Prevention and treatment of thrombosis associated with central venous catheters in cancer patients

Abstract

Central venous catheters (CVC) play an essential role in the management of cancer patients. Venous thrombosis is a common complication of CVC. The incidence of CVC-associated venous thromboembolism (CVC-VTE) is 1.7 per 1000 catheter days. Risk factors for CVC-VTE include the patient’s underlying cancer, a history of previous thrombotic events and the location and type of CVC. Anticoagulant prophylaxis is not effective for CVC-VTE. Anticoagulation alone is the preferred initial treatment for CVC-VTE. CVC removal may be considered in refractory cases or when anticoagulation is contraindicated. Thrombolytic therapy is reserved for patients with limb-threatening thrombosis or thrombosis unresponsive to conventional treatment. Anticoagulation should be continued for at least 3 months or as long as the CVC is present.

Keywords::

• anticoagulation
• cancer
• central venous access device
• central venous catheter
• prevention
• prophylaxis
• treatment

Financial and competing interests disclosure

MB Streiff has been a consultant for Boehringer-Ingelheim, Daichi-Sankyo, Janssen Healthcare, Eisai and Pfizer, and he has received a grant from Portola for the APEX clinical trial. He has also received CME honoraria and been a consultant for Sanofi-Aventis. 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.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Central venous catheters (CVC) are an important cause of venous thromboembolism (VTE).

• Consider patient-, disease- and CVC-related thrombosis risk factors when making decisions on CVC use.

• Conventional CVC thromboprophylaxis is ineffective and not recommended by guidelines. In patients with a history of CVC-VTE who need a new CVC, consider the risks and benefits of therapeutic anticoagulation to prevent recurrent VTE.

• Maintain a high degree of suspicion for CVC-VTE. Strongly consider diagnostic testing in patients with CVC malfunction or ipsilateral upper extremity or chest discomfort or swelling.

• Anticoagulation without CVC removal is the preferred initial approach to CVC-VTE.

• CVC removal can be considered in patients who are not anticoagulation candidates or patients who failed to improve despite initial anticoagulation. If possible, an initial course of anticoagulation should be administered prior to CVC removal to minimize the risk of thromboembolism in patients with a proximal DVT (axillary, subclavian or more central).

• Thrombolytic therapy should be reserved for patients with limb-threatening CVC-VTE or continued symptoms despite anticoagulation.

• Superior vena cava filters should be avoided in the treatment of CVC-VTE as their risk–benefit balance does not appear to be favorable.

• Patients with CVC-VTE should be treated with anticoagulation for at least 3 months or as long as the CVC remains in place, whichever is longer.

Notes