Abstract
Background: Central venous catheters (e.g., PICC lines and Hickman-type catheters) in patients with cancer are associated with development of DVT in 1–3%. Patient management varies from immediate removal of the line, with or without anticoagulation, to the extreme of thrombolytic therapy. This multicenter cohort clinical trial was designed to assess the safety and effectiveness of a management strategy for central venous catheter-related UEDVT in cancer patients consisting of dalteparin and warfarin as a means of salvaging the line without the need for line removal.
Methods: Patients greater than 18 years-of-age with an active malignancy and who had symptomatic, acute, objectively documented UEDVT were eligible. Patients were excluded if the catheter was a dialysis catheter, they had active bleeding or a high risk for major bleeding, platelet count <100 ×09/L, serum creatinine >177μmol/l, if they were currently on therapeutic doses of warfarin, inability to infuse through the catheter after a trial of intraluminal thrombolytic therapy (2mg TPA), had AML or ALL or bone marrow/stem cell transplant planned in the next 3 months or if they did not provided written informed consent. Four centers in Canada participated. Patients were treated with dalteparin 200 IU/kg per day for 5–7 days and simultaneously initiated on warfarin with a target INR of 2.0–3.0. Patients were followed for 3 months for recurrent venous thromboembolism, major hemorrhage and survival of the central venous catheter.
Results: There were 74 patients (48 males) enrolled from November 2002 to December 2005. The average age was 58 years. Seventy-one UEDVTs were diagnosed by ultrasound and three by CT. There were 57 PICC lines, 14 portacaths and 3 Hickman catheters. Sixty-four patients (86%) completed three-month follow-up. Of the 10 who did not, 7 died (6 due to cancer and 1 due to a major bleed) and 3 others were no longer evaluable (2 patients were treated with LMWH only and another patient had the line removed against protocol). There were no episodes of recurrent venous thromboembolism and 3 (4%) major bleeds. For the endpoint of line survival, 42 (57%) of the lines were in situ and still functional at three months. No lines were removed due to infusion failure or recurrence/extension of DVT. In the 32 patients who had line removal before the study three-month endpoint, 21 were due to the end of therapeutic need, 2 were due to infection and 9 for other reasons such as falling out, skin irritation, patient request, etc. Hence, 63 (85%) patients were able to maintain the central line until it was no longer needed, or for at least three months. For the 11 others, none were removed due to venous thrombosis or line failure.
Conclusion: Treatment of UEDVTs secondary to central catheters in cancer patients with standard dalteparin/warfarin can allow the central line to remain in situ with little risk of line failure or recurrence/extension of the DVT.
An endoluminal brush to detect the infected central venous catheter in situ: a pilot study
