Internal jugular, subclavian, and axillary deep venous thrombosis and the risk of pulmonary embolism. Vascular. 2008 Mar-Apr;16(2):73-9.

The objective of this study was to investigate the risk of acute internal jugular, subclavian, and axillary deep venous thrombosis (upper torso DVT [UTDVT]) and pulmonary embolism (PE) and the role of anticoagulation in a cohort of hospitalized patients. A 2-year retrospective review of hospitalized patients who underwent upper torso vein duplex scanning was performed. Patient demographics, underlying comorbidities, indication for scanning, diagnostic tests, intensive care unit stay, length of stay, presence of a central line (current or within the last 2 weeks), malignancy (current or former), hypercoaguable condition, postoperative state, renal failure, mortality, and use of anticoagulation were recorded. Univariate and multivariate analyses were performed to investigate significant risk factors for acute UTDVT. The impact of an acute UTDVT and use of anticoagulation on hospital length of stay, survival to 30 days and 1 year, and PE rate were calculated. One hundred eighty-nine patients were scanned. Sixty-three patients (33%) were found to have an acute UTDVT. The internal jugular vein was the most common site of thrombosis. The presence of a central venous catheter was the only factor found to be a significant risk factor for an acute UTDVT (p = .03). Five patients (7.9%) with an UTDVT had a PE documented by computed tomographic angiography-pulmonary arteriography, and all had an internal jugular thrombosis (four isolated and one combined with an axillary-subclavian thrombosis). No PE was fatal. Thirty-eight (60%) patients with an acute UTDVT were treated with therapeutic anticoagulation; the remainder were observed. All patients with a PE received anticoagulation. Hospital length of stay, 30-day mortality, and 12-month survival were no different for patients with and without an UTDVT (p = .7). The use of anticoagulation had no observable effect on survival in patients with UTDVT (p = .1). An acute internal jugular, subclavian, or axillary DVT is a relatively common finding in the hospitalized patient. Patients with a central line (current or within the previous 14 days) were at greatest risk, with an internal jugular vein thrombosis being the most common source. The inconsistent use of anticoagulation therapy for UTDVT was associated with a moderate risk of PE. A survival benefit for anticoagulation could not be documented.

A critical review of thromboembolic complications associated with central venous catheters: [Une synthese critique des complications thromboemboliques associees aux catheters veineux centraux].Can J Anaesth. 2008 Aug;55(8):532-41.

Purpose: Central venous catheters (CVC) are commonly used in critical care. While thrombosis is a well-recognized and frequent complication associated with their use, CVC-related thromboembolic complications, including pulmonary embolism (PE) and right heart thromboembolism (RHTE), occur less frequently and often evade diagnosis. Little information exists to guide clinicians in the diagnosis and management of CVC-related thromboembolic complications. SOURCE: We critically review and synthesize the literature highlighting the incidence of CVC-related thrombosis. We highlight the risk for developing thromboembolic complications and provide approaches to diagnosing and managing RHTE.Principle findings: The incidence of CVC-related thrombosis varies depending on patient, site, instrument, and infusate-related factors. Central venous catheters-related thrombosis represents an important source of morbidity and mortality for affected patients. Pulmonary embolism occurs in approximately 15% of patients with CVC-related upper extremity deep venous thrombosis (UEDVT). More frequent use of transesophageal echocardiography, in patients with suspected and confirmed PE, has resulted in increased detection of RHTE. While it is recognized that the occurrence of RHTE, in association with PE, increases mortality, the optimal strategy for their management has not been established in a clinical trial. CONCLUSION: Central venous catheter-related thrombosis occurs frequently and represents an important source of morbidity and mortality for affected patients. Our review supports that surgery and thrombolysis have both been demonstrated to enhance survival in patients with RHTE and PE. However, important patient, clot, and institutional considerations mandate that treatment for patients with RHTE and PE be individualized.

Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. Rev Med Interne. 2007 Jul;28(7):471-83. Epub 2007 Apr 19.

OBJECTIVES: Increased incidence of cancers and the development of totally implanted venous access devices that contain their own port to deliver chemotherapy will lead to a greater than before numbers of central venous catheter related thrombosis (CVCT). Medical consequences include catheter dysfunction and pulmonary embolism. Compared with lower extremity deep venous thrombosis (DVT) (3 d) and with non CVC associated thrombosis (5 d), CVCT is associated with an increased duration of hospitalisation (9 d). CVCT oftentimes leads to the need to replace such ports at an average cost of 4500 euros. CURRENT KNOWLEDGE AND KEY POINTS: Vessel injury caused by the procedure of CVC insertion is the most important risk factor for development of CVCT. This event could cause the formation of a fresh thrombus, which is reversible in the large majority of patients. The incidence of CVC-related DVT assessed by venography has been reported to vary from 30 to 60% but catheter-related DVT in adult patients is symptomatic in only 5% of cases. The majority of patients with CVC-related DVT is asymptomatic or has non-specific symptoms: arm or neck swelling or pain, distal paresthesias, headache, congestion of subcutaneous collateral veins. In the case of clinical suspicion of CVC-related DVT, compressive ultrasonography (US), especially with Doppler and color imaging, currently is first used to confirm the diagnosis. The main criteria of color-Doppler US are visualization of mural thrombi or incompressibility of the veins. Consequently, contrast venography is reserved for clinical trials and difficult diagnostic situations. There is no consensus on the optimal management of patients with CVC-related DVT. Treatment of CVC-related VTE requires a 5- to 7-day course of adjusted-dose unfractionated heparin or LMWH followed by oral anticoagulants. Long-term LMWH that has been shown to be more effective than oral anticoagulant in cancer patients with lower limb DVT could be used in these patients. The optimal duration of oral anticoagulation treatment for CVC-related DVT is unknown, but patients with active cancer should be treated for at least 6 months or indefinitely. FUTURE PROSPECTS AND PROJECTS: The efficacy and safety of pharmacologic prophylaxis for CVC related thrombosis is not established. Additional studies performed in high risk populations are needed to define if LMWH or oral anticoagulation is indicated in this clinical setting.

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