Treatment Of Catheter-related Thrombosis Research Articles

Mid-term analysis of prospective cohort study of rivaroxaban in preventing CRT in breast cancer

Objective: To explore the efficacy and safety of Rivaroxaban in preventing catheter related thrombosis (CRT) in patients with breast cancer who are undergoing central venous catheter chemotherapy, and provide basis for making standardized prevention and treatment strategies. Methods: In this research, a prospective cohort study was adopted, and breast cancer patients who received central venous catheter chemotherapy in Sanhuan Cancer Hospital during September 2020 to March 2022 were selected as a treatment group to take the rivaroxaban anticoagulation therapy with 10 mg.po.qd for one month. The control group got no preventive anticoagulation therapy. Vascular ultrasound examination was taken to confirm the occurrence of CRT, and a chi-square test was done for comparison the disparity between the groups. Logistic regression was applied to analyze the univariate and multivariate factors for the formation of CRT. Results: In the research, a total of 235 patients were selected, and there were a total of 19 035 days of catheterization with 81 days of catheterization on average. While in the control group, the incidence of CRT was 28.0% (33/118), the incidence of CRT in the treatment group was 20.5% (24/117), the difference was no significant (P=0.183). Subgroup analysis results showed that the peripherally inserted central catheter (PICC) was performed in 165 cases with the CRT incidence of 18.2% (30/165) and thrombosis was mostly seen around axillary vein, accounting for 63.3%. Subclavian vein catheterization was performed in 63 cases with the CRT incidence of 39.7% (25/63), and thrombosis was mostly seen around subclavian vein, accounting for 88.0% (22/25). Implantable venous access port was implanted in 7 cases around subclavian vein and internal jugular vein with the CRT incidence of 28.6% (2/7). The patients who developed CRT within 30 days after catheterization accounted for 54.4% (31/57), 22.8% (13/57) in a period during 30 days and 60 days) and 22.8% (13/57) in a period during 60 days and 180 days). The diagnosed CRT patients had been treated with rivaroxaban 15 mg.bid.po for 3 months. During the 3 months, 100.0% of the thrombosis waned, 71.9% (41/57) of the thrombosis waned within 30 days, 19.3% (11/57) in a period during 30 and 60days and 8.8% (5/57) in a period during 60 days and 90 days. Univariate and multivariate analysis indicated that the risk of CRT in subclavian vein catheterization was higher than that in PICC, respectively (OR=2.898, 95% CI:1.386-6.056 P=0.005), and the type of catheterization was an independent factor for the formation of thrombosis. Safety analysis result showed that in the prevention of CRT, rivaroxaban treatment did not induce drug-related bleeding, liver function damage, bone marrow suppression or any other side effects. While CRT diagnosed patients were treated with anticoagulation, they kept the central venous catheter, and the infusion was smooth. These patients all finished the anti-tumor treatment as planned, and no abnormalities like new thrombosis or pulmonary embolism were observed. Conclusions: In the mid-term analysis, the proportion of Rivaroxaban in preventing anticoagulant CRT decreases, but it don't reach statistical significance. The sample size should be further increased for observation. Rivaroxaban is proved effective and very safe in the treatment of CRT, and does not affect the concurrent chemotherapy. Medical personnel should carry out the policy of "early prevention, early detection and early treatment" for CRT so as to improve the patients' quality of life.

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

BackgroundPostoperative lung cancer patients belong to the high-risk group for venous thromboembolism (VTE). The standardized preventive measures for perioperative VTE in lung cancer are not perfect, especially for the prevention and treatment of catheter-related thrombosis (CRT) caused by carried central venous catheters (CVCs) in lung cancer surgery.Patients and methodsThis study included 460 patients with lung cancer undergoing video-assisted thoracic surgery (VATS) in our center from July 2020 to June 2021. Patients were randomized into two groups, and intraoperatively-placed CVCs would be carried to discharge. During hospitalization, the control group was treated with low-molecular-weight heparin (LMWH), and the experimental group with LMWH + intermittent pneumatic compression (IPC). Vascular ultrasound was performed at three time points which included before surgery, before discharge, and one month after discharge. The incidence of VTE between the two groups was studied by the Log-binomial regression model.ResultsCRT occurred in 71.7% of the experimental group and 79.7% of the control group. The multivariate regression showed that the risk of developing CRT in the experimental group was lower than in the control group (Adjusted RR = 0.889 [95%CI0.799–0.989], p = 0.031), with no heterogeneity in subgroups (P for Interaction > 0.05). Moreover, the fibrinogen of patients in the experimental group was lower than control group at follow-up (P = 0.019).ConclusionIPC reduced the incidence of CRT during hospitalization in lung cancer patients after surgery.Trial registrationNo. ChiCTR2000034511.

