Chokri Ben Lamine: CVC-Associated UE-DVT and Catheter Removal

Chokri Ben Lamine, Assistant Consultant at King Faisal Specialist Hospital and Research Center, shared a post on X:

”50 pearls | CVC-associated UE-DVT and catheter removal

Credits for sharing: Dr Ruaa Alyamani – KFSHRC

Study:

1. UE-DVT is a common CVC complication in hematologic malignancy

2. Incidence with PICC around 6–7 percent in cancer patients

3. Standard care is anticoagulation if feasible

4. Major dilemma is when to remove the CVC

5. Concern: catheter removal may lead to embolization and PE

6. Evidence before this study was weak and based mainly on expert opinion

7. ISTH suggests 3–5 days of anticoagulation before removal, but evidence level is low

8. Large multicenter cohort including 626 patients with hematologic malignancy

9. 480 patients received anticoagulation

10. 255 underwent early removal within 48 hours

11. 225 had delayed or no removal

12. PE within 7 days:

• Early removal — 0.78 percent
• Delayed or no removal — 0.44 percent
• No statistical difference observed

13. PE or death within 7 days:

• Early removal – 1.18 percent
• Delayed or no removal – 1.33 percent
• Outcomes were equivalent

14. Key clinical takeaway:

Early removal within 48 hours appears safe under anticoagulation

15. No signal that early removal increased PE risk

16. No justification to delay removal solely because of PE concern

17.Findings support practical bedside decision-making

18. Removal-only group without anticoagulation:

19. Zero PE events observed, However, deaths occurred in 2.6 percent

This is not considered a safe overall strategy

20. Important nuance:

• The study evaluated only short-term outcomes over 7 days
• Long-term recurrence was not assessed

21. Prior data suggest removal-only strategies increase recurrence and mortality, Anticoagulation remains the standard approach

22. Thrombocytopenia is a major limitation to anticoagulation in hematology patients

23. This often leads to real-world deviations such as removal only

24. Bleeding and thrombosis risks must be individualized

25. PICCs were the most common catheters associated with UE-DVT

26. Ports were less frequently associated

27. Leukemia and MDS patients carried a higher burden

28. Typical thrombus locations include:

• Subclavian vein
• Internal jugular vein
• Axillary vein

29. PE events mainly originated from proximal veins such as the brachiocephalic vein and SVC

28. Distal UE-DVT carries a lower PE risk

29. Historically, UE-DVT coexists with PE in approximately 9–36 percent of cases

30. Patients with PE at baseline were excluded from this study

31. Anticoagulation options included:

• LMWH, most commonly used in the study
• UFH in ICU or CRRT settings
• DOACs, increasingly used in practice

32. Benefits of anticoagulation extend beyond PE prevention:

• Reduced recurrence
• Reduced post-thrombotic syndrome

33. Risk of post-thrombotic syndrome after UE-DVT is approximately 15–25 percent

34. Chronic morbidity may occur if undertreated

35. Indications for urgent CVC removal include:

• Infection
• Dysfunction
• Catheter no longer needed

36. If the catheter is still required, it can remain in place with anticoagulation

37. Removal is not mandatory in all cases

38. Common clinical myth:

• ‘Early catheter removal causes PE’
• Current data do not support this assumption

39. Actual risk drivers include:

• Clot burden
• Proximal thrombus location
• Underlying hypercoagulability

40.Catheter manipulation alone is not the main driver

41. No routine imaging was performed for asymptomatic PE

• Possible underestimation or overestimation should be considered

42. Some PE events may have existed before catheter removal

• Important for interpretation of results

43. Platelet counts were lower in the no-anticoagulation group

• This reflects real-world practice patterns

44. Bedside decision framework:

• Can the patient tolerate anticoagulation?
• Is the catheter still needed?
• Is there infection present?

45. If anticoagulation is possible, early removal can be performed when needed

46. If anticoagulation is not possible, risk increases

47. Removal-only strategies should be avoided when feasible

48. Optimal management requires multidisciplinary collaboration:

• Hematology
• Vascular medicine
• Infectious disease when line infection is suspected

49. Bottom line:

Do not delay CVC removal solely because of fear of PE if the patient is appropriately anticoagulated.”

Other posts featuring Chokri Ben Lamine on Hemostasis Today.