From the Guidelines
Management of subclavian deep vein thrombosis (DVT) in dialysis patients with port catheters should prioritize anticoagulation without catheter removal as the initial treatment, provided the catheter is necessary, functional, and free of infection, as recommended by the NCCN guidelines 1. The approach to managing subclavian DVT in dialysis patients with port catheters involves a careful balance between treating the thrombosis and preserving vascular access. Key considerations include:
- Therapeutic anticoagulation with low molecular weight heparin (LMWH) or unfractionated heparin, adjusted for renal function, as the initial treatment 1.
- Transitioning to warfarin with a target INR of 2-3 for at least 3 months, or potentially longer if the port remains in place, while avoiding direct oral anticoagulants (DOACs) due to altered pharmacokinetics in dialysis patients 1.
- Considering catheter-directed thrombolysis with tissue plasminogen activator (tPA) for extensive thrombosis causing severe symptoms or compromising the extremity, based on guidelines for catheter-related DVT management 1.
- Regular monitoring of the thrombosis with ultrasound at 1 week and 1 month after diagnosis, and coordinating anticoagulation management during dialysis sessions to minimize bleeding complications 1. This approach is supported by the most recent guidelines from the National Comprehensive Cancer Network (NCCN) 1, which emphasize the importance of anticoagulation in the management of catheter-related DVT, while also considering the unique needs and risks of dialysis patients.
From the Research
Management of Subclavian DVT in Patients with Port Catheter on Dialysis
- The management of subclavian deep vein thrombosis (DVT) in patients with a port catheter on dialysis involves several considerations, including the risk of thrombosis, diagnosis, and treatment options 2.
- Catheter-related thrombosis is a known complication of central venous catheters, and the risk may be increased by factors such as primary thrombophilic disorders, thrombogenic catheter material, and catheter tip malposition 2.
- Duplex ultrasound can be used to detect catheter-related thrombi involving the jugular, axillary, distal subclavian, and arm veins, while contrast venographic imaging is required for indeterminate duplex findings and to evaluate the deep central veins and pulmonary arteries 2.
- Therapeutic anticoagulation, with or without catheter removal, is indicated for patients with acute DVT or pulmonary embolism who have no contraindications 2.
- The use of subclavian vein access for dialysis is associated with a low rate of complications, including thrombosis and stenosis, and may be a safe alternative to internal jugular vein access 3.
- Subclavian vein effort thrombosis, also known as Paget-Schroetter syndrome, is a distinct entity that requires unique diagnostic and treatment considerations, including early catheter-directed therapy and prompt surgical thoracic outlet decompression 4.
Diagnosis and Treatment
- Diagnosis of subclavian DVT can be made using duplex ultrasound and contrast venographic imaging 2.
- Treatment options for subclavian DVT include therapeutic anticoagulation, catheter removal, and thrombolytic therapy 2, 4.
- The management of subclavian DVT in patients with a port catheter on dialysis should be individualized based on the patient's underlying condition, the presence of contraindications to anticoagulation, and the risk of thrombosis 2, 3.
Note: The study 5 is not relevant to the management of subclavian DVT in patients with a port catheter on dialysis.