Catheter-related thrombosis natural history in adult patients: a tale of controversies, misconceptions, and fears

Abstract

Catheter-related thrombosis natural history understanding might play a pivotal role in the way we approach to symptomatic and asymptomatic events. At the moment, little is known about catheter-related thrombosis natural history in adult patients, where the fear for embolic events and thrombus extension often leads to a precautionary behavior as for screening and management. In adult population, the knowledge of the natural history of symptomatic and asymptomatic catheter-related thromboses can only be indirectly inferred by studies designed for other purposes. From the available evidence on symptomatic patients, it can be assumed that the majority of catheter-related thromboses are early-onset events, where the endothelial damage during vein puncture might play a significant role in their development. Furthermore, symptomatic thrombotic events seem to have a low potential for major complications following treatment. On the contrary, catheter-related thrombosis natural history is more controversial in asymptomatic patients due to the lack of studies in this setting. At the moment, we can only make assumptions from studies in the pediatric population, where asymptomatic events appear to have a low potential for acute embolism and long-term sequelae when no treatment is established.

Reconsidering the GAVeCeLT Consensus on catheter-related thrombosis, 13 years later

“…On the contrary, the natural history of asymptomatic thrombosis is quite mysterious, so that a precautionary behavior still influences our approach toward this poorly understood phenomenon. 60,61 Also, some pharmacological aspects in the management of CRT are not yet well defined. 2,55 The actual length of treatment is not known.…”

“…On the contrary, the natural history of asymptomatic thrombosis is quite mysterious, so that a precautionary behavior still influences our approach toward this poorly understood phenomenon. 60,61…”

Assessment of the MAGIC recommendations in context of evolving evidence based on the use of PICC in ICU

“…Catheter-related thrombosis (CRT) is an early-onset complication that may result from many different causes (endothelial damage during vein puncture, malposition of the tip, excessive venous stasis, patient's thrombophilia, etc.). 25 Asymptomatic and symptomatic thrombosis have different impact, since asymptomatic events are often reported to have minimal clinical relevance. Pulmonary embolism (PE) rates resulting from asymptomatic CRT were reported to be negligible or often non-existent.…”

Should ultrasound evaluation for catheter-related thrombosis always be required before PICC removal?

“…As a matter of fact, despite several effective preventive strategies described in the recent literature 5,6 PICCs—as much as CICCs and FICCs—are inevitably associated with the potential development of catheter-related thrombosis (CRT). 7–10 This complication is a relatively early-onset event (usually within 2 weeks), and it may be symptomatic or—more often—asymptomatic. 9,11,12…”

“…On the other hand, when the PICC is notoriously associated with a diagnosed CRT, the current guidelines 10,14 on CRT usually recommend postponing removal (if there is no evidence of infection) and reconsidering it after some days of antithrombotic treatment at full dosage (usually, low molecular weight heparin, 100 units/kg/12 h). 15,16 However, there is controversy about the time delay required for a “safe” removal.…”