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Catheter-Related Thrombosis

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Coagulation in Cancer

Part of the book series: Cancer Treatment and Research ((CTAR,volume 148))

The use of central venous catheters (CVC) has greatly facilitated the delivery of chemotherapeutic agents and is one of the most important aspects of the supportive care of patients with cancer. The most frequently utilized central venous catheters in cancer care include totally implanted catheter systems and single or multilumen tunneled catheters. Despite the convenience of use of CVC, thrombosis and infection remain frequent and serious complications of these devices [1]. This chapter will address the different types of catheter-related thrombosis as well as their diagnosis and management.

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References

  1. Ganeshan A, Warakaulle DR, Uberoi R. Central venous access. Cardiovasc Intervent Radiol 2007;30:26–33.

    Article  PubMed  Google Scholar 

  2. Hoshal VL Jr, Ause RG, Hoskins PA. Fibrin sleeve formation on indwelling subclavian central venous catheters. Arch Surg 1971;102:253–8.

    Google Scholar 

  3. Balestreri L, De Cicco M, Matovic M, et al. Central venous catheter-related thrombosis in clinically asymptomatic oncologic patients: a phlebographic study. Eur J Radiol 1995;20:108–11.

    Article  PubMed  CAS  Google Scholar 

  4. De Cicco M, Matovic M, Balestreri L, et al. Central venous thrombosis: an early and frequent complication in cancer patients bearing long-term silastic catheter. A prospective study. Thromb Res 1997;86:101–13.

    Article  PubMed  Google Scholar 

  5. Xiang D, Verbeken EK, Van Lommel AT, et al. Composition and formation of the sleeve enveloping a central venous catheter. J Vasc Surg 1998;28:260–71.

    Article  PubMed  CAS  Google Scholar 

  6. Forauer AR, Theoharis CG, Dasika NL. Jugular vein catheter placement: histologic features and development of catheter-related (fibrin) sheaths in a swine model. Radiology 2006;240:427–34.

    Article  PubMed  Google Scholar 

  7. Starkhammar H, Bengtsson M, Morales O. Fibrin sleeve formation after long term brachial catheterisation with an implantable port device. A prospective venographic study. Eur J Surg 1992;158:481–4.

    PubMed  CAS  Google Scholar 

  8. Raad II, Luna M, Khalil SA, et al. The relationship between the thrombotic and infectious complications of central venous catheters. JAMA 1994;271:1014–6.

    Article  PubMed  CAS  Google Scholar 

  9. Mehall JR, Saltzman DA, Jackson RJ, et al. Fibrin sheath enhances central venous infection. Crit Care Med 2002;30:908–12

    Article  PubMed  Google Scholar 

  10. Keller JE, Hindman JW, Mehall JR, et al. Enoxaparin inhibits fibrin sheath formation and decreases central venous catheter colonization following bacteremic challenge. Crit Care Med 2006;34:1450–5

    Article  PubMed  CAS  Google Scholar 

  11. Hurtubise MR, Bottino JC, Lawson M, McCredie KB. Restoring patency of occluded central venous catheters. Arch Surg 1980;115:212–3.

    Article  PubMed  CAS  Google Scholar 

  12. Stephens LC, Harie WD, Kotulak GD. Are clinical signs accurate indicators of the cause of central venous catheter occlusion? JPEN J Parenter Enteral Nutr 1995;19:75–79.

    Article  PubMed  CAS  Google Scholar 

  13. Schifferdecker B, Shaw JA, Piemonte TC, et al. Nonmalignant superior vena cava syndrome: pathophysiology and management. Catheter Cardiovasc Interv 2005;65:416–23.

    Article  PubMed  Google Scholar 

  14. Monreal M, Lafoz E, Ruiz J, et al. Upper-extremity deep venous thrombosis and pulmonary embolism. A prospective study. Chest 1991;99:280–3.

    Article  PubMed  CAS  Google Scholar 

  15. Prandoni P, Polista P, Bernardi E, et al. Upper-extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med 1997;157:57–62.

