Risk of pulmonary emboli after removal of an upper extremity central catheter associated with a deep vein thrombosis

Abstract

Standard treatment of catheter-associated upper extremity deep vein thrombosis (UE-DVT) is anticoagulation, although catheters are often removed for this indication. The optimal time for catheter removal and whether the act and/or timing of catheter removal is associated with pulmonary embolism (PE) remain unknown. A retrospective cohort study was performed at 8 participating institutions through the Venous thromboEmbolism Network US. Patients with hematologic malignancies and central venous catheter (CVC)–associated UE-DVT were included from 1 January 2010 through 31 December 2016. The primary outcome was objectively confirmed PE within 7 days of UE-DVT diagnosis in anticoagulated patients comparing early (≤48 hours) vs delayed (>48 hours) catheter removal. A total of 626 patients were included, among whom 480 were treated with anticoagulation. Among anticoagulated patients, 255 underwent early CVC removal, while 225 had delayed or no CVC removal; 146 patients received no anticoagulation, among whom 116 underwent CVC removal alone. PE within 7 days occurred in 2 patients (0.78%) with early removal compared with 1 patient (0.44%) with delayed or no CVC removal (P > .9). PE or any cause of death within 7 days occurred in 3 patients in both the early removal (1.18%) and delayed/no removal (1.33%) groups (P > .9). In patients treated with CVC removal only (no anticoagulation), there were no PEs but 3 deaths within 7 days. In patients with hematological malignancy and CVC-associated UE-DVT, early removal of CVCs was not associated with an increased risk of PE compared with delayed or no removal.

Characteristics and predictors of venous thrombosis recurrence in patients with cancer and catheter‐related thrombosis

“… 13 However, these recommendations to overlap therapeutic anticoagulation with catheter removal are not based on strong evidence, and the variation in recommended days can be confusing for clinicians, thus leading to the lack of uniformity in treatment approaches. Anticoagulation for several days before removal is intended to minimize the risk of embolization; however, a recent study by Houghton et al 37 showed that early catheter removal (<48 hours after anticoagulant initiation) in patients with hematologic malignancies and CRT was not associated with increased risk of pulmonary embolism within 7 days. This finding aligns with our study, as none of the patients developed PE within 7 days from presentation.…”

Symptomatic pulmonary embolus after catheter removal in children with catheter related thrombosis: A report from the CHAT Consortium

“…This grouping was independent from subjects’ use of prophylactic anticoagulation. Forty‐eight hours was chosen as a timeframe that had previously been established (through the VENUS study) 9 as a timing of concern for early removal of CVCs.…”

“…A recent study by Houghton et al by the Venous Thromboembolism Network United States (VENUS) evaluated this clinical scenario in adult cancer patients with upper extremity CRT. 9 In their cohort of 663 subjects, there was no difference in rates of embolization with less than or greater than 48 h of anticoagulation prior to CVC removal. To address this issue in children, this current study evaluated the incidence of symptomatic pulmonary embolism (PE) after CVC removal in children within the multi-institutional Children's Hospital-Acquired Thrombosis (CHAT) Consortium Registry diagnosed with a CRT.…”

“…These guidelines lack specific guidance regarding duration of anticoagulation prior to CVC removal, because of paucity of evidence on this issue. A recent study by Houghton et al by the Venous Thromboembolism Network United States (VENUS) evaluated this clinical scenario in adult cancer patients with upper extremity CRT 9 . In their cohort of 663 subjects, there was no difference in rates of embolization with less than or greater than 48 h of anticoagulation prior to CVC removal.…”

EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer

“… 110 However, a recent study of 626 patients with acute CRT showed that early (≤48 h) removal of CVCs (with and without anticoagulation) was not associated with an increased risk of PE within 7 days compared with delayed (>48 h) or no removal (0.78% versus 0.44%; respectively, P > 0.9). 112 All 3 patients with PE had brachiocephalic vein or superior vena cava thrombosis as the index CRT. Therefore, in patients with brachiocephalic vein or superior vena cava thrombosis, the benefit of early removal should be carefully weighed against a potential thromboembolic risk.…”