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Introduction: Heart transplant patients have risk factors that place them at higher risk for acute venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), than the general population. We assessed for rate of VTE and incidence of PE-related mortality among heart transplant patients., Materials and Methods: A total of 1258 heart transplant patients were evaluated for the development of VTE. The diagnosis of DVT was made by Duplex ultrasonography, and PE was diagnosed by computerized tomography pulmonary angiography or ventilation-perfusion radionuclide scan. PE-related mortality was assessed at one yr, three yr, and five yr post-transplant., Results: A total of 117 (9.3%) patients were diagnosed with DVT, including 65 of 117 (55.5%) with lower extremity DVT (LEDVT) and 52 of 117 (44.4%) with upper extremity DVT (UEDVT). A total of 24 (1.9%) patients experienced PE with seven (29.2%) resulting deaths. The rate of LEDVT and UEDVT was similar (55.5% vs. 44.4%); however, the incidence of PE was greater for those with LEDVT (23.1% vs. 7.7%; p = 0.04). Patients with PE had lower survival over the five-yr follow-up period compared to those with DVT only (67% vs. 81%; p = 0.51)., Conclusion: Heart transplant patients have a high incidence of VTE despite current best practice, indicating a need for a more aggressive approach to thromboprophylaxis., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: No studies have identified which patients with upper-extremity deep vein thrombosis (DVT) are at low risk for adverse events within the first week of therapy., Methods: We used data from Registro Informatizado de la Enfermedad TromboEmbólica to explore in patients with upper-extremity DVT a prognostic score that correctly identified patients with lower limb DVT at low risk for pulmonary embolism, major bleeding, or death within the first week., Results: As of December 2014, 1135 outpatients with upper-extremity DVT were recruited. Of these, 515 (45%) were treated at home. During the first week, three patients (0.26%) experienced pulmonary embolism, two (0.18%) had major bleeding, and four (0.35%) died. We assigned 1 point to patients with chronic heart failure, creatinine clearance levels 30-60 mL min(-1) , recent bleeding, abnormal platelet count, recent immobility, or cancer without metastases; 2 points to those with metastatic cancer; and 3 points to those with creatinine clearance levels < 30 mL min(-1) . Overall, 759 (67%) patients scored ≤ 1 point and were considered to be at low risk. The rate of the composite outcome within the first week was 0.26% (95% confidence interval [CI] 0.004-0.87) in patients at low risk and 1.86% (95% CI 0.81-3.68) in the remaining patients. C-statistics was 0.73 (95% CI 0.57-0.88). Net reclassification improvement was 22%, and integrated discrimination improvement was 0.0055., Conclusions: Using six easily available variables, we identified outpatients with upper-extremity DVT at low risk for adverse events within the first week. These data may help to safely treat more patients at home., (© 2015 International Society on Thrombosis and Haemostasis.)

Background: There are two upper-extremity deep venous thrombosis (UEDVT) cases after whole blood donation reported in the English medical literature. Three additional UEDVT cases after whole blood donation were reported to our blood center within a 13-month period., Study Design and Methods: A case study was done for each case in collaboration with a clinical physician. A description of the donation event, donor demographics, risk factors for thrombosis, treatment, and outcome were described., Results: A 33-year-old woman and two 17-year-old, first-time-donating men presented with arm pain, swelling, and bruising within hours to 3 days after donation. Two had distal UEDVTs in the basilic or brachial veins, and one had a proximal UEDVT in the subclavian and axillary veins extending into the basilic vein. One donor (woman) had known risk factors for DVT and the other two did not. Anticoagulant therapy was initiated on all patients and was continued for 3, 4, and 9 months. Two donors with the distal UEDVTs recovered completely while the donor with the proximal UEDVT was treated with anticoagulation for 9 months and continued to have a slight residual, nonobstructive thrombosis. The donor was switched to low-dose aspirin prevention. The two donors reported in the literature had complete resolution of thrombosis., Conclusions: Four of five donors recovered completely after anticoagulation treatment for UEDVT, including two of three donors in this study. A review of all cases in the medical literature, including 20 recent Australian cases described in an abstract, provides a more complete description of this adverse donation injury., (© 2015 AABB.)

