Combined thrombolytic therapy for atrial thrombus in a preterm infant

Intracardiac thrombosis is a rare event in newborn (5.1 per 100000 live births). It is associated with an high morbidity and mortality. Most of intracardiac thrombi are related to intravascular catheterism. The use of thrombolytic therapy in neonates has rapidly improved in the last few years, particularly with the introduction of more clot-selective second-generation agents like urokinase and tissue plasminogen activator. In literature there is no therapeutic trial concerning the pharmacological approach of atrial thrombosis in newborns; different approaches are described in the case reports present in literature. In all of them, tissue plasminogen activator or urokinase are alternatively administered. In no case report urokinase and tissue plasminogen activator are administered in a combined thrombolytic therapy. Combined thrombolytic therapy with urokinase and tissue plasminogen activator, in association with low-dose heparin, allows the use of lower drug doses, less therapy's duration and a rapid resolution of thrombus. Thormbolytic therapy is sometimes complicated with hemorrhagic complications. This article describes the case of a preterm infant (25 weeks of gestational age) with peduncolate thrombus in the right atrium, treated with combined thrombolytic therapy. The authors noticed a rapid decrease in thrombus dimension, no thrombus replacement and no organ bleeding.     

Outcome of Cardiac Thrombi in Infants

Use of central lines in the neonatal intensive care unit (NICU) has led to the formation of intracardiac thrombi. A paucity of data exists on the management of neonatal cardiac thrombi, with the few reported cases focusing on outcomes following thrombolytic therapy. This study was undertaken to evaluate the outcome of cardiac thrombi in neonates who do not receive thrombolytic therapy. Nineteen patients younger than 3 months of age diagnosed with cardiac thrombi were included. All 19 patients had a central line. Management consisted of a combination of antibiotics and low-molecular-weight heparin (n = 16) or surgical removal (n = 2). In one case, no treatment was instituted. One patient was lost to follow-up after partial resolution of the thrombus. Complete thrombus resolution occurred in 18 patients, 9 with negative blood cultures and 9 with positive blood cultures. It took longer for resolution of thrombi associated with positive blood cultures than for sterile thrombi. No patient had evidence of thrombus embolization. From these data we concluded that the natural history of cardiac thrombi is resolution. Infected thrombi require more prolonged therapy. Surgery is seldom required and thrombolytics are not usually necessary for clot resolution.     

A Single-Center Experience with Intracardiac Thrombosis in Children with Dilated Cardiomyopathy

Intracardiac thrombosis in patients with a dilated cardiomyopathy can be life threatening. This study investigated the incidence, risk factors, and outcome of intracardiac thrombosis in children with dilated cardiomyopathy. A retrospective review of the clinical records was performed in 83 children with dilated cardiomyopathy diagnosed from January 1995 to December 2008. Intracardiac thrombi were detected in 5 patients (6.0%). The intracardiac thrombi were found mainly in the left ventricle (n = 3). One patient had a thrombus in the left atrium at the time of diagnosis, and a right ventricular thrombus was found in 1 patient with unrepaired ventricular septal defect complicated by pulmonary hypertension. Intracardiac thrombosis developed during rapid deterioration of ventricular function, and all patients had a poor ejection fraction of the left ventricle. All patients were treated with heparinization, and thrombectomy was performed in 1 patient. Three patients achieved complete resolution of the thrombus without further embolic complications. Careful evaluation and aggressive anticoagulation are necessary for the prevention of intracardiac thrombosis in children with poor ventricular function, especially during rapid deterioration of ventricular function.     

Pediatric sinovenous thrombosis

PURPOSE: To determine if anticoagulation therapy is effective for preventing progression of pediatric sinovenous thrombosis, to determine the safety of anticoagulation therapy in the pediatric population, and to outline risk factors and clinical presentation in the authors' population of patients with sinovenous thrombosis. METHODS: A retrospective chart review was conducted of 17 consecutive pediatric patients with sinovenous thrombosis at the authors' institution regardless of treatment option and outcome. RESULTS: Fifteen children underwent anticoagulation therapy; two did not. Surgical intervention was undertaken in two patients. None of the children died. None had recurrence after anticoagulation was initiated. Of the patients who had follow-up studies performed, 33% had some resolution of the clot, 60% had complete resolution, and 13% had no change. Both children who did not undergo anticoagulation therapy had resolution of the thrombus. All of the children had improvement of their symptoms at presentation. No patient had worsening of radiologic findings during the follow-up period. CONCLUSIONS: Anticoagulation therapy did not result in bleeding complications. Fifteen of 17 patients were safely anticoagulated. All children had improvement of their presenting symptoms. There was no worsening of radiologic findings in any patient, and there was improvement in 13 patients. One patient has long-term neurologic sequelae (a learning disability). This patient underwent extensive surgeries for subdural and epidural empyemas.     

