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Anticoagulation without catheter removal in children with catheter-related central vein thrombosis
Anticoagulation Without Catheter-Related By Brian D. Kenney,
Catheter Central
WORDS: Deep anticoagulation.
venous
thrombosis,
central
out catheter removal in a limited number of patients. The experience with these cases is reviewed. MATERIALS
The usual treatment of deep central venous thrombosis related to an indwelling catheter is removal of the catheter, which, in most situations, necessitates insertion of another catheter at a different site to continue treatment.3 For patients who still need treatment via their catheters and because catheter insertion requires an uncomfortable procedure often with general anesthesia, we have attempted to use standard anticoagulation (heparin followed by warfarin) with-
From the Division of Pediatric General Surgery, Department of Hematology, Hopital Sainte-Justine, Montreal, Quebec. Presented at the 27th Annual Meeting of the Canadian Associatzon of Paediatric Surgeons, Montreal, Quebec, September 2-4, 1995. Address reprint requests to Arie L. Bensoussan, MD, Hopital Sainte-Justine, 3175 St Catherine Rd, Montreal, Quebec, Canada H3T lC5. Copyright 0 1996 by WB. Saunders Company 0022-3468/9613106-0021$03.00/0
AND METHODS
A patient registry was established at the St Justine Hospital in February 1991 to collect information about all patients with clinical symptoms or radiological signs of deepvenous thrombosis. Thrombosis was confirmed by contrast venography or ultrasonography or both. Included in the present study are patients from the registry in whom thrombosis related to a central venous catheter developed between February 1991 and April 1995. Patients who had a blocked central venous catheter without evidence of venous thrombosis were excluded from the study. Charts were reviewed with respect to treatment methods, including anticoagulation or thrombolytic therapy. Heparin was prescribed according to standard protocols, which provided for systemic anticoagulation with activated partial thromboplastm times at 1.5 to 2 times the normal values. This was followed by conversion to oral warfarin therapy with international normalized ratios of 1.5 to 2.0. Systemic thrombolytic agents such as urokinase, streptokinase or tissue plasminogen activator were not used in these patients. Catheter removal was classified as early if it occurred within 1 week of the diagnosis. The reason for catheter removal was noted. The follow-up period ended with the latest chart documentation.
venous
ATHETER-RELATED central venous thromboC sis is a serious and common problem in children, with rates that exceed 30% in some series.1*2
816
With
Michelle David, and Arid L. Bensoussan Montreal, Quebec
6 Catheter-related central venous thrombosis is a serious and common problem among children. The traditional management has been anticoagulation and early catheter removal. Unfortunately, many patients require a new catheter, which is associated with complications that include possible further thrombosis. Although others have used thrombolytic agents in attempts to avoid catheter removal, the authors of the present study believe that the associated complications occur too frequently and are too serious. They have had success with standard anticoagulation in a limited number of patients. Between February 1991 and April 1994,17 patients (6 weeks to 19 years of age) were treated for catheter-related deep venous thrombosis. Eight patients underwent early catheter removal accompanied by anticoagulation; two of them had intrinsic catheter problems that necessitated removal, and one had hemophilia. Nine others received anticoagulation without catheter removal. Df these, one required catheter removal after 10 days heparin administration failed to diminish the thrombosis. Another patient responded well to anticoagulation but required catheter removal several weeks later because of catheter-site infection. The other seven patients responded well to anticoagulation, and their catheters were retained. For patients with a functional catheter essential to their care, anticoagulation may safely prevent catheter removal. Copyright o 1996 by W. B. Saunders Company INDEX catheter,
Removal in Children Vein Thrombosis
RESULTS