We report the case of a 40-year-old right-handed man who developed a right subclavian vein thrombosis due to work as a TV cameraman. He presented with a sudden onset of marked swelling and blue discolouration of his right arm 3 weeks after the most strenuous and prolonged episode of TV camera work that he had ever undertaken. This involved carrying a 9kg camera on his shoulder, with his right arm flexed and abducted, for a 60min period with provocation of severe pain and marked discomfort persisting during the subsequent 3 weeks before presentation. A clinical diagnosis of upper extremity deep vein thrombosis (UEDVT) was made, with the diagnosis confirmed by ultrasound. He was treated with catheter-induced thrombolysis and a 3 month course of anticoagulation. He was advised that his UEDVT was caused by his occupation and that he should no longer work as a cameraman. This case shows the importance of identifying any occupational cause of UEDVT., (© The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Upper extremity deep vein thrombosis (UEDVT) represents less than 10 % of thromboembolic events, but has been associated with higher incidence of asymptomatic pulmonary embolism. Data regarding UEDVT and its treatment is limited. Our objective was to investigate UEDVT incidence, diagnosis, and treatment in our bariatric patient population. We conducted a retrospective review of patients undergoing laparoscopic bariatric surgery at our institution. Variables analyzed included patient demographics, body mass index (BMI), history of venous thromboembolic event (VTE), type of procedure, and other comorbidities. One thousand five hundred three patients were included in the study. Twenty patients developed VTE events, of which five suffered UEDVT. Although infrequent, awareness of UEDVT is necessary in order to initiate treatment in a timely fashion and to prevent major complications.

Background: Peripherally inserted central catheters (PICCs) are associated with upper extremity-deep vein thrombosis (DVT). However, patterns, risk factors and treatment associated with this event remain poorly defined., Objective: To determine patterns, risk factors and treatment related to PICC-DVT in hospitalized patients., Design, Setting & Patients: Between 2012-2013, consecutive cases of ultrasound-confirmed, symptomatic PICC-DVT were identified. For each case, at least two contemporaneous controls were identified and matched by age and gender. Patient- and device-specific data were obtained through electronic-medical records. Using variables selected a priori, multivariable logistic regression models were fit to the outcome of PICC-DVT, comparing cases to controls., Results: 909 adult hospitalized patients (268 cases, 641 controls) were included in the study. Indications for PICC placement included long-term intravenous antibiotic therapy (n=447; 49.1%), in-hospital venous access for blood draws or infusion of medications (n=342; 44.2%), and total parenteral nutrition (n=120; 6.7%). Patients with PICC-DVT were more likely to have a history of venous thromboembolism (OR 1.70, 95% CI=1.02-2.82) or have undergone surgery while the PICC was in situ (OR 2.17, 95%CI=1.17-4.01 for surgeries longer than two hours). Treatment for PICC-DVT varied and included heparin bridging, low molecular weight heparin only and device removal only; the average duration of treatment also varied across these groups. Compared to 4-Fr PICCs, 5- and 6-Fr PICCs were associated with greater risk of DVT (OR 2.74, 95%CI=0.75-10.09 and OR 7.40 95%CI=1.94-28.16, respectively). Patients who received both aspirin and statins were less likely to develop PICC-DVT than those that received neither treatment (OR 0.31, 95%CI=0.16-0.61). Receipt of pharmacological DVT prophylaxis during hospitalization showed a non-significant trend towards reduction in risk of PICC-DVT (OR=0.72, 95%CI=0.48-1.08)., Conclusion: Several factors appear associated with PICC-DVT. While some of these characteristics may be non-modifiable, future studies that target potentially modifiable variables to prevent this adverse outcome would be welcomed., (Published by Elsevier Ltd.)

