosis related to long-term indwelling CVCs in cancer patients. Additional studies performed in high risk populations with appropriate dosage and timing will help to define which patients could benefit from prophylaxis.

Thromboses sur cathéter central chez le patient cancéreux

Increased incidence of cancers and the development of totally implanted venous access devices that contain their own port to deliver chemotherapy will lead to a greater than before numbers of central venous catheter related thrombosis (CVCT). Medical consequences include catheter dysfunction and pulmonary embolism. Compared with lower extremity deep venous thrombosis (DVT) (3 d) and with non CVC associated thrombosis (5 d), CVCT is associated with an increased duration of hospitalisation (9 d). CVCT oftentimes leads to the need to replace such ports at an average cost of 4500 euros. Vessel injury caused by the procedure of CVC insertion is the most important risk factor for development of CVCT. This event could cause the formation of a fresh thrombus, which is reversible in the large majority of patients. The incidence of CVC-related DVT assessed by venography has been reported to vary from 30 to 60% but catheter-related DVT in adult patients is symptomatic in only 5% of cases. The majority of patients with CVC-related DVT is asymptomatic or has non-specific symptoms: arm or neck swelling or pain, distal paresthesias, headache, congestion of subcutaneous collateral veins. In the case of clinical suspicion of CVC-related DVT, compressive ultrasonography (US), especially with Doppler and color imaging, currently is first used to confirm the diagnosis. The main criteria of color-Doppler US are visualization of mural thrombi or incompressibility of the veins. Consequently, contrast venography is reserved for clinical trials and difficult diagnostic situations. There is no consensus on the optimal management of patients with CVC-related DVT. Treatment of CVC-related VTE requires a 5- to 7-day course of adjusted-dose unfractionated heparin or LMWH followed by oral anticoagulants. Long-term LMWH that has been shown to be more effective than oral anticoagulant in cancer patients with lower limb DVT could be used in these patients. The optimal duration of oral anticoagulation treatment for CVC-related DVT is unknown, but patients with active cancer should be treated for at least 6 months or indefinitely. The efficacy and safety of pharmacologic prophylaxis for CVC related thrombosis is not established. Additional studies performed in high risk populations are needed to define if LMWH or oral anticoagulation is indicated in this clinical setting.

Di-(2-ethylhexyl)phthalate and Deep Venous Thrombosis in Children: A Clinical and Experimental Analysis

Five children with catheter-related deep venous thrombosis were encountered in our PICU. Three types of polyvinyl chloride tubing for the administration of intravenous solutions were in use (Terumo, Codan, and Perfusend). All were di-(2-ethylhexyl)phthalate plasticized. We suspected problems with the Codan tubing. Different types of tubing at different time intervals in vitro were investigated. Tubing segments were assessed on structural alterations by surface electron microscopy. High-performance liquid chromatography-diode array detection and liquid chromatography-mass spectrometry-diode array detection were performed to identify and to quantify di-(2-ethylhexyl)phthalate. The hospital's minimal clinical data set (coded with the International Classification of Diseases, Ninth Revision, Clinical Modification) was investigated on catheter-related deep venous thrombosis between 2000 and 2004. Surface electron microscopy demonstrated that the Codan tubing's inner surface was severely altered, showing large particles (34.5 +/- 6.1 microm). High-performance liquid chromatography documented that all Codan samples showed a peak at the di-(2-ethylhexyl)phthalate retention time. The analysis of the minimal clinical data set for total catheter-related deep venous thrombosis showed an unusual high incidence in 2001 (52) compared with the expected 36 per year. Such occurrence of catheter-related deep venous thrombosis led to the assumption that disintegration of intravenous tubing resulted in intravenous administration of debris. Our data suggested that the particles derived from the tubing are of such size that they might induce catheter-related deep venous thrombosis. The absence of catheter-related deep venous thrombosis caused by the introduction of submicron inline filters outlines the important pathophysiological role of di-(2-ethylhexyl)phthalate-plasticized particles in the onset of catheter-related deep venous thrombosis. Our data indicate that a considerable number of patients might have been exposed to di-(2-ethylhexyl)phthalate, and a major concern is whether this jeopardized the health of the patients at that time.

Catheter-Related Deep Venous Thrombosis and Other Catheter Complications in Children With Cancer

Asymptomatic deep vein thrombosis (DVT) is a complication of central venous catheter (CVC) use in children with cancer, but its clinical significance is not well defined. Children with CVCs commonly experience two other CVC-related complications: occlusion and infection. The aim of this study was to determine the frequency of these two complications and their association with DVT. We conducted a retrospective cohort study of patients who were diagnosed with cancer. Data collected included number and type of catheter insertions, duration of use, reason for removal, associated catheter complications, and demographic information. Catheters were placed in 287 patients for a total of 128,403 days (mean, 290 +/- 269 days/catheter). Of 21 patients (7%) diagnosed with CVC-related DVT, only five had specific signs or symptoms. Nineteen (90%) of these 21 children had prior history of catheter occlusion, and 10 of the 19 also experienced infection. Ten children (48%) were not identified as having DVT until they had had multiple catheters with recurrent complications. Odds of having DVT were higher in patients who had a single catheter complicated by repeated occlusions (odds ratio [OR], 3.7; P = .001) or infection (OR, 2.2; P = .016). Patients experiencing both infection and occlusion were at 6.4 times (P < .0001) higher risk of developing DVT. Children with CVC-related DVT frequently have recurrent catheter complications. Unrecognized thrombosis may therefore be clinically important. Prospective studies are needed to determine if identification and treatment of occult DVT will prevent additional CVC-related complications and prolong the duration of catheter use.

