What is the treatment for Astro-CVT (Central Venous Thrombosis)?

Treatment of Central Venous Catheter-Related Thrombosis (CVC-RT)

Anticoagulation is the primary treatment for central venous catheter-related thrombosis, and the catheter should be maintained unless it is non-functional, infected, or no longer needed. 1

Initial Anticoagulation Therapy

Start with low-molecular-weight heparin (LMWH) as first-line therapy:

• Enoxaparin 1 mg/kg subcutaneously every 12 hours OR 1.5 mg/kg once daily 1, 2
• Dalteparin 200 IU/kg once daily subcutaneously 1
• Continue LMWH for a minimum of 5 days 1

Alternative: Unfractionated heparin (UFH) intravenously if LMWH is contraindicated or in severe renal failure (creatinine clearance <25-30 mL/min):

• Initial bolus of 5000 IU followed by continuous infusion of approximately 30,000 IU over 24 hours 1
• Adjust to maintain aPTT at 1.5-2.5 times baseline 1

Transition to Long-Term Anticoagulation

For patients WITHOUT cancer or malabsorption:

• Initiate vitamin K antagonist (warfarin) within 24 hours of starting heparin 1
• Target INR 2.0-3.0 1
• Continue full-dose heparin until INR ≥2.0 for at least 2 consecutive days (minimum 5 days total) 1

For patients WITH cancer or poor oral absorption:

• Continue LMWH as monotherapy (preferred over warfarin) 1
• Continue anticoagulation as long as cancer treatment is ongoing 1

Duration of Anticoagulation

Standard duration: 3-6 months 1

Factors that may warrant longer duration or indefinite anticoagulation:

• Persistent risk factors 1
• Extensive thrombus characteristics 1
• Active malignancy (continue throughout cancer treatment) 1
• Recurrent thrombosis 1

Catheter Management

Maintain the catheter if:

• It remains functional 1, 3
• Central venous access is still required 1
• No infection is present 1
• Patient responds clinically to anticoagulation 1

Remove the catheter if:

• No longer needed for therapy 1
• Catheter is infected or occluded 1
• Contraindication to anticoagulation exists 1
• Persistent symptoms despite adequate anticoagulation 1
• Catheter is non-functional 3

Thrombolytic Therapy

Thrombolytics are NOT routinely recommended for upper extremity CVC-related thrombosis 1

Consider thrombolysis ONLY in:

• Massive thrombosis with severe symptoms and signs 1
• Low bleeding risk 1
• Recent thrombus (less than 10 days old) 1

Advanced Interventions (Rarely Needed)

Consider only if anticoagulation fails or is contraindicated:

• Superior vena cava filter placement (if contraindication to anticoagulation, thrombus progression despite treatment, or symptomatic pulmonary embolism despite anticoagulation) 1
• Catheter mechanical interventions (aspiration, fragmentation, thrombectomy, balloon angioplasty, stenting) 1
• Surgical procedures (thrombectomy, venoplasty, venous bypass) 1

Common Pitfalls and Caveats

Do NOT routinely remove the catheter - Studies show that either anticoagulation alone or catheter removal (or both) results in similar excellent outcomes, with no pulmonary embolism, limb compromise, or death in most series 1, 3

Do NOT withhold anticoagulation due to concern about bleeding - The evidence supports anticoagulation as safe and effective, with major bleeding rates of approximately 10% in prospective studies 1

In cancer patients, prefer LMWH over warfarin due to drug interactions, malnutrition, and liver dysfunction that complicate warfarin management 1

Monitor for resolution of symptoms - Only 4% of patients fail to respond to treatment, and these typically require catheter removal 3