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.     

Managing peripherally inserted central catheter‐related venous thrombosis: How I do it

Imaging‐guided insertion of central venous catheters, either in the form of a peripherally inserted central catheter (PICC) or through a subclavian or a jugular approach, is becoming the preferred method of acquiring long‐term venous access for a variety of therapeutic purposes. The most significant complication from central venous catheters is thrombosis of the catheterized vein. Venous thrombosis related to the insertion of PICC lines is conventionally treated with line removal followed by anticoagulation. Direct thrombolysis with urokinase, using the lumen of the PICC line to facilitate the insertion of the infusion catheter is a simple, safe and effective treatment option. In this article, we describe our experience with this procedure and the technique used.     

Risk factors for central venous catheter thrombotic complications in children and adolescents with cancer

BACKGROUND:

The use of central venous catheters (CVCs) has greatly improved the quality of care in children with cancer, yet these catheters may cause serious infectious and thrombotic complications. The aim of this prospective registry study was to assess the host and CVC‐related risk factors for CVC‐created thrombotic complications.

METHODS:

Patients undergoing CVC insertion for chemotherapy were followed prospectively for CVC complications. At the time of enrollment, demographic, clinical, and CVC‐related data, and family history of thrombosis were collected. Survival and Cox regression analyses were performed.

RESULTS:

A total of 423 CVCs were inserted into 262 patients for a total of 76,540 catheter days. The incidence of CVC‐related deep‐vein thrombosis (DVT) was 0.13 per 1000 catheter‐days (95% confidence interval [CI], 0.06‐0.24). Insertion of peripherally inserted central catheters (PICCs) and insertion in an angiography suite significantly increased the risk of symptomatic CVC‐related DVT. The incidence of CVC occlusion was 1.35 per 1000 catheter‐days (95% CI, 1.1‐1.63). Positive family history of thrombosis significantly increased the risk of CVC occlusion (hazard ratio [HR], 2.16; 95% CI, 1.2‐3.8). The CVC‐related risk factors were insertion of Hickman catheters, insertion in angiography suite, and proximal‐tip location. Patients developing at least 1 episode of both CVC occlusion and infection had an increased risk for developing symptomatic CVC‐related DVT (HR, 4.15; 95% CI, 1.2‐14.4).

CONCLUSIONS:

Both patient‐related and CVC‐related factors are associated with higher risk of symptomatic thrombotic complications. These risk factors could be used in the clinical setting and in developing future studies for CVC thromboprophylaxis. Cancer 2010. © 2010 American Cancer Society.     

肿瘤患者导管相关性深静脉血栓应用预防性抗凝治疗的临床观察

目的 探讨预防性抗凝治疗对恶性肿瘤患者外周静脉置入中心静脉导管(PICC)后相关性血栓的作用.方法 选取2013年1月至2016年12月间广州医科大学附属第一医院收治的系统治疗前予PICC置管的143例患者的临床资料进行回顾性分析,根据治疗方式不同进行分组,其中化疗过程接受预防性抗凝治疗的95例患者纳入预防性抗凝组,仅...     

Catheter-related infection and thrombosis of the internal jugular vein in hematologic-oncologic patients undergoing chemotherapy: a prospective comparison of silver-coated and uncoated catheters

BACKGROUND: Catheter-related venous thrombosis is one of the most frequent complications of central venous catheters (CVCs). This complication occurs in 4- 40% of patients with hematologic malignancies receiving conventional chemotherapy after placement of CVCs. METHODS: The objective of this prospective study was to assess whether a silver-coated CVC poses an additional risk in the development of catheter-related thrombosis in hematologic-oncologic patients. Patients were randomized to receive either silver-coated polyurethane catheters (BactiGuard; Metacot, Stockholm, Sweden) or uncoated standard polyurethane catheters (Cavatheter, Fresenius AG, Bad Homburg, Germany) for central venous access. Silver-coated catheters (n = 120) and standard catheters (n = 113) were inserted into the jugular vein in 233 consecutive patients. Variables that may be significant for the development of thrombosis were comparable in the two groups. After removal of the CVC, the patency of both jugularian veins internal as well as external was assessed with real-time ultrasound (Sonolayer-SAL-35A; Toshiba, Tokyo, Japan). RESULTS: Four of 233 patients (1.5%) were found to have venous thrombosis. Incomplete occlusion of the internal jugular vein occurred in 2 patients (0.75%, parietal thrombosis), and complete thrombosis, although clinically silent, was found in 2 patients (0.75%). There was no difference between patients with silver-coated and uncoated CVCs. CONCLUSIONS: The authors concluded that this novel silver-coated CVC does not cause a higher rate of central venous thrombosis compared with standard CVCs. The low overall incidence of central venous thrombosis might be attributed to the routine application of low-dose heparin in our patients during chemotherapeutic treatment.     

