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A novel approach to central venous catheter thrombosis in a patient with cystic fibrosis
Journal of Cystic Fibrosis 6 (2007) 417 – 418 www.elsevier.com/locate/jcf
Case studies
A novel approach to central venous catheter thrombosis in a patient with cystic fibrosis J.H.K. Hull a , W. Tucker a , A.G. Hatrick b , R.K. Knight a , T.B.L. Ho a,? a
Knight Centre for Cystic Fibrosis, Frimley Park Hospital NHS Foundation Trust, Camberley, Surrey GU16 7UJ, UK b Department of Radiology, Frimley Park Hospital NHS Foundation Trust, Camberley, Surrey GU16 7UJ, UK Received 22 October 2006; received in revised form 28 January 2007; accepted 12 February 2007 Available online 26 March 2007
Abstract Catheter directed thrombolysis has been described as a treatment for large pulmonary emboli resistant to systemic therapy [Kelly P, Carroll N, Grant C, Barrett C, Kocka V. Successful treatment of massive pulmonary embolism with prolonged catheter-directed thrombolysis. Heart Vessels 2006;21:124?6]. We now describe a case in which local catheter directed thrombolysis, via a peripherally inserted central catheter (PICC), was used to treat a large thrombus surrounding the tip of an indwelling central venous line that was causing superior vena cava obstruction (SVCO), in a patient with cystic fibrosis. ̀ 2007 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved. Keywords: Cystic fibrosis; Thrombolysis; Central venous catheter; Complications
1. Case report
24 h at a rate of 1000 i.u./h. This improved her SVCO symptoms, however a repeat venogram showed no significant
A 34-year-old female with cystic fibrosis had a totally implantable venous access device (TIVAD) (Groshong, Bard Access Systems) sited in the left subclavian vein for longterm intravenous therapy. The line was used for multiple courses of intravenous antibiotics without complication for 2 years following insertion. She presented to clinic complaining of distended neck veins and facial discomfort on coughing. Examination revealed facial and upper limb oedema and a fixed elevated jugular venous pressure. On injecting through the central venous catheter, flow was demonstrated but reduced. Urgent venography visualised a large discrete thrombus occluding the distal tip of the catheter and causing superior vena cava obstruction (Fig. 1). The patient was treated with a 10 mg bolus of intra-line alteplase, followed by a 90 mg infusion over 2 h and subsequently with an unfractionated heparin infusion for a further ? Corresponding author. Tel.: +44 1276 526660; fax: +44 1276 604032.
Fig. 1. Initial venogram demonstrating a large thrombus occluding the tip of the central venous catheter. The arrow indicates the site of the thrombus.
1569-1993/$ - see front matter ̀ 2007 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.jcf.2007.02.003
418
J.H.K. Hull et al. / Journal of Cystic Fibrosis 6 (2007) 417–418
Fig. 2. Final venogram showing complete resolution of the thrombus and the presence of the second central venous catheter.
change in thrombus size. Infusions of both the alteplase and heparin were repeated but again there was no resolution on venography. It was decided to use a novel approach whereby a peripherally inserted central catheter (PICC) was introduced via the right basilic vein and its tip placed next to the thrombus within the SVC. A continuous infusion of alteplase at 1 mg/h was then administered for 7 days via the PICC. A final venogram showed complete resolution of the thrombus (Fig. 2). The TIVAD was removed and the patient discharged with the PICC line in situ to continue intravenous antibiotics for a concomitant chest infection. 2. Discussion Indwelling intravenous catheters play an important role in the long-term management of patients with cystic fibrosis. They allow patients to have long-term intravenous antibiotic courses and can facilitate blood sampling. Long-term venous catheters are positioned so their tips lie within the superior vena cava, aiding safe administration of systemic treatments by causing less local venous inflammation. The most common complications reported are line infection and catheter occlusion with rates estimated at up to 21% a year [1]. Vascular thrombosis, as in this case, has a reported frequency between 4.7% and 9% [1,2]. A single discrete organised thrombus surrounding the catheter tip is unusual with few descriptions in the literature. In cases of thrombosis within catheter, the options to manage this complication are essentially intra-line thrombolysis or removal of the line. For intra-line thrombolysis, 2 mg
of alteplase is injected into the occluded line and allowed to dwell for 2 h. This can be repeated. The procedure has a reported success rate of 74% [3]. Line removal is essentially a fall-back position, usually when patency of the catheter is not achieved. In the case we describe, the central venous line was patent but partially obstructed at its tip by thrombus enveloping the catheter. This led to incomplete SVC obstruction. A full thrombolysis regime, as used in treating pulmonary emboli, was employed. This has been described as being beneficial in this situation [4]. Since a large thrombolytic dose was contemplated, the potential for significant haemorrhagic complications was discussed with the patient and informed consent obtained. Intra-line alteplase infusions have been reported to dissolve a large catheter-tip thrombus [5], but in our case it only restored line patency at the tip and left a significant thrombus around the distal catheter, despite repeated thrombolytic infusions. The normal fall-back option of line removal was considered hazardous as there was a substantial risk that the thrombus would have been sheared off as the line was pulled through the vein wall, potentially causing pulmonary emboli. Warfarinisation was considered but deemed to be less efficacious at clot resolution [6]. Catheter directed thrombolysis provided a novel solution. Due to the expanding use of centrally placed venous catheters in all populations of patients, it is likely that the prevalence of catheter-tip thrombus will increase. We would encourage physicians to consider a catheter-directed approach as an alternative to intra-line therapy. References [1] Munck A, Malbezin S, Bloch J, Gerardin M, Lebourgeois M, Derelle J, et al. Follow-up of 452 totally implantable vascular devices in cystic fibrosis patients. Eur Respir J 2004;23:430–4. [2] Deerojanawong J, Sawyer SM, Fink AM, Stokes KB, Robertson CF. Totally implantable venous access devices in children with cystic fibrosis: incidence and type of complications. Thorax 1998;53:285–9. [3] Ponec D, Irwin D, Haire WD, Hill PA, Li X, McCluskey ER. Recombinant tissue plasminogen activator (alteplase) for restoration of flow in occluded central venous access devices: a double-blind placebo-controlled trial?the Cardiovascular Thrombolytic to Open Occluded Lines (COOL) efficacy trial. J Vasc Interv Radiol 2001;12:951–5. [4] Peckham DG, Hill J, Manhire AR, Knox AJ. Resolution of superior vena cava obstruction following thrombolytic therapy in a patient with cystic fibrosis and a long-term indwelling catheter. Respir Med 1994;88: 627–9. [5] Mathur M, Desai N, Sharma J, Rao SP, Goldman GM. Management of a large organized intraatrial catheter-tip thrombus in a child with acquired immunodeficiency syndrome using escalating tissue plasminogen activator infusions. Pediatr Crit Care Med 2005;6:79–82. [6] Baldwin ZK, Comerota AJ, Schwartz LB. Catheter-directed thrombolysis for deep venous thrombosis. Vasc Endovascular Surg 2004;38: 1–9.
Case studies
A novel approach to central venous catheter thrombosis in a patient with cystic fibrosis J.H.K. Hull a , W. Tucker a , A.G. Hatrick b , R.K. Knight a , T.B.L. Ho a,? a
Knight Centre for Cystic Fibrosis, Frimley Park Hospital NHS Foundation Trust, Camberley, Surrey GU16 7UJ, UK b Department of Radiology, Frimley Park Hospital NHS Foundation Trust, Camberley, Surrey GU16 7UJ, UK Received 22 October 2006; received in revised form 28 January 2007; accepted 12 February 2007 Available online 26 March 2007
Abstract Catheter directed thrombolysis has been described as a treatment for large pulmonary emboli resistant to systemic therapy [Kelly P, Carroll N, Grant C, Barrett C, Kocka V. Successful treatment of massive pulmonary embolism with prolonged catheter-directed thrombolysis. Heart Vessels 2006;21:124?6]. We now describe a case in which local catheter directed thrombolysis, via a peripherally inserted central catheter (PICC), was used to treat a large thrombus surrounding the tip of an indwelling central venous line that was causing superior vena cava obstruction (SVCO), in a patient with cystic fibrosis. ̀ 2007 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved. Keywords: Cystic fibrosis; Thrombolysis; Central venous catheter; Complications
1. Case report
24 h at a rate of 1000 i.u./h. This improved her SVCO symptoms, however a repeat venogram showed no significant
A 34-year-old female with cystic fibrosis had a totally implantable venous access device (TIVAD) (Groshong, Bard Access Systems) sited in the left subclavian vein for longterm intravenous therapy. The line was used for multiple courses of intravenous antibiotics without complication for 2 years following insertion. She presented to clinic complaining of distended neck veins and facial discomfort on coughing. Examination revealed facial and upper limb oedema and a fixed elevated jugular venous pressure. On injecting through the central venous catheter, flow was demonstrated but reduced. Urgent venography visualised a large discrete thrombus occluding the distal tip of the catheter and causing superior vena cava obstruction (Fig. 1). The patient was treated with a 10 mg bolus of intra-line alteplase, followed by a 90 mg infusion over 2 h and subsequently with an unfractionated heparin infusion for a further ? Corresponding author. Tel.: +44 1276 526660; fax: +44 1276 604032.
Fig. 1. Initial venogram demonstrating a large thrombus occluding the tip of the central venous catheter. The arrow indicates the site of the thrombus.
1569-1993/$ - see front matter ̀ 2007 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.jcf.2007.02.003
418
J.H.K. Hull et al. / Journal of Cystic Fibrosis 6 (2007) 417–418
Fig. 2. Final venogram showing complete resolution of the thrombus and the presence of the second central venous catheter.
change in thrombus size. Infusions of both the alteplase and heparin were repeated but again there was no resolution on venography. It was decided to use a novel approach whereby a peripherally inserted central catheter (PICC) was introduced via the right basilic vein and its tip placed next to the thrombus within the SVC. A continuous infusion of alteplase at 1 mg/h was then administered for 7 days via the PICC. A final venogram showed complete resolution of the thrombus (Fig. 2). The TIVAD was removed and the patient discharged with the PICC line in situ to continue intravenous antibiotics for a concomitant chest infection. 2. Discussion Indwelling intravenous catheters play an important role in the long-term management of patients with cystic fibrosis. They allow patients to have long-term intravenous antibiotic courses and can facilitate blood sampling. Long-term venous catheters are positioned so their tips lie within the superior vena cava, aiding safe administration of systemic treatments by causing less local venous inflammation. The most common complications reported are line infection and catheter occlusion with rates estimated at up to 21% a year [1]. Vascular thrombosis, as in this case, has a reported frequency between 4.7% and 9% [1,2]. A single discrete organised thrombus surrounding the catheter tip is unusual with few descriptions in the literature. In cases of thrombosis within catheter, the options to manage this complication are essentially intra-line thrombolysis or removal of the line. For intra-line thrombolysis, 2 mg
of alteplase is injected into the occluded line and allowed to dwell for 2 h. This can be repeated. The procedure has a reported success rate of 74% [3]. Line removal is essentially a fall-back position, usually when patency of the catheter is not achieved. In the case we describe, the central venous line was patent but partially obstructed at its tip by thrombus enveloping the catheter. This led to incomplete SVC obstruction. A full thrombolysis regime, as used in treating pulmonary emboli, was employed. This has been described as being beneficial in this situation [4]. Since a large thrombolytic dose was contemplated, the potential for significant haemorrhagic complications was discussed with the patient and informed consent obtained. Intra-line alteplase infusions have been reported to dissolve a large catheter-tip thrombus [5], but in our case it only restored line patency at the tip and left a significant thrombus around the distal catheter, despite repeated thrombolytic infusions. The normal fall-back option of line removal was considered hazardous as there was a substantial risk that the thrombus would have been sheared off as the line was pulled through the vein wall, potentially causing pulmonary emboli. Warfarinisation was considered but deemed to be less efficacious at clot resolution [6]. Catheter directed thrombolysis provided a novel solution. Due to the expanding use of centrally placed venous catheters in all populations of patients, it is likely that the prevalence of catheter-tip thrombus will increase. We would encourage physicians to consider a catheter-directed approach as an alternative to intra-line therapy. References [1] Munck A, Malbezin S, Bloch J, Gerardin M, Lebourgeois M, Derelle J, et al. Follow-up of 452 totally implantable vascular devices in cystic fibrosis patients. Eur Respir J 2004;23:430–4. [2] Deerojanawong J, Sawyer SM, Fink AM, Stokes KB, Robertson CF. Totally implantable venous access devices in children with cystic fibrosis: incidence and type of complications. Thorax 1998;53:285–9. [3] Ponec D, Irwin D, Haire WD, Hill PA, Li X, McCluskey ER. Recombinant tissue plasminogen activator (alteplase) for restoration of flow in occluded central venous access devices: a double-blind placebo-controlled trial?the Cardiovascular Thrombolytic to Open Occluded Lines (COOL) efficacy trial. J Vasc Interv Radiol 2001;12:951–5. [4] Peckham DG, Hill J, Manhire AR, Knox AJ. Resolution of superior vena cava obstruction following thrombolytic therapy in a patient with cystic fibrosis and a long-term indwelling catheter. Respir Med 1994;88: 627–9. [5] Mathur M, Desai N, Sharma J, Rao SP, Goldman GM. Management of a large organized intraatrial catheter-tip thrombus in a child with acquired immunodeficiency syndrome using escalating tissue plasminogen activator infusions. Pediatr Crit Care Med 2005;6:79–82. [6] Baldwin ZK, Comerota AJ, Schwartz LB. Catheter-directed thrombolysis for deep venous thrombosis. Vasc Endovascular Surg 2004;38: 1–9.