Current approaches in the treatment of catheter-related deep venous thrombosis in children

ABSTRACT

Introduction

Acutely ill and medically complex pediatric patients typically rely on central venous catheters (CVCs) for vascular access. CVCs can have serious complications, including venous thromboembolism (VTE). In children, CVCs are the most common risk factor for VTE.

Area covered

Studies focused on the prevention and treatment of CVC-related VTE in children have been lacking until recently. Currently, there is one U.S. Food and Drug Administration (FDA) approved anticoagulant, dalteparin, and phase 3 trial results for two direct oral anticoagulants (DOACs) in pediatrics have recently been published. This review focuses on the epidemiology, risk factors, prevention, and treatment for CVC-related VTE in children. Data are included from relevant articles in PubMed, 1990 to present.

Expert opinion

With a paucity of FDA-approved anticoagulants for VTE treatment or prophylaxis in children, dosing and monitoring recommendations are often based largely on adult studies. DOACs are a promising group of anticoagulants to be used for children since they are given orally and do not require monitoring. Currently, children at the highest risk for CVC-related VTE are not well represented in the published pediatric DOAC trials.

KEYWORDS:

• Venous thromboembolism
• pediatrics
• central venous catheter
• treatment
• anticoagulation

Article highlights

• The incidence of venous thromboembolism (VTE) in children has been increasing over the last two decades, which is most likely secondary to increased placement of central venous catheters (CVCs) in hospitalized children.

• Children who have cancer, congenital heart disease, critically ill in an intensive care unit, have a systemic or inflammatory condition are at the highest risk of developing a CVC-related VTE.

• Peripherally inserted central venous catheters in children have been shown to have an increased VTE rate over tunneled lines (cuffed and uncuffed) and totally implanted central lines.

• Asymptomatic CVC-related VTE in children may not require treatment and studies have shown lack of short and long-term consequences.

• Anticoagulant prophylaxis strategies against CVC-related VTE in children have been studied in only a few clinical trials, without clear evidence of efficacy to date, but with a few DOAC TE prevention studies still ongoing.

• Treatment for CVC-related VTE is generally initiated to decrease the risk of thrombosis progression, the development of a new VTE or paradoxical embolism.

• Dalteparin is the only FDA-approved anticoagulant for use in children, although more FDA-approved choices, especially the DOACs rivaroxaban and dabigatran, may be anticipated in the near future in light of recently published phase 3 trial results showing favorable efficacy and safety.

Declaration of interest

N Goldenberg receives research support and salary support from the National Institutes, National Heart Lung and Blood Institute for clinical and translational investigation in venous thromboembolism in patients <21 years old; receives consultancy fees from Daiichi Sankyo Inc., Novartis, and the Academic Research Organization CPC Clinical Research for roles in clinical trial oversight committees (e.g. Steering, Data, and Safety Monitoring) in pharmaceutical industry-sponsored pediatric clinical trials of antithrombotics and other agents. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.