A Frontline Approach With Peripherally Inserted Versus Centrally Inserted Central Venous Catheters for Remission Induction Chemotherapy Phase of Acute Myeloid Leukemia: A Randomized Comparison

BackgroundThe incidence of peripherally inserted central catheter (PICC)-related adverse events has been uncertain in the setting of acute myeloid leukemia (AML) compared with the incidence of centrally inserted central catheter (CICC) adverse events.Patients and MethodsWe conducted a monocentric, randomized trial of patients with previously untreated AML. Of the 93 patients, 46 had received a PICC and 47 had received a CICC as frontline intravascular device. Thereafter, all patients underwent intensive chemotherapy for hematologic remission induction. The primary endpoint was catheter-related (CR)-bloodstream infection (BSI) and venous thrombosis (VT) rate. The secondary endpoints catheter malfunction, catheter removal, and patient overall survival.ResultsThe CR-BSI and CR-VT rate in the PICC and CICC groups was 13% and 49%, respectively, with a difference of 36 percentage points (relative risk for CR-BSI or CR-VT, 0.266; P = .0003). The CR-BSI incidence was 1.4 and 7.8 per 1000 catheters daily in the PICC and CICC groups, respectively. Among the CR thromboses, the symptomatic VT rate was 2.1% in the PICC group and 10.6% in the CICC group. In the CICC group, 16 of the 47 patients (34%) had the catheter removed for BSI (n = 5), septic thrombophlebitis (n = 4), VT (n = 2), or malfunction (n = 5) a median of 7 days after insertion. In the PICC group, only 6 of the 46 patients (13%) required catheter removal for VT (n = 2) or malfunction (n = 4). At a median follow-up of 30 days, 6 patients in the CICC group died of CR complications versus none of the patients in the PICC group (P = .012). Using PICCs, the reduction in BSI and symptomatic VT decreased mortality from CR infection and venous thromboembolism. In contrast, the CICC approach led to early catheter removal mostly for difficult-to-treat infectious pathogens.ConclusionOur data have confirmed that BSI and symptomatic VT are the major complications affecting frontline central intravascular device-related morbidity in the leukemia setting. The use of a PICC is safer than that of a CICC and maintains the effectiveness for patients with AML undergoing chemotherapy, with an approximate fourfold lower combined risk of infection or thrombosis at 30 days.     

Reducing the risk of peripherally inserted central catheter line complications in the oncology setting

At our institution, a retrospective review of peripherally inserted central catheters (PICCs) in oncology patients had previously demonstrated a complication rate of 40.7%. Since then we have implemented strategies to reduce complications including staff and patient education, insertion technique modification and PICC maintenance utilizing a PICC nurse. The objectives of this study were to evaluate the recent PICC complication rate and to compare it with the previously reported findings. Prospectively collected PICC complication data and medical records from all patients with solid tumours who had PICCs inserted in 2003 were analysed. A historical cohort comparative analysis was performed using our PICC complication rate from 2000 to 2001. Eighty-eight PICC lines were inserted in 73 patients under radiological guidance. The median PICC dwell time was 44 days (1-524 days). The overall complication rate was 15.9% (14/88) or 2.0 complications per 1,000 PICC-days. Infections developed in 5.7% (5/88) and thrombotic events occurred in 4.5% (4 /88) of PICCs. The mean time to complication was 45 days. The complication rate for 2003 was significantly lower than the rate for 2001 (P = 0.006), especially of infective complications (P = 0.004). Strategies introduced to reduce PICC complications may have been the reason for this improvement.     

Diagnosis prevention and treatment for PICC-related upper extremity deep vein thrombosis in breast cancer patients

Aim: To study the incidence, diagnosis, prevention and treatment of peripherally inserted central catheter (PICC)‐related upper extremity deep vein thrombosis (DVT) in breast cancer patients using a PICC catheter for chemotherapy. Methods: The data of the incidence, diagnosis and treatment of PICC‐related upper extremity DVT in 187 breast cancer patients using a PICC catheter for chemotherapy, from August 2009 to July 2011 were retrospectively analyzed. Results: In total 188 PICC were inserted between August 2009 and July 2011 and followed up for a total of 14 399 catheter‐days (median placement, 76.6 days; range, 1 to 170 days). Four (2.1%) of 188 PICC were removed as a result of PICC‐related upper extremity DVT in 14 to 112 catheter‐days, at a rate of 0.28/1000 catheter‐days. Conclusion: The use of PICCs in breast cancer patients for chemotherapy is safe and effective. However, some patients may develop catheter‐related upper extremity DVT. In order to minimize complications, we should pay attention to its early symptoms and signs, as well as the timely removal of the catheter and appropriate anti‐coagulant treatment.     