恶性肿瘤中心静脉置管并发血栓22例分析

目的：探讨中心静脉置管肿瘤患者发生血栓的原因及治疗对策。方法：对2003年-2006年808例中心静脉置管的恶性肿瘤患者发生深静脉血栓的病例进行回顾性分析。结果：22例发生深静脉血栓,4例腋静脉,18例股静脉。结论：术后及下肢静脉置管的肿瘤患者易发生血栓。贵要和锁骨下静脉穿刺置管可减少血栓发生。     

Preoperative duplex venous imaging in the assessment of patients with venous access

Occult or clinically apparent central venous thrombosis frequently complicates central venous catheter placemnt in patients requiring long-term vascular access. Thirty-three patients, aged 12-83 years, underwent duplex scanning of the internal jugular, axillary, and brachial veins prior to placement of long-term venous access catheters. Twenty-seven patients underwent duplex scanning because of a prior history of either long-term or short-term central venous access. Of 12 patients with a history of long-term central venous access, without complications, 42% (5/12) had an abnormal duplex scan demonstrating thrombosis. Duplex scans on 15 patents having complications associated with central venous access demonstrated thrombosis of one or more of the central veins, 46% (7/15). Five patients who underwent duplex scanning without a history of a previous central venous catheter or other indication were found to have normal normal central veins. In 13 patients found to have thrombosis or obstruction by duplex scan, the surgeon was directed to successful venous access in all cases. Normal findings were very helpful in confirming that the venous system was normal in selected patients. In approximately 40% of patients with a history of venous access, catheters were found to have evidence of thrombosis of one or more of the central veins. In 13 patients found to have thrombosis or obstruction by duplex scan, the surgeon was directed to a successful site for venous access in all cases. © 1993 Wiley-Liss, Inc.     

Appropriate posture of cancer patients treated with PICC to prevent internal jugular vein ectopic

We aimed to study the appropriate posture of peripherally inserted central catheter （PICC） patients, to reduce the incidence of internal jugular vein heterotopia. Methods： From 2009 to 2013, a total of 290 cases with PICC were enrolled in our study. They were divided into two groups. The patients in control group took regular position, which mean pros- tration, upper limb of tube side was abduction 90°, head moved to puncture side in order to block the internal jugular vein. On the basis of conventional body position putting, posture of patients in observation group was improved, the head remain neutral, and had 180° angle with trunk longitudinal axis, not favor any side. After ensuring the upper limb abduction, had 90° angle with the trunk, then catheter was inserted slowly. The jugular venous catheter heterotopia rate was judged by X.ray results. Results： The jugular venous catheter heterotopia rate of control group and observation was 12.8% and 0.68%, respectively. The difference between two groups was statistically significant （P 〈 0.01）. Conclusion： The body posture improvement can prevent discomfort of patients and reduce the jugular venous catheter heterotopia rate of PICC.     

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.     

