Central Venous Catheters and Upper Extremity DVT: Update, Diagnosis and Management

Transcription

1 Central Venous Catheters and Upper Extremity DVT: Update, Diagnosis and Management David Hahn, MD Interventional Radiology NorthShore University HealthSystem

2 Objectives Discuss the epidemiology and clinical impact of catheter related venous thrombosis Examine various strategies in the management of catheter related UEDVT Discuss the literature and national guidelines for upper extremity venous thrombosis Assess current practices for the management of PICCrelated DVT

3 prog ress - A forward or onward movement - Gradual betterment; especially: the progressive betterment of mankind Merriam-Webster Dictionary

4 Central Venous Catheters (CVCs) Historical Perspective: 1656 Sir Christopher Wren: first attempt at IV nutrition/ drugs in dogs: Goose quill attached to a pig s bladder, administered wine, ale and opium 1667 Major: infused saline into human antecubital vein via silver cannula and pig s bladder + +

5 Central Venous Catheters (CVCs) Historical Perspective: 1929 Berlin, Werner Forrsmann: originator of central venous catheter technique But he was not the only one

6 Central Venous Catheters (CVCs) Historical Perspective: 1912 Chemotherapeutic Era, Bleichroeder and Unger believed chemotherapeutic agent should be applied as close as possible to the diseased organ 1931 Forrsmann: conceived idea of drug delivery into right heart during emergency surgery; went on to win the Nobel Prize for Medicine 1956

7 Central Venous Catheters (CVCs) Historical Perspective: Long term CVCs first available in Broviac et al. improved design 1975 PICC line: Hoshal VL. "Total intravenous nutrition with peripherally inserted silicone elastomer central venous catheters". Arch Surg 110 (5): Dr. Robert O. Hickman; tunneled design and cuff Central Venous Catheters (Wiley Series in Nursing) Andy Bodenham (Author), Helen Hamilton (Editor). Wiley-Blackwell, 2009.

8 Deep Venous Thrombosis 130, ,000 cases in the U.S. per year DVT (lower extremity)= 0.1% incidence, increasing with age to 1% in elderly UEDVT= 1-4% all episodes of DVT Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and casefatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991;151:

9 Deep Venous Thrombosis Deep venous thrombosis (DVT) and thromboembolism include a complex spectrum of pathological conditions that are categorized by: 1. Etiology 2. Location a. primary b. secondary (ie from catheter, hypercoag.) a. upper extremity b. lower extremity Primary DVT of the lower extremity is a common clinical problem with significant risk for morbidity (postphlebitic syndrome) and mortality (pulmonary embolism).

10 Upper Extremity Deep Venous Thrombosis 1-4% of all causes of venous thrombosis 30% Primary DVT includes: thoracic outlet syndrome, effort thrombosis, and idiopathic venous thrombosis 70% Secondary DVT includes: central venous catheters, transvenous pacemakers, or cancer (thrombophilia)

11 Incidence of Catheter-Related Upper Extremity Venous Thrombosis Recent placement of a central venous catheter increases the risk for upper-extremity deep vein thrombosis (DVT) by 5- to 7-fold. Arch Intern Med 2000; 160: Upper extremity DVT is 2.6 to 8x more likely among patients with active cancer; a central venous catheter increases that risk. J Thromb Haemost 2005; 3:

12 UEDVT Symptoms Arm edema/swelling Shoulder/neck discomfort Pain Head fullness Facial edema Vertigo Dyspnea fevers

13 Signs and symptoms of upper extremity venous thrombosis include arm swelling, erythema, pain, distal paresthesias, and prominence of subcutaneous collateral veins along the ipsilateral chest wall. Arm remains swollen after removal of PICC

14 Incidence of Catheter-Related Deep Venous Thrombosis of the Upper Extremity Asymptomatic upper extremity venous thrombosis has been reported to occur in 20% 60% of patients with a central venous catheter. Symptomatic DVT has been reported to occur in 0% - 30% of patients with a central venous catheter.

15 Inadvertent PICC removal one day post placement Allen a et al. JVIR 2000; 11:

16 42 y/o female with ESRD, HTN, lupus presenting with malfunctioning HD catheter; pulling clots

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19 UEDVT and PE Owens CA et al. JVIR 2010; 21: Review of literature: 28 publications, 3747 cases UEDVT Rate of PE: 5.6% Mortality from PE: 0.7%

20 PICC associated risk factors Young age Hx of DVT Discharge to skilled nursing facility Amphotericin B therapy Cancer treatment Large diameter catheters; high catheter to lumen ratio Evans RS et al. AMIA 2007 Symposium Proceedings

21 Chest 2010;138; Evans RS et al. Risk of Symptomatic DVT Associated With Peripherally Inserted Central Catheters 2014 PICCs inserted in 1728 patients RISK FACTORS FOR PICC-ASSOCIATED DVT: -prior DVT -surgery lasting >1 hour -larger catheter size (5F or greater)

22 Chest 2010;138; Evans RS et al. Risk of Symptomatic DVT Associated With Peripherally Inserted Central Catheters

23 Catheter size: The Triple Lumen PICC (The Holy Grail of the ICU) Trerotola SO et al. Radiology 2010: 256(1) Prospective, 1:1 randomization 6F TL PICC vs. central line PICC team/ir team placed at bedside US done at PICC removal to assess for clot N= 50 (167 patients planned); enrollment stopped, reached clinical equipoise 58% venous thrombosis rate (both symptomatic and asymptomatic) 20% symptomatic Don t use 6F triple lumen PICCs!!!

