Among patients with a hematologic malignancy and central venous catheter (CVC)–associated upper extremity deep vein thrombosis (UEDVT), removing CVCs within 48 hours of diagnosis was not associated with an increased short-term risk of pulmonary embolism (PE), compared with delayed or no removal. This is according to research published in Blood Advances.
Lead study author Damon Houghton, MD, of Mayo Clinic, stated that these findings "do not provide a compelling reason to delay CVC removal for the concern of PE."
In patients with hematologic malignancies, UEDVT is a well-known complication of using CVCs. Historically, the removal of the CVC is typically considered following diagnosis with a CVC-associated UEDVT. The optimal timing for removal, however, remains unknown.
Current guidelines recommend leaving functional CVCs in place but suggest that patients with cancer and CVC-associated DVT receive three to five days of anticoagulation treatment prior to CVC removal. This guidance is based on expert opinion rather than high-quality evidence. In addition, there is a lack of rigorous data to suggest the recommended strategies are safe, effective, or even necessary.
In this multicenter retrospective cohort study, Dr. Houghton and colleagues assessed the risk of PE with different CVC management strategies in patients with hematologic malignancies and CVC-associated UEDVT.
Patients were divided into two groups based on treatment and CVC removal strategies:
- anticoagulation treatment with early CVC removal (≤48 hours after the diagnosis of UEDVT; n=255)
- anticoagulation treatment with either delayed CVC removal (>48 hours) or no CVC removal (n=225)
A total of 116 patients in the study underwent CVC removal only. The majority of patients in the overall cohort received anticoagulation treatment (n=480). The mean ages were 54 years in the early removal group and 51 years in the delayed or no removal group.
Of patients who received anticoagulation treatment, two who had early CVC removal experienced a PE within seven days (0.8%), while only one who had a delayed CVC removal experienced a PE within this timeframe (0.4%; p>0.9). A total of three patients in the early CVC removal group (1.2%) and the delayed/no CVC removal group (1.3%) had a PE or any cause of death within seven days (p>0.9).
There were no PEs in the group of patients who were treated with CVC removal only and no anticoagulation; however, three deaths were reported in this group within seven days.
While the study identified a low risk of PE In patients not treated with anticoagulation, the findings do not endorse treatment with CVC removal only without anticoagulation. The authors pointed out that the small number of patients in the nonanticoagulated group and the short-term outcome of PE limit the clinical implications.
In this study, routine radiographic surveillance for PE was not performed. Some events may have occurred prior to anticoagulation or CVC removal. "This means that the small number of PEs may represent an overestimation of the number that occur with CVC removal," the researchers wrote.
Another limitation of the study is its retrospective nature, which prevented the researchers from identifying why anticoagulation was not prescribed in some patients. Additionally, the investigators were unable to examine imaging from all patients to assess for asymptomatic PE.
Study authors report no relevant conflicts of interest.
Reference
Houghton DE, Billett HH, Gaddh M, et al. Risk of pulmonary emboli after removal of an upper extremity central catheter associated with a deep vein thrombosis. Blood Adv. 2021 Jul 27;5(14):2807-2812.