列线图预测恶性肿瘤患者PICC导管相关血栓风险的研究

  目的  经外周中心静脉置管（peripherally inserted central catheters,PICC）在恶性肿瘤化疗中的应用越来越广泛,其导管相关血栓的发生率也呈现上升的趋势,显著影响患者的治疗及生存质量。  方法  回顾性分析2014年12月至2015年12月就诊于西安交通大学第一附属医院的286例进行PICC置管的恶性肿瘤患者相关临床资料,并对潜在的危险因素进行最小绝对收缩选择算子（least absolute shrinkage and selection operator,LASSO）回归分析,最终构建列线图模型。  结果  286例PICC置管患者中,72例出现导管相关血栓。将研究所纳入的27个潜在的血栓相关危险因素进行LASSO回归分析,结果显示进行外周血管穿刺时是否应用超声引导、患者既往是否接受过经外周静脉化疗、置管期间是否存在其他合并症以及置管时的血浆D-二聚体含量为影响PICC置管患者发生导管相关血栓的危险因素,最终应用上述风险因素构建列线图预测模型,其C-index指数为0.688,拟合曲线和校正后地拟合曲线均位于10%的误差范围内。  结论  结合穿刺技术、既往治疗,合并症以及D二聚体等因素所构建的列线图可以较准确的预测PICC相关血栓形成的风险,为临床诊疗工作的开展提供一定的理论基础和数据支持。      

肿瘤患者合并深静脉血栓的临床分析

目的:探讨恶性肿瘤并发血栓性疾病的危险因素,为及早预防提供依据.方法:收集30例恶性肿瘤并发血栓栓塞患者为病例组,并收集同期不伴有血栓栓塞的38例恶性肿瘤患者为对照组,回顾性分析恶性肿瘤并发血栓栓塞的危险因素.结果:病例组30例患者中,下肢深静脉血栓形成者24例,上肢深静脉血栓5例,肺栓塞者1例.观察组红细胞计数和血红蛋白值均低于对照组,血小板计数和D-二聚体高于对照组,差异均有统计学意义(P<0.05).恶性肿瘤并发血栓性疾病的发生在并发感染、接受手术、地塞米松治疗和中心静脉置管上存在差异(P<0.05).30例患者在肿瘤确诊2个月内并发血栓性疾病.结论:恶性肿瘤并发感染、地塞米松的应用、接受手术和中心静脉置管的应用时易并发血栓形成.     

恶性肿瘤患者PICC相关血栓形成危险因素分析

目的:探讨PICC相关血栓形成的危险因素。方法:对我院肿瘤科2012-2013年接受PICC置管的411例患者进行回顾性分析,采用SPSS 17.0软件包进行统计分析,先进行单因素卡方检验或t检验,再进行多因素非条件Logistic回归分析。结果:发生血栓25例,未发生血栓386例,其中男性发生静脉血栓的概率为5.3%,女性为6.8%;卵巢癌发生血栓的概率最高,达到25%,其次为结肠癌为16.3%;Ⅰ、Ⅱ期患者血栓发生率为9.4%,Ⅲ、Ⅳ为4.9%;BD公司PICC导管血栓发生率为1.8%,巴德公司PICC导管发生率为11.1%。单因素及多因素分析均表明,巴德PICC（导管内径大）及结肠癌是血栓发生的危险因素。结论:在PICC导管外径相同情况下,内径越大,PICC相关血栓形成的风险越高,另外,结肠癌患者较其他肿瘤有更高的血栓发生概率。     

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。     

The Incidence of Venous Thromboembolism and Impact on Survival in Hodgkin Lymphoma

BackgroundThrombosis increase the acute and long-term morbidity and mortality in malignancy patients. We analyzed venous thromboembolism (VTE) in patients with Hodgkin lymphoma, the impact of VTE on survival, predisposing factors for VTE, and predicting value of Khorana and ThroLy score models.Patients and MethodsWe included 150 adult patients with Hodgkin lymphoma between January 2010 and 2018 at our university hospital.ResultsVTE was observed in 31 patients (20.7%). The types of VTE were 18 upper and 3 lower extremity deep vein thrombosis and 10 pulmonary embolism (1 with lower extremity deep vein thrombosis). Twenty-nine patients developed VTE during the treatment with a median time of episode as 5 months. In logistic regression analysis, a body mass index of >32 kg/m², high fibrinogen levels, initial thrombocytosis and leukocytosis, splenic and extranodal involvement, presence of a central venous line, advanced stage, line of treatment status of thromboprophylaxis, VTE timing, and better Eastern Cooperative Oncology Group performance scores were observed to be related with VTE. Kaplan Meier survival analysis showed a negative impact of VTE on survival. Khorana and ThroLy risk assessment models were found predictive for VTE (P = .000 and P = .003, respectively), although only ThroLy score was associated with the survival.ConclusionThromboprophylaxis and precautions for VTE in patients with Hodgkin lymphoma according to validated risk assessment models can improve prognosis and quality of life owing to the impact of VTE on survival in the study.     