Between February 1991 and April 1995,17 patients at St Justine Hospital were noted to have deep venous thrombosis related to an indwelling catheter. Their age range was 6 weeks to 19 years. The catheters were placed for a variety of reasons; most were because of a malignancy or gastrointestinal disease. Early catheter removal was performed in eight patients, all of whom also received anticoagulation with heparin and subsequently warfarin. Of these eight, two had intrinsic catheter problems that necessitated removal (1 had an infection, the other had a blocked catheter). One catheter fell out. The fourth patient had hemophilia and therefore anticoagulation was contraindicated. In two patients the catheters were removed because of atria1 extension of the thrombosis. Finally, in two patients the catheter was removed as part of treatment for the deep venous thrombosis, with no other reason specified. Of the 17 patients with catheter-related deep venous thrombosis, nine were able to have their catheter retained for a prolonged period after diagnosis. Two of these later required catheter removalone for chronic infection and one for failure of clot
Journa/ofPed/atricSurge~
Vol31,No6(June),1996:
pp816-818
CATHETER-RELATED
CENTRAL
VENOUS
817
THROMBOSIS
resolution with anticoagulation therapy of more than 10 days’ duration. In the remaining seven, the catheters were retained for several weeks to several months, with clearance of symptoms. For those who had follow-up radiological studies, clot size diminution or the development of collateral flow was demonstrated. With one exception, the catheters were removed only after completion of their usefulness given the clinical situation. One patient required catheter removal because of recurrent venous thrombosis, which developed several weeks after clinical resolution of the initial thrombosis, while the patient was on warfarin therapy. The patient responded well to catheter removal, and anticoagulant therapy was continued. The only death in this series involved a patient who initially responded to anticoagulation without catheter removal but eventually succumbed to his underlying disease. Except for the one case of recurrence of venous thrombosis, there were no complications associated with anticoagulation therapy. DISCUSSION
Significant differences exist in the epidemiology of deep venous thrombosis between adults and children.1.2 Although one third of adult cases of deep venous thrombosis are idiopathic, almost all childhood cases are associated with a serious underlying medical condition. In children, central venous catheters are associated with one third of all deep venous thromboses and more than three fourths of upper extremity thromboses. Increased catheter use in children has led to an increased frequency of deep venous thrombosis. The incidence varies according to the degree of surveillance because the presentation is usually subclinica1.l One cross-sectional study4 of all patients (n = 12) in one hospital on home parenteral nutrition showed that all five with symptomatic superior vena caval syndrome had thrombosis on venography. By contrast, none of the four asymptomatic patients had thrombosis. However, the remaining three, who were described as having increased collateral circulation in
the skin, had thrombosis. This latter group is perhaps the most troublesome because the diagnosis is subtle. This study demonstrates not only the high rate of thrombosis in this population but also the presence of subtle signs in three of eight patients with proven thrombosis. An important complication of catheterassociated deep venous thrombosis was apparent from this study: 50% of patients lost all venous access to the upper extremities. Other complications of deep venous thrombosis are uncommon yet severe.r Postphlebitic syndrome is rare and often self-limited as collateral vessels develop. The incidence of secondary pulmonary embolus, like that of thrombosis, depends on the intensity of surveillance.5 One study, in which 34 patients on parenteral nutrition were screened perfusion scans and echocardiography, showed that the 5-year actuarial free-of-thrombosis survival rate was only 53%.(j Recurrence of venous thrombosis while on anticoagulation therapy is a possible complication. Although one patient in our series experienced recurrence, he was easily treatable. Some physicians have attempted to treat catheterrelated deep venous thrombosis with anticoagulation or thrombolytic therapy. 3,7-10The main advantage of thrombolytic therapy is that some patients show complete clot resolution. The main complication of these therapies is posttraumatic or intracranial bleeding (particularly gastrointestinal). Bleeding problems were not experienced in the present series perhaps because thrombolytic therapy was avoided. However, the limited numbers in this report may mask complications. For patients who no longer need the indwelling catheter, early catheter removal remains the best therapy for catheter-related venous thrombosis. Unfortunately, many patients continue to require central venous access and, after catheter removal, will need a replacement. For patients with a functional central venous catheter essential to their care, anticoagulation allows retention of the catheter in selected cases, with resolution of symptoms and avoidance of significant complications.