    Article  PubMed  CAS  Google Scholar 

  16. Bernardi E, Pesavento R, Prandoni P. Upper extremity deep venous thrombosis. Semin Thromb Hemost 2006;32:729–36.

    Article  PubMed  Google Scholar 

  17. Agnelli G, Verso M. Therapy insight: Venous-catheter-related thrombosis in cancer patients. Nat Clin Pract Oncol 2006;3:214–22.

    Article  PubMed  Google Scholar 

  18. Bozzetti F, Scarpa D, Terno G, et al. Subclavian venous thrombosis due to indwelling catheters: a prospective study on 52 patients. JPEN J Parenter Enteral Nutr 1983;7:560–2.

    Article  PubMed  CAS  Google Scholar 

  19. Lokich JJ, Becker B. Subclavian vein thrombosis in patients treated with infusion chemotherapy for advanced malignancy. Cancer 1983;52:1586–9.

    Article  PubMed  CAS  Google Scholar 

  20. Bern MM, Lokich JJ, Wallach SR, et al. Very low doses of warfarin can prevent thrombosis in central venous catheters. A randomized prospective trial. Ann Intern Med 1990;112:423–8.

    PubMed  CAS  Google Scholar 

  21. Monreal M Alastrue A, Rull M, et al. Upper extremity deep venous thrombosis in cancer patients with venous access devices – prophylaxis with a low molecular weight heparin (fragmin). Thromb Haemost 1996;75:251–3.

    PubMed  CAS  Google Scholar 

  22. Horne MK III, May DJ, Alexander HR, et al. Venographic surveillance of tunneled venous access devices in adult oncology patients. Ann Surg Oncol 1995;2:174–8.

    Article  PubMed  Google Scholar 

  23. Barzaghi A, Dell’Orto M, Rovelli A, et al. Central venous catheter clots: incidence, clinical significance and catheter care in patients with hematologic malignancies. Pediatr Hematol Oncol 1995;12:243–50.

    Article  PubMed  CAS  Google Scholar 

  24. Glaser DW, Medeiros D, Rollins N, et al. Catheter-related thrombosis in children with cancer. J Pediatr 2001;138:255–9.

    Article  PubMed  CAS  Google Scholar 

  25. Haire WD, Lieberman RP, Edney J, et al. Hickman catheter-induced thoracic vein thrombosis. Frequency and long-term sequelae in patients receiving high-dose chemotherapy and marrow transplantation. Cancer 1990;66:900–8.

    Article  PubMed  CAS  Google Scholar 

  26. Kuter DJ. Thrombotic complications of central venous catheters in cancer patients. Oncologist 2004;9:207–16.

    Article  PubMed  Google Scholar 

  27. Couban S, Goodyear M, Burnell M, et al. Randomized placebo-controlled study of low-dose warfarin for the prevention of central venous catheter-associated thrombosis in patients with cancer. J Clin Oncol 2005;23:4063–9.

    Article  PubMed  CAS  Google Scholar 

  28. Lee AY, Levine MN, Butler G, et al. Incidence, risk factors, and outcomes of catheter-related thrombosis in adult patients with cancer. J Clin Oncol 2006;24:1404–8.

    Article  PubMed  Google Scholar 

  29. Biffi R, De Braud F, Orsi F, et al. A randomized, prospective trial of central venous ports connected to standard open-ended or Groshong catheters in adult oncology patients. Cancer 2001;92:1204–12.

    Article  PubMed  CAS  Google Scholar 

  30. Verso M, Agnelli G, Bertoglio S, et al. Enoxaparin for the prevention of venous thromboembolism associated with central vein catheter: a double-blind, placebo-controlled, randomized study in cancer patients. J Clin Oncol 2005;23:4057–62.

    Article  PubMed  CAS  Google Scholar 

  31. Karthaus M, Kretzschmar A, Kroming H, et al. Dalteparin for prevention of catheter-related complications in cancer patients with central venous catheters: final results of a double-blind, placebo-controlled phase III trial. Ann Oncol 2006;17:289–96.