经外周插管的中心静脉导管的预处理对乳腺癌化疗患者机械性静脉炎发生率的影响

目的通过对导管的预处理及送管速度的控制,减少对血管内膜的刺激,以期降低机械性静脉炎的发生率。方法将需要插管化疗的女性乳癌患者分为两组,试验组对导管进行预处理,即插管前将导管浸泡在无菌生理盐水100ml加地塞米松5mg、利多卡因2ml的混合液中,时间1min,穿刺成功后缓慢匀速送入导管;对照组插管前导管不浸泡,穿刺成功后快速送入导管。结果对导管进行预处理之后,机械性静脉炎发生率由原来的26.7%降至10.7%,两组静脉炎的发生率差异有显著性(P(0.05)。结论插管前对导管进行浸泡、穿刺成功后缓慢匀速送管可以降低机械性静脉炎的发生率。     

乳腺癌患者携带PICC化疗并发PICC相关性上肢深静脉血栓形成的诊治探讨

探讨乳腺癌患者携带PICC化疗出现PICC相关性上肢深静脉血栓形成的发生及其临床诊治。方法：回顾性分析本院2009年8月～2011年7月携带PICC化疗的187例乳腺癌患者中PICC相关性上肢深静脉血栓形成的发生及其临床诊治情况。结果：187例携带PICC化疗的乳腺癌患者,共放置PICC188根,PICC管总置管时间为14,399天,平均置管时间为76.6天,最长170天。4例在PICC置管后14～112d（平均45.25d）出现上肢深静脉血栓形成,发生率为2.1%,发病密度为0.28/PICC置管1 000天（0.28‰）。结论：乳腺癌患者化疗期间携带PICC化疗是一种安全有效的方法,但少数病例可能出现PICC相关性上肢深静脉血栓形成,此时应注意观察患者的症状和体征,早期发现,正确诊治,患者均能获得较好的疗效。     

A retrospective analysis of Hickman line-associated complications in patients with solid tumours undergoing infusional chemotherapy

We present a retrospective analysis of Hickman line use and associated complications in patients with solid tumours undergoing treatment with infusional chemotherapy. One hundred and ten lines were inserted in 94 patients (55 females and 39 males, median age 51), of whom 107 were placed under radiological screening, the remainder by a surgical approach. Catheters were in situ for a total of 9670 days (median 101 days, range 1-278). Fifty-five complications occurred during the lifespan of 39 catheters (35.5%), giving an overall complication rate of 4.03/1000 catheter days. Early complications included pneumothorax (4%), arterial puncture (1%) and failure of placement (1%). Late complications included sepsis (superficial and systemic) (24.5%), venous thrombosis (9%), line displacement (10%) and catheter blockage (1%). Fifteen episodes of systemic sepsis occurred in 12 patients, giving an overall sepsis rate of 1.55/1000 catheter days, while complications requiring catheter removal occurred in 20 cases (18% of insertions, 2.07/1000 catheter days). We conclude that the use of Hickman catheters as a means of long-term venous access in infusional chemotherapy patients is generally safe, but is associated with significant morbidity.     