REFERENCES 1. David M, Andrew M: Venous thromboembolic coagulation in children. J Pediatr 123:337-346, 1993 2. Andrew M, David M. Adams M, et al: Venous thromboembolic complications (VTE) in children. First analysis of the Canadian Registry of VTE. Blood 83:1251-1257,1994 3. Rodenhuis S, van? Hek LG, Vlasveld LT, et al: Central venous catheter associated thrombosis of major veins: Thrombolytic treatment with recombinant tissue plasminogen activator. Thorax 48:558-559, 1993 4. Andrew M, Marzinotto V, Penchory P, et al: A cross-sectional
study of catheter parenteral nutrition
related thrombosis at home. J Pediatr
m children 126:358-363,
receiving 1995
total
5. Horattas MC, Wright DJ, Fenton AH, et al: Changing concepts of deep venous thrombosis of the upper extremity. Report of a series and review of the literature. Surgery 104:561-567.1988 6. Dollery CM, Sullivan ID, Bauraind 0, et al: Thrombosis embolism in long-term central venous access for parenteral tion. Lancet 344:1043-1045,1994 7. Rantis
PC Jr, Littooy
FN:
Successful
treatment
and nutri-
of prolonged
818
superior vena cava syndrome with thrombolytic therapy: A case report. J Vast Surg 20:108-113,1994 8. Seigel EL, Jew AC, Delcore R, et al: Thrombolytic therapy for catheter-related thrombosis. Am J Surg 166:716-718, 1993 9. Greenberg S, Kosinski R, Daniels J: Treatment of superior
KENNEY,
DAVID,
AND
BENSOUSSAN
vena cava thrombosis with recombinant tissue type plasminogen activator. Chest 99:1298-1301,199l 10. Gray BH, Olin JW, Graor RA, et al: Safety and efficacy of thrombolytic therapy for superior vena cava syndrome. Chest 99:54-69,199l
Catheter Central
WORDS: Deep anticoagulation.
venous
thrombosis,
central
out catheter removal in a limited number of patients. The experience with these cases is reviewed. MATERIALS
The usual treatment of deep central venous thrombosis related to an indwelling catheter is removal of the catheter, which, in most situations, necessitates insertion of another catheter at a different site to continue treatment.3 For patients who still need treatment via their catheters and because catheter insertion requires an uncomfortable procedure often with general anesthesia, we have attempted to use standard anticoagulation (heparin followed by warfarin) with-
From the Division of Pediatric General Surgery, Department of Hematology, Hopital Sainte-Justine, Montreal, Quebec. Presented at the 27th Annual Meeting of the Canadian Associatzon of Paediatric Surgeons, Montreal, Quebec, September 2-4, 1995. Address reprint requests to Arie L. Bensoussan, MD, Hopital Sainte-Justine, 3175 St Catherine Rd, Montreal, Quebec, Canada H3T lC5. Copyright 0 1996 by WB. Saunders Company 0022-3468/9613106-0021$03.00/0
AND METHODS
A patient registry was established at the St Justine Hospital in February 1991 to collect information about all patients with clinical symptoms or radiological signs of deepvenous thrombosis. Thrombosis was confirmed by contrast venography or ultrasonography or both. Included in the present study are patients from the registry in whom thrombosis related to a central venous catheter developed between February 1991 and April 1995. Patients who had a blocked central venous catheter without evidence of venous thrombosis were excluded from the study. Charts were reviewed with respect to treatment methods, including anticoagulation or thrombolytic therapy. Heparin was prescribed according to standard protocols, which provided for systemic anticoagulation with activated partial thromboplastm times at 1.5 to 2 times the normal values. This was followed by conversion to oral warfarin therapy with international normalized ratios of 1.5 to 2.0. Systemic thrombolytic agents such as urokinase, streptokinase or tissue plasminogen activator were not used in these patients. Catheter removal was classified as early if it occurred within 1 week of the diagnosis. The reason for catheter removal was noted. The follow-up period ended with the latest chart documentation.