Low-dose tissue plasminogen activator thrombolysis in children

PURPOSE: To compare results of low-dose tissue plasminogen activator (TPA) in children with arterial and venous thrombi relative to standard published dosing. METHODS: Subjects consisted of all consecutive children with objectively confirmed thrombi for whom TPA thrombolysis was clinically ordered by the authors. Initial dosing used published standard dose (0.1-0.5 mg/kg per hour). With experience, a low-dose regimen (0.01-0.06 mg/kg per hour) was given in an attempt to derive a minimal effective dose. RESULTS: Thirty-five children were treated with TPA. Either standard or low-dose infusions of TPA resulted in complete thrombolysis of 28 of 29 (97%) acute thrombi, while all 6 chronic thrombi had a partial response. In contrast to the recommended adult-derived dosages of 0.1 to 0.5 mg/kg per hour, the authors found that initial doses of less than 0.01 mg/kg per hour were effective in 12 of 17 patients with acute thrombosis. Neonates required 0.06 mg/kg per hour. Route of administration (local or systemic) did not affect efficacy. Major bleeding occurred in only one extremely preterm infant. Minor bleeding, primarily oozing at intravenous sites, occurred in 27% of children during TPA infusions. Prophylactic unfractionated or low-molecular-weight heparin was infused concomitant with TPA in 42% of the children and did not increase the risk of bleeding. CONCLUSIONS: TPA in very low doses appears to be safe and effective for thrombolysis of acute thromboses in most children, given appropriate patient selection.     

Metabolism of fibrinogen in children with acute lymphoblastic leukaemia

The metabolism and in vivo kinetics of fibrinogen were studied using homologous ¹²⁵I-labelled fibrinogen in 21 children with acute lymphoblastic leukaemia (ALL). Ten patients were undergoing induction therapy, 11 children were in complete remission on maintenance therapy.Results in the patients undergoing induction therapy were: plasma fibrinogen levels were normal in all except one patient, the plasma fibrinogen pool was elevated in six cases, seven patients had a shortened fibrinogen half-life and increased fractional catabolic rate for fibrinogen. The absolute catabolic rate for fibrinogen was elevated in six cases. This shortened fibrinogen half-life together with the correcting effect of heparinisation on the fibrinogen turnover indicated that fibrinogen was consumed by chronic disseminated intravascular coagulation. Inhibition of the fibrinolytic system with epsilon-aminocaproic acid in five patients had no influence on the fibrinogen half-life in three of them but resulted in its prolongation in two patients.All except two children in complete remission had normal fibrinogen levles. Six patients had elevated plasma fibrinogen pools and in all of the cases survival and fractional catabolic rate of fibrinogen were normal. The absolute catabolic rate for fibrinogen was normal in eight, elevated in three of the patients. This observation indicates that fibrinogen synthesis remains accelerated in some cases of ALL in complete remission, but the cause of this is not known.Abbreviations ALL acute lymphoblastic leukaemia - DIC disseminated intravascular coagulation - PTT partial thromboplastin time - PT prothrombin time - TT thrombin time - EG ethanol gelation test - ELT euglobulin clot lysis time - FDP fibrinogen/fibrin degradation products - FCR fractional catabolic rate constant - ACR absolute catabolic rate - IFP intravascular plasma fibrinogen pool - PV plasma volume     

Successful thrombolysis by prolonged low-dose alteplase in catheter-directed infusion

Catheter-directed thrombolysis is a sophisticated method in the treatment of thromboembolism with maximum effect on the thrombus and minimal systemic effect. The consequences are enhanced local thrombolysis and a reduction in general bleeding tendency, compared with systemic thrombolysis. At our institution, two children had successful thrombolysis by prolonged continuous catheter-directed low-dose alteplase. The first patient, a boy with Fontan physiology, was successfully treated for a massive pulmonary thromboembolism by catheter-directed very low-dose alteplase for five days. The second patient, who suffered from relapsing nephrotic syndrome, achieved satisfactory thrombolysis of an arterial leg thrombosis after four days of continuous catheter-directed low-dose alteplase.