Complication rates of peripherally inserted central catheters vs implanted ports in patients receiving systemic anticancer therapy: A retrospective cohort study

While implanted port catheters (“PORTs”) have historically been the standard device for intravenous systemic anticancer therapy, the use of peripherally inserted central catheters (PICCs) has increased continuously and reliable catheter selection guidelines are lacking. We compare complication rates of PORTs and PICCs in cancer treatment in a retrospective study of 3365 patients with both solid organ (n = 2612) and hematologic (n = 753) malignancies, between 2001 and 2021. 26.4% (n = 890) of all patients were treated via PICCs and 73.6% (2475) via PORTs. 20.7% (578) experienced a major catheter-related complication with a higher rate in PICCs than in PORTs (23.5% vs 14.9%, P < .001). Among major complications, infections and mechanical complications were more common in PICCs than in PORTs (11.9% vs 6.4%, P = .001, 7.3% vs 4.2%, P = .002), whereas the rate of thrombosis was similar (3.4% vs 3.0%, P = .9). While PORTs had a higher rate of periprocedural complications (2.7% vs 1.1%, P < .05), PICCs overall complication rate exceeded PORTs within 3 days from implantation. Median follow-up was 49 (PICC) and 60 weeks (PORT). PORTs are safer and therefore should be preferred in this setting regardless of catheter dwell time.     

Utilisation des cathéters centraux insérés par voie périphérique (PICC) en oncohématologie

Peripherally inserted central catheters (PICC) have the advantage of limiting the risk of accidents during installation and are easy to remove. Its use in oncology remains debated because of possible infectious complications. We analyzed 52 PICC in patients with hematological tumor from Nice Hospital. An installation failure was noted in 5.8% of cases. After a follow-up of 15 months, the complication rate was 26.9%, mainly mechanical complications: obstruction (13.5%) or accidental removal (9.6%). The organic complications such as infection or thrombophlebitis represented 3.8%. The median duration was 26 days [2-291]. The longest duration was associated with PICC for chemotherapy (median: 58 days). Frequent blood samples (above: 2 week) were associated with lower duration (median: 23 days). In conclusion, PICC represent a simple and effective alternative to intra-venous central devices in onco-hematology. However, physicians have to focus on short-course treatment.     

Efficacy and complications in peripherally inserted central catheter insertion: A study using 4‐Fr non‐valved catheters and a single infusate

The purpose of this prospective study was to evaluate the efficacy and complications associated with the use of 4‐Fr single‐lumen non‐valved peripherally inserted central venous catheters (PICC) for the infusion of long‐term antibiotics. Forty‐four non‐valved PICC were inserted using micropuncture technique by interventional radiologists. Six patients were lost to unrelated death or follow up. The remaining 38 patients (24 men and 14 women; mean age 54.79 years) were analysed. Catheters were placed under ultrasound guidance using micropuncture technique and subsequently advanced over guidewire through peel‐away sheath under fluoroscopic guidance. Doppler ultrasound was used before PICC removal in order to detect possible complications. All non‐valved PICC were flushed with 5 ml of heparinized saline before and after each antibiotic infusion. Efficacy was evaluated and analysed on the average duration of catheter patency and whether any complication was present. Procedural success rate was 100% in our patient population. Seven patients had complications necessitating early PICC removal with the average patency duration of 44 days (95% confidence interval 7.79–80.21 days), whereas an average indwelling patency duration of the remaining 31 patients with no complication was 30.58 days (95% confidence interval 25.74–35.43 days). Total complication rate was calculated to be 5.58 incidences per 1000 catheter days. Complication rate associated with the placement and use of 4‐Fr non‐valved PICC for antibiotic therapy was observed to be low when compared with other studies using valved and non‐valved PICC for various infusates.     

Utilization and Complications of Central Venous Access Devices in Oncology Patients

Purpose: To describe how central venous access devices (CVADs) are utilized for ambulatory oncology patients and to evaluate the rate of complications. Method: Single institution retrospective study of oncology patients with CVADs who received systemic treatment at the Walker Family Cancer Centre (WFCC) between 1 January and 31 December 2018. Results: A total of 480 CVADS were placed in 305 patients, of which 408 (85%) were peripherally inserted central catheters (PICCs) and 72 (15%) were implanted vascular access devices (PORTs). The incidence of early and late complications was 9% and 24%, respectively. For the entire cohort, the rate of venous thromboembolism (VTE) was 16%, of which 9% were CVAD-related thrombosis (CRTs) and 7% were distant VTE. The CRT rates were similar for PICCs and PORTs (9% vs. 7%). A total of 6% of CVADs were complicated by infection (i.e., localized infections and bacteremia), with a total infection rate of 0.43 and 0.26 per 1000 indwelling days for PICCs and PORTs, respectively. The incidence of central line associated bloodstream infections (CLABSI) was greater for PICCs than PORTs, at a rate of 0.22 compared with 0.08 per 1000 indwelling days, respectively. The premature catheter removal rate was 26% for PICCs and 18% for PORTs. PORTs required more additional hospital visits. Conclusions: PICCs were utilized more frequently than PORTs and had a higher rate of premature removal. The rates of VTE and CRT were similar for both CVAD types. PORTs had a lower rate of infection per 1000 indwelling days. However, the management of PORT related complications required more visits to the hospital and oncology clinic.     

