Central catheter-related venous thrombosis

Note: “Catheter” here refers to central lines such as PICC, portacath, and similar devices, not peripheral IV cannulae.

Routine anticoagulation is recommended in all cases of catheter-related DVT.

Routine prophylaxis is not recommended in patients with catheters.

Management depends on whether the catheter is still required and whether the patient has underlying malignant disease.

Pathophysiology

• Catheter-related venous thrombosis is a common cause of upper limb DVT, particularly in patients with underlying malignancy
• Central venous catheters can lead to thrombosis directly through mechanical and endothelial disruption.
• In malignancy, a hypercoagulable state may contribute significantly to thrombosis risk.
• A new thrombosis may also signify progression of underlying cancer.

Clinical Assessment

• In patients with malignancy, assess for:
  • Catheter function and positioning
  • Underlying cancer progression
  • Pulmonary embolism
  • Associated infection or sepsis

Investigations

• Bloods:
  1. FBE
  2. U&Es / glucose
  3. Others as clinically indicated
  4. Thrombophilia screen not routinely required unless additional risk factors
  5. Microbiological studies on removed catheter if infection suspected
• Imaging:
  • Plain radiograph: to confirm catheter positioning

Management

General Principles

• All cases: commence therapeutic anticoagulation (typically LMWH initially)

Catheter No Longer Required

• Remove catheter
• Commence LMWHThen:
  • If no active malignancy: switch to warfarin or NOAC, treat for 3 months post-removal
  • If active malignancy: continue LMWH for 3 months post-removal

Catheter Still Required

• Ensure catheter is functional and well-positioned
• Continue LMWHThen:
  • If no malignancy: switch to warfarin or NOAC for 3 months
  • If active malignancy: continue LMWH until catheter no longer needed, then treat for 3 months after removal

Catheter Dysfunction or Malposition

• Remove and replace catheter

Additional Notes

• Indefinite anticoagulation is not generally indicated unless recurrent thrombosis occurs
• IVC filter and catheter-directed thrombolysis are not routinely recommended

Disposition

• Follow-up required by General Medicine, Oncology, or Clinical Haematology
• A clear plan for anticoagulation duration must be documented

Haematology follow-up is particularly recommended if:

• Duration of anticoagulation is unclear
• Bleeding risk is elevated
• NOAC use is planned
• Clinical concerns arise

At follow-up:

• Repeat Doppler US of affected limb:
  • Residual clot is common
  • Does not typically alter treatment duration unless extensive or worsening

Future Management

• DVT prophylaxis is recommended for all future inpatient stays
• Routine prophylaxis is not required for new catheters in those with previous catheter-related DVT
• Consider therapeutic anticoagulation in high-risk cases

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References

Publications

• Debourdeau P et al. International clinical practice guidelines for the treatment and prophylaxis of thrombosis associated with central venous catheters in patients with cancer. J Thromb Haemost. 2013 Jan;11(1):71-80.

FOAMed

• Nickson C. Cervical artery dissection. LITFL