title: International clinical practice guidelines for the treatment and prophylaxis of thrombosis associated with central venous catheters in patients with cancer.
abstract: BACKGROUND
  Although long-term indwelling central venous catheters (CVCs) may lead to pulmonary embolism (PE) and loss of the CVC, there is lack of consensus on management of CVC-related thrombosis (CRT) in cancer patients and heterogeneity in clinical practices worldwide.
  
  
  OBJECTIVE
  To establish common international Good Clinical Practices Guidelines (GCPG) for the management of CRT in cancer patients.
  
  
  METHODS
  An international working group of experts was set up to develop GCPG according to an evidence-based medicine approach, using the GRADE system.
  
  
  RESULTS
  For the treatment of established CRT in cancer patients, we found no prospective randomized studies, two non-randomized prospective studies and one retrospective study examining the efficacy and safety of low-molecular-weight heparin (LMWH) plus vitamin K antagonists (VKAs). One retrospective study evaluated the benefit of CVC removal and two small retrospective studies were on thrombolytic drugs. For the treatment of symptomatic CRT, anticoagulant treatment (AC) is recommended for a minimum of 3 months; in this setting, LMWHs are suggested. VKAs can also be used, in the absence of direct comparisons of these two types of anticoagulants in this setting [Guidance]. The CVC can be kept in place if it is functional, well-positioned and non-infected and there is good resolution under close surveillance; whether the CVC is kept or removed, no standard approach in terms of AC duration has been established [Guidance]. For the prophylaxis of CRT in cancer patients, we found six randomized studies investigating the efficacy and safety of VKA vs. placebo or no treatment, one on the efficacy and safety of unfractionnated heparin, six on the value of LMWH, one double-blind randomized and one non randomized study on thrombolytic drugs and six meta-analyses of AC and CVC thromboprophylaxis. Type of catheter (open-ended like the Hickman(®) catheter vs. closed-ended catheter with a valve like the Groshong(®) catheter), its position (above, below or at the junction of the superior vena cava and the right atrium) and method of placement may influence the onset of CRT on the basis of six retrospective trials, four prospective non-randomized trials, three randomized trials and one meta-analysis. In light of these data: use of AC for routine prophylaxis of CRT is not recommended [1A]; a CVC should be inserted on the right side, in the jugular vein, and distal extremity of the CVC should be located at the junction of the superior vena cava and the right atrium [1A].
  
  
  CONCLUSIONS
  Dissemination and implementation of these international GCPG for the prevention and treatment of CRT in cancer patients at each national level is a major public health priority, needing worldwide collaboration.
authors.affiliation: D R S M Centre médical, Marseille, France.
authors.forename: P
authors.initials: P
authors.lastname: Debourdeau
authors.forename: D
authors.initials: D
authors.lastname: Farge
authors.forename: M
authors.initials: M
authors.lastname: Beckers
authors.forename: C
authors.initials: C
authors.lastname: Baglin
authors.forename: R M
authors.initials: RM
authors.lastname: Bauersachs
authors.forename: B
authors.initials: B
authors.lastname: Brenner
authors.forename: D
authors.initials: D
authors.lastname: Brilhante
authors.forename: A
authors.initials: A
authors.lastname: Falanga
authors.forename: G T
authors.initials: GT
authors.lastname: Gerotzafias
authors.forename: N
authors.initials: N
authors.lastname: Haim
authors.forename: A K
authors.initials: AK
authors.lastname: Kakkar
authors.forename: A A
authors.initials: AA
authors.lastname: Khorana
authors.forename: R
authors.initials: R
authors.lastname: Lecumberri
authors.forename: M
authors.initials: M
authors.lastname: Mandala
authors.forename: M
authors.initials: M
authors.lastname: Marty
authors.forename: M
authors.initials: M
authors.lastname: Monreal
authors.forename: S A
authors.initials: SA
authors.lastname: Mousa
authors.forename: S
authors.initials: S
authors.lastname: Noble
authors.forename: I
authors.initials: I
authors.lastname: Pabinger
authors.forename: P
authors.initials: P
authors.lastname: Prandoni
authors.forename: M H
authors.initials: MH
authors.lastname: Prins
authors.forename: M H
authors.initials: MH
authors.lastname: Qari
authors.forename: M B
authors.initials: MB
authors.lastname: Streiff
authors.forename: K
authors.initials: K
authors.lastname: Syrigos
authors.forename: H R
authors.initials: HR
authors.lastname: Büller
authors.forename: H
authors.initials: H
authors.lastname: Bounameaux
mesh_terms: D000970:Antineoplastic Agents / Q000008:administration & dosage*; D019985:Benchmarking; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000295:instrumentation; D062905:Central Venous Catheters / Q000009:adverse effects*; D032921:Consensus; D003299:Cooperative Behavior; D020878:Device Removal; D004867:Equipment Design; D019317:Evidence-Based Medicine; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D007391:International Cooperation; D009369:Neoplasms / Q000188:drug therapy*; D018579:Patient Selection; D018570:Risk Assessment; D012307:Risk Factors; D015912:Thrombolytic Therapy; D013997:Time Factors; D016896:Treatment Outcome; D056824:Upper Extremity Deep Vein Thrombosis / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000970:Antineoplastic Agents; D005343:Fibrinolytic Agents