This case report summarises the presentation of a 28-year-old female with signs and symptoms characteristic of thoracic outlet syndrome, but who was later found to have an effort-induced Upper Extremity Deep Vein Thrombosis (UEDVT), otherwise known as Paget-Schroetter syndrome. Effort-induced UEDVT is rare, but the similarity between the signs and symptoms of thoracic outlet syndrome and this type of thrombosis can result in patients with this condition presenting to musculoskeletal therapists. The key features of the case are described, followed by an overview of UEDVT and the importance of recognising this condition in musculoskeletal therapy practice. The role of therapists in referring for early medical diagnostics is key to ensuring management of the thrombosis is instigated early, therefore reducing the risk of life threatening consequences such as pulmonary embolism., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: Data on efficacy and safety of using low molecular weight heparin in cancer patients with catheter-related upper extremity deep vein thrombosis is scarce and the risk of recurrent venous thromboembolism after discontinuation of anticoagulation is unknown., Material and Methods: We conducted a retrospective cohort study including consecutive cancer outpatients assessed for the management of symptomatic central venous catheter-associated proximal upper extremity deep vein thrombosis., Results: Of 99 included patients, 89 were treated with one month of full therapeutic weight-adjusted dose of low molecular weight heparin followed by an intermediate dose. Median duration of anticoagulation was 124 days (range 40 to 1849). No recurrent venous thromboembolism and two major bleeding episodes occurred during the first 3 months of treatment. Eighty patients were followed-up after anticoagulation discontinuation for a median of 632 days (range 6 to 2495). Central venous line was pulled in all patients in remission and in 26 of the 29 patients (89.6%) with active cancer. Five recurrences were observed during follow-up. The cumulative probability of recurrent venous thromboembolism was higher in patients whose cancer was active at the time of anticoagulation discontinuation as compared with those in remission (22.2% (95% CI: 0 to 40.6) vs. 2.3% (95% CI: 0 to 6.7))., Conclusion: The risk of venous thromboembolism recurrence in patients whose central venous catheter has been pulled out and cancer is in remission appears low following anticoagulation discontinuation and after a minimum of 3 months of full/intermediate dose., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Purpose: To report a retrospective observational analysis of standard balloon angioplasty (BA) vs. paclitaxel-coated balloon angioplasty (PCBA) for symptomatic central vein restenoses in patients with impaired native hemodialysis fistulas., Methods: A retrospective review was conducted of 27 consecutive patients (15 men; mean age 66 ± 13.8 years, range 39-90) with 32 central vein stenoses (CVS; 6 axillary, 11 subclavian, 12 brachiocephalic, and/or 3 superior caval veins) treated successfully using BA. Freedom from reintervention after BA of de novo lesions was 7.4 ± 7.9 months (range 1-24). Twenty-five (92.6%) patients developed symptomatic restenoses and were treated one or more times by BA (n = 32) or PCBA (n = 20) using custom-made paclitaxel-coated balloons (diameter 6-14 mm)., Results: Technical (< 30% residual stenosis) and clinical (functional fistula) success rates for the initial and secondary angioplasty procedures were 100%. No minor/major procedure-associated complications occurred. Mean follow-up was 18.4 ± 17.5 months. Kaplan-Meier analysis for freedom from target lesion revascularization (TLR) found PCBA superior to BA (p = 0.029). Median freedom from TLR after BA was 5 months; after PCBA, > 50% of patients were event-free during the observation period (mean freedom from TLR 10 months). Restenosis intervals were prolonged by PCBA (median 9 months) vs. BA (median 4 months; p = 0.023)., Conclusion: Paclitaxel-coated balloon angioplasty of central vein restenosis in patients with hemodialysis shunts yields a statistically significant longer freedom from TLR compared to standard balloon angioplasty., (© The Author(s) 2015.)

Objective: Previous studies estimated the incidence of catheter-associated venous thrombosis to be between 2% and 81%. Our goals were to define the incidence rate of catheter-related thrombosis in a hospitalized, noncritically ill, pediatric population and to determine modifiable factors that alter the risk of thrombosis., Methods: A retrospective cohort study was performed at the North Carolina Children's Hospital from 2009 to 2012. Chart review was performed with extraction of patient characteristics and line-related variables. Presence of symptomatic catheter-associated venous thrombosis was the primary outcome. Bivariable analysis and multivariable logistic regression were used to explore associations between line-related variables and thrombosis., Results: A total of 1135 lines were placed in 815 patients for 118,023 catheter-days. Thirty-six were complicated by venous thrombosis (3.2%) yielding a rate of 0.3 events per 1000 catheter-days. In multivariable analysis, increasing age (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.03-1.13; P=.002), renal dialysis (OR 3.2, 95% CI 1.09-9.66; P=.035), and a diagnosis of inflammatory bowel disease or short bowel syndrome (OR 4.3, 95% CI 1.2-15.0; P=.02) were associated with increased risk of thrombosis. Modifiable risk factors, such as line site, size, and lumens, were not significantly associated with thrombosis. No thromboembolic events were observed., Conclusions: We observed a lower incidence rate of catheter-associated venous thrombosis than in most previous reports. No modifiable characteristics altered the risk of thrombosis. Additional investigation of measures to prevent thrombosis is warranted in higher-risk populations, such as patients undergoing dialysis or patients with inflammatory bowel disease., (Copyright © 2015 by the American Academy of Pediatrics.)