Conclusion: Although catheter-directed thrombolysis seems to be a valuable method in thrombolytic therapy, there is a lack of evidence-based recommendations concerning dosage, effect of bolus, simultaneous anticoagulation and duration of treatment for children.     

Successful clot lysis using low dose of streptokinase in 22 neonates with aortic thromboses

OBJECTIVE: To determine whether intravenous infusion of low dose of streptokinase was effective in lysing umbilical arterial catheter (UAC)-associated aortic thrombi. METHOD: A prospective cohort study of 31 consecutive newborn infants with UAC-associated aortic thrombi which were detected by abdominal ultrasonography after removal of UAC. Twenty-two infants were treated with intravenous infusion of low dose (1000 U/h) streptokinase, while nine others were not treated due to various contra-indications. Thrombolysis occurred after a mean interval of 2.2 days (standard deviation (SD) = 1.8) in the treated infants. In the untreated infants, spontaneous thrombolysis occurred significantly later, after a mean interval of 16.9 days (SD = 14.7) (95% confidence intervals of difference between mean intervals - 26.0, - 3.4; P = 0.02). Only one treated infant developed mild bleeding directly attributed to streptokinase therapy. CONCLUSION: Low dose streptokinase infusion was effective and safe in thrombolysing UAC-associated aortic thrombi.     

Superior vena cava thrombus treated with low-dose, peripherally administered recombinant tissue plasminogen activator in a child: case report and review of the literature

Thrombotic complications in pediatrics are more common today due to our ability to treat complicated diseases. In pediatric patients where thrombolytic therapy is indicated, the lack of evidence-based medicine forces practitioners to extrapolate dose recommendations for recombinant tissue plasminogen activator (rt-PA) from adult studies. This often results in a high rate of major complications. Low-dose rt-PA is an option that is effective and safe. The authors describe a child with septic thrombus of the superior vena cava who was successfully treated with low-dose, peripherally administered rt-PA, and review the efficacy and safety of standard- versus low-dose rt-PA in children. A Medline search was completed for the use of standard- and low-dose rt-PA in children with thromboembolic disease. Five studies large enough to present efficacy and safety data on standard- and/or low-dose t-PA use in children and neonates were analyzed. Two studies using low-dose rt-PA reported efficacy rates equal to or greater than those reported for standard-dose regimens. Rates of major complications were approximately 5% for low-dose regimens and up to 40% for standard-dose ones. Low-dose, peripherally administered rt-PA is safe and may be as effective as standard-dose rt-PA. A randomized controlled trial should be done to confirm this assumption.     

Polyethylene glycol for constipation in children younger than eighteen months old

BACKGROUND: Polyethylene glycol (PEG) is a safe and effective treatment for constipation in children older than 18 months. Data on its safety and efficacy in infants are lacking. The goal of this study was to determine safety, efficacy, and optimal dose of polyethylene glycol powder for treatment of constipation in patients younger than 18 months. METHODS: The authors reviewed the charts of patients younger than 18 months treated with PEG 3350 for constipation. The initial dose, effective maintenance dose, response to therapy, duration of therapy, and side effects were recorded. RESULTS: Twenty-eight patients younger than 18 months of age treated with PEG were identified (3, age 0-5 months; 9, age 6-11 months; 16, age 12-17 months). Mean duration of therapy was 6.2 +/- 5 months (range, 3 weeks-21 months). Mean initial dose was 0.88 g/kg/day (range, 0.26-2.14 g/kg/day). Mean effective maintenance dose was 0.78 g/kg/day (range, 0.26-1.26 g/kg/day). PEG relieved constipation in 97.6% of patients. One infant experienced increased gas per rectum and four others experienced transient diarrhea that resolved after adjusting the dose. CONCLUSION: Oral powdered polyethylene glycol at a maintenance dose of 0.78 g/kg/day is safe and effective for patients younger than 18 months. Dose and safety profiles are similar for those reported in older children.     

