From the Guidelines
The primary recommendation for managing a patient with a Peripherally Inserted Central Catheter (PICC) line and Deep Vein Thrombosis (DVT) is to initiate therapeutic anticoagulation for at least 3 months while maintaining the PICC line in place if it remains functional and necessary for patient care. This approach is based on the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) study 1, which suggests that removal of a functional PICC in the presence of DVT is inappropriate when irritants or vesicant infusions remain necessary, or when the patient has poor peripheral venous access and requires frequent phlebotomy.
Key considerations in managing PICC-related DVT include:
- Initiating anticoagulation with low-molecular-weight heparin (LMWH) or unfractionated heparin, and transitioning to oral anticoagulation with direct oral anticoagulants (DOACs) or warfarin for at least 3 months 1
- Targeting an international normalized ratio (INR) of 2-3 when using warfarin, as lower or higher INR targets are rated as inappropriate 1
- Preferring the use of LMWH over warfarin in patients with cancer, and avoiding the use of target-specific oral anticoagulants over traditional agents among patients with cancer due to insufficient evidence 1
- Considering urgent referral to interventional radiology for catheter-directed treatment of PICC-related DVT when symptoms of venous occlusion are associated with phlegmasia cerulea dolens 1
It is essential to daily assess the PICC site for signs of infection, proper functioning, and continued necessity, and to remove the PICC line only if it is malfunctioning, infected, or no longer needed. The MAGIC study 1 also strongly urges against placement of a new PICC in patients who experienced PICC-related DVT within the past 30 days, due to the high risk for recurrent thrombosis.
From the Research
Management of PICC Line with DVT
- The management of a patient with a Peripherally Inserted Central Catheter (PICC) line and Deep Vein Thrombosis (DVT) involves several steps, including diagnosis, treatment, and prevention of further complications 2, 3, 4, 5, 6.
- Diagnosis of PICC-DVT can be made using ultrasonography, which has excellent sensitivity and specificity, and is recommended as the initial diagnostic test 2, 3.
- Contrast venography can be used in cases with high clinical probability and negative ultrasound findings, but it is not the first line of diagnosis 2.
- Treatment of PICC-DVT typically involves anticoagulation with low-molecular-weight heparin or warfarin for at least 3 months, and removal of the PICC line is not always necessary 2, 4, 6.
- In some cases, direct thrombolysis with urokinase can be used as a treatment option, which is a simple, safe, and effective procedure 6.
Risk Factors and Prevention
- The risk of developing PICC-DVT is associated with several factors, including male gender, recent surgery, sepsis, family history of clots, and malignancy 4, 5.
- Prophylaxis for DVT can be reserved for patients with previous DVT or known hypercoagulable state, but the role of pharmacologic prophylaxis and screening for PICC-DVT in the absence of clinical symptoms is unclear 2, 4.
- Decision to insert a PICC should be taken after careful risk stratification, and well-designed randomized controlled trials are required to estimate the prevalence of upper extremity venous thrombosis (UEVT) in ICU patients with PICCs and evaluate the efficacy and magnitude of clinical benefit and cost-effectiveness of therapeutic strategies 3.
Treatment Outcomes
- The treatment outcomes for PICC-DVT vary, but most patients can be treated with anticoagulation and removal of the PICC line, with a significant proportion of patients achieving clot resolution 4, 5.
- Pulmonary embolus attributed to PICC-DVT can occur in a small percentage of patients, and some patients may require additional treatments such as superior vena cava filter placement 5.