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.