Exploration of the high-risk factors of catheter-related thrombosis in breast cancer

Objective: To explore the high risk factors of catheter-related thrombosis (CRT) in breast cancer patients, and provide the basis for the development of appropriate prevention and treatment strategies. Methods: A total of 1 432 breast cancer patients scheduled to receive central venous catheterization in National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College from January 1, 2015 to August 31, 2019 were selected. Baseline information and catheterization information of patients were collected. The occurrence of CRT was confirmed by vascular ultrasound examination, and the influencing factors of CRT were analyzed. Results: The total number of catheter days were 121, 980 days in 1 432 patients with breast cancer, and the average number of catheter days in each patient was 85.2 days. The incidence of CRT was 6.8% (97/1 432), which was 0.79 cases/1 000 catheter days. Among 815 patients with centrally inserted central venous catheters (CICC), 43 (5.3%) had CRT, which was 0.70 cases/1 000 catheter days. Among 617 patients with peripherally inserted central venous catheters (PICC), 54 (8.8%) developed CRT, which was 0.90 cases/1 000 catheter days. CRT was most common in subclavian vein (63.9%). Multivariate regression analysis showed that age ≥ 60 years old (OR=1.712, 95% CI: 1.056-2.775, P=0.029), PICC (OR=1.732, 95% CI: 1.130-2.656, P=0.012), the catheter position except subclavian vein (OR=10.420, 95% CI: 1.207-89.991), secondary adjustment of catheter position (OR=3.985, 95% CI: 1.510-10.521, P=0.005) and high D-Dimer level (OR=1.129, 95% CI: 1.026-1.241, P=0.012)were independent risk factors for CRT. Conclusions: The CRT problem can't be ignored in the clinical treatment of breast cancer patients with central venous catheterization. Screening the appropriate age of patients and the type of central venous catheters, reducing the secondary adjustment of catheter position, and timely monitoring the level of D-dimer are helpful to the prevention and treatment of CRT.

Treatment of catheter-related thrombosis in patients with hematologic malignancies: A Venous thromboEmbolism Network U.S. retrospective cohort study

IntroductionOptimal treatment of catheter-related thrombosis (CRT) is uncertain in patients with hematologic malignancy. We aimed to evaluate the treatment strategies, outcomes, and predictors of recurrent venous thromboembolism (VTE) associated with catheter-related thrombosis (CRT) in patients with hematologic malignancy. MethodsWe performed a multicenter retrospective cohort study of eight institutions through the Venous thromboEmbolism Network US. Patients with hematologic malignancies with documented CRT were identified using ICD-9 and ICD-10 diagnostic codes. Semi-competing risks proportional hazard regression models were created. Results and conclusionsOf the 663 patients in the cohort, 124 (19%) were treated with anticoagulation alone, 388 (58%) were treated with anticoagulation and catheter removal, 119 (18%) treated with catheter removal only, and 32 (5%) had neither catheter removal nor anticoagulation. 100 (15%) patients experienced a recurrent VTE event. In the 579 patients who had catheter removal, the most common reason for catheter removal was the CRT [392 (68%)]. For subjects who received any anticoagulation (n = 512), total anticoagulation duration was not associated with VTE recurrence [1.000 (0.999–1.002)]. After adjustment patients treated with catheter removal only had an increased risk of VTE recurrence [2.50 (1.24–5.07)] and death [4.96 (2.47–9.97)]. Patients with no treatment had increased risk of death [16.81 (6.22–45.38)] and death after VTE recurrence [27.29 (3.13–238.13)].In this large, multicenter retrospective cohort, we found significant variability in the treatment of CRT in patients with hematologic malignancy. Treatment without anticoagulation was associated with recurrent VTE.

