Should we treat thrombi caused by central venous catheter (central line) and cannula?

From the Guidelines

Thrombus caused by cannula and central lines should be treated with anticoagulation therapy, prioritizing low molecular weight heparin (LMWH) for a minimum of 3 months, as recommended by the most recent guidelines. The treatment approach involves administering LMWH, such as enoxaparin, with the goal of preventing further thrombosis and reducing the risk of bleeding complications 1.

Key Considerations

• The central venous catheter can be kept in place if it is functional, well positioned, and not infected, with close surveillance while anticoagulation therapy is administered 1.
• Anticoagulant treatment should be continued for as long as the central venous catheter is in place, with a minimum duration of 3 months 1.
• Direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) can be considered as alternatives to LMWH, although direct comparisons between these options have not been made 1.

Treatment Duration and Catheter Removal

• Treatment duration typically ranges from 3-6 months, depending on whether the catheter is removed or remains in place 1.
• If the catheter can be safely removed, this should be done, but only after at least 3-5 days of anticoagulation to reduce the risk of embolization during removal 1.

Complications and Risks

• Catheter-related thrombi can lead to serious complications, including pulmonary embolism, loss of venous access, post-thrombotic syndrome, and systemic infection if the thrombus becomes colonized with bacteria.
• Appropriate antibiotics are essential alongside anticoagulation for infected thrombi.

Evidence-Based Recommendation

The most recent guidelines, published in 2022, provide a comprehensive approach to the treatment and prophylaxis of venous thromboembolism in patients with cancer, including those with COVID-19 1. These guidelines prioritize LMWH as the preferred treatment option for catheter-related thrombosis, emphasizing the importance of anticoagulant therapy in preventing further thrombosis and reducing the risk of bleeding complications.

From the FDA Drug Label

Also excluded were patients considered at high risk for bleeding or embolization Trial 1 tested the efficacy of a 2 mg/2 mL Alteplase dose in restoring function to occluded catheters in 150 patients with catheter occlusion up to 24 hours in duration. A total of 112 (88%) of 127 Alteplase‑treated patients had restored function after up to two doses Across Trials 1 and 2,796 (68%) of 1043 patients with occlusions present for less than 14 days had restored function after one dose, and 902 (88%) had function restored after up to two doses

Treatment of thrombus caused by cannula and central line with alteplase (IV) is supported by the drug label. The studies show that alteplase can restore function to occluded catheters, with a significant proportion of patients achieving restored function after one or two doses.

• The rate of catheter function restoration was 88% after up to two doses in Trial 1.
• Across Trials 1 and 2, 88% of patients had function restored after up to two doses. 2

From the Research

Treatment of Thrombus Caused by Cannula and Central Line

• The treatment of catheter-related thrombosis is not standardized and international guidelines are based on extrapolation of evidence from lower extremity thrombosis 3.
• Therapeutic anticoagulation, with or without catheter removal, is indicated for patients with acute deep vein thrombosis (DVT) or pulmonary embolism who have no contraindications 4.
• Anticoagulation remains the cornerstone of therapy, with direct oral anticoagulants increasingly favored due to their safety profile and efficacy 5.
• Catheter removal alone, with close follow-up, may be sufficient when bleeding risk precludes safe anticoagulation 4.

Diagnosis of Thrombus Caused by Cannula and Central Line

• Duplex ultrasound can accurately detect CVC-related thrombi involving the jugular, axillary, distal subclavian, and arm veins 4.
• Contrast venographic imaging is required for indeterminate duplex findings and to evaluate the deep central veins and pulmonary arteries 4.
• Ultrasonography is the primary diagnostic method, but computed tomography angiography and magnetic resonance imaging play a complementary role, particularly in anatomically challenging cases or when complications such as pulmonary embolism or superior vena cava syndrome are suspected 5.

Risk Factors for Thrombus Caused by Cannula and Central Line

• Risk factors for catheter-related thrombosis are multifactorial, encompassing patient-related characteristics such as cancer, prior venous thromboembolism, and infection, as well as catheter-specific factors like device type, lumens, and insertion site 5.
• Thrombotic risk may be increased by primary thrombophilic disorders, especially the factor V G1691A (Leiden) mutation, thrombogenic catheter material, larger catheter diameter and greater number of lumens, catheter tip malposition, left-sided placement, percutaneous or multiple insertion attempts, a previous CVC or preexisting venous obstruction, prothrombotic therapeutic agents, catheter-associated infections, and fibrinous catheter lumen occlusion 4.

Management of Thrombus Caused by Cannula and Central Line

• Treatment strategies for catheter-related thrombosis include anticoagulation, catheter removal when feasible, and, in select cases, local thrombolysis or catheter-directed interventions 5.
• A practical approach to managing catheter-related thrombosis involves recognizing, diagnosing, and treating the condition, taking into account the risk factors and individual patient characteristics 6.
• Anticoagulation therapy using low molecular-weight heparin during catheter-directed thrombolysis for deep venous thrombosis is likely to be feasible and safe 7.