venous
ATHETER-RELATED central venous thromboC sis is a serious and common problem in children, with rates that exceed 30% in some series.1*2
816
With
Michelle David, and Arid L. Bensoussan Montreal, Quebec
6 Catheter-related central venous thrombosis is a serious and common problem among children. The traditional management has been anticoagulation and early catheter removal. Unfortunately, many patients require a new catheter, which is associated with complications that include possible further thrombosis. Although others have used thrombolytic agents in attempts to avoid catheter removal, the authors of the present study believe that the associated complications occur too frequently and are too serious. They have had success with standard anticoagulation in a limited number of patients. Between February 1991 and April 1994,17 patients (6 weeks to 19 years of age) were treated for catheter-related deep venous thrombosis. Eight patients underwent early catheter removal accompanied by anticoagulation; two of them had intrinsic catheter problems that necessitated removal, and one had hemophilia. Nine others received anticoagulation without catheter removal. Df these, one required catheter removal after 10 days heparin administration failed to diminish the thrombosis. Another patient responded well to anticoagulation but required catheter removal several weeks later because of catheter-site infection. The other seven patients responded well to anticoagulation, and their catheters were retained. For patients with a functional catheter essential to their care, anticoagulation may safely prevent catheter removal. Copyright o 1996 by W. B. Saunders Company INDEX catheter,
Removal in Children Vein Thrombosis
RESULTS
Between February 1991 and April 1995,17 patients at St Justine Hospital were noted to have deep venous thrombosis related to an indwelling catheter. Their age range was 6 weeks to 19 years. The catheters were placed for a variety of reasons; most were because of a malignancy or gastrointestinal disease. Early catheter removal was performed in eight patients, all of whom also received anticoagulation with heparin and subsequently warfarin. Of these eight, two had intrinsic catheter problems that necessitated removal (1 had an infection, the other had a blocked catheter). One catheter fell out. The fourth patient had hemophilia and therefore anticoagulation was contraindicated. In two patients the catheters were removed because of atria1 extension of the thrombosis. Finally, in two patients the catheter was removed as part of treatment for the deep venous thrombosis, with no other reason specified. Of the 17 patients with catheter-related deep venous thrombosis, nine were able to have their catheter retained for a prolonged period after diagnosis. Two of these later required catheter removalone for chronic infection and one for failure of clot
Journa/ofPed/atricSurge~
Vol31,No6(June),1996:
pp816-818
CATHETER-RELATED
CENTRAL
VENOUS
817
THROMBOSIS
resolution with anticoagulation therapy of more than 10 days’ duration. In the remaining seven, the catheters were retained for several weeks to several months, with clearance of symptoms. For those who had follow-up radiological studies, clot size diminution or the development of collateral flow was demonstrated. With one exception, the catheters were removed only after completion of their usefulness given the clinical situation. One patient required catheter removal because of recurrent venous thrombosis, which developed several weeks after clinical resolution of the initial thrombosis, while the patient was on warfarin therapy. The patient responded well to catheter removal, and anticoagulant therapy was continued. The only death in this series involved a patient who initially responded to anticoagulation without catheter removal but eventually succumbed to his underlying disease. Except for the one case of recurrence of venous thrombosis, there were no complications associated with anticoagulation therapy. DISCUSSION
