Peripherally inserted central catheter‐related deep vein thrombosis: contemporary patterns and predictors: comment

We read with great interest the recently published paper by Chopra et al. 1.Chopra V. Ratz D. Kuhn L. Lopus T. Lee A. Krein S. Peripherally inserted central catheter‐related deep vein thrombosis: contemporary patterns and predictors.J Thromb Haemost. 2014; 12: 847-54Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar on peripherally inserted central catheter (PICC)‐related deep vein thrombosis (DVT). As the authors point out, a recent diagnosis of cancer and PICC gauge are associated with PICC‐associated DVT. This conclusion is consistent with previous reports 2.Evans R.S. Sharp J.H. Linford L.H. Lloyd J.F. Tripp J.S. Jones J.P. Woller S.C. Stevens S.M. Elliott C.G. Weaver L.K. Risk of symptomatic DVT associated with peripherally inserted central catheters.Chest. 2010; 138: 803-10Abstract Full Text Full Text PDF PubMed Scopus (179) Google Scholar. However, several issues described in this article warrant further discussion. First, the type of cancer and metastasis can influence the risk of venous thromboembolism (VTE). Patients with hematologic malignancies have a high incidence of PICC‐associated DVT 3.Tran H. Arellano M. Chamsuddin A. Flowers C. Heffner L.T. Langston A. Lechowicz M.J. Tindol A. Waller E. Winton E.F. Khoury H.J. Deep venous thromboses in patients with hematological malignancies after peripherally inserted central venous catheters.Leuk Lymphoma. 2010; 51: 1473-7Crossref PubMed Scopus (69) Google Scholar. Lung cancer patients with advanced disease and/or receiving chemotherapy were at higher risk of VTE 4.Verso M. Gussoni G. Agnelli G. Prevention of venous thromboembolism in patients with advanced lung cancer receiving chemotherapy: a combined analysis of the PROTECHT and TOPIC‐2 studies.J Thromb Haemost. 2010; 8: 1649-51Crossref PubMed Scopus (55) Google Scholar. Patients with malignant processes involving the right lung, lymph nodes or other mediastinal structures may present with catheter thrombosis as a consequence of central vein compression and thrombosis. Metastasis is a risk factor for the development of VTE 5.Blom J.W. Doggen C.J. Osanto S. Rosendaal F.R. Old and new risk factors for upper extremity deep venous thrombosis.J Thromb Haemost. 2005; 3: 2471-8Crossref PubMed Scopus (114) Google Scholar, 6.Verso M. Agnelli G. Kamphuisen P.W. Ageno W. Bazzan M. Lazzaro A. Paoletti F. Paciaroni M. Mosca S. Bertoglio S. Risk factors for upper limb deep vein thrombosis associated with the use of central vein catheter in cancer patients.Intern Emerg Med. 2008; 3: 117-22Crossref PubMed Scopus (82) Google Scholar. A retrospective cohort study found that metastatic cancer increased the risk of developing PICC‐related DVT in chemotherapy patients 7.Aw A. Carrier M. Koczerginski J. McDiarmid S. Tay J. Incidence and predictive factors of symptomatic thrombosis related to peripherally inserted central catheters in chemotherapy patients.Thromb Res. 2012; 130: 323-6Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar. Second, it was reported that the presence of a PICC is a risk factor for VTE 8.Barbar S. Noventa F. Rossetto V. Ferrari A. Brandolin B. Perlati M. De Bon E. Tormene D. Pagnan A. Prandoni P. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction score.J Thromb Haemost. 2010; 8: 2450-7Crossref PubMed Scopus (698) Google Scholar, 9.Woller S.C. Stevens S.M. Jones J.P. Lloyd J.F. Evans R.S. Aston V.T. Elliott C.G. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients.Am J Med. 2011; 124: 947-54Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar. In these studies, the VTE was usually identified through ICD‐9 codes. The ICD‐9 codes for VTE may include not only lower‐extremity DVT (LEDVT), but also upper‐extremity DVT (UEDVT), superficial thrombophlebitis, and chronic DVT 10.Spyropoulos A.C. Anderson F.A. The ‘risk’ of risk assessment models for venous thromboembolism in medical patients.Am J Med. 2012; 125: e23-4Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar. It is well established that the pathophysiology of UEDVT is quite different from that of LEDVT 11.Spyropoulos A.C. Upper vs. lower extremity deep vein thrombosis: outcome definitions of venous thromboembolism for clinical predictor rules or risk factor analyses in hospitalized patients.J Thromb Haemost. 