Upper extremity thrombosis in traditional cvc v


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risk of thrombosis and pulmonary embolism with cvc and picc lines

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Upper extremity thrombosis in traditional cvc v

  1. 1. Upper ExtremityThrombosis in traditional CVC v. PICC line…and more.<br />James K. O’Brien MD<br />CCPSA<br />Denver, Co<br />
  2. 2. What is DVT of upper extremities?<br />CVC v. PICC line thrombosis?<br />What is the risk of DVT of upper extremities?<br />PE<br />Postphlebitic syndrome<br />Infection: CVC v. PICC<br />Comments<br />
  3. 3. What is upper extremity DVT (UEDVT)?<br />UEDVT most commonly refers to thrombosis of the axillary and/or subclavian veins.<br />Circulation. 2002;106:1874 <br />NEJM. 2011;364:861<br />AJM. 2011; 124:402 <br />Internal jugular, innominate and superior vena cava are central veins.<br />
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  5. 5. DVT Free Steering Committee: Cross-sectional, Brigham and Women’s/multicenter prospective eval of DVT/PE:<br />592/5388 (11%) had UEDVT.<br />Circulation. 2004;110:1605<br />REITE registry: Europe and South America prospective registry of VTE. <br />523/11,564 (4.5%) enrolled had UEDVT, symptomatic.<br />124/523 (24%) had non-cancer, catheter related UEDVT.<br />Mortality: 15-30% UEDVT with cancer, with and without catheter. 5% no cancer with catheter. 3% no cancer, no catheter.<br />Chest. 2008;133:143<br />
  6. 6. PICCs v. CVC, thrombosis<br />Asymptomatic<br />Florence, Italy: Post critical care placement, U/S at 7,15,30 days. No symptoms.<br />PICC: 31/114 (27.2%) UEDVT<br />CVC: 12/125 (9.6%) UEDVT<br />Int Car Med. 2011;37:284<br />Kuala Lampur, Indonesia: Prior to removal of PICC venogram was performed. No symptoms.<br />10/26 (38.5%) had evidence of UEDVT<br />Brit J Rad. 2005;78:596<br />Symptomatic<br />Mayo Clinic: retrospective, cancer patients in outpatient setting.<br />PICC: 17/149 (11.4%) developed UEDVT<br />CVC: 13/273 (4.8%) developed UEDVT<br />JVIR 2002; 13: 179<br />University of Tennessee: retrospective, symptomatic patients with hospital PICC line.<br />38/777 (4.9%) UEDVT<br />J Hosp Med. 2009;4:417<br />Univ of Utah: prospective, symptomatic patients with hospital PICC line.<br />57/1,728 (3.3%) UEDVT<br />Chest. 2010;138:803<br />
  7. 7. Risk of UEDVT: PE<br />Pontiac, MI: 2/23 (9%) patients with brachiocephalic and SVC thrombosis with PE. One patient had LEDVT.<br />Chest 2003;123: 809 <br />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.<br />J of Hospital Med 2009; 4: 417<br />
  8. 8. Risk of UEDVT: PE<br />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.<br />JVIR 2010; 21: 779<br />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.<br />Circulation 2004; 110: 1605 <br />RIETE Registry (Europe and S. America): 46/512 (9.6%) with UEDVT and PE.<br />Chest 2008; 133: 143<br />Pontiac, MI: 0/65 with UEDVT and PE.<br />Chest 2003; 123: 1953<br />
  9. 9. Risk of UEDVT: Post-phlebitis Syndrome<br />McGill University: 7 studies reviewed; in UEDVT, mean of 15% patients suffered post-phlebitic edema, pain, discoloration, etc. “Less with catheter related phlebitis.”<br />Thrombosis Res 2005; 117: 609<br />
  10. 10. Risks for catheter related thrombosis of upper extremity<br />Cancer<br />BMI<br />History of VTE<br />Prior catheter<br />Bore of catheter, larger the higher the risk<br />Chemotherapy<br />Left arm<br />
  11. 11. Risk of catheter related bloodstream infection with PICCs in hospitalized patients:<br />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).<br />Chest 2005; 128: 489<br />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.<br />J Burn Care and Res 2010; 31: 31<br />
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  13. 13. Thoughts after reviewing this literature:<br />Thrombosis seems more likely with PICC lines placed on ICU especially with large bore catheters used for chest CT angio infusion and CVP monitoring.<br />But, there may be fewer infectious complications with PICC lines v. CVC lines.<br />PE and post phlebitic risk are of questionable clinical significancewith UEDVT compared to LEDVT.<br />Consider looking for LEDVT when UEDVT and PE diagnosed. 30-40% of patients with UEDVT and PE had evidence of LEDVT as well.<br />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.<br />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.<br />Can we follow PICC thrombosis of non-axillary or subclavian origin with serial dopplers without anticoagulation?<br />