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Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
Upper extremity thrombosis in traditional cvc v
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Upper extremity thrombosis in traditional cvc v

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risk of thrombosis and pulmonary embolism with cvc and picc lines

risk of thrombosis and pulmonary embolism with cvc and picc lines

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  • 1. Upper ExtremityThrombosis in traditional CVC v. PICC line…and more.
    James K. O’Brien MD
    CCPSA
    Denver, Co
  • 2. What is DVT of upper extremities?
    CVC v. PICC line thrombosis?
    What is the risk of DVT of upper extremities?
    PE
    Postphlebitic syndrome
    Infection: CVC v. PICC
    Comments
  • 3. What is upper extremity DVT (UEDVT)?
    UEDVT most commonly refers to thrombosis of the axillary and/or subclavian veins.
    Circulation. 2002;106:1874
    NEJM. 2011;364:861
    AJM. 2011; 124:402
    Internal jugular, innominate and superior vena cava are central veins.
  • 4.
  • 5. DVT Free Steering Committee: Cross-sectional, Brigham and Women’s/multicenter prospective eval of DVT/PE:
    592/5388 (11%) had UEDVT.
    Circulation. 2004;110:1605
    REITE registry: Europe and South America prospective registry of VTE.
    523/11,564 (4.5%) enrolled had UEDVT, symptomatic.
    124/523 (24%) had non-cancer, catheter related UEDVT.
    Mortality: 15-30% UEDVT with cancer, with and without catheter. 5% no cancer with catheter. 3% no cancer, no catheter.
    Chest. 2008;133:143
  • 6. PICCs v. CVC, thrombosis
    Asymptomatic
    Florence, Italy: Post critical care placement, U/S at 7,15,30 days. No symptoms.
    PICC: 31/114 (27.2%) UEDVT
    CVC: 12/125 (9.6%) UEDVT
    Int Car Med. 2011;37:284
    Kuala Lampur, Indonesia: Prior to removal of PICC venogram was performed. No symptoms.
    10/26 (38.5%) had evidence of UEDVT
    Brit J Rad. 2005;78:596
    Symptomatic
    Mayo Clinic: retrospective, cancer patients in outpatient setting.
    PICC: 17/149 (11.4%) developed UEDVT
    CVC: 13/273 (4.8%) developed UEDVT
    JVIR 2002; 13: 179
    University of Tennessee: retrospective, symptomatic patients with hospital PICC line.
    38/777 (4.9%) UEDVT
    J Hosp Med. 2009;4:417
    Univ of Utah: prospective, symptomatic patients with hospital PICC line.
    57/1,728 (3.3%) UEDVT
    Chest. 2010;138:803
  • 7. Risk of UEDVT: PE
    Pontiac, MI: 2/23 (9%) patients with brachiocephalic and SVC thrombosis with PE. One patient had LEDVT.
    Chest 2003;123: 809
    University of Tennessee: 777 patients with PICCs, 38/777 (5%) UEDVT, 8/777 (1%) PE, 8/38 (21%) UEDVT+PE. Only 3/8 had neg. venous dopplers of lower extrmities.
    J of Hospital Med 2009; 4: 417
  • 8. Risk of UEDVT: PE
    University of Illinois: Lit. review, 207/3747 (5.5%) with UEDVT had PE. Mortality in these patients was 0.7%. 35-40% have LEDVT suggesting alternative source of PE.
    JVIR 2010; 21: 779
    DVT Free Steering Committee (Brigham/Women’s): 5/592 (0.8%) with UEDVT had PE. Also, UEDVT plus… dyspnea only 8/49 (16%) had PE, chest pain only 11% had PE, and syncope only 25% had PE.
    Circulation 2004; 110: 1605
    RIETE Registry (Europe and S. America): 46/512 (9.6%) with UEDVT and PE.
    Chest 2008; 133: 143
    Pontiac, MI: 0/65 with UEDVT and PE.
    Chest 2003; 123: 1953
  • 9. Risk of UEDVT: Post-phlebitis Syndrome
    McGill University: 7 studies reviewed; in UEDVT, mean of 15% patients suffered post-phlebitic edema, pain, discoloration, etc. “Less with catheter related phlebitis.”
    Thrombosis Res 2005; 117: 609
  • 10. Risks for catheter related thrombosis of upper extremity
    Cancer
    BMI
    History of VTE
    Prior catheter
    Bore of catheter, larger the higher the risk
    Chemotherapy
    Left arm
  • 11. Risk of catheter related bloodstream infection with PICCs in hospitalized patients:
    University of Wisconsin: PICC in ICU, 115 patients had 251 lines placed, CR-BSI was 2/1000 catheter days; CVC, 2-5/1000 catheter days (historic).
    Chest 2005; 128: 489
    University of Utah: ICU burn patients. CR-BSI for PICC was 0/1000 catheter days, for CVC was 6/1000 days. 2/36 (5.5%) PICC lines were removed on suspicion of infection, 12/82 (15%) CVC lines were removed on suspicion of infection.
    J Burn Care and Res 2010; 31: 31
  • 12.
  • 13. Thoughts after reviewing this literature:
    Thrombosis seems more likely with PICC lines placed on ICU especially with large bore catheters used for chest CT angio infusion and CVP monitoring.
    But, there may be fewer infectious complications with PICC lines v. CVC lines.
    PE and post phlebitic risk are of questionable clinical significancewith UEDVT compared to LEDVT.
    Consider looking for LEDVT when UEDVT and PE diagnosed. 30-40% of patients with UEDVT and PE had evidence of LEDVT as well.
    Littledata exists regarding treatment guidelines for UEDVT. All ACCP recommendations are 1C- 2C (strong recommendation-1- to merely recommended-2-based on scant to no evidence-C). No anticoagulation prophylaxis recommended.
    The opportunity cost/benefit of having a PICC placed by nursing v. MD placing CVC line has not been studied but may play a role in decisions on a busy unit.
    Can we follow PICC thrombosis of non-axillary or subclavian origin with serial dopplers without anticoagulation?

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