Upper Extremity Deep Venous Thrombosis in Cancer Patients with Venous Access Devices - Prophylaxis with a Low Molecular Weight Heparin (Fragmin)

Abstract

SummaryCentral venous access devices are often essential for the administration of chemotherapy to patients with malignancy, but its use has been associated with a number of complications, mainly thrombosis. The true incidence of upper extremity deep vein thrombosis (DVT) in this setting is difficult to estimate since there are very few studies in which DVT diagnosis was based on objective tests, but its sequelae include septic thrombophlebitis, loss of central venous access and pulmonary embolism.We performed an open, prospective study in which all cancer patients who underwent placement of a long-term Port-a-Cath (Pharmacia Deltec Inc) subclavian venous catheter were randomized to receive or not 2500 IU sc of Fragmin once daily for 90 days. Venography was routinely performed 90 days after catheter insertion, or sooner if DVT symptoms had appeared. Our aims were: 1) to investigate the effectiveness of low doses of Fragmin in preventing catheter-related DVT; and 2) to try to confirm if patients with high platelet counts are at a higher risk to develop subclavian DVT, as previously suggested.On the recommendation of the Ethics Committee, patient recruitment was terminated earlier than planned: DVT developed in 1/16 patients (6%) taking Fragmin and 8/13 patients (62%) without prophylaxis (Relative Risk 6.75; 95% Cl: 1.05-43.58; p = 0.002, Fisher exact test). No bleeding complications had developed. As for prediction of DVT, there was a tendency towards a higher platelet count in those patients who subsequently developed DVT, but differences failed to reach any statistical significance (286 ±145 vs 207 ±81 X 109/1; p = 0.067). According to our experience, Fragmin at the dosage used proved to be both effective and safe in these patients.

Prevalence of inherited prothrombotic abnormalities and central venous catheter-related thrombosis in haematopoietic stem cell transplants recipients

“…[23][24] Recently, in a randomised controlled trial, we showed that low-dose of UFH was safe and effective to prevent CVC-related thrombosis in patients with haemato-oncological disease. 25 However, many clinicians are reluctant to prescribe anticoagulant prophylaxis routinely in patients with cancer and a CVC because of the low expected incidence of thrombosis and the fear of bleeding during anticoagulant prophylaxis.…”

Venous Thrombosis in Cancer Patients: Insights from the FRONTLINE Survey

“…In a series of 92 patients with implanted devices managed with heparin flushes and, in high-risk patients, a low-dose oral anticoagulant, Lokich et al reported a 16% thrombosis rate, which they contrasted with the 43% thrombosis rate in a previous series of patients with tunneled subclavian catheters [17]. Thrombosis rates of 37%-62% were observed in the control groups of two small trials [18,19].…”

“…In North America, fixed low-dose oral anticoagulants were the more common treatment. Both of these strategies are supported by small prospective studies [18,19]. In the event that thrombosis developed when a central venous access device was in use, most physicians favored removal of the device and additional therapy.…”

Safety of low-dose low-molecular-weight-heparins in thrombocytopenic stem cell transplantation patients: a case series and review of the literature

“…Neither bleeding events nor information on the degree of thrombocytopenia and dose interruptions were reported in this retrospective trial. 26 Similarly, the use of very-low-dose warfarin (ie 1-mg daily) for the prevention of CVC-TE in thrombocytopenic cancer patients was either not fully described 27,28 or discontinued when platelets were below o50 Â 10 9 /l. 29 In clinical practice, practitioners are inclined to empirically withhold antithrombotic therapy until platelet count is above 50 Â 10 9 /l for fear of bleeding.…”