Catheter Related Thrombosis (CRT) in Hematologic Malignancy: A Retrospective Study of Venous Thromboembolism Management

Introduction: Central Venous Catheters (CVC) improve quality of life for patients with hematologic malignancy but long-term presence may result in CRT. Optimal treatment of CRT is uncertain. Here, we focus on a retrospective study of CRT in patients with hematologic malignancy to identify clinical features associated with increased risk for recurrent thrombosis. Methods: Demographic and management information of patients with CRT and hematologic malignancy was extracted from the medical record of a single academic medical center. Data was described using summary statistics. Nonparametric Cox proportional hazard models were utilized for thrombosis recurrence and bleeding occurrence. Unadjusted models were utilized for CRT treatment, type of anticoagulation, platelet count, and other factors. Results: 85 patients were included for analysis. Summary statistics are noted in Table 1. Median platelet count differed across initial treatment approach [Anticoagulation (AC): 177 (106.5- 662), Anticoagulation and Catheter Removal (AC+): 112 (61.75-304), Catheter Removal only 24 (20.25-35.5), No treatment 30.5 (16.75-10.8), p<0.0001]. For CRT treatment, patients with AC+ have more than a 660 % chance of thrombosis recurrence compared to AC as reference group. This significant difference is also seen in the Kaplan Meir curves for CRT treat (log-rank p=0.0484), Figure 1. Of note, 15 patients treated with AC+ developed recurrent thrombosis, the majority of which (53%, 8/15) occurred within 100 days. Of these patients, 62% (5/8 patients) had at least 2 days delay in starting anticoagulation while no delays in starting anticoagulation were noted in patients who were primarily treated with AC. Of the 8 patients who received no therapy for CRT, 7/8 patients (87%) had noted brachial (peripheral deep). Discussion: Significant variability in management of CRT in patients with hematologic malignancy is noted. Platelet count at time of thrombosis may influence treatment decision. Our data indicate that treatment with anticoagulation is superior to treatment without anticoagulation. The difference in thrombosis recurrence seen in patients who received AC v. AC+ could potentially be explained by delays in starting AC in the latter group. Interestingly, patients who did not receive any therapy for CRT had no recurrence, which may be explained by the fact that the majority had peripheral deep thrombosis, which are less likely to have deep recurrences. In addition, type of anticoagulation used for treatment was notHowever, our data is limited by its population of single institutional patients and retrospective nature. Prospective, studies are needed to better delineate differences in outcomes. Disclosures Jaglal: NOVARTIS: Consultancy.

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

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

Wide Variation in Duration of Anticoagulation after Catheter-Related Thrombosis: A Venous Thromboembolism Network US Multicenter Retrospective Cohort Study