    Article  PubMed  CAS  Google Scholar 

  32. Levine M, Kakkar AK. Catheter-associated thrombosis: thromboprophylaxis or not? J Clin Oncol 2005;23:4006–8.

    Article  PubMed  CAS  Google Scholar 

  33. Köksoy C, Kuzu A, Kutlay J, et al. The diagnostic value of colour Doppler ultrasound in central venous catheter related thrombosis. Clin Radiol 1995;50:687–9.

    Article  PubMed  Google Scholar 

  34. Knudson GJ, Wiedmeyer DA, Erickson SJ, et al. Color Doppler sonographic imaging in the assessment of upper-extremity deep venous thrombosis. AJR Am J Roentgenol1990;154:399–403

    PubMed  CAS  Google Scholar 

  35. Baarslag HJ, van Beek EJR, Koopman Maria MW, et al. Prospective study of color duplex ultrasonography in patients suspected of having deep venous thrombosis of the upper extremities. Ann Intern Med 2002;136:865–872

    PubMed  Google Scholar 

  36. Baxter GM, Kinkaid W, Jeffrey RF, et al. Comparison of colour Doppler ultrasound with venography in the diagnosis of axillary subclavian vein thrombosis. Br J Radiol 1991;64:777–81

    Article  PubMed  CAS  Google Scholar 

  37. Gaitini D, Beck-Razi N, Haim N, et al. Prevalence of upper extremity deep venous thrombosis diagnosed by color Doppler duplex sonography in cancer patients with central venous catheters. J Ultrasound Med 2006;25:1297–303.

    PubMed  Google Scholar 

  38. Male C, Chait P, Ginsberg, Ginsberg JS, et al. Comparison of venography and ultrasound for the diagnosis of asymptomatic deep vein thrombosis in the upper body in children: results of the PARKAA study. Prophylactic antithrombin replacement in kids with ALL treated with sparaginase. Thromb Haemost 2002;87:593–8.

    PubMed  CAS  Google Scholar 

  39. Kroencke TJ, Taupitz M, Arnold R, et al. Three-dimensional gadolinium-enhanced magnetic resonance venography in suspected thrombo-occlusive disease of the central chest veins. Chest 2001;120:157–6.

    Article  Google Scholar 

  40. Thornton MJ, Ryan R, Varghese JC, et al. A three-dimensional gadolinium-enhanced MR venography technique for imaging central veins. AJR Am J Roentgenol 1999;173:999–1003.

    PubMed  CAS  Google Scholar 

  41. Verso M, Agnelli G. Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. J Clin Oncol 2003;21:3665–75.

    Article  PubMed  Google Scholar 

  42. Adess M, Eisner R, Nand S, et al. Thromboembolism in cancer patients: pathogenesis and treatment. Clin Appl Thromb Hemost 2006;12:254–66.

    Article  PubMed  CAS  Google Scholar 

  43. Fijnheer R, Paijman B, Verdonck LF, Nieuwenhuis HK, Dekker AW. Factor V Leiden in central venous catheter-associated thrombosis. Br J Haematol 2002;118:267–70.

    Article  PubMed  CAS  Google Scholar 

  44. Riordan M, Weiden PL. Factor V Leiden mutation does not account for central venous catheter-related thrombosis. Am J Hematol 1998;58:150–2.

    Article  PubMed  CAS  Google Scholar 

  45. Mandalã M, Curigliano G, Bucciarelli P, et al. Factor V Leiden and G20210A prothrombin mutation and the risk of subclavian vein thrombosis in patients with breast cancer and a central venous catheter. Ann Oncol 2004;15:590–3.

    Article  PubMed  Google Scholar 

  46. Abdelkefi A, Ben Romdhane N, Kriaa A, et al. Prevalence of inherited prothrombotic abnormalities and central venous catheter-related thrombosis in haematopoietic stem cell transplants recipients. Bone Marrow Transplant 2005;36:885–9.

