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INTRODUCTION

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Incidence1,2,3,4,5

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Incidence
  Central Venous Catheter (CVCs) Peripherally Inserted Central Catheters (PICCs)
Symptomatic DVT 1–10% 1–4%
Asymptomatic DVT (documented by venography) ~30% ~20%
Catheter occlusion (without DVT) ~10%  

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Evaluation5,6,7

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Evaluation

Differential diagnosis:

  1. Cellulitis

  2. Fluid retention

  3. Local vein compression by tumor

Upper extremity DVT predication score8

Parameter Category Point Designation
Presence of catheter or access device in a subclavian or jugular vein or a pacemaker +1
Unilateral pitting edema in catheterized extremity +1
Localized pain in catheterized extremity +1
Another diagnosis at least as plausible −1
Probability Category (Prevalence) Risk Score
Low (9–13%) −1 or 0
Intermediate (20–38%) +1
High (64–70%) >1

Imaging procedures:

  1. Ultrasound: Use for jugular, axillary, and subclavian veins (sensitivity and specificity 80%)

  2. Venography: Use for more central veins including innominate and vena cava, and when high clinical suspicion despite negative ultrasound

Complications of Upper Limp DVT5

  1. Pulmonary embolism (PE): The incidence of clinical overt PE is estimated at 12%; the incidence of PE in persons with cancer is higher at 15–25%

  2. Postphlebitic syndrome occurs in ~15%

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Risk Factors Associated with Central Venous Catheter-Related Thromboembolism Among Patients with Cancer9

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Risk Factors Associated with Central Venous Catheter-Related Thromboembolism Among Patients with Cancer
Technical

Thrombogenicity of catheter material (polyethylene > polyurethane or silicone)

Large catheter diameter and number of lumens

Malpositioned catheter tip

Percutaneous insertion > cut down

More than 1 insertion attempt

Prior CVC insertion

Left-sided placement

Subclavian vein insertion > internal jugular insertion

Patient and Vascular

Catheter-associated infection

Fibrinous catheter lumen occlusion

Extrinsic vascular compression (enlarged cervical and/or mediastinal lymph nodes, etc)

Factor V Leiden mutation (and perhaps other thrombophilias)

Prior venous thromboembolism

Ovarian cancer

Treatment-Related

Asparaginase

Estrogens and/or progesterone

Growth factors (ie, epoetin, GM-CSFs, G-CSFs)

Aldesleukin (IL-2)

Thalidomide

Lenalidomide

Heparin-induced thrombocytopenia and thrombosis (HIT, HITT)

Chemical irritation

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Treatment of Catheter-Related Venous Thrombosis10,11,12,13

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Treatment of Catheter-Related Venous Thrombosis
  1. If a CVC is functioning and does not appear to be infected, there is no imperative to remove it

  2. If CVC removal is planned, consider full anticoagulation with unfractionated or low-molecular-weight heparin for 5–7 days prior to removal to reduce the risk embolization with device extraction

  3. Clinicians should keep in mind patients with active malignancy may require prolonged anticoagulation after catheter removal should it be determined that the event occurred independent of the presence of CVC (eg, an additional thrombotic event distant to catheter site)

  4. Catheter-related thrombosis occurring in patients with HIT/HITT is a special circumstance. These patients should receive a direct thrombin inhibitor or fondaparinux for acute anticoagulation with a transition to warfarin or fondaparinux for ...

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