Background: Consensus guidelines recommend anticoagulation for 3 months in patients with upper extremity catheter-related thrombosis (CRT); however, recommendations are primarily extrapolated from data on provoked lower extremity thrombosis. Many patients with hematologic malignancy are treated with shorter durations of anticoagulation due to thrombocytopenia and other bleeding concerns. It is not known if duration of anticoagulation in patients with hematologic malignancy patients and CRT predicts risk of recurrence or hemorrhage.Methods: We performed a multicenter retrospective cohort study at five institutions through the Venous thromboEmbolism Network US (VENUS). Patients with hematologic malignancies with documented deep vein thrombosis associated with a catheter from 1/1/2010-12/31/2016 were identified using ICD-9 and ICD-10 diagnostic codes. Demographic information, management of the CRT, duration of anticoagulation, recurrent thrombosis, and bleeding during anticoagulation were extracted from the electronic medical record. Descriptive statistics will be used for demographic variables, disease and thrombosis characteristics, treatment type, duration of anticoagulation, recurrent thrombosis and bleeding outcomes. Non-parametric Kruskal Wallis were used to evaluate platelet count between treatment groups. Mann-Whitney U test was used to determine if duration of anticoagulation was associated with thrombosis recurrence.Results: Of the 379 patients included in the analysis, 151 (40%) had lymphoma, 143 (38%) had leukemia, 74 (20%) had plasma cell disorder, and 11 (3%) had myelodysplastic syndrome or a myeloproliferative neoplasm. 214 (56%) were male. Median follow-up duration was 274 days, and 134 (35%) patients died within the follow-up period. PICCs accounted for 254 (67%) of the CRT events, 74 (20%) of cases had tunneled catheters, and 50 (13%) had Port-a-Caths. The most proximal involvement of the thrombosis were as follows: 37 (10%) brachial vein, 81 (21%) axillary vein, 149 (39%) subclavian vein, 90 (24%) internal jugular vein, 5 (1%) brachiocephalic vein, and 14 (4%) superior vena cava. 252 (66%) patients were treated with anticoagulation and removal of the catheter, but 50 (13%) were treated with anticoagulation alone, 60 (16%) were treated with removal of the catheter only, and 17 (4%) did not have treatment for the CRT. Median platelet count at diagnosis differed between the treatment groups [anticoagulation: 145,000 (range 27,000-443,000); anticoagulation and catheter removal: 130,000 (6,000-963,000); catheter removal only: 42,000 (5,000-251,000); no treatment: 39,000 (6,000-423,000); p<0.0001]. For the 302 patients treated with anticoagulation, 229 (76%) were initially treated with low-molecular weight heparin, 31 (10%) were treated with unfractionated heparin, and 30 (10%) were bridged to warfarin. Median duration of anticoagulation therapy for the initial CRT was 56.5 days (range 1- 1,108 days). Among the 340 patients who had their catheter removed, 245 (72%) were removed due to the CRT, 56 (16%) due to completion of cancer therapy, 22 (6%) due to infection, and 17 (5%) for other reasons. Fifty-six patients (15%) experienced a recurrent VTE, and 7 (2%) patients experienced a second recurrent VTE event. Thirty-eight (10%) patients experienced bleeding during anticoagulation of which 19 (5%) were major hemorrhages. Duration of first anticoagulation did not differ between patients with and without recurrent thrombosis [with recurrence: median 67 days (range: 4-1,108), without recurrence: 54 (range: 1-453, p=0.32)].Conclusions: Significant variability remains in treatment of CRT in patients with hematologic malignancy. Despite the guidelines, many catheters are removed due to the thrombosis. Our results suggest that duration of anticoagulation is not associated with VTE recurrence. DisclosuresGaddh:Hema Biologics: Consultancy; Pharmacyclics LLC: Consultancy. Wang:Daiichi Sankyo: Consultancy, Other: Travel. Billett:Bayer: Consultancy; Janssen: Research Funding.

Safety and Feasibility of Temporary Superior Vena Cava Filter Combined with Balloon Dilatation and Catheter-Directed Thrombolysis for Catheter-Related Thrombosis

The objective was to evaluate the safety and feasibility of temporary superior vena cava (SVC) filter combined with balloon dilatation and catheter-directed thrombolysis for the treatment of catheter-related thrombosis (CRT) caused by implanted ports. Between February 2014 and October 2016, 13 patients with implanted port-related CRT in internal jugular vein, brachiocephalic vein, and/or subclavian vein were treated by temporary SVC filter, balloon dilatation, and catheter-directed thrombolysis. Clinical data were retrospectively analyzed with respect to clinical characteristics, SVC filter placement and retrieval, balloon dilatation, and catheter-directed thrombolysis. Filter placement and retrieval, balloon dilatation, and catheter-directed thrombolysis were successful in all patients with complete patency of the suffered vessels. No complications such as local infection, filter migration, bleeding, and pulmonary embolism were found. Based on the small number of patients, it appears that temporary SVC filter combined with balloon dilatation and catheter-directed thrombolysis is a safe and effective method for the treatment of CRT associated with malfunction of the implanted ports and complete obstruction of affected veins. Further studies are required to demonstrate the cost-effectiveness and complications compared to conventional therapy.

