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Case

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A 62-year-old man with a ventriculoperitoneal shunt infection on parenteral antibiotics administered via a right upper extremity peripherally inserted central catheter (PICC) line is admitted with increasing swelling of the right upper extremity. The shunt was placed 7 weeks prior to admission following the onset of obstructive hydrocephalus after a craniotomy for a glioblastoma resection. The patient is placed in the neurologic intensive care unit (NeuroICU) because of mental status changes. A right upper extremity ultrasound documents a peri-catheter thrombosis in the brachial, axillary, and subclavian veins.

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What is the thrombosis risk associated with PICC lines?

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Background

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Seventy-five percent of upper extremity deep vein thrombosis is provoked by central venous catheters (CVCs) or PICCs.1 PICC line use for antibiotics, chemotherapy, total parenteral nutrition, and venous access has increased most likely because of the associated lower risk of insertion complications compared with CVCs. Serious mechanical complications are reported to occur in approximately 3% of patients undergoing CVC placement.2 Chopra et al evaluated 966 PICC line placements and showed 33 symptomatic PICC line deep vein thromboses (DVTs).3 Bivariate analysis revealed the following factors are associated with PICC line thrombosis: recent diagnosis of cancer (last 6 months), interventional radiology placement, chemotherapy administration, number of lumens, and PICC line gauges. On the other hand, multivariate analysis identified recent cancer diagnosis and PICC line gauge with hazard ratios of 2.21 and 3.56, respectively. Chopra et al found that a cancer diagnosis in the past six months and catheter gauge were the strongest predictors of PICC-associated DVT.3 In addition 5 Fr and 6 Fr PICCs showed an earlier time to DVT, suggesting an accelerated course with large devices.

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Management

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The use of PICC lines in NeuroICUs has demonstrated an 8.4% cumulative incidence of symptomatic PICC line–related thrombosis, of which 15% were associated with pulmonary embolism.4,5 With this background information, the treatment with full anticoagulation is appropriate in order to prevent pulmonary embolism and further propagation of the current thrombosis.

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Patients with 5 Fr and 6 Fr catheter devices are not only at greater risk, but also develop thrombosis earlier compared with those with 4 Fr devices.6,7 Dual lumen 4 Fr PICCs may offer the best option for venous access and therapies from a complication perspective.

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A significant increase in the use of single lumen and the smaller 5 Fr triple lumen PICCs was associated with a significant decrease in PICC-associated DVT. PICC-associated DVT also increases the cost of hospitalization.

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In patients with an upper extremity DVT that is associated with a central venous catheter that involves the axillary or more proximal veins and is functional, therapeutic anticoagulation with intravenous unfractionated heparin (IV UFH), low-molecular-weight heparin (LMWH), fondaparinux, or weight-based subcutaneous unfractionated heparin (SC UFH) should be initiated (Table 44-1).8 Anticoagulation therapy should ...

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