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      Long-Term Follow-Up and Clinical Relevance of Incidental Findings of Fibrin Sheath and Thrombosis on Computed Tomography Scans of Cancer Patients with Port Catheters

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          Abstract

          Purpose

          This retrospective study examined the incidence, progression, and clinical relevance of catheter-related thrombosis (CRT) and/or fibrin sheaths presenting as incidental findings on routine staging computed tomography (CT) scans performed in cancer patients.

          Patients and Methods

          Patients who underwent central venous port catheter (CVC) placement in a tertiary care hospital between September 2010 and August 2013 were followed up for up to five years. Two radiologists assessed the presence of fibrin sheath and thrombosis in consensus in staging CT scan. Patient demographics, type of cancer, preoperative comorbidities, date of CVC placement and CTs, preexisting anticoagulation, as well as the type and treatment of catheter-related complications were determined from the electronic medical record.

          Results

          A total of 194 patients with 530 CT scans and a mean follow-up time of 394 days were included. Fibrin sheaths and thromboses were seen on 46 scans (8.7%) in 30 patients and 80 scans (15.1%) in 35 patients. The incidence of fibrin sheaths and thromboses was found to be 15.5% and 18%, respectively. The comparison to initial CT reports results indicated that fibrin sheaths or thromboses were missed in 106 examinations (20%). Catheter-associated complications were reported in 14 patients (21.5%) without specific therapy.

          Conclusion

          Fibrin sheaths and CRTs are often overlooked on routine CT scans when patients are asymptomatic. The subsequent high complication rate demonstrates the clinical relevance of the initial incidental finding on CT scan. Further studies should elucidate the effect of thrombolytic agents and interventional radiologic treatment in asymptomatic patients.

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          Most cited references 20

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          KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 update.

          (2015)
          The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for all stages of chronic kidney disease (CKD) and related complications since 1997. The 2015 update of the KDOQI Clinical Practice Guideline for Hemodialysis Adequacy is intended to assist practitioners caring for patients in preparation for and during hemodialysis. The literature reviewed for this update includes clinical trials and observational studies published between 2000 and March 2014. New topics include high-frequency hemodialysis and risks; prescription flexibility in initiation timing, frequency, duration, and ultrafiltration rate; and more emphasis on volume and blood pressure control. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Limitations of the evidence are discussed and specific suggestions are provided for future research.
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            Anticoagulation for people with cancer and central venous catheters