Although tunneled hemodialysis catheter must be considered the last option for vascular access, it is necessary in some circumstances in the dialysis patient. Thrombosis and infections are the main causes of catheter-related comorbidity. Fibrin sheath, intimately related with the biofilm, is the precipitating factor of this environment, determining catheter patency and patient morbidity. Its association with bacterial overgrowth and thrombosis has led to the search of multiple preventive measures. Among them is the development of catheter coatings to prevent thrombosis and infections. There are two kinds of treatments to cover the catheter surface: antithrombotic and antimicrobial coatings. In nondialysis-related settings, mainly in intensive care units, both have been shown to be efficient in the prevention of catheter-related infection. This includes heparin, silver, chlorhexidine, rifampicine and minocycline. In hemodialysis population, however, few studies on surface-treated catheters have been made and they do not provide evidence that shows complication reduction. The higher effectiveness of coatings in nontunneled catheters may depend on the short average life of these devices. Hemodialysis catheters need to be used over long periods of time and require clinical trials to show effectiveness of coatings over long periods. This also means greater knowledge of biofilm etiopathogeny and fibrin sheath development.

Background: The incidence of acute kidney injury (AKI) is estimated at 10 to 20% in patients admitted to intensive care units (ICU) and often requires renal replacement therapy (RRT). ICU mortality in AKI patients can exceed 50%. Venous catheters are the preferred vascular access method for AKI patients requiring RRT, but carry a risk of catheter thrombosis or infection. Catheter lock solutions are commonly used to prevent such complications. Heparin and citrate locks are both widely used for tunneled, long-term catheters, but few studies have compared citrate versus heparin for patients with short-term, non-tunneled catheters. We aim to compare citrate 4% catheter lock solution versus heparin in terms of event-free survival of the first non-tunneled hemodialysis catheter inserted in ICU patients with AKI requiring RRT. Secondary objectives are the rate of fibrinolysis, incidence of catheter thrombosis and catheter-related infection per 1,000 catheter days, length of stay in ICU and in-hospital and 28-day mortality., Methods/design: The VERROU-REA study is a randomized, prospective, multicenter, double-blind, parallel-group, controlled superiority study carried out in the medical, surgical and nephrological ICUs of two large university hospitals in eastern France. A catheter lock solution composed of trisodium citrate at 4% will be compared to unfractionated heparin at a concentration of 5,000 IU/mL. All consecutive adult patients with AKI requiring extracorporeal RRT, and in whom a first non-tunneled catheter is to be inserted by the jugular or femoral approach, will be eligible. Catheters inserted by the subclavian approach, patients with acute liver failure, thrombopenia or contraindication to systemic anticoagulation will be excluded. Patients will be followed up daily in accordance with standard practices for RRT until death or discharge., Discussion: Data is scarce regarding the use of non-tunneled catheters in the ICU setting in patients with AKI. This study will provide an evidence base for recommendations regarding the use of anticoagulant catheter locks for the prevention of dysfunction in non-tunneled hemodialysis catheters in patients with AKI in critical or intensive care., Trial Registration: Registered with Clinicaltrials.gov (registration number: NCT01962116) on 27 August 2013.

Background: Peripherally inserted central catheters (PICC) are being increasingly used in critical care setting. However, PICCs are associated with a number of complications, particularly upper extremity venous thrombosis (UEVT), leading to post-thrombotic syndrome, pulmonary embolism and increased risk of catheter-related infection., Objective: To review the literature surrounding PICCs and highlight the epidemiology, pathophysiology, diagnosis and management of PICC-related thrombosis in critically ill patients., Data Sources and Extraction: We performed an electronic literature search of the databases PubMed, EMBASE and Google scholar using set search terms, from their commencement date to the end of January 2014., Summary of Review: It has been shown that PICCs may double the risk of deep venous thrombosis compared with centrally inserted venous catheters, in critically ill patients. However, the incidence of PICC-related thrombosis in critically ill patients has not been quantified. Ultrasonography is the preferred diagnostic imaging modality. There are no randomized controlled trials (RCTs) on the best treatment of PICC-related thrombosis in the intensive care unit (ICU) setting and in most cohort studies, anticoagulation strategies with or without PICC removal have been used., Conclusions: Decision to insert a PICC should be taken after careful risk stratification. There is lack of high-quality evidence assessing prevention strategies and management of PICC-related thrombosis in the ICU. Well-designed RCTs are required to estimate the prevalence of UEVT in ICU patients with PICCs and evaluate the efficacy and magnitude of clinical benefit and cost-effectiveness of therapeutic strategies.