Use of a fully implantable drug delivery system in the treatment of acute leukemias and disseminated lymphomas

In an open study, 42 venous Port-A-Cath systems (PAC) were implanted in 40 patients with AML (12), ALL/AUL (11), NHL with bone marrow infiltration (8), Hodgkin's lymphoma (3), solid tumors (5) and severe aplastic anemia (1). Mean duration of system use was 212 days. The cumulated duration of use of all systems was 8.883 days. 1,627 blood samples were taken from the PAC. Blood sampling was possible on 8,696 of 8,883 days of cumulated access (98%). A total of 522 blood transfusions were administrated. Fifty-two episodes of neutropenia (granulocyte counts less than 0.5 x 10(9)/l) with a mean duration of 17 days were observed in the group of the 23 patients with acute leukemias. A total of 25 complications were registered. The incidence was 2.8/1,000 days of access. Twelve complications were regarded as severe. Venous thrombosis was observed in 3 cases. In addition, there were 2 disruptions of the catheter, 1 disconnection, 1 looping and 4 local infections. The rate of systemic infection could not be accurately estimated because the catheter was always left in place and antibiotic treatment was started immediately in case of fever with or without bacteriemia. The overall rate of catheter-related complications in patients with acute leukemia was not higher than in patients with solid tumors.     

A trial with a new peripheral implanted vascular access device

In a prospective study, a new implanted vascular access device designed for peripheral placement in the arm was evaluated. Thirty-two patients requiring long-term venous access received the Port-A-Cath P.A.S. Port over a 13-month period. The access devices were used for multiple therapies including chemotherapy, antibiotics, antivirals, antifungals, and blood products. After 4,896 patient days (range 12-388), 19 complications occurred in 14 patients or 3.88/1,000 catheter days. The infection rate was 3% or 0.2/1,000 catheter days. Port pocket cellulitis was reported in 3% of patients or 0.2/1,000 catheter days. Vein phlebitis occurred at 12.5% or 0.8/1,000 catheter days. Two instances of vessel thrombosis occurred (6.2% or 0.4/1,000 catheter days). Ten incidents in six patients of inability to aspirate blood samples were noted (18.75% or 2/1,000 catheter days). No infiltrations or extravasations were reported. Nurses involved in this early trial found performance similar to the standard venous chest ports. Peripheral port placement was accepted well by patients.     

Complication rates among cancer patients with peripherally inserted central catheters.

PURPOSE: Peripherally inserted central catheters (PICCs) are frequently used to deliver outpatient courses of intravenous therapy. However, the rates and risks of complication for this device have not been well-studied. Our objective was to determine the incidence and risk factors of PICC-related complications with a 1-year prospective observational study. PATIENTS AND METHODS: All PICCs inserted in adult and pediatric patients at Memorial Sloan-Kettering Cancer Center (MSKCC) were followed prospectively. The device insertion team, inpatient nurses, and various home-care companies and outside institutions collected longitudinal data. RESULTS: Three hundred fifty-one PICCs were inserted during the study period and followed for a total of 10,562 catheter-days (median placement, 15 days; range, 1 to 487 days). Two hundred five PICCs (58%) were managed by home-care companies and outside institutions, and 146 PICCs (42%) were managed exclusively at MSKCC. For these 205 PICCs, 131 nurses from 74 home-care companies and institutions were contacted for follow-up clinical information. In all, 115 (32.8%) of 351 PICCs were removed as a result of a complication, for a rate of 10.9 per 1,000 catheter-days. Patients with hematologic malignancy or bone marrow transplant were more likely to develop a complication, whereas those with metastatic disease were less likely. CONCLUSION: Complications occur frequently among cancer patients with PICCs, and long-term follow-up is onerous. Despite a high complication rate, the ease of insertion and removal argues for continued PICC use in the cancer population.     