Left ventricular thrombi in three children with dilated cardiomyopathy: Diagnostic procedure and clinical course

Summary In three of nine children with dilated cardiomyopathy (aged 1–9 years), left ventricular thrombi were diagnosed and followed by echocardiography. Thrombi recurred in two patients, in one of them, embolized to the cerebral arteries. Resolution of the thrombi was observed under therapy directed against platelet aggregation. However, this did not prevent thrombus formation.     

The low molecular weight heparin dalteparin for prophylaxis and therapy of thrombosis in childhood: a report on 48 cases

We investigated the efficacy, safety and relation of dose to plasma anti-Xa activity of the low molecular weight heparin (LMWH) dalteparin in prophylaxis and therapy of arterial and venous thrombosis in pediatric patients. A total of 48 children were enrolled: 10 received dalteparin for prophylaxis (group I), 8 for reocclusion prophylaxis following successful thrombolysis (group II), 5 following failed thrombolysis (group III) and 23 for primary antithrombotic therapy (group IV). Two children were treated with dalteparin for pulmonary veno-occlusive disease (PVOD) and for primary pulmonary hypertension (PPH), respectively. Outcome: In group I no thrombo-embolic event occurred. In group II recanalization was maintained or improved, in group III vascular occlusion persisted under dalteparin. In group IV we saw complete recanalization in 7/23 (30%), partial recanalization in 7/23 (30%) and no recanalization in 9/23 (40%) cases. The child with PVOD had recanalization proven by lung biopsy; the clinical condition of the child with PPH also improved. Minor bleeding occurred in 2/48 (4%) children. For prophylaxis 95 - 52 (mean and SD) anti-Xa IU/kg BW, for therapy 129 - 43 (mean and SD) anti-Xa IU/kg BW proved effective. For both prophylaxis and therapy the required dose per kg BW was inversely related with age (r² = 0.64, P = 0.017; r² = 0.13, P = 0.013). Conclusion Dalteparin proved to be an effective and well tolerated drug for prophylaxis and therapy of thrombosis in pediatric patients. Dose requirement for effective treatment was higher in younger children and decreased with age.     

Transesophageal Echocardiography of Intracardiac Thrombus in Congenital Heart Disease and Atrial Flutter: The Importance of Thorough Examination of the Fontan

Transesophageal echocardiography (TEE) is used in atrial flutter or fibrillation (AFF) before electric cardioversion to detect intracardiac thrombi. Previous studies have described the use of TEE to diagnose intracardiac thrombi in the left atrium and left atrial appendage, which has an incidence of 8 % among patients without congenital heart disease (CHD). In their practice the authors have noted a significant incidence of intracardiac thrombi in other structures of patients with CHD and AFF. This study aimed to determine the incidence and location of intracardiac thrombi using TEE in patients with CHD requiring electric cardioversion of AFF and to compare the use of TEE and transthoracic echo (TTE) to detect intracardiac thrombus in this population. A retrospective chart review of TEE and TTE findings for all patients with CHD who had electric cardioversion of AFF at our institution from 2005 to 2013 was conducted. The diagnosis, presence, and location of intracardiac thrombus were determined. The TEE and TTE results were compared. The study identified 27 patients with CHD who met the study entry criteria at our institution between 2005 and 2013. Seven of these patients had a single ventricle with Fontan palliation. All the patients presented with AFF and had TEE before electric cardioversion. No patients were excluded from the study. The patients ranged in age from 2 to 72 years (median, 21 years) and weighed 17–100 kg (median, 65 kg). The duration of AFF before TEE and attempted cardioversion ranged from 1 day to 3 weeks (median, 3.5 days). Intracardiac thrombus was present in 18 % (5/27) of the patients and in 57 % (4/7) of the Fontan patients with AFF. No embolic events were reported acutely or during a 6-month follow-up period. Among patients with CHD who present with AFF, a particularly high incidence of intracardiac thrombi is present in the Fontan patients that may be difficult to detect by TTE. Thorough TEE examination of the Fontan and related structures is indicated before electric cardioversion of AFF. The incidence of intracardiac thrombus in CHD patients is more than double that reported in non-CHD patients.     