Anticoagulants for the prevention and treatment of catheter-related thrombosis in adults and children on parenteral nutrition: a systematic review and critical appraisal.

Patients on parenteral nutrition require a central venous access and are at risk of catheter-related thrombosis, pulmonary embolism, and vena cava syndrome. Parenteral nutrition guidelines suggest anticoagulation for the primary prevention of catheter-related thrombosis during long-term parenteral nutrition. We conducted a systematic review of the efficacy, safety and feasibility of anticoagulant use for preventing and treating catheter-related thrombosis during parenteral nutrition. We searched for interventional and observational studies on adults and children receiving systemic anticoagulants during either short- or long-term parenteral nutrition delivered via central venous access. Primary outcomes were: objectively-confirmed catheter-related thrombosis, pulmonary embolism and bleeding. Secondary outcomes were: heparin-induced thrombocytopenia, prevalence of anticoagulation, and quality of International Normalised Ratio management in vitamin K antagonist-treated patients. We identified 1,199 studies, of which 23 were included. Seven interventional studies of short-term parenteral nutrition (adult population, n=5) were classified as low-quality: in those, intravenous unfractionated heparin did not prevent catheter-related thrombosis if compared to saline. No interventional studies were conducted in patients on long-term parenteral nutrition. Observational data were sparse, rarely focusing on anticoagulation, and overall of low quality. The reported use of anticoagulants was between 22 and 66% in recent multicentre cohorts. The amount and quality of data in this area are very suboptimal: most studies are outdated and involved heterogeneous populations. Currently, there is insufficient evidence to allow conclusions to be reached regarding the efficacy and safety of anticoagulants in this setting.

Research progness of central venous catheter-related thrombosis in hematological malignancy patients with central venrus catherer

Central venous catheter-related thrombosis(CRT) is a significant complication in patients with hematological malignancy who accepted central venous catheter (CVC). However, there are considerable uncertainties about the risks, mechanism and treatment of CRT. Through the study of relevant literatures, we concluded that contributing factors of CRT include patient-related factors, the treatment protocols, the usage of CVC and other catheter events. Anticoagulant thromboprophylaxis is not recommended at present except multiple myeloma patients. When CRT is clear diagnosed, we can choose antithrombotic therapy or directly removeing the CVC based on the specific circumstances. Key words: Hematological malignancy; Central venous catheter; Thrombosis

Catheter-related thrombosis: lifeline or a pain in the neck?

Central venous catheters (CVCs) are used extensively in cancer patients for the administration of therapy and phlebotomy. An important complication of CVCs is the development of catheter-related thrombosis (CRT), which becomes symptomatic in approximately 5% of the patients. Several factors, such as insertion location and position of the catheter tip, increase the risk of CRT. Prevention of CRT with systemic anticoagulant prophylaxis has largely been ineffective. In addition, the optimal diagnostic strategy and anticoagulant treatment are unclear due to the lack of well-designed studies. The most recent American College of Chest Physicians guidelines recommend (color) Doppler ultrasound more than venography as the initial diagnostic test in patients with suspected arm thrombosis. Only if the ultrasound is negative and clinical suspicion is high is further testing with D-dimer, serial ultrasound, or venography advocated. In case of CRT, removal of the catheter is not necessary if it is functional and needed for chemotherapy. Anticoagulant treatment of CRT consists of treatment with low-molecular-weight heparin (LMWH) followed by vitamin K antagonists for at least 3 months. Whether long-term treatment with LMWH is more effective than vitamin K antagonists in cancer patients with CRT is unknown, but LMWH may be advocated following the recommendations in lower limb thrombosis and cancer. In addition, the effect of new anticoagulants in CRT has not been studied.

