International clinical practice guidelines for the treatment and prophylaxis of thrombosis associated with central venous catheters in patients with cancer
Debourdeau P, Farge D, Beckers M, Baglin C, Bauersachs RM, Brenner B, Brilhante D, Falanga A, Gerotzafias GT, Haim N, Kakkar AK, Khorana AA, Lecumberri R, Mandala M, Marty M, Monreal M, Mousa SA, Noble S, Pabinger I, Prandoni P, Prins MH, Qari MH, Streiff MB, Syrigos K, Büller HR, Bounameaux H.
Internal Medicine and Oncology Department, Desgenettes Military Hospital, Lyon, France
Although long term indwelling central venous catheters (CVC) may lead to pulmonary embolism (PE) and loss of the CVC, there is lack of consensus on management of CVC related thrombosis (CRT) in cancer patients and heterogeneity in clinical practices worldwide.
To establish common international Good Clinical Practices Guidelines (GCPG) for the management of CRT in cancer patients.
An international working group of experts was set up to develop GCPG according to an evidence-based medicine approach, using the GRADE system.
For the treatment of established CRT in cancer pts, we found no prospective randomized study, 2 non-randomized prospective studies and 1 retrospective study examining the efficacy and safety of Low Molecular Weight Heparin (LMWH) plus vitamin K antagonists (VKA). One retrospective study evaluated the benefit of CVC removal and 2 small retrospective studies on thrombolytic drugs. For the treatment of symptomatic CRT, anticoagulant treatment (AC) is recommended for a minimum of 3 months; in this setting, LMWH are suggested. VKA can be also be used, in the absence of direct comparisons of these two types of anticoagulants in this setting [Guidance]. The CVC can be kept in place if it is functional, well-positioned, non-infected and there is good resolution under close surveillance; whether the CVC is kept or removed, no standard approach in terms of AC duration is established [Guidance]. For the prophylaxis of CRT in cancer patients, we found 6 randomized studies investigating the efficacy and safety of VKA vs placebo or no treatment, 1 on the efficacy and safety of Unfractionnated Heparin, 6 on the value of LMWH, one double-blind randomized and 1 non randomized study on thrombolytic drugs with 6 meta-analyses of AC and CVC thromboprophylaxis. Type of catheter (open-ended like the Hickman(®) catheter versus closed-ended catheter with a valve like the Groshong(®) catheter), its position (above, below or at the junction of the superior vena cava and the right atrium), and method of placement may influence the onset of CRT on the basis of 6 retrospective, 4 prospective non-randomized trials, 3 randomized trials and 1 meta-analysis. In light of these data: Use of AC for routine prophylaxis of CRT is not recommended [1A]; CVC should be inserted on the right side, in the jugular vein, and distal extremity of the CVC should be located at the junction of the superior vena cava and the right atrium [1A].
Dissemination and implementation of these international GCPG for the prevention and treatment of CRT in cancer patients at each national level is a major public health priority, needing worldwide collaboration. © 2012 International Society on Thrombosis and Haemostasis.
CITA DEL ARTÍCULO J Thromb Haemost. 2012 Dec 8. doi: 10.1111/jth.12071