Management and outcomes of pediatric septic thrombophlebitis: a case series

Abstract

Septic thrombophlebitis is a potentially life-threatening condition. Pediatric hematologists are often consulted to provide recommendations regarding anticoagulation management. We conducted a ten-year retrospective, single-center study of hospitalized pediatric patients who were treated for septic thrombophlebitis. Our primary outcome was resolution of thrombophlebitis. Twenty-eight patients were included in the study. Eighty-nine percent of patients received both antibiotic and anticoagulation therapy. The median durations of intravenous and total antibiotic therapy were 47.5?days (range 14-120) and 65?days (range 14-281), respectively, and median duration of anticoagulation therapy was 92?days (range 41-268). Resolution of thrombosis defined by magnetic resonance imaging, computed tomography, or ultrasound imaging was documented in 16 of 28 (57%) patients. Despite the high rate of persistent thrombosis, there was a low risk of relapse of infection in cases where antibiotic and/or anticoagulation was discontinued prior to complete resolution of the thrombus. Further research is needed to determine if duration of antibiotic and/or anticoagulation treatment can be shortened.     

Oral oseltamivir treatment of influenza in children

BACKGROUND: Oral oseltamivir administration is effective treatment for influenza in adults. This study was conducted to determine the efficacy, safety and tolerability of oseltamivir in children with influenza. METHODS: In this randomized, double blind, placebo-controlled study, children 1 through 12 years with fever [> or =100 degrees F (> or =38 degrees C)] and a history of cough or coryza <48 h duration received oseltamivir 2 mg/kg/dose or placebo twice daily for 5 days. The primary efficacy endpoint was the time to resolution of illness including mild/absent cough and coryza mild/absent, return to normal activity and euthermia. RESULTS: Of 695 enrolled children 452 (65%) had influenza (placebo, n = 235; oseltamivir, n = 217). Among infected children the median duration of illness was reduced by 36 h (26%) in oseltamivir compared with placebo recipients (101 h; 95% confidence interval, 89 to 118 vs. 137 h; 95% confidence interval, 125 to 150; P < 0.0001). Oseltamivir treatment also reduced cough, coryza and duration of fever. New diagnoses of otitis media were reduced by 44% (12% vs. 21%). The incidence of physician-prescribed antibiotics was significantly lower in influenza-infected oseltamivir (68 of 217, 31%) than placebo (97 of 235, 41%; P = 0.03) recipients. Oseltamivir therapy was generally well-tolerated, although associated with an excess frequency of emesis (5.8%). Discontinuation because of adverse events was low in both groups (1.8% with oseltamivir vs. 1.1% with placebo). Oseltamivir treatment did not affect the influenza-specific antibody response. CONCLUSIONS: Oral oseltamivir administration is an efficacious and well-tolerated therapy for influenza in children when given within 48 h of onset of illness.     

Safe use of alteplase in a 10 months old infant with cardio-embolic stroke

The knowledge about safety and efficacy of thrombolysis in paediatric stroke is limited, especially for very young children. We present an infant with cardioembolic stroke treated with alteplase. He had hypoplastic left heart syndrome since birth. He underwent Norwood operation, followed by bidirectional cavopulmonary anastomosis at 3 months. On aspirin therapy he was well until heart failure developed at the age of 9 months with 2 thrombi in the right ventricle. During the course of enoxaparin therapy sudden acute left-sided haemiplegia occurred. The emergency brain CT scan was normal. Informed consent was obtained from parents after explaining the alteplase treatment protocol and possible complications. Alteplase was administered i.v. according to standard adult stroke regimen. A control CT scan obtained 24 h later was negative for intracranial haemorrhage but the hypodense area in insula, internal capsule and subcortical area of the right parietal region were indicative of ischaemic stroke. Anticoagulation therapy was continued. He recovered hand functions after 5 days and full repertoire of movements on his left side 3 weeks later. A neurological examination performed 2 months after indicated mild residual haemiparesis and a modified Rankin scale score of 1. Three months later, the patient died of progressive heart failure. An international multicentre prospective trial is ongoing to investigate the safety and appropriate dose of alteplase for paediatric ages 2–17 years. The aim of this paper is to report safe use of alteplase even in a very young child.     

Thrombolytic therapy in Kawasaki disease: A report of four cases

Four patients with a thrombus in a coronary artery aneurysm due to Kawasaki disease (KD) were treated at our hospital between 1994 and 2009. All the cases were treated with intravenous coronary thrombolysis (IVCT) therapy and the cases with acute myocardial infarction were treated with additional intracoronary thrombolysis therapy. Although both thrombolytic therapies were effective, IVCT required more time than intracoronary thrombolysis to resolve the thrombus. We concluded that IVCT can be used as the first‐line thrombolytic therapy for KD, except in cases with acute myocardial infarction.     

