Peripherally inserted central catheters (PICC) are associated with both upper- and lower-extremity deep vein thrombosis (DVT), indicate findings published in The American Journal of Medicine.

Although PICCs are both increasingly accessible and convenient for medical providers, clinicians should carefully consider potential complication, according to study researchers M. Todd Greene, PhD, MPH, of the University of Michigan School of Medicine in Ann Arbor, and colleagues.

Physiologically, they said the association between PICC use and DVT and pulmonary embolism (PE) was unsurprising – PICCs often satisfy all conditions of Virchow’s triad, creating the perfect setting for thrombosis. Previous studies have shown an association between PICCs and upper extremity DVT, but incidence of DVTs in the lower extremities and incidence of PE were poorly understood.


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So Greene and colleagues conducted a multicenter retrospective cohort study across 48 Michigan hospitals between January 2011 and March 2014, analyzing the relationship between PICC placement and the 90-day hazard of upper- and lower-extremity DVT or PE in 76 242 hospitalized patients.

They collected detailed data on all patients, including demographics, medical history, comorbidities, physical examination findings, and laboratory and medication data. Additionally, any clinical parameters (eg, leg swelling) were recorded, as well as any hospital admittance within 1 year prior to the patient entering the study. For the purposes of the study, only catheters that terminated at or near the cavoatrial junction were categorized as PICCs.

Primary outcomes included symptomatic, image-confirmed proximal upper-extremity DVT, proximal lower-extremity DVT, and PE.

On average, participants were aged 66.7 years old. A total of 7.4% patients had a history of cancer within the year preceding the index hospitalization, and 8.1% of patients had a history of venous thromboembolism. Patients with PICCs were more likely to have had prior inpatient stays, cancer diagnoses within the last year, prior venous thromboembolism, immobility, leg swelling during hospitalization, surgery within 30 days, diabetes, inflammatory bowel disease, sepsis, and pneumonia, compared to those who did not receive PICCs. 

The study recorded a total of 876 venous thromboembolism events occurring in 774 unique patients. Of those events, 208 were upper-extremity DVTs, 372 were lower-extremity DVTs, and 296 were PEs. Post-risk adjustment, PICCs were independently associated with upper-extremity DVT (hazard ratio [HR] 3.16; 95% CI: 2.59-3.85) and were modestly associated with lower-extremity deep vein thrombosis (HR 1.48; 95% CI: 1.02-2.15). The procedure was not associated with pulmonary embolism (HR 1.34; 95% CI, 0.86-2.06)

Among all eligible patients, 1.91% were transferred to the ICU for reasons outside of venous thromboembolism, or were otherwise transitioned to palliative care. Overall, 6.2% of patients died between initial hospitalization and the 90-day mark.

“These findings suggest that the thrombotic burden associated with peripherally inserted central catheters may not be restricted to the extremity where the device resides,” the researchers wrote.

They suggested a treatment model that incorporates risks, benefits, and alternatives to PICC use, a DVT risk assessment before PICC placement, and a lower threshold of testing for arm or leg thrombosis in patients with PICCs.

Reference

  1. Greene MT, Flanders SA, Woller SC, Bernstein SJ, et al. The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities.  Am J Med. 2015;128:986-993.