    Article  PubMed  CAS  Google Scholar 

  47. Tesselaar ME, Ouwerkerk J, Nooy MA, et al. Risk factors for catheter-related thrombosis in cancer patients. Eur J Cancer 2004;40: 2253–9.

    Article  PubMed  CAS  Google Scholar 

  48. Van Rooden CJ, Rosendaal FR, Meinders AE, et al. The contribution of factor V Leiden and prothrombin G20210A mutation to the risk of central venous catheter-related thrombosis. Haematologica 2004;89:201–6.

    PubMed  Google Scholar 

  49. Dentali F, Gianni M, Agnelli G, et al. Association between inherited thrombophilic abnormalities and central venous catheter thrombosis in patients with cancer: a meta-anlysis. J Thromb Haemost 2008;6:70–5

    Article  PubMed  CAS  Google Scholar 

  50. Wermes C, von Depka Prondzinski M, Lichtinghagen R, et al. Clinical relevance of genetic risk factors for thrombosis in paediatric oncology patients with central venous catheters. Eur J Pediatr 1999;158 Suppl 3:S143–6.

    Article  PubMed  Google Scholar 

  51. Eastman ME, Khorsand M, Maki DG, et al. Central venous device-related infection and thrombosis in patients treated with moderate dose continuous-infusion interleukin-2. Cancer 2001;91:806–14.

    Article  PubMed  CAS  Google Scholar 

  52. Stephens LC, Haire WD, Schmit-Pokomy K, et al. Granulocyte macrophage colony stimulating factor: high incidence of apheresis catheter thrombosis during peripheral stem cell collection. Bone Marrow Transplant 1993;11:51–4.

    PubMed  CAS  Google Scholar 

  53. Borow M, Crowley JG. Evaluation of central venous catheter thrombogenicity. Acta Anaesthesiologica Scandinavica – Supplementum 1985;81:59–64.

    Article  PubMed  CAS  Google Scholar 

  54. Krafte-Jacobs B, Sivit CJ, Mejia R, et al. Catheter-related thrombosis in critically ill children: Comparison of catheters with and without heparin bonding. J Pediatr1995;126:50–4.

    Article  PubMed  CAS  Google Scholar 

  55. Pierce CM, Wade A, Mok Q. Heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill children. Intensive Care Med 2000;26:967–72.

    Article  PubMed  CAS  Google Scholar 

  56. Eastridge BJ, Lefor AT. Complications of indwelling venous access devices in cancer patients. J Clin Oncol 1995;13:233–8.

    PubMed  CAS  Google Scholar 

  57. Brown-Smith JK, Stoner MH, Barley ZA. Tunneled catheter thrombosis: factors related to incidence. Oncol Nurs Forum 1990;17:543–9.

    PubMed  CAS  Google Scholar 

  58. Craft PS, May J, Dorigo A, et al. Hickman catheters: left-sided insertion, male gender, and obesity are associated with an increased risk of complications. Aust N Z J Med 1996;26:33–9.

    Article  PubMed  CAS  Google Scholar 

  59. Male C, Chait P, Andrew M, et al. Central venous line-related thrombosis in children: association with central venous line location and insertion technique. Blood 2003;101:4273–8.

    Article  PubMed  CAS  Google Scholar 

  60. Petersen J, Delaney JH, Brakstad MK, et al. Silicone venous access devices positioned with their tips high in the superior vena cava are more likely to malfunction. Am J Surg 1999;178:38–41

    Article  PubMed  CAS  Google Scholar 

  61. van Rooden CJ, Shippers EF, Barge RM, et al. Infectious complications of central venous catheters increase the risk of catheter-related thrombosis in hematology patients: a prospective study. J Clin Oncol 2005;23:2655–60.

    Article  PubMed  Google Scholar 

  62. Trerotola SO, Kuhn-Fulton J, Johnson MS, et al. Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology 2000;217:89–93.

    PubMed  CAS  Google Scholar 

  63. Macdonald S, Watt AJ, McNally D, et al. Comparison of technical success and outcome of tunneled catheters inserted via the jugular and subclavian approaches. J Vasc Interv Radiol 2000;11:225–31.