Comparison of the Quality of Life of Patients with Breast or Colon Cancer with an Arm Vein Port (TIVAD) Versus a Peripherally Inserted Central Catheter (PICC)

Introduction: Venous access is a crucial element in chemotherapy delivery. It remains unclear whether cancer patients prefer a port to a peripherally inserted central catheter (PICC). Our study aimed to assess cancer patients’ satisfaction with their venous access device and to compare the quality of life (QoL) of subjects with a PICC to those with a port. Methods: In this prospective cohort study, EORTC QLQ-C30, and a locally developed quality of life survey (QLAVD), designed to assess satisfaction with venous access devices, were administered to breast or colorectal cancer patients over a one-year period following the device insertion. Mixed effects models were used to assess changes on mean scores at different time points. Results: A total of 101 patients were recruited over a three-year period, (PICC group, n = 50; port group, n = 51). Survey response rates for months one and three were 72% and 48%, respectively. Overall, no significant differences were noted between the two groups in relation to EORTC QOL. At three months, the mean pain scores were 3.5 ± 2.3 for the port and 1.3 ± 0.75 for PICC (<0.001). The mean score for a negative effect of the venous access device on psychosocial well-being was 6.0 ± 4.1 for PICC and 3.0 ± 2.7 for the port (p = 0.005). Complications related to PICCs occurred in 38% patients versus 41% with a port (p > 0.24). Conclusions: Although subjects with a port experienced more pain during the device insertion or access for chemotherapy, it had a smaller negative impact on psychosocial scores than the PICC. No significant differences in complications rates were observed between the two devices.     

An evaluation of prolonged venous access catheters in patients with leukaemia and other malignancies

Two hundred and fifty venous access catheters were inserted into 218 patients undergoing prolonged chemotherapy for the treatment of leukaemia and other malignancies in the 2-year period from July 1984 to July 1986. In 37% of patients the catheter was removed before the completion of treatment for a variety of infective and other complications (mean survival of catheters V96.7 days). This retrospective study analysed the causes of catheter failure and has allowed us to draw up guidelines for the future management of such catheters.     

Central venous catheter-related complications in patients with hematological malignancies: a retrospective analysis of risk factors and prophylactic measures

We retrospectively analyzed the incidence of thrombotic and infectious complications in relation with the use of central venous catheters (CVCs), in a series of patients with hematological malignancies and low platelet and leucocyte counts. PATIENTS AND METHODS: 126 patients with hematological malignancies were analyzed. A total of 207 CVCs were implanted: 137 centrally (CICCs) and 70 peripherally (PICCs). The median duration of the CVCs was 19 days for a total of 4051 catheter-days. Antithrombotic prophylaxis was unfractionated heparin (UFH), 2,500 IU daily by 24 h continuous infusion in 169 CVCs, low molecular weight heparin (LMWH), 3,800 IU daily by single bolus intravenous injection (i.v.) in 21 and warfarin in one. No prophylaxis was given in 16 CVCs. Thrombotic complications developed in 15.5% of the CVCs (7.9 events/1000 catheter days), and the frequency of infectious complications was 10.6% (5.2 events/1000 catheter days). On multivariate analysis thromboses were more frequent and earlier with PICCs than CICCs (p = 0.0001), and in patients on UFH (16.6%) than in LMWH prophylaxis (4.7%), but the last difference was not statistically significant. In conclusions the incidence of thrombotic complications in our series was comparable to that observed in non-thrombocytopenic patients and was significantly higher in those carrying PICC than CICC (p = 0.0001). There were fewer thrombotic events in the patients receiving i.v. LMWH prophylaxis than in those receiving i.v. UFH. The use of anticoagulants was safe and not associated with hemorrhages.     

Totally implantable femoral vein catheters in cancer patients.

