Secondary Anticoagulation Prophylaxis for Catheter‐Related Thrombosis in Pediatric Intestinal Failure: Comparison of Short‐ Vs Long‐Term Treatment Protocols

Abstract

Introduction: Catheter-related thrombosis (CRT) is a devastating complication of central venous catheters in children with intestinal failure (IF), but the optimal preventive therapy of CRT is unknown. This study assessed the efficacy and safety of 2 protocols of secondary anticoagulation prophylaxis with low-molecular-weight heparin (LMWH). Methods: This is a comparative cohort study of children from 2 IF programs who received secondary anticoagulation prophylaxis with LMWH for CRT. The short-term protocol group (N = 13) received therapeutic dosing until thrombus resolution or ≤3 months. In the long-term protocol group (N = 26), prophylactic dosing continued until line removal. Patients underwent routine annual vascular ultrasound and were followed for ≥1 year. The primary outcome was development of secondary thrombosis; post hoc analysis assessed rates of secondary thrombosis at 12 months. Results: Patient demographics were similar between groups. Secondary thrombosis occurred in 8 of 13 (62%) patients in the short-term group and in 9 of 26 (35%) in the long-term protocol group (P = .019) in a median time of 144.5 and 689 days, respectively (P = .01). Secondary thrombosis within 12 months occurred in 7 of 13 (54%, short term) and 2 of 26 (8%, long term) patients (P = .001). Secondary thrombosis was associated with catheter replacements (23.5 vs 5.5 catheters per 1000 catheter days; P = .016) and longer daily parenteral nutrition (PN) infusion (24 vs 15.25 hours; P = .044). Compliance was good (>80% of doses) in 92% of patients. Conclusions: Long-term secondary anticoagulation prophylaxis with LMWH reduces the incidence of secondary thrombosis and should be considered in children with CRT that require PN for prolonged periods of time. (JPEN J

Prophylactic anticoagulation in children receiving home parenteral nutrition

“…McLaughlin et al reported no bleeds in a cohort of 18 children treated with secondary prophylactic anticoagulation for ≤18 months after the start of anticoagulation 24 . Schmidt et al reported on the effect of short‐term (≤3 months) or long‐term (until line removal) anticoagulation after thrombosis and found that 15% of patients (2 of 13) in the short‐term and 8% of the patients in the long‐term group (2 of 26) experienced a clinically relevant nonmajor bleed 25 . Klaassen et al performed a systematic review on the safety of prophylactic LMWHs used in pediatric patients.…”

“…24 Schmidt et al reported on the effect of short-term (≤3 months) or long-term (until line removal) anticoagulation after thrombosis and found that 15% of patients (2 of 13) in the short-term and 8% of the patients in the long-term group (2 of 26) experienced a clinically relevant nonmajor bleed. 25 Klaassen et al performed a systematic review on the safety of prophylactic LMWHs used in pediatric patients. They showed that in 18 studies on 1286 children, eight major bleeding events (0.6%; 95% CI, 0.2%-1.0%) were reported; no duration of follow-up is described.…”

Venous Thromboembolic Complications in Pediatric Gastrointestinal Diseases: Inflammatory Bowel Disease and Intestinal Failure

“…When looking at individual studies published after publication of the meta-analysis, ranging prevalences have been reported. Asouzo et al reported one or more thrombi in 30 patients from a cohort of 65 patients with IF (46%) with a median age of 6.83 years ( 20 ), while Schmidt et al reported thrombosis in 95 out of 388 patients with IF (24%) during a median follow-up time of 398 days ( 21 ). Secondary (i.e., recurrent) VTE occurred in 44% of the patients of the latter study.…”

“…However, in the new NASPGHAN recommendations (from 2021), the authors state that children with incomplete resolution of thrombus should be maintained on prophylactic anticoagulation with LMWH ( 71 ). Schmidt et al retrospectively compared two different regimens for secondary anticoagulation prophylaxis with LMWH in two pediatric IF centers ( 21 ). In the short-term regimen, children with CVT received therapeutic dosing until thrombus resolution or up to 3 months without prophylactic dosing thereafter, and in the long-term regimen, therapeutic dosing was given up to 3 months and prophylactic dosing continued thereafter until line removal.…”

Central venous catheter-associated deep vein thrombosis in critically ill pediatric patients: risk factors, prevention, and treatment

“…There was no significant association between anticoagulation dose and bleeding. Schmidt et al also looked at secondary prophylaxis for CADVT among children dependent on total parenteral nutrition [34 ▪ ]. They found that children with history of CADVT had lower recurrence rates if they were continued indefinitely on prophylactic anticoagulation than if they only received anticoagulation for 3 months after the previous thrombosis.…”