Introduction:
Central venous catheters (CVCs) are the main cause of thrombosis in children, particularly hospitalized, critically ill children1. Current evidence suggests an increased incidence in venous thromboembolism (VTE) in the last decade, likely due to increased detection and advanced medical interventions leading to improved survival of previously fatal conditions1,2. The incidence of asymptomatic CVC-related VTE varies between studies (7-35%)3,4. Asymptomatic CVC-related VTE has been associated with other thrombotic risk factors (i.e., cancer, cardiac diseases, and critically ill children)1,5. The current literature suggests that the difference in thrombotic burden between asymptomatic and symptomatic VTE in children may influence the differences in complication rates and long-term outcomes (i.e., residual thrombus, recurrence, and post-thrombotic syndrome (PTS))6.
Thrombophilia testing on children with CVC related VTE in the absence of positive family history is not advised by Choosing Wisely®. The current evidence has not shown that thrombophilia testing either predicts recurrence of venous thrombosis or guides the duration of anticoagulant therapy7–10
Data regarding anticoagulation to prevent recurrent CVC-related VTE in children are scarce. The current guidelines are primarily based on expert opinion regarding the anticoagulation prophylaxis in children with a previously diagnosed CVC-related VTE in whom a new CVC placement is required11. Although anticoagulation is not protective against the first episode of CVC-related VTE in children12, it seems to have a role in preventing recurrent CVC-related VTE, as secondary prophylaxis13.
Although there is reasonable evidence that the use of anticoagulation is safe and effective in children, the implementation of this evidence into daily clinical practice is not straightforward14. The previous 2012 Chest guideline from The American College of Chest Physicians (ACCP) recommended treating provoked asymptomatic VTE for 12 weeks, even when the provoking risk factor is no longer present11. In contrast, the 2018 guideline from the American Hematology Society (ASH) for symptomatic CVC-related thrombosis suggests that anticoagulation likely to minimizes complications. More so, the same guideline gives an equivocal recommendation for pediatric patients with asymptomatic deep vein thrombosis (DVT)14.
This case-based survey was designed to assess the current local management strategies for pediatric patients with an asymptomatic CVC- related VTE with a focus on the use of thrombophilia testing, the management approach, the duration of anticoagulation, and the use of secondary prophylaxis. We hypothesize that there will be a significant variation in these four management areas, in large part due to a paucity of available data.