Systematic review of anticoagulant treatment of catheter-related thrombosis

Central venous catheter-related thrombosis (CRT) is a complication seen in patients requiring long-term intravenous access. Treatment of CRT is not standardized and international guidelines for treatment are based on extrapolation of evidence from lower extremity thrombosis. We performed a systematic review of the literature to evaluate if duration of anticoagulation affects the risk of recurrent venous thrombosis, post-thrombotic syndrome, or major hemorrhage. We searched PubMed, Embase, Medline, CINAHL, Cochrane, and ACP Journal club for studies of CRT treated with anticoagulation. Of 1648 titles and abstracts, 23 studies met our inclusion criteria. No randomized trials were identified. Duration of anticoagulation varied from 8days to more than 6months. Outcomes of patients with upper extremity thrombosis due to CRT or other etiologies were often combined. The incidence of post-thrombotic syndrome varied between 0 and 75% depending on the definition used. Seven percent of patients with upper extremity thrombosis treated with anticoagulation experienced recurrent deep vein thrombosis and 2.8% experienced pulmonary embolism. Major hemorrhage was reported in 2.8–4.9% of anticoagulated patients. Prospective studies evaluating the optimal duration of anticoagulation in patients with CRT are needed.

Catheter-related thrombosis: lifeline or a pain in the neck?

AbstractCentral venous catheters (CVCs) are used extensively in cancer patients for the administration of therapy and phlebotomy. An important complication of CVCs is the development of catheter-related thrombosis (CRT), which becomes symptomatic in approximately 5% of the patients. Several factors, such as insertion location and position of the catheter tip, increase the risk of CRT. Prevention of CRT with systemic anticoagulant prophylaxis has largely been ineffective. In addition, the optimal diagnostic strategy and anticoagulant treatment are unclear due to the lack of well-designed studies. The most recent American College of Chest Physicians guidelines recommend (color) Doppler ultrasound more than venography as the initial diagnostic test in patients with suspected arm thrombosis. Only if the ultrasound is negative and clinical suspicion is high is further testing with D-dimer, serial ultrasound, or venography advocated. In case of CRT, removal of the catheter is not necessary if it is functional and needed for chemotherapy. Anticoagulant treatment of CRT consists of treatment with low-molecular-weight heparin (LMWH) followed by vitamin K antagonists for at least 3 months. Whether long-term treatment with LMWH is more effective than vitamin K antagonists in cancer patients with CRT is unknown, but LMWH may be advocated following the recommendations in lower limb thrombosis and cancer. In addition, the effect of new anticoagulants in CRT has not been studied.

International Clinical Practice Guidelines for the Treatment and Prophylaxis of Thrombosis Associated with Central Venous Catheters in Patients with Cancer

