Catheter-related central venous thrombosis: The development of a nationwide consensus paper in Italy

Catheter-related central venous thrombosis is a serious complication in patients who need long-term venous access. Though scientific data and clinical experience are steadily increasing, many uncertainties still exist about several aspects of this complication, including etiology, pathogenesis, diagnosis, management, and prevention of this complication. The GAVeCeLT (the Italian Study Group for Long Term Central Venous Access) promoted a nationwide consensus, and 12 experts reviewed systematically all the available literature. A preliminary document was presented and discussed during a specific Consensus Meeting, in front of a panel of more than 80 experts (representing different health professions and disciplines). This led to a prefinal document, which was presented to more than 800 health professionals. After peer review by an external board of experts, the final document was prepared. In this article, methodology and results of the consensus are presented. Venous thromboembolism (VTE) is a frequent complication of long-term access using central venous catheters, with the highest frequency in hemato-oncology diseases, and is one of the leading causes of death in oncology patients.[1] Cohort studies of surgical patients have shown that the incidence of VTE is markedly higher in patients with cancer than in patients without cancer.[2] Postmortem studies have also demonstrated a higher incidence of VTE in patients with cancer.[3] The association between cancer and VTE arises both as a direct consequence of tumor growth and host inflammatory responses and indirectly as a consequence of cancer treatment, venous stasis, and direct vessel trauma.[4] It is well known that the risk for developing VTE in cancer patients is significantly increased during chemotherapy and as a result of long-term central venous catheter (CVC) placement. Many cancer patients require long-term central venous access for the safe deliverance of chemotherapeutic agents, nutrients and fluids, and transfusion of blood and blood products, as well as for the withdrawal of blood samples from the central circulation. Long-term CVCs may remain in position for months or years, and their role in facilitating patient care is clear. Nevertheless, they are associated with a number of early and late complications, including catheter-related deep vein thrombosis (CVC-related DVT), which represents the second cause for catheter loss, after infection.[5] Though scientific evidences and clinical experience are steadily increasing, many uncertainties still exist about several aspects concerning etiology, pathogenesis, diagnosis, management, and prevention of this common complication of central venous long-term access. The incidence of this complication has been investigated in several studies, but major differences and inconsistencies in study design, patient populations, techniques of catheter insertion, and accuracy of tests used to diagnose thrombosis have hampered an accurate estimation. In a recently performed systematic review,[6] the incidence of symptomatic CVC-related DVT in adult varied between 0.3% and 28.3%, whereas the incidence of venography-assessed cases (mostly asymptomatic) ranged from 27% to 66%. Pulmonary embolism has been reported to occur in 15% to 25% of patient with CVC-related DVT. Although the thrombosis rate is high, only a third of the thrombosed CVCs become symptomatic. Nonetheless, CVC thrombosis can result in clinical symptoms, the loss of catheter function, a higher rate of infection, postphlebitic syndrome of the upper extremity, pulmonary embolus, and greater costs. Considering the lack of official and widely accepted guidelines on this subject, the Italian Study Group for Long Term Central Venous Access (GAVeCeLT) decided to develop a nationwide Consensus. Adopted methodology and results of this work are the subject of this article.