            Central venous catheter (CVC) placement increases the risk of thrombosis in people with cancer. Thrombosis often necessitates the removal of the CVC, resulting in treatment delays and thrombosis‐related morbidity and mortality. This is an update of the Cochrane Review published in 2014. To evaluate the efficacy and safety of anticoagulation for thromboprophylaxis in people with cancer with a CVC. We conducted a comprehensive literature search in May 2018 that included a major electronic search of Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), and Embase (Ovid); handsearching of conference proceedings; checking of references of included studies; searching for ongoing studies; and using the 'related citation' feature in PubMed. This update of the systematic review was based on the findings of a literature search conducted on 14 May 2018. Randomized controlled trials (RCTs) assessing the benefits and harms of unfractionated heparin (UFH), low‐molecular‐weight heparin (LMWH), vitamin K antagonists (VKA), or fondaparinux or comparing the effects of two of these anticoagulants in people with cancer and a CVC. Using a standardized form, we extracted data and assessed risk of bias. Outcomes included all‐cause mortality, symptomatic catheter‐related venous thromboembolism (VTE), pulmonary embolism (PE), major bleeding, minor bleeding, catheter‐related infection, thrombocytopenia, and health‐related quality of life (HRQoL). We assessed the certainty of evidence for each outcome using the GRADE approach ( Balshem 2011 ). Thirteen RCTs (23 papers) fulfilled the inclusion criteria. These trials enrolled 3420 participants. Seven RCTs compared LMWH to no LMWH (six in adults and one in children), six RCTs compared VKA to no VKA (five in adults and one in children), and three RCTs compared LMWH to VKA in adults. LMWH versus no LMWH 
 Six RCTs (1537 participants) compared LMWH to no LMWH in adults. The meta‐analyses showed that LMWH probably decreased the incidence of symptomatic catheter‐related VTE up to three months of follow‐up compared to no LMWH (risk ratio (RR) 0.43, 95% confidence interval (CI) 0.22 to 0.81; risk difference (RD) 38 fewer per 1000, 95% CI 13 fewer to 52 fewer; moderate‐certainty evidence). However, the analysis did not confirm or exclude a beneficial or detrimental effect of LMWH on mortality at three months of follow‐up (RR 0.82, 95% CI 0.53 to 1.26; RD 14 fewer per 1000, 95% CI 36 fewer to 20 more; low‐certainty evidence), major bleeding (RR 1.49, 95% CI 0.06 to 36.28; RD 0 more per 1000, 95% CI 1 fewer to 35 more; very low‐certainty evidence), minor bleeding (RR 1.35, 95% CI 0.62 to 2.92; RD 14 more per 1000, 95% CI 16 fewer to 79 more; low‐certainty evidence), and thrombocytopenia (RR 1.03, 95% CI 0.80 to 1.33; RD 5 more per 1000, 95% CI 35 fewer to 58 more; low‐certainty evidence). VKA versus no VKA 
 Five RCTs (1599 participants) compared low‐dose VKA to no VKA in adults. The meta‐analyses did not confirm or exclude a beneficial or detrimental effect of low‐dose VKA compared to no VKA on mortality (RR 0.99, 95% CI 0.64 to 1.55; RD 1 fewer per 1000, 95% CI 34 fewer to 52 more; low‐certainty evidence), symptomatic catheter‐related VTE (RR 0.61, 95% CI 0.23 to 1.64; RD 31 fewer per 1000, 95% CI 62 fewer to 51 more; low‐certainty evidence), major bleeding (RR 7.14, 95% CI 0.88 to 57.78; RD 12 more per 1000, 95% CI 0 fewer to 110 more; low‐certainty evidence), minor bleeding (RR 0.69, 95% CI 0.38 to 1.26; RD 15 fewer per 1000, 95% CI 30 fewer to 13 more; low‐certainty evidence), premature catheter removal (RR 0.82, 95% CI 0.30 to 2.24; RD 29 fewer per 1000, 95% CI 114 fewer to 202 more; low‐certainty evidence), and catheter‐related infection (RR 1.17, 95% CI 0.74 to 1.85; RD 71 more per 1000, 95% CI 109 fewer to 356; low‐certainty evidence). LMWH versus VKA 
 Three RCTs (641 participants) compared LMWH to VKA in adults. The available evidence did not confirm or exclude a beneficial or detrimental effect of LMWH relative to VKA on mortality (RR 0.94, 95% CI 0.56 to 1.59; RD 6 fewer per 1000, 95% CI 41 fewer to 56 more; low‐certainty evidence), symptomatic catheter‐related VTE (RR 1.83, 95% CI 0.44 to 7.61; RD 15 more per 1000, 95% CI 10 fewer to 122 more; very low‐certainty evidence), PE (RR 1.70, 95% CI 0.74 to 3.92; RD 35 more per 1000, 95% CI 13 fewer to 144 more; low‐certainty evidence), major bleeding (RR 3.11, 95% CI 0.13 to 73.11; RD 2 more per 1000, 95% CI 1 fewer to 72 more; very low‐certainty evidence), or minor bleeding (RR 0.95, 95% CI 0.20 to 4.61; RD 1 fewer per 1000, 95% CI 21 fewer to 95 more; very low‐certainty evidence). The meta‐analyses showed that LMWH probably increased the risk of thrombocytopenia compared to VKA at three months of follow‐up (RR 1.69, 95% CI 1.20 to 2.39; RD 149 more per 1000, 95% CI 43 fewer to 300 more; moderate‐certainty evidence). The evidence was not conclusive for the effect of LMWH on mortality, the effect of VKA on mortality and catheter‐related VTE, and the effect of LMWH compared to VKA on mortality and catheter‐related VTE. We found moderate‐certainty evidence that LMWH reduces catheter‐related VTE compared to no LMWH. People with cancer with CVCs considering anticoagulation should balance the possible benefit of reduced thromboembolic complications with the possible harms and burden of anticoagulants. Blood thinners to prevent blood clots in people with cancer and central venous catheters Background 
 A central venous catheter (CVC) is a tube that is inserted into a large vein to give fluids or medicines. CVC placement increases the risk of blood clots in people with cancer. This review evaluated the effectiveness and safety of blood thinning agents (anticoagulants) in people with cancer and a CVC. Study characteristics 
 We searched the scientific literature for studies of anticoagulants in people with cancer and a CVC. The evidence is current to 14 May 2018. Key results 
 We included 13 trials enrolling 3420 people with cancer and a CVC. Most trials included people with various types and stages of cancer. Seven studies compared injectable blood thinners to no anticoagulation, six studies compared blood thinner pills to no anticoagulation, and three studies compared injectable blood thinners to blood thinner pills. When considering people with cancer and a CVC, injectable blood thinners probably reduced the risk of CVC‐related blood clots compared to no anticoagulation and probably increased the risk of thrombocytopenia (low levels of platelets in the blood, which causes bleeding into the tissues) compared to blood thinner pills. Certainty of the evidence 
 When comparing injectable blood thinners to no anticoagulation, we judged the certainty of the evidence to be moderate for blood clot at the catheter site, low for mortality, infection at the catheter site and minor bleeding, and very low for major bleeding. When comparing blood thinner pills to no anticoagulation, we judged the certainty of the evidence to be low for mortality major and minor bleeding, premature catheter removal and catheter‐related infection low, and very low for blood clot at the catheter site. When comparing injectable blood thinners to blood thinner pills, we judged the certainty of the evidence to be low for mortality and blood clots in the limbs and very low for blood clot at the catheter site, major and minor bleeding.
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              Thromboprophylaxis in cancer patients with central venous catheters. A systematic review and meta-analysis.