AbstractAbstract 4357 BackgroundUse of long term indwelling central venous catheter (CVC) is associated with symptomatic (Σ) events in up to 30% of cancer patients (pts), which may lead to pulmonary embolism (PE) and loss of the CVC. Lack of consensus on management of CVC related thrombosis (CVCT) and heterogeneity in clinical practices worldwide led us to establish international Good Clinical Practices Guidelines (GCPG) for the management of CRT in cancer pts. MethodsThe international working group (WG) met 4 times and worked 2 years with the methodological support and quality control of the French institute of Cancer (INCa). All studies on cancer, venous thromboembolism (VTE, including pulmonary embolism PE), and anticoagulant drugs (AC) published from 1996 to 2011 weree searched using MEDLINE®database. Meta-analyses, systematic reviews, randomized or non-randomized prospective or retrospective studies in the absence of randomized clinical trials, and abstracts only if a full paper had been accepted in a peer-reviewed medical journal were included in the analysis. The included studies concerned the prophylaxis and treatment of CVC in cancer pts. Studies in non-cancer pts, pts with a peripheral or dialysis catheter, or with a history of cancer in remission for more than 5 years were not considered. The main study outcomes were rates of proven catheter related thrombosis (CRT), extension of CRT, PE associated with CRT, major and minor bleeding, thrombocytopenia, and death. Quality of the studies was evaluated in a double-blind manner by the methodologists using the GRADE appraisal grids. Extracted data were entered in evidence tables, subsequently validated by all the WG. The level of evidence (High A, Moderate B, Low C, Very low D) depended on study design, limitations, inconsistency, indirectness, imprecision and publication bias. For each question, results analysis were summarized and discussed by the WG. Overall conclusions and recommendations were classified as Strong (Grade 1 Guideline) or Weak (Grade 2 Guideline) based on evidence levels, the balance between desirable/undesirable effects, values and preferencesand costs. In the absence of scientific evidence, judgment based on consensus within the WG was defined as Best Clinical Practice (BCP). The GCP were reviewed and evaluated using a specific grid in February 2012 by 45 independent experts in managing cancer pts worldwide and 3 pt representatives. Results1.For the treatment of established CVC in cancer pts, we found no prospective randomized study, only 2 non-randomized prospective studies and 1 retrospective study examining the efficacy and safety of LMWH+VKA. One retrospective study evaluated the benefit of CVC removal and 2 retrospective studies, with few patients assessing the thrombolytic drugs values. We recommend A) For the treatment of Σ CRT in cancer pts, AC is recommended for a minimum of months; in this setting, LMWH are suggested. Oral VKA can be used [BCP]. B) The CVC can be kept in place if it is functional, well-positioned, non-infected and shows good evolution under close surveillance; whether the CVC is kept or removed, no standard approach in term of duration of anticoagulation is established [BCP].2.For the prophylaxis of CVCRT in cancer pts, 6 randomized studies investigated the efficacy and safety of VKA vs. placebo or no treatment, 1 the efficacy and safety of UFH, 6 the value of LMWH and one double-blind randomized study the thrombolytic drugs in the prevention of CVC-RT. Six meta-analyses of AC and CVC thromboprophylaxis have been performed. The type of catheter (open-ended, such as the Hickman® catheter, versus closed-ended catheter with a valve, such as the Groshong®catheter), its position (above, below or at the junction of the superior vena cava and the right atrium), and the method of placement may influence the onset of CVCT on the basis of 6 retrospective, 4 prospective non-randomized trials, 3 randomized trials and 1 meta-analysis. In light of these data,A.Use of AC for routine prophylaxis of CRT is not recommended [1A];B.CVC should be inserted on the right side, in the jugular vein, and distal extremity of the central catheter should be located at the junction of the superior vena cava and the right atrium [1A]. ConclusionDissemination and implementation of these international GCPG on the prevention and treatment of CRT in cancer ptsat each national level is a major public health priority, necssitating world wide collaboration. Disclosures:No relevant conflicts of interest to declare.

Prospective Cohort Study of the Incidence, Risk Factors and Long-Term Sequelae of Symptomatic Catheter-Related Thrombosis in Adults with Cancer.