24 Five days ago a 30 year-old man developed a post-operative infection and a double lumen PICC was placed for administration of parenteral antibiotic therapy. As a member of your hospital s PICC nursing team you have been asked to evaluate his right upper arm. You examine the patient and discover that he has moderate edema of his entire right upper extremity and he complains of intermittent pain in his right shoulder region. He states that the edema of his right arm developed yesterday but significantly worsened overnight.

25 Upon further examination you notice mild tenderness and mild erythema at the PICC insertion site but no clear evidence of local infection. The PICC continues to work well for delivery of antibiotic therapy and blood draws. What is your diagnosis and treatment plan?

26 Catheter Related UEDVT Management Options: Removal of PICC Leave PICC in place Anticoagulation Thrombolysis Observation of extremity / re-ultrasound

27 Diagnosis: PICC associated upper extremity venous thrombosis Management: 1) Removal of PICC 2) Placement of new PICC in a new location 3) Oral anticoagulation therapy

28 PICC-related thrombosis

29 tract of old catheter thrombus adherent to SVC Venogram after removal of catheter

30 Risk Factors Associated with Central Venous Catheter Related Thrombosis Technical Larger catheter diameter Larger number of catheter lumens Catheter tip malposition Two or more insertion attempts Left-sided placement Subclavian vein insertion Patient and Vascular Catheter-associated infection Fibrinous catheter lumen occlusion Extrinsic vascular compression Treatment-Related L-asparaginase Estrogen or progesterone agents Recombinant human Interleukin-2 Granulocyte-macrophage CSF Thalidomide JNCCN 2006;4:

31 Insertion of a PICC causes significant trauma to the vein

32 Virchow s Triad Rudolph Virchow Theorized about the etiology of thrombus formation in veins published these ideas as they related to the pathophysiology of PE

33 damage to cephalic vein Damage (thrombus, fibrosis) to cephalic vein due to previous PICC

34 Stenosis and thrombosis of cephalic vein due to PICC

35 PICC-related stenosis may progress to chronic venous occlusion

36 collateral veins occlusion of brachiocephalic vein Venous hypertension due to occlusion of left brachiocephalic vein dilatation of veins

37 CLOT E V O L U T I O N Clot forms and gets worse R E S O L U T I O N Biological process of clearing clot

38 Retrospective review of 101 patients with catheter-related deep venous thrombosis of the upper extremity Two study groups: DVT resolved vs. DVT did not resolve All patients had ultrasound imaging

39 DVT DVT Total Resolved Not Resolved # Patients Catheter duration (days) Catheter removed Catheter not removed Anticoagulated

40 Duration of Catheter Placement Jones MA et al. J Vasc Surg 2010; 51: The average duration of catheter placement was 127 days. When central venous catheters were in place days, 26% of patients had resolution of thrombus When central venous catheters were in place >90 days, 42% of patients had resolution of thrombus Conclusion: Resolution of DVT was not affected by the length of time the catheter was in place.

41 Duplex Ultrasound Results Jones MA et al. J Vasc Surg 2010; 51: Removed Not Removed (n =77) (n =24) Resolved 52% 25% Partial resolution 23% 12% No change 18% 33% Progression 6% 29%

42 Influence of Combined Catheter Removal and Anticoagulation Jones MA et al. J Vasc Surg 2010; 51: Catheters were removed from 77% of 101 patients with upper extremity DVT Anticoagulation was used in 62% Both catheter removal and anticoagulation were used in 49%. In multivariate analysis, only catheter removal predicted likelihood of thrombus resolution (P=0.025).

43 Catheter Removal Jones MA et al. J Vasc Surg 2010; 51: Complete resolution DVT occurred in 52% of patients when the catheter was removed. Complete resolution DVT occurred in 25% of patients when the catheter was NOT removed.

44 Outcome of New Site Catheter Placement Jones MA et al. J Vasc Surg 2010; 51: patients had removal of initial catheter and placement of a new catheter at a new site presumably, not involved with thrombus. A new upper extremity DVT developed in association with the new catheter in 12 of these 14 (86%). Three (25%) of these 12 patients were receiving anticoagulation therapy when the old catheter was removed and the new catheter was placed in a different anatomic site.

45 Conclusions Removal of a central venous catheters associated with thrombus and subsequent placement of a new central venous access at a new site almost always resulted in new DVT. The implication is that it may be best to leave the catheter in place as long as it is needed, functions, and is not infected and then remove the catheter once it is no longer required for therapy. Such an algorithm will limit the development of DVT and may not adversely affect resolution of the initial DVT.

46 Clinical Practice Guidelines

47 8.1 For patients with acute upper-extremity DVT we recommend initial treatment with therapeutic doses of low molecular weight heparin, unfractionated heparin, or fondaparinux, as described for leg DVT

48 For patients with acute DVT, we recommend initial treatment with low molecular weight heparin, unfractionated heparin, or fondaparinux for at least 5 days and until the INR is > 2.0 for 24 h In patients with acute DVT, we recommend initiation of Coumadin together with LMWH, UFH, or fondaparinux on the first treatment day.

49 For patients with acute UEDVT, we recommend treatment with Coumadin for > 3 months For patients who have UEDVT in association with a central venous catheter that is removed, we do not recommend that the duration of long-term anticoagulant treatment be shortened to < 3 months

50 compression sleeve In patients with UEDVT who have persistent edema and pain, we suggest elastic bandages or elastic compression sleeves to reduce symptoms of post-thrombotic syndrome of the upper extremity

51 For most patients with UEDVT in association with a central venous catheter we suggest that the catheter not be removed if it is functional and there is an ongoing need for the catheter

52 Conclusions Management of catheter-related upper extremity deep venous thrombosis : Follow ACCP Guidelines (Chest 2008; 133:454S 545S) If the catheter is still needed and still works then do not remove. Treat with oral anticoagulation for 3 months

53 Discussion