    Article  PubMed  CAS  Google Scholar 

  64. Araújo C, Silva JP, Antunes P, Fernandes JM, et al. A comparative study between two central veins for the introduction of totally implantable venous access devices in 1201 cancer patients. Eur J Surg Oncol 2008;34:222–6.

    Article  PubMed  Google Scholar 

  65. Nightingale CE, Norman A, Cunningham D, et al. A prospective analysis of 949 long-term central venous access catheters for ambulatory chemotherapy in patients with gastrointestinal malignancy. Eur J Cancer 1997;33:398–403.

    Article  PubMed  CAS  Google Scholar 

  66. Boraks P, Seale J, Price J, et al. Prevention of central venous catheter associated thrombosis using minidose warfarin in patients with haematological malignancies. Br J Haematol 1998;101:483–6.

    Article  PubMed  CAS  Google Scholar 

  67. Heaton DC, Han DY, Inder A. Minidose (1 mg) warfarin as prophylaxis for central vein catheter thrombosis. Intern Med J 2002;32:84–8.

    Article  PubMed  CAS  Google Scholar 

  68. Mismetti P, Mille D, Laporte S, et al. Low-molecular-weight heparin (nadroparin) and very low doses of warfarin in the prevention of upper extremity thrombosis in cancer patients with indwelling long-term central venous catheters: a pilot randomized trial. Haematologica 2003;88:67–73.

    PubMed  CAS  Google Scholar 

  69. Rawson KM, Newburn-Cook CV. The use of low-dose warfarin as prophylaxis for central venous catheter thrombosis in patients with cancer: a meta-analysis. Oncol Nurs Forum 2007;34:1037–43.

    Article  PubMed  Google Scholar 

  70. Niers TM, Di Nisio M, Klerk CP, et al. Prevention of catheter-related venous thrombosis with nadroparin in patients receiving chemotherapy for hematologic malignancies: a randomized, placebo-controlled study. J Thromb Haemost 2007;5:1878–1882.

    Article  PubMed  CAS  Google Scholar 

  71. Chaukiyal P, Nautiyal A, Radhakrishnan S, et al. Thromboprophylaxis in cancer patients with central venous catheters. A systematic review and meta-analysis. Thromb Haemost 2008;99:38–43.

    PubMed  CAS  Google Scholar 

  72. Akl EA, Kamath G, Yosuico V et al. Thromboprophylaxis for patients with cancer and central venous catheters: a systematic review and meta-analysis. Cancer 2008;112:2483–92.

    Google Scholar 

  73. Cunningham MS, White B, Hollywood D, O'Donnell J. Primary thromboprophylaxis for cancer patients with central venous catheters – a reappraisal of the evidence. Br J Cancer 2006;94:189–94.

    Article  PubMed  CAS  Google Scholar 

  74. Levine M. Is antithrombotic prophylaxis required in cancer patients with central venous catheters? Still an open question. J Thromb Haemost 2006;4:16.

    Article  PubMed  CAS  Google Scholar 

  75. Huisman MV. Is antithrombotic prophylaxis required in cancer patients with central venous catheters? Yes for special patient groups. J Thromb Haemost 2006;4:10.

    Article  PubMed  CAS  Google Scholar 

  76. Hooke C. Recombinant tissue plasminogen activator for central venous access device occlusion. J Pediatr Oncol Nurs 2000;17:174–8.

    Article  PubMed  CAS  Google Scholar 

  77. Timoney JP, Malkin MG, Leone DM, et al. Safe and cost effective use of alteplase for the clearance of occluded central venous access devices. J Clin Oncol 2002;20:1918–22.

    Article  PubMed  CAS  Google Scholar 

  78. Haire WD, Deitcher SR, Mullane KM, et al. Recombinant urokinase for restoration of patency in occluded central venous access devices. a double-blind, placebo-controlled trial. Thromb Haemost 2004;92:575–82.