Long-term indwelling central venous catheters (CVCs) are used for delivering chemotherapy, parenteral nutrition, antibiotics, and blood products, as well as for facilitating blood drawing, in many patients with malignancy. Although the important supportive role of CVCs is unquestioned, there is uncertainty regarding the prevention and treatment of catheter-related thrombosis (CRT) because there is a lack of prospective and contemporary data on the natural history of this complication. As a first step towards improving CRT management, we conducted a prospective cohort study to examine the incidence, clinical risk factors, and the long-term sequelae of symptomatic CRT in adults with cancer. Consecutive patients undergoing insertion of a CVC at a tertiary care center were enrolled and followed for the duration of their catheter-dwell time plus 4 weeks or a maximum of 52 weeks, whichever comes first. Scheduled assessments were done at weeks 1, 2, 4, 8, 12, 24, 36 and 52 weeks after insertion. Patients with symptomatic CRT were treated with anticoagulants and were followed for an additional 52 weeks from the date of CRT diagnosis. Baseline information and follow-up data regarding catheter patency, thromboprophylaxis, clinical symptoms, and thrombotic events was collected. Standardized regional guidelines for catheter care were followed and symptomatic CRT was diagnosed based on objective testing and satisfaction of prespecified criteria. Between March 2002 and July 2003, 444 patients underwent 500 catheter insertions. The mean patient age was 56 y (range 18–91 y) and 55% of patients were female. Catheters inserted included PICCs (65%), ports (18%), pheresis (11%), and Hickman catheters (6%). As of July 22, 2004, 442 patients had completed follow-up. The total catheter-dwell time was 59,959 d (median 88 d), while the total follow-up was 73,654 pt-d (median 151 d). Colorectal was the most common tumor type in 18% of patients and 41% of all patients at enrolment had metastatic solid tumor. Overall, there were 19 episodes of symptomatic CRT, representing an incidence of 4.3% (95% CI 2.6–6.6%) of patients or 0.3 CRTs per 1000 catheter-dwell days (95% CI 0.2–0.5 per 1000 d). The mean time to CRT was 53 d (range 6–162 d). Development of CRT was not associated with age, ECOG performance status, cancer treatment, catheter type, side of insertion, thromboprophylaxis, infection, or previous history of thrombosis. The only significant risk factor was ovarian cancer (P=0.02). In patients with symptomatic CRT, 89% (17/19) of CRTs were treated with anticoagulant therapy alone, 5.3% (1/19) had the catheter removed, and 5.3% (1/19) were treated with both; none had symptomatic pulmonary embolism or post-thrombotic syndrome during follow-up. In summary, the incidence of symptomatic CRT in adults with cancer is low and treatment with anticoagulant therapy alone was not associated with any serious long-term sequelae. Due to the small number of CRTs observed, larger studies are required to further evaluate risk factors and identify the optimal therapeutic approach for CRTs.

Prevention and Treatment of Thrombosis Associated With Long-Term Hemodialysis Catheters.

Soft, cuffed, central vein hemodialysis catheters are used in about 20% of chronic hemodialysis patients in the United States, because long-term arteriovenous blood access cannot be maintained in an aging patient population with a large proportion of diabetics. The most frequent complication of these catheters is thrombosis. The treatment of catheter-related thrombosis is difficult and expensive; thus the emphasis should be on prevention. The preferred material for a long-term catheter is silicone rubber, since it is the least thombogenic. Anticoagulation should be more vigorous during "catheter dialysis" than during "fistula dialysis." Heparin is the least expensive and most convenient anticoagulant, suitable for over 99% of chronic dialysis patients. The dose of heparin for sufficient anticoagulation depends on many factors, varies widely, and should be established for each patient based on activated clotting time (ACT). ACT should be kept over 270 sec throughout dialysis. Recently we introduced a method of locking catheter lumina with a predetermined amount of heparin; this heparin is not discarded before the next dialysis, but serves as a loading dose. This saves a number of connections/ disconnections and decreases dialysis-associated blood losses. To prevent catheter thrombosis, over 60% of patients require warfarin in sufficient doses to keep the international normalized ratio (INR) between 1.5 and 2.5. The most common catheter-related thrombus is a periluminal fibrin sleeve. Locking the catheter with urokinase to dissolve the clot is of little value, because the bulk of the thrombus is outside the catheter. We have found a high-dose (250 000 U or more) intradialytic urokinase infusion through the venous chamber to be a very efficient and convenient method for dissolving clots. Cumulative success of up to three infusions is over 99%. This obviates the need of catheter stripping or replacement, which is more cumbersome and expensive.

Venous catheter-related thrombosis and infection

To the Editor.— The report by Chakravarthy et al1inJAMAdescribes an interesting cardiac complication of chronic central venous access but misses the true lesson of the case, the prevention and treatment of catheter-related thrombosis and infection. Fever and evidence for central venous thrombosis were present for months prior to the terminal hospitalization of the patient. It is therefore not surprising that advanced venous thrombosis with extension to the tricuspid valve was found. The authors fail to discuss the diagnosis of the underlying problem, catheter-related septic central venous thrombosis. The diagnosis of catheter-related septic central venous thrombosis is predicated on symptoms and signs of systemic sepsis, blood cultures that continue to be positive even after catheter removal, and central venous thrombosis, best confirmed by venography.2The syndrome is probably underdiagnosed in the seriously ill population at risk with prolonged catheterization, and no more than 50 well-documented cases