2009; 7: 1041-2Crossref PubMed Scopus (18) Google Scholar. Over 50% of patients with LEDVT had pulmonary embolism (PE) 12.Girard P. Decousus M. Laporte S. Buchmuller A. Hervé P. Lamer C. Parent F. Tardy B. PREPIC Study GroupDiagnosis of pulmonary embolism in patients with proximal deep vein thrombosis: specificity of symptoms and perfusion defects at baseline and during anticoagulant therapy.Am J Respir Crit Care Med. 2001; 164: 1033-7Crossref PubMed Scopus (62) Google Scholar, whereas the incidence of PE resulting from UEDVT was 1% 13.Lobo B.L. Vaidean G. Broyles J. Reaves A.B. Shorr R.I. Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters.J Hosp Med. 2009; 4: 417-22Crossref PubMed Scopus (96) Google Scholar. Furthermore, patients with asymptomatic DVT were not included in this retrospective study, and the incidence of this may be 14–18% 14.Lee A.Y. Kamphuisen P.W. Epidemiology and prevention of catheter‐related thrombosis in patients with cancer.J Thromb Haemost. 2012; 10: 1491-9Crossref PubMed Scopus (55) Google Scholar. The conclusion that PICC was associated with LEDVT was questionable because of these confounding factors. Third, a large number of prospective studies have found that increasing catheter size is significantly associated with an increased risk of UEDVT 15.Evans R.S. Sharp J.H. Linford L.H. Lloyd J.F. Woller S.C. Stevens S.M. Elliott C.G. Tripp J.S. Jones S.S. Weaver L.K. Reduction of peripherally inserted central catheter‐associated DVT.Chest. 2013; 143: 627-33Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar. There may be an interaction between lumens and the diameter of PICCs. Evans et al. 15.Evans R.S. Sharp J.H. Linford L.H. Lloyd J.F. Woller S.C. Stevens S.M. Elliott C.G. Tripp J.S. Jones S.S. Weaver L.K. Reduction of peripherally inserted central catheter‐associated DVT.Chest. 2013; 143: 627-33Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar found that the UEDVT incidence rates with the use of triple‐lumen 5 Fr PICCs and the use of double‐lumen 5 Fr PICCs were similar, and lower than the incidence rate with the use of triple‐lumen 6 Fr PICCs. POWER‐PICCs were usually 5 Fr and 6 Fr, which might increase the risk of UEDVT, although POWER‐PICCs did not confer a greater risk of thrombosis than non‐POWER devices. We assume that, if fewer 5 Fr and 6 Fr PICCs are used in the non‐POWER device group, the risk of VTE in this group might decrease. Fourth, in this study, 97.1% (n = 938) of the patients were male, and gender was not included in the logistic analysis. It was reported that male patients tend to develop catheter‐related VTE 16.Piran S. Ngo V. McDiarmid S. Le Gal G. Petrcich W. Carrier M. Incidence and risk factors of symptomatic venous thromboembolism related to implanted ports in cancer patients.Thromb Res. 2014; 133: 30-3Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar. Therefore, the demographics suggest a potential for bias, and could have an impact on the observed incidence. Additionally, several other risk factors that have been reported previously were not included in the logistic analysis, such as chronic obstructive pulmonary disease and diabetes mellitus 7.Aw A. Carrier M. Koczerginski J. McDiarmid S. Tay J. Incidence and predictive factors of symptomatic thrombosis related to peripherally inserted central catheters in chemotherapy patients.Thromb Res. 2012; 130: 323-6Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar. In conclusion, the conceptual model may not be suitable for cancer patients and patients with asymptomatic PICC‐related DVT. A further prospective study involving asymptomatic UEDVT is needed. J. Kang conceived the project, interpreted the data, and wrote the manuscript. H. Li wrote the manuscript. W. Chen conceived the project, wrote the manuscript, and gave final approval. The authors state that they have no conflict of interest.