Upper extremity deep vein thrombosis (DVT) is a common finding after implantation of an automatic implantable cardiac defrillator (AICD). We describe the case of a patient who developed a left upper extremity DVT 4.5 months after implantation of an AICD and was found to have a lead-induced stenosis with possible underlying Paget-Schroetter syndrome (PSS) in the midbrachiocephalic vein on venography. While his symptoms resolved after the combination of pharmacomechanical thrombolysis, angioplasty, and anticoagulation, his long-term management is complicated by the presence of both PSS and lead-induced stenosis. Herein, we discuss his presentation, treatment, and future management options., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Patients and Methods: In this study, 13 patients (11 men and 2 women) undergoing hemodialysis (HD) with the use of a catheter placed into the inferior vena cava with percutaneous translumbar access were retrospectively evaluated. In the studied group, 16 procedures of percutaneous translumbar catheterization were performed. Complications connected with the presence of catheter, such as hematoma, thrombosis, infection, catheter movement or unsuccessful catheterization, were analyzed. Moreover, another aspect of our report was to evaluate the adequacy of HD treatment performed by lumbar catheter., Results: The total time of translumbar catheter observation was 4,169 days. Average time of their functioning was 261 days. The most frequent reason for termination of the use of translumbar HD catheters was spontaneous/idiopathic removal - 2 cases. Episodes of infection and thrombosis per 1,000 days of catheter observation were 2.2 and 1.2, respectively., Conclusions: Based on our study, we can conclude that correctly performed percutaneous translumbar catheterization of the inferior vena cava, in order to produce a long-term vascular access for HD, is a valuable and safe method in patients after depletion of standard vascular accesses.

Purpose: Fibrin deposition and thrombotic occlusion represent a serious cause of access dysfunction in hemodialysis central venous catheters (CVCs). The aim of this work was to define and apply a method for imaging and quantifying fibrin in thrombi formed into the side holes of CVCs., Methods: Forty-three CVCs removed from a cohort of dialyzed patients were analyzed in this pilot study. Hematoxylin and eosin and a modified Carstair's staining were applied on permanent thrombus sections. Fluorescence microscopy and image analysis were performed to quantify the fibrin amount., Results: Highly fluorescent areas were invariably associated with fibrin by Carstair's method. The deposition of concentric layers of fibrin and erythrocytes was easily identified by fluorescence microscopy, showing growth features of the thrombus. Fibrin amount in diabetic patients was significantly higher than that in nondiabetic patients with median (interquartile range) values of 51% (47-68%) and 44% (30-54%), respectively (p=0.032). No significant difference in fibrin content was found by grouping data according to catheter type, permanence time, insertion site and dialysis vintage. Higher variability in fibrin values was found in thrombi from CVCs removed after 1-15 days compared with 16-60 days. A trend of an increase in fibrin amount in thrombi was noted according to blood platelet count at CVC insertion., Conclusions: The analytical method presented here proved to be a rapid and effective way for quantifying fibrin content in thrombi formed on CVCs with potential application in future clinical studies.

Background: According to the 2011 Infusion Nursing Standards of Practice, the low pH of intravenous vancomycin requires that it be administered through a central line. However, a careful review of the literature and a retrospective analysis of the experience at New York Hospital Queens (NYHQ) did not support the position of the Standards., Purpose: A prospective, controlled, randomized clinical trial was conducted to determine if intravenous vancomycin could be safely administered through a novel midline catheter (POWERWAND®, Access Scientific, San Diego, CA)., Methods: Patients scheduled to receive short-term (<6 days) intravenous vancomycin were randomly assigned to receive treatment through either a peripherally inserted central catheter (PICC) or the midline study device. Complications and the costs of insertion were recorded., Results: The two groups did not differ significantly with respect to total complications (17.9% with PICCs vs. 19.9% with the midline), phlebitis (0% vs. 0%) or thrombosis (0% vs. 0%). One suspected catheter-associated bloodstream infection did occur in the PICC group. Insertion costs were $90.00 less per insertion in the midline group., Conclