Upper Extremity DVT with subclavians/piccs

[VentdependenT]

I placed a subclavian in a patient with pylephlebitis, put the dude on hepatin and coumadin. All is well. A week later he complains of UE pain and swelling in ipsilateral arm (pt refused IJ). Got U/S and kablamo: clot running from basilic through subclavian.

We pulled the line slllooowwwwllllyyyy (he needed placement with long term iv abx so he eventually got an IJ tunnelled picc). we had to heparinize the guy for his portal/superior mesenteric vein clot.

How often do you guys see them?
How often do you you sweat pulling the line?
should you pull the line if its around a picc in a pt who needs long term IV access?
If theres a line and a clot and pt bacteremic do you have to pull it (source if bacteremia NOT line)
And finally, if no severe sequelae of clot (pain, gross swelling, ischemia) do you anticoagulate?

my final thought for this post: had a pt with picc, recovered pna, started having fevers, usual icu w/u neg for source. Attending said "i bet this guy had subclavian clot." bam! there it was.

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[Bostonredsox]

I placed a subclavian in a patient with pylephlebitis, put the dude on hepatin and coumadin. All is well. A week later he complains of UE pain and swelling in ipsilateral arm (pt refused IJ). Got U/S and kablamo: clot running from basilic through subclavian.

We pulled the line slllooowwwwllllyyyy (he needed placement with long term iv abx so he eventually got an IJ tunnelled picc). we had to heparinize the guy for his portal/superior mesenteric vein clot.

How often do you guys see them?
How often do you you sweat pulling the line?
should you pull the line if its around a picc in a pt who needs long term IV access?
If theres a line and a clot and pt bacteremic do you have to pull it (source if bacteremia NOT line)
And finally, if no severe sequelae of clot (pain, gross swelling, ischemia) do you anticoagulate?

my final thought for this post: had a pt with picc, recovered pna, started having fevers, usual icu w/u neg for source. Attending said "i bet this guy had subclavian clot." bam! there it was.

I have had one subclavian TLC clot. not nearly as many as the antecub PICC that come back in with DVTs. Not sure how common it happens, though the # of subclavian placement is decreasing so might have something to do with it.

I would sweat pulling the line I admit. a busted off emboli would really ruin my day.

Yes I would pull it with a clot around the picc and place another picc opposite side or a medi-port for convience if it is truly 'long-term' access.

Its hard to justify not pulling it in a bactermic pt. If the line didnt cause the infection, theres a good chance it could get seeded by whatever did cause it. ID at my shopt would say pull it and dont place another til repeat cultures are negative for 24 hours.

If its a true DEEP venous clot in the UE, then yes I would anticoagulate it the same as a popliteal. The risk of forming the UE is much lower, but once its formed the PE risk is the same.

 

[Hernandez]

It happens, not uncommonly. per ACCP guidelines

9.3.1. In most patients with UEDVT that is associated with a central venous catheter, we suggest that the catheter not be removed if it is functional and there is an ongoing need for the catheter (Grade 2C).

We just had a guy die when a vas cath was pulled and he threw a clot on the end, after a conference with our IR folks, they actually see a lot of incidental clots on lines they pull and don't think too much about it.

 

[Hernandez]

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Yes I would pull it with a clot around the picc and place another picc opposite side or a medi-port for convience if it is truly 'long-term' access.

That isn't guideline practice. Granted the guideline is a 2C rec

 

[Bostonredsox]

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That isn't guideline practice. Granted the guideline is a 2C rec

hmm. Strange to me. I wasnt aware the guidelines say to leave it in. I suppose if you are leaving it in and anticoagulating them to prevent clot extesnsion or PE, that makes physiologic sense. But if their 2c recommendation is to leave the catheter in if there is a need for long term access, and they are not doing anything about the clot, I see bad outcomes.

 

[Hernandez]

, and they are not doing anything about the clot, I see bad outcomes.

http://www.ncbi.nlm.nih.gov/m/pubmed/21549911/

Uhm there is lots of data that suggests the incidence of PR from UEDVT is vey very low. However, my link says nothing about treatment with anticoagulants. I'd suggest you read the ACCP guidelines

.

9.1.1. In patients with acute upper-extremity DVT (UEDVT) that involves the axillary or more proximal veins, we recommend acute treatment with parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) over no such acute treatment (Grade 1B).
9.1.2. In patients with acute UEDVT that involves the axillary or more proximal veins, we suggest LMWH or fondaparinux over IV UFH (Grade 2C) and over SC UFH (Grade 2B).
9.2.1. In patients with acute UEDVT that involves the axillary or more proximal veins, we suggest anticoagulant therapy alone over thrombolysis (Grade 2C).
Remarks: Patients who (i) are most likely to benefit from thrombolysis (see text); (ii) have access to CDT; (iii) attach a high value to prevention of PTS; and (iv) attach a lower value to the initial complexity, cost, and risk of bleeding with thrombolytic therapy are likely to choose thrombolytic therapy over anticoagulation alone.
9.2.2. In patients with UEDVT who undergo thrombolysis, we recommend the same intensity and duration of anticoagulant therapy as in similar patients who do not undergo thrombolysis (Grade 1B).
9.3.1. In most patients with UEDVT that is associated with a central venous catheter, we suggest that the catheter not be removed if it is functional and there is an ongoing need for the catheter (Grade 2C).
9.3.2. In patients with UEDVT that involves the axillary or more proximal veins, we suggest a minimum duration of anticoagulation of 3 months over a shorter period (Grade 2B).
Remarks: This recommendation also applies if the UEDVT was associated with a central venous catheter that was removed shortly after diagnosis.
9.3.3. In patients who have UEDVT that is associated with a central venous catheter that is removed, we recommend 3 months of anticoagulation over a longer duration of therapy in patients with no cancer (Grade 1B), and we suggest this in patients with cancer (Grade 2C).
9.3.4. In patients who have UEDVT that is associated with a central venous catheter that is not removed, we recommend that anticoagulation is continued as long as the central venous catheter remains over stopping after 3 months of treatment in patients with cancer (Grade 1C), and we suggest this in patients with no cancer (Grade 2C).
9.3.5. In patients who have UEDVT that is not associated with a central venous catheter or with cancer, we recommend 3 months of anticoagulation over a longer duration of therapy (Grade 1B).
9.4. In patients with acute symptomatic UEDVT, we suggest against the use of compression sleeves or venoactive medications (Grade 2C).

 

[PlutoBoy]

I've seen this happen a couple pf times. If the patient truly has a DVT, you should anticoagulate as usual. There is no rush to remove the catheter if you still need it.

If it is a superficial thrombosis, we just remove the catheter.

 

[Bostonredsox]

http://www.ncbi.nlm.nih.gov/m/pubmed/21549911/

Uhm there is lots of data that suggests the incidence of PR from UEDVT is vey very low. However, my link says nothing about treatment with anticoagulants. I'd suggest you read the ACCP guidelines

.

Thanks for posting the guidelines, saved me some time. But if I am reading them right, nearly every single bullet point IS recommending anticoagulation. They are saying leave the catheter in, ok, but they are also saying to anticoagulate (ranging from 1B to 2C), which is what I said makes sense to me to avoid a PE. It seems most of their recommendations are for 3 months.

9.3.3. In patients who have UEDVT that is associated with a central venous catheter that is removed, we recommend 3 months of anticoagulation over a longer duration of therapy in patients with no cancer (Grade 1B), and we suggest this in patients with cancer (Grade 2C).
9.3.4. In patients who have UEDVT that is associated with a central venous catheter that is not removed, we recommend that anticoagulation is continued as long as the central venous catheter remains over stopping after 3 months of treatment in patients with cancer (Grade 1C), and we suggest this in patients with no cancer (Grade 2C).

 

[Hernandez]

Thanks for posting the guidelines, saved me some time. But if I am reading them right, nearly every single bullet point IS recommending anticoagulation. They are saying leave the catheter in, ok, but they are also saying to anticoagulate (ranging from 1B to 2C), which is what I said makes sense to me to avoid a PE. It seems most of their recommendations are for 3 months.

9.3.3. In patients who have UEDVT that is associated with a central venous catheter that is removed, we recommend 3 months of anticoagulation over a longer duration of therapy in patients with no cancer (Grade 1B), and we suggest this in patients with cancer (Grade 2C).
9.3.4. In patients who have UEDVT that is associated with a central venous catheter that is not removed, we recommend that anticoagulation is continued as long as the central venous catheter remains over stopping after 3 months of treatment in patients with cancer (Grade 1C), and we suggest this in patients with no cancer (Grade 2C).

Correct. However, there is lots of data to suggest UEDVT don't embolize. So physiologically your thought process isn't necessarily correct. My thoughts for anticoag is to give it unless there is contra indication

 

[redy]

One slightly related thing I have thought about before is placing a picc line in a bacteremic patient. In our hospital it's a strict no no, and I believe ID had even reported the picc line guy for placing it in a bacteremic guy. How come it's that big a deal when we don't think twice before a ij or subclavian in a septic patient who may be bacteremic? Even if you can argue you don't know the bacteremia at the time, it's not like we will take it out once the cultures come positive.

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[Hernandez]

Sounds stupid to me. Unless they're arguing that central venous access isn't needed and peripherals will work.

 

[Bobblehead]

We had a semi-recent M&M of a fatal PE from removal of a PICC with a known attached thrombus without prior anticogulation. My feeling is to anticoagulate as suggested by the ACCP and leave the catheter in until it is no longer needed.