              It was the aim of the review to determine the risks and benefits of primary thromboprophylaxis with anticoagulants in cancer patients with central venous devices. Medline, Central and Google Scholar databases were searched for randomized controlled trials (RCTs) in June 2006. Two reviewers extracted data and appraised the quality of RCTs. Results were expressed as relative risk (RR) with 95% confidence intervals (CI) using random effects model for the outcomes of catheter-related thrombosis, bleeding and thrombocytopenia. Eight RCTs (1,428 patients) were included. There was no statistically significant difference in the risk of catheter-related thrombosis for the use of warfarin versus placebo (3 trials, 425 patients, RR 0.75, 95% CI 0.24-2.35, p = 0.63), heparin versus placebo (4 trials, 886 patients, RR 0.46 95% CI 0.18-1.20, p = 0.06) or warfarin, unfractionated heparin or low-molecular-weight heparin versus placebo (7 trials, 1,311 patients, RR 0.59, 95% CI 0.31-1.13, p = 0.11). Substantial statistical heterogeneity was noted among these trials (I(2) > 50%). The use of anticoagulants showed no statistically significant difference in the risk of overall bleeding (5 trials, 1,193 patients, RR 1.24, 95% CI 0.84-1.82, p = 0.28), and thrombocytopenia for heparin versus placebo (4 trials, 958 patients, RR 0.85, 95% CI 0.49, 1.46, p = 0.55) without any statistical heterogeneity (I(2) = 0%). In cancer patients with central venous devices, thromboprophylaxis has no significant effect on the risk of catheter related thrombosis or bleeding. The use of primary thromboprophylaxis in cancer patients with central venous catheters while not causing any harm provides no benefit.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                tcrm
                tcriskman
                Therapeutics and Clinical Risk Management
                Dove
                1176-6336
                1178-203X
                27 January 2021
                2021
                : 17
                : 111-118
                Affiliations
                [1 ]Department of Radiology, University Hospital of Cologne , Cologne, Germany
                [2 ]Department of Radiology, Klinikum Aschaffenburg , Aschaffenburg, Germany
                [3 ]Department of Diagnostic and Interventional Radiology, University Medical Center Heidelberg , Heidelberg, Germany
                Author notes
                Correspondence: Thorsten Lichtenstein Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Köln (AöR) , Kerpener Str. 62, Cologne50937, GermanyTel +49 221 478-82035 Email thorsten.lichtenstein@uk-koeln.de
                Article
                287544
                10.2147/TCRM.S287544
                7850422
                33536758
                © 2021 Lichtenstein et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 4, Tables: 4, References: 20, Pages: 8
                Funding
                Funded by: None;
                Source(s) of support in the form of grants, equipment, drugs, or other assistance, whether from public or private sources: None.
                Categories
                Original Research

                Medicine

                catheter-related complications, central venous catheters, port-a-cath, imaging, staging

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