INTRODUCTION: Totally implantable devices are increasingly being utilized for chemotherapy treatment of oncological patients. When it is impossible to implant the reservoir on the anterior wall of the thorax, or when there is an obstruction of the superior vena cava system, alternative access routes must be sought. Of these, the femoral vein is the most utilized. Few studies have been performed to analyse the results obtained from the implantation and utilization of such catheters in the femoral vein. The goal of this work was to prospectively study the results obtained from the implantation of 20 TIC in femoral veins in a large-sized cancer hospital with its own dedicated vascular clinical team. MATERIAL AND METHODS: Twenty femoral TIC were inserted in 20 patients out of a group of 560 cancer patients submitted to TIC implantation for chemotherapy. Evaluations were made of the early and late-stage complications and patient evolution until removal of the device, death or the end of the treatment. RESULTS: The prospective analysis showed a mean duration of 215 days for the catheters. There were 16 patients with no complications. There were no early complications. Among the late complications, three were infections, representing 0.69/1000 days of catheter use, and one was a deep vein thrombosis (0.23/1000 days of catheter use). One catheter was removed due to primary bacteremia and one due to subcutaneous pocket infection. Fourteen patients died while the catheter was functioning and four patients are still making use of the catheter. CONCLUSION: The low rate of complications implying catheter loss in this study confirms the safety and convenience of the use of femoral TIC in patients who cannot be submitted to implantation in the superior vena cava system.     

Prospective evaluation of a low maintenance policy for semipermanent silicone vascular access catheters

Twenty-six women had semipermanent vascular access catheters (VACs) inserted to allow weekly outpatient infusion chemotherapy for advanced breast cancer. VACs were maintained without occlusive dressings, antibiotics, repeated flushings or heparin for a total of 2294 patient days (range 6 to 217 days, median 55 days). Three exit site and one subcutaneous tunnel infection occurred but no patient suffered septicaemia. VACs allowed both blood sampling and drug administration on 267 occasions and drug administration only on 19 occasions. No catheter became completely occluded.     

A new technique for placement of tunneled subclavian right atrial catheters: experience with 130 cases

We have developed a new single step technique for placement of indwelling silastic subclavian right atrial catheters through a short subcutaneous tunnel that is simple, relatively inexpensive, and can be done in the outpatient clinic. Between December 1984 and July 1986, 130 catheters were inserted in 122 patients using this approach for a cumulative total of 8,900 catheter days. Major complications have included five catheter infections with bacteremia, two procedure-related pneumothoraces, one internal jugular vein thrombosis, and one catheter fragment embolization to the right heart (total major complication rate, 6.9%). Minor complications have included five catheter migrations, seven catheter or catheter hub leaks, and two irreversible lumen occlusions (total minor complication rate 10.8%). Damaged or malpositioned catheters can be replaced through the same subcutaneous tract using a guidewire exchange technique. When this has not been possible, we have not encountered technical difficulties (due to subclavian thrombosis or stenosis) prohibiting insertion of a new catheter, even on the same side. These catheters provide reliable venous access for patients requiring frequent blood sampling, intravenous (IV) fluid or blood product administration, chemotherapy, IV narcotics for pain control, long-term antibiotic therapy, or hyperalimentation. They are ideal for infusion of vesicant chemotherapeutic agents and for patients undergoing ambulatory outpatient infusion chemotherapy. They have a low overall morbidity rate and excellent patient acceptance. Catheter maintenance procedures are simple and non-time-consuming. The same technique can be used to place multichannel catheters in patients requiring greater venous access. We now recommend early placement of these catheters in patients who will require frequent phlebotomy or drug administration during the course of their treatment.     

Percutaneous subclavian catheterization for prolonged systemic chemotherapy

Recent experience with 108 Broviac catheters was reviewed. Sixty-eight were percutaneously placed in the subclavian veins of adults receiving systemic chemotherapy. For subclavian catheters perioperative and late complications were unusual. There was no pneumothorax or serious bleeding associated with insertion, even in severely thrombocytopenic patients. Mean catheter life was 93 days. Infection occurred in only five cases (7%). We conclude that percutaneous placement of right atrial catheters is a safe procedure which provides reliable access for prolonged chemotherapy in cancer patients.