risk of thrombosis and pulmonary embolism with cvc and picc lines

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.

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

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?