Pediatric Norms for Assessment of Upper Venous Post-Thrombotic Syndrome.

Local collateral vessel formation, increased arm circumference, and upper extremity pain are the most frequently used clinical criteria for upper venous system post-thrombotic syndrome (PTS), a potentially serious complication of central venous catheter-related deep venous thrombosis. However, norms for variation of arm circumferences and vessel prominence have not been established for either children or adults. The objective of this study was to define average arm circumference differences and upper body vein prominence in normal children. Healthy children were recruited for the study at both an inner city continuity care clinic and a suburban private practice office. Efforts were made to include age and race/ethnicity distributions similar to the US population. Children with serious medical conditions or history of central venous catheter use were excluded. After permission was obtained from a parent or guardian, bilateral upper arm circumferences were measured, and data were collected regarding hand dominance, race/ethnicity, gender, age, height, weight, and history of chronic or intermittent arm pain. To evaluate the superficial veins, we developed and utilized an objective 5-point scale of chest, upper arm, neck, and shoulder vein prominence. Two hundred fifteen normal children (age 3–18 yrs, median 7 yrs; 53% female; 47% Caucasian, 21% African American, 26% Hispanic, 6% Asian) were evaluated. The mean variation between arm circumferences was 0.4 ± 0.03 cm (mean± SEM, 95% CI 0.35–0.46), and the mean percent difference between arms was 1.93 ± 0.1% (95% CI 1.7%–2.2%). There was no correlation of arm circumference measurements with age, gender, race/ethnicity, handedness, or body mass index. Of the 215 children examined, 47 (22%) had veins that were more than minimally visible (grade ≥ 2), with 54% of those demonstrating asymmetry in vessel prominence. Race/ethnicity did influence vessel prominence (p = 0.02), with an apparent correlation between vessel prominence and skin pigmentation. Twenty-eight percent of Caucasian and 27% of Hispanic children had veins that were more than minimally visible, while only 9% of African American and 7% of Asian children had veins that were more than minimally visible. There was no correlation between vessel prominence and age, gender, handedness, or body mass index. Although a history of arm pain was reported by 29 children (13%), it was rarely validated by parents. Almost all reports of arm pain were easily explained as muscle strain, sprains, broken bones, or “sleeping wrong,” and only 1 child had parentally confirmed pain of unexplained etiology. In conclusion, arm circumference variation, reports of pain, and prominent superficial veins on the chest wall, neck, shoulder, or arm are encountered frequently in normal children. Caution should be used when applying these criteria for a diagnosis of upper venous system PTS in children with prior or current central venous catheters in place. These data should be employed to develop and validate a scale for more objective diagnosis of PTS.

Factor V Leiden and G20210A prothrombin mutation and the risk of subclavian vein thrombosis in patients with breast cancer and a central venous catheter

BackgroundTo analyze the influence of the prothrombotic gene mutation factor V G1691A (factor V Leiden) and prothrombin G20210A on the risk of a first episode of catheter-related deep venous thrombosis (DVT) in a group of patients with breast cancer treated with chemotherapy. Patients and methodsBetween January 1999 and February 2001, the occurrence of a first symptomatic DVT was investigated in a cohort of 300 consecutive patients with locally advanced or metastatic breast cancer treated at a single institution with fluorouracil-based chemotherapy, administered continuously through a totally implanted access port. A nested case–control study included 25 women (cases) with catheter-related DVT and 50 controls without DVT matched with cases for age, identical chemotherapy, stage of disease and prognostic features. The G1691A factor V and G20210A prothrombin mutation genotypes were analyzed. ResultsFive cases [20%; 95% confidence interval (CI) 9% to 39%)] and two controls (4%; 95% CI 1% to 14%) were heterozygous carriers of G1691A factor V (P = 0.04). The age-adjusted odds ratio for catheter-related DVT was 6.1 (95% CI 1.1–34.3). Only one patient (case) had the G20210A prothrombin gene mutation. Time from start of chemotherapy infusion to DVT was not significantly different between patients with (median 31 days) and without (median 43 days) G1691A factor V mutation (P = 0.6). ConclusionsFactor V Leiden carriers with locally advanced or metastatic breast cancer have an increased risk of developing catheter-related DVT during chemotherapy.