Upper extremity deep venous thrombosis in patients with 5-fluorouracil-containing adjuvant chemotherapy--three case reports and a review

Catheter-related deep venous thrombosis is a complication that can occur in patients receiving chemotherapy. Three such cases are described and a review of the literature is made, focusing on recent results regarding possible thrombogenic mechanisms and the high prevalence of non-symptomatic thrombosis as well as the high morbidity and mortality associated with upper extremity deep venous thrombosis. Special emphasis is given to the cytotoxic effects of 5-fluorouracil on vascular endothelium and the likely link to thrombotic complications. The possible differences between two different methods of administering chemotherapy, continuous infusion and bolus dose administration, in this regard are briefly discussed. It is concluded that the first steps towards an understanding of the mechanisms behind the vascular effects of 5-fluorouracil have been taken. Much remains to be done before active interaction with the pathogenic processes leading to vascular and cardiac complications can be realized, yet various forms of anticoagulant therapy could well be an efficient form of prophylaxis.     

Thrombosis related to the use of L-asparaginase in adults with acute lymphoblastic leukemia: a need to consider coagulation monitoring and clotting factor replacement

L-asparaginase (L-asp) has become an important component of combination chemotherapy for acute lymphoblastic leukemia (ALL). However, L-asp can produce depletions in many of the clotting factors with an associated risk for thrombosis and hemorrhage. Three consecutive patients seen at the Mayo Clinic with L-asp related thrombosis are described and an in-depth review of the literature is provided. Two of the 3 patients developed central nervous system (CNS) complications with evidence of thrombosis and hemorrhagic infarction. Two of the patients also developed extensive upper extremity thrombosis. The results of comprehensive hemostatic surveys showed marked abnormalities in all 3 patients. Many of the thrombotic complications related to L-asp involve the CNS, as illustrated in 2 of our patients. These patients should be treated aggressively since full recovery is possible. The precise cause of thrombosis is yet to be determined but is likely multifactorial. The optimal treatment and prevention of thrombosis in this group of patients remains poorly defined.     

Anticoagulants in thrombosis and cancer: the missing link

Many cancer patients reportedly have hypercoaguable state, with recurrent thrombosis due to the impact of cancer cells and chemotherapy on the coagulation cascade. A number of retrospective studies showed that cancer patients are at higher risk of developing venous thromboembolism. In addition to the pathological mechanisms associated with tumor-mediated increase in thrombotic events, cancer therapies including chemotherapy, immobilization, cancer surgery and the use of central venous catheters contribute toward a hypercoaguable state and are therefore independent risk factors of venous thromboembolism in cancer patients. Studies have demonstrated that unfractionated heparin or low molecular weight heparin (LMWH) interferes with various processes involved in tumor growth and metastasis. These processes might include fibrin formation, binding of heparin to angiogenic growth factors – such as basic fibroblast growth factor and VEGF – modulation of tissue factor, release of tissue factor pathway inhibitor and other mechanisms. Clinical trials have suggested an improved efficacy of LMWH, as compared with UFH on the survival of cancer patients with deep vein thrombosis. Similarly, the impact of warfarin on the survival of cancer patients with thromboembolic disorders was demonstrated. Recent studies from our laboratory defined the role of the LMWH (tinzaparin), warfarin, antifactor VIIa and recombinant tissue factor pathway inhibitor in the modulation of angiogenesis, tumor growth and tumor metastasis.     

恶性肿瘤合并静脉血栓栓塞症21例临床分析

目的探讨恶性肿瘤合并静脉血栓栓塞症（VTE）高危因素、诊断、治疗以及预防。方法回顾性分析21例恶性肿瘤合并静脉血栓栓塞症的临床资料。结果 21例病例中1例深静脉血栓形成（DVT）患者因为活动性咯血而未进行抗凝治疗,随诊发现患者患肢肿胀加重,超声复查提示血栓较前增大。1例肺血栓栓塞症（PTE）患者因病情危重未来得及行抗凝治疗以及溶栓治疗已经死亡。另1例PTE患者经对症治疗病情稳定后接受低分子肝素、华法林抗凝治疗,复查超声提示静脉血栓较前缩小。其余18例DVT患者经过抗凝治疗后患肢肿胀,疼痛减轻、消失或（和）超声检查提示静脉血栓较前缩小、消失,血流恢复通畅。结论通过分析恶性肿瘤合并静脉血栓栓塞症高危因素、诊断、治疗以及预防,提高DVT诊疗水平,减少PTE的发生,对防治VTE有重要意义。     

化疗患者经外周静脉置入中心静脉导管相关性感染危险因素分析

目的探讨化疗患者经外周静脉置入中心静脉导管(PICC)留置后导管相关性感染的危险因素。方法选取接受化疗且接受PICC治疗的260例患者为研究对象,记录患者PICC留置期间感染发生率,并进行病原菌分布检测,对PICC相关性感染的危险因素进行单因素分析以及多因素Logistic分析。结果260例患者中有35例患者发生PICC导管相关性感染,感染率为13.46%,其中局部感染率为65.71%(23/35),其次为血流感染28.57%(10/35),其他原因为5.71%(2/35)。35例发生PICC感染患者共分离出病原菌48株,病原菌分布依次为:金黄色葡萄球菌43.75%(21/48),表皮葡萄球菌27.08%(13/48),白色假丝酵母菌14.58%(7/48),鲍氏不动杆菌8.33%(4/48),肺炎克雷伯杆菌4.17%(2/48),其他葡萄球菌2.08%(1/48)。导管留置时间≥60 d、化疗疗程≥8次、外周血象异常、换药频次≥7 d、护士置管经验不足、免疫功能低下、有合并症是导致患者出现PICC相关性感染的独立危险因素(P﹤0.05)。结论化疗患者PICC导管相关性感染发生率较高,且受多种因素影响,需要结合危险因素以及患者自身情况给予合理的护理措施,以降低PICC留置期间感染率。     

Vascular access via peripherally inserted central venous catheters (PICCs): experience in 40 patients with acute myeloid leukemia at a single institute.

Reliable long-term vascular access is essential for the treatment of patients with acute myeloid leukemia (AML). Although peripherally inserted central catheters (PICCs) have been in use for many years, little data exist on their use in patients receiving intensive chemotherapy. We retrospectively reviewed all AML patients who had a PICC inserted between July 95 and May 98. Fifty two PICCs were inserted in 40 patients with AML. Thirty three PICCs were inserted during severe thrombocytopenia (platelets < 50 x 10(9)/L), and 31 during severe neutropenia (neutrophils < 0.5 x 10(9)/L). Mean catheter duration was 82 (median 63, range 3-441) days for a total of 4274 catheter days. A mean of 1.8 chemotherapy courses were administered via each PICC. There were 5 early complications of PICC placement. Other mechanical complications occurred in 14 catheters and phlebitis in 12. Twenty blood stream infections (BSI) occurred in 17 patients. All BSIs occurred during neutropenia. Seventeen PICCs were removed due to the following complications - phlebitis (11), possible catheter related BSI (4), mechanical reasons in 3 (2 with concomitant phlebitis) and persistent fever (1). PICC duration was significantly shorter in these 17 catheters (52.9 v 96.4 days in the other 35, p=0.0289). We conclude that PICCs provide long-term vascular access with an acceptable complication rate in patients with AML. However, a randomised trial is required before PICCs can be considered an alternative to tunneled central venous catheters in these patients.