    PubMed  CAS  Google Scholar 

  79. Linenberger ML. Catheter-related thrombosis: risks, diagnosis, and management. J Natl Comp Canc Netw 2006;4:889–901.

    Google Scholar 

  80. Muñoz FJ, Mismetti P, Poggio R, et al. Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE registry. Chest 2008;133:143–8.

    Article  PubMed  Google Scholar 

  81. Savage KJ Wells PS, Schulz V. Outpatient use of low molecular weight heparin (dalteparin) for the treatment of deep vein thrombosis of the upper extremity. Thromb Haemost 1999;82:1008–10.

    PubMed  CAS  Google Scholar 

  82. Kovacs MJ, Kahn SR, Rodger M, et al. A pilot study of central venous catheter survival in cancer patients using low-molecular-weight heparin (dalteparin) and warfarin without catheter removal for the treatment of upper extremity deep vein thrombosis (the catheter study). J Thromb Haemost 2007;5:1650–3.

    Article  PubMed  CAS  Google Scholar 

  83. Frank DA, Meuse J, Hirsch D, Ibrahim JG, van den Abbeele AD. The treatment and outcome of cancer patients with thromboses on central venous catheters. J Thromb Thrombolysis 2000;10:271–5.

    Article  PubMed  CAS  Google Scholar 

  84. Sabeti S, Schillinger M, Mlekusch W, et al. Treatment of subclavian-axillary vein thrombosis: long-term outcome of anticoagulation versus systemic thrombolysis. Thromb Res 2002;108:279–85.

    Article  PubMed  Google Scholar 

  85. Schindler J, Bona RD, Chen HH, et al. Regional thrombolysis with urokinase for central venous catheter-related thrombosis in patients undergoing high-dose chemotherapy with autologous blood stem cell rescue. Clin Appl Thromb Hemost 1999;5:25–9.

    PubMed  CAS  Google Scholar 

  86. Kim HS, Preece SR, Black JH, et al. Safety of catheter-directed thrombolysis for deep venous thrombosis in cancer patients. J Vasc Surg 2008;47:388–94.

    Article  PubMed  Google Scholar 

  87. Spence LD, Gironta MG, Malde HM, et al. Acute upper extremity deep venous thrombosis: Safety and effectiveness of superior vena caval filters. Radiology 1999;210:53–8.

    PubMed  CAS  Google Scholar 

  88. Ascher E, Hingorani A, Mazzariol F, et al. Clinical experience with superior vena caval Greenfield filters. J Endovasc Surg 1999;6:365–9.

    Article  PubMed  CAS  Google Scholar 

  89. Wagman LD, Baird MF, Bennett CL, et al. Venous thromboembolic disease. Clinical practice guidelines in oncology. J Natl Compr Canc Netw 2006;4:838–69.

    PubMed  CAS  Google Scholar 

  90. Braner DA, Lai S, Eman S, et al. central venous catheterization – subclavian vein. N Engl J Med 2008;357:e26.

    Google Scholar 

  91. Harris S, Naina HV. Central venous catheterization – subclavian vein. N Engl J Med 2008;358:1758–9

    PubMed  CAS  Google Scholar 

  92. Graham CA. Central venous catheterization – subclavian vein. N Engl J Med 2008;358:1759

    PubMed  CAS  Google Scholar 

  93. Evans FC. Central venous catheterization – subclavian vein. N Engl J Med 2008;358:1759

    PubMed  CAS  Google Scholar 

  94. Schummer W, Frober R, Schummer C. Central venous catheterization – subclavian vein. N Engl J Med 2008;358:1759–60

    PubMed  CAS  Google Scholar 

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  1. Audie L. Murphy Memorial Veterans Hospital and University of Texas Health Science Center, Mail Code 7880, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900

    César O. Freytes

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    Freytes, C.O. (2009). Catheter-Related Thrombosis. In: Kwaan, H., Green, D. (eds) Coagulation in Cancer. Cancer Treatment and Research, vol 148. Springer, Boston, MA. https://doi.org/10.1007/978-0-387-79962-9_12

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