Elsevier

The Lancet

Volume 374, Issue 9684, 11–17 July 2009, Pages 159-169
The Lancet

Review
Management of occlusion and thrombosis associated with long-term indwelling central venous catheters

https://doi.org/10.1016/S0140-6736(09)60220-8Get rights and content

Summary

Long-term central venous catheters (CVCs) are important instruments in the care of patients with chronic illnesses, but catheter occlusions and catheter-related thromboses are common complications that can result from their use. In this Review, we summarise management of these complications. Mechanical CVC occlusions need cause-specific treatment, whereas thrombotic occlusions usually resolve with thrombolytic treatment, such as alteplase. Prophylaxis with thrombolytic flushes might prevent CVC infections and catheter-related thromboses, but confirmatory studies and cost-effectiveness analysis of this approach are needed. Risk factors for catheter-related thromboses include previous catheter infections, malposition of the catheter tip, and prothrombotic states. Catheter-related thromboses can lead to catheter infection, pulmonary embolism, and post-thrombotic syndrome. Catheter-related thromboses are usually diagnosed by Doppler ultrasonography or venography and treated with anticoagulation therapy for 6 weeks to a year, dependent on the extent of the thrombus, response to initial therapy, and whether thrombophilic factors persist. Prevention of catheter-related thromboses includes proper positioning of the CVC and prevention of infections; anticoagulation prophylaxis is not currently recommended.

Introduction

For patients with chronic illnesses, long-term central venous catheters (CVCs) provide easy venous access for laboratory tests, drug delivery, and parenteral nutrition. However, several complications that result from the use of CVCs, including sepsis, extravasation of infusions, and venous thrombosis, can increase associated morbidity and mortality. These complications can also interrupt and delay treatment for the underlying disease and thereby affect outcome. In this Review, we discuss the diagnosis, management, and prevention of catheter occlusions and catheter-related thromboses, the most common complications of CVCs. Since the incidence, risk factors, and management of occlusion and catheter-related thromboses differ between long-term and short-term CVCs, we focus on long-term catheters only. For the purposes of this Review, long-term CVCs include subcutaneously tunnelled catheters or implanted ports, but do not include those placed in the intensive care or perioperative setting, haemodialysis catheters, and catheters intended for short-term use. The Kids with Catheter-Associated Thrombosis (KIDCAT) study recently investigated thrombosis of short-term CVCs.1

CVC occlusion occurs in 14–36% of patients within 1–2 years of catheter placement.2, 3, 4, 5, 6, 7, 8 A CVC occlusion can be partial, in that blood cannot be aspirated but infusion through the catheter is possible, or complete, with neither aspiration nor infusion possible. A CVC occlusion can arise from mechanical obstruction, precipitation of drugs or parenteral nutrition preparations, or from thrombotic obstruction. Catheter-related thrombosis occurs in up to 50% of children and 66% of adults with a long-term CVC, and can cause long-term vascular complications.9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 In a survey of health-care workers from Children's Cancer Study Group centres in the UK, CVC occlusion and catheter-related thrombosis were judged clinically important by 80% and 70% of the respondents, respectively. However, the investigators reported substantial variation in the diagnosis, management, and prevention of CVC occlusions and associated thrombotic complications.22

Section snippets

Causes of central venous catheter occlusion

Accurate diagnosis of the cause of catheter occlusion is essential to effectively treat the problem. Table 1 lists causes and recommendations for management of catheter occlusions. An obstruction can occur secondary to various mechanical problems, including an uncommon, but potentially life-threatening, pinch-off syndrome (figure 1, table 1).26, 27, 28 Drugs or parenteral nutrition preparations can also obstruct flow through the catheter; obstruction can be acute or gradual. Inappropriate

Catheter-related thromboses

Patients with long-term CVCs are prone to catheter-related thrombosis because of the direct effects of the catheter on adjacent veins and blood flow, the underlying disease and its treatment, the nature of substances being infused, and the location and time of placement of the catheter.80 Catheter-related thromboses most often occur in the upper extremity where most long-term catheters are located.81 Symptoms include pain, tenderness to palpation, swelling, oedema, warmth, erythema, and

Conclusion

The underlying cause of a catheter occlusion determines its appropriate treatment, but most occlusions are thrombotic and should be treated with thrombolytic agents. Alteplase is widely used in North America but new agents have shown promising improvements in efficacy and onset of action. Further studies are needed to compare new thrombolytic agents with those currently available.

Thrombotic CVC occlusions can cause catheter-related thromboses, which can lead to post-thrombotic syndrome,

Search strategy and selection criteria

We searched Medline and PubMed for articles published in the English language from 1965 to January, 2009, with the keywords “central venous catheter”, “central venous access device”, and “central venous line” associated with “occlusion”, “obstruction”, and “catheter-related thrombosis”. We only included articles that assessed long-term CVCs. In some instances, review articles were selected over original articles because of space constraints.

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