Cavoatrial tumor extension in children with wilms tumor: a retrospective review of 17 children in a single center

The aim of this study was to evaluate the clinical characteristics and treatment results of 17 children with cavoatrial tumor extension of Wilms tumor. Of the 360 Wilms tumors diagnosed between 1980 and 2000, 17 patients with intracaval thrombus were identified from the medical records at the pediatric oncology department of Hacettepe University. The following data were collected and reviewed: age, sex, presenting symptoms, tumor site, presence of anaplasia, stage, associated congenital anomalies, localization of tumor thrombus, radiologic findings, type and duration of preoperative chemotherapy, response to preoperative chemotherapy, recurrences, and survival. The frequency of cavoatrial extension in this group was 4.7% (15 in the inferior vena cava and 2 in the right atrium). Fourteen patients received preoperative chemotherapy consisting of two-drug regimen (vincristine and actinomycin D) ranging from 1 to 12 weeks (median 4 weeks). Since intravascular invasion is often asymptomatic, a careful radiologic examination to detect tumor thrombus before surgery is essential. There is no need for aggressive surgery in the presence of tumor thrombus. It may be resolved by preoperative chemotherapy. Surgical removal of the thrombus should be considered in the presence of life-threatening tumor thrombosis at diagnosis and in patients who had residual thrombus after chemotherapy.     

Intracardiac Thrombus in Children: The Fine Equilibrium Between the Risk and the Benefit

The medical records of 16 patients diagnosed as intracardiac thrombus were searched. The size, location and outcome of thrombus together with demographic data of patients were assessed. The median age of the patients was 2.2 years. Six patients were newborn and two patients were infant. The median size of thrombus was 9 mm. The localization was right atrium in seven, right ventricle in five, left ventricle in one, pulmonary artery in one, and superior vena cava in two patients. There was prematurity in five, ciyanotic congenital heart disease in one, blood culture positivity in three, malignancy in four, nephrotic syndrome in one, indwelling catheters in 10, and acquired or genetic thrombophilia in six patients as risk factors. In the treatment, the first choice was tissue plasminogen activator in two patients, heparin infusion in one patient and low molecular weight heparin in remaining 12 patients. In nine patients, therapy included parenteral antimicrobials together with anticoagulants. The result was complete resolution in 15 patients and in one patient thrombus was surgically removed. The median time was 16 (2–70) days for 50% resolution and 26 (3–93) days for complete resolution. There was a statistically significant (P = .027 and r = 0.5) correlation between the size and the complete resolution time. There was no anticoagulant therapy related major complication. In patients with intracardiac thrombus, selection of anticoagulant therapy may decrease the risk of complications. Surgery is rarely required and thrombolytics are not usually necessary for resolution of thrombus.     

Use of Tissue Plasminogen Activator as a Surrogate Measure for Central Venous Catheter Dysfunction and Survival Outcome in Children with Cancer: A Population-Based Retrospective Cohort Study

Abstract

Central venous catheter (CVC) dysfunction is often associated with thrombosis, which in turn has been linked with poorer survival outcomes in cancer patients. Our objective was to examine the association of tissue plasminogen activator (tPA) administration as a surrogate measure of CVC dysfunction with survival in pediatric cancer patients. The present study uses data from a population-based retrospective cohort of pediatric oncology patients from the Canadian Maritime provinces treated between 2000 and 2017 at the IWK Health Centre, Halifax, NS. Demographics, diagnosis, date of death or date of last visit, and tPA use for CVC dysfunction were obtained from clinical databases and the provincial Cancer in Young People in Canada registry. The association between tPA administration and survival was examined using a Cox regression model adjusted for sex, age at diagnosis, cancer type, thrombosis, CVC duration, diagnosis era, and treatment modalities. Out of 821 patients, 206 received one or more doses of tPA during upfront therapy. The death rate was 21% and 15% respectively in patients who did and did not receive tPA. In the adjusted regression model, after receiving one or more doses of tPA, children had significantly poorer survival as compared to those that did not receive tPA (HR: 1.496, 95% CI: 1.019, 2.197). CVC dysfunction may be associated with a poorer prognosis in pediatric cancer patients. Future studies should corroborate these findings in other populations, examine the influence of other potential confounders, and determine the role of CVC dysfunction in prognostic models of cancer survival.