Significant differences exist in the epidemiology of deep venous thrombosis between adults and children.1.2 Although one third of adult cases of deep venous thrombosis are idiopathic, almost all childhood cases are associated with a serious underlying medical condition. In children, central venous catheters are associated with one third of all deep venous thromboses and more than three fourths of upper extremity thromboses. Increased catheter use in children has led to an increased frequency of deep venous thrombosis. The incidence varies according to the degree of surveillance because the presentation is usually subclinica1.l One cross-sectional study4 of all patients (n = 12) in one hospital on home parenteral nutrition showed that all five with symptomatic superior vena caval syndrome had thrombosis on venography. By contrast, none of the four asymptomatic patients had thrombosis. However, the remaining three, who were described as having increased collateral circulation in
the skin, had thrombosis. This latter group is perhaps the most troublesome because the diagnosis is subtle. This study demonstrates not only the high rate of thrombosis in this population but also the presence of subtle signs in three of eight patients with proven thrombosis. An important complication of catheterassociated deep venous thrombosis was apparent from this study: 50% of patients lost all venous access to the upper extremities. Other complications of deep venous thrombosis are uncommon yet severe.r Postphlebitic syndrome is rare and often self-limited as collateral vessels develop. The incidence of secondary pulmonary embolus, like that of thrombosis, depends on the intensity of surveillance.5 One study, in which 34 patients on parenteral nutrition were screened perfusion scans and echocardiography, showed that the 5-year actuarial free-of-thrombosis survival rate was only 53%.(j Recurrence of venous thrombosis while on anticoagulation therapy is a possible complication. Although one patient in our series experienced recurrence, he was easily treatable. Some physicians have attempted to treat catheterrelated deep venous thrombosis with anticoagulation or thrombolytic therapy. 3,7-10The main advantage of thrombolytic therapy is that some patients show complete clot resolution. The main complication of these therapies is posttraumatic or intracranial bleeding (particularly gastrointestinal). Bleeding problems were not experienced in the present series perhaps because thrombolytic therapy was avoided. However, the limited numbers in this report may mask complications. For patients who no longer need the indwelling catheter, early catheter removal remains the best therapy for catheter-related venous thrombosis. Unfortunately, many patients continue to require central venous access and, after catheter removal, will need a replacement. For patients with a functional central venous catheter essential to their care, anticoagulation allows retention of the catheter in selected cases, with resolution of symptoms and avoidance of significant complications.
REFERENCES 1. David M, Andrew M: Venous thromboembolic coagulation in children. J Pediatr 123:337-346, 1993 2. Andrew M, David M. Adams M, et al: Venous thromboembolic complications (VTE) in children. First analysis of the Canadian Registry of VTE. Blood 83:1251-1257,1994 3. Rodenhuis S, van? Hek LG, Vlasveld LT, et al: Central venous catheter associated thrombosis of major veins: Thrombolytic treatment with recombinant tissue plasminogen activator. Thorax 48:558-559, 1993 4. Andrew M, Marzinotto V, Penchory P, et al: A cross-sectional
study of catheter parenteral nutrition
related thrombosis at home. J Pediatr
m children 126:358-363,
receiving 1995
total
5. Horattas MC, Wright DJ, Fenton AH, et al: Changing concepts of deep venous thrombosis of the upper extremity. Report of a series and review of the literature. Surgery 104:561-567.1988 6. Dollery CM, Sullivan ID, Bauraind 0, et al: Thrombosis embolism in long-term central venous access for parenteral tion. Lancet 344:1043-1045,1994 7. Rantis
PC Jr, Littooy
FN:
Successful
treatment
and nutri-
of prolonged
818
superior vena cava syndrome with thrombolytic therapy: A case report. J Vast Surg 20:108-113,1994 8. Seigel EL, Jew AC, Delcore R, et al: Thrombolytic therapy for catheter-related thrombosis. Am J Surg 166:716-718, 1993 9. Greenberg S, Kosinski R, Daniels J: Treatment of superior
KENNEY,
DAVID,
AND
BENSOUSSAN
vena cava thrombosis with recombinant tissue type plasminogen activator. Chest 99:1298-1301,199l 10. Gray BH, Olin JW, Graor RA, et al: Safety and efficacy of thrombolytic therapy for superior vena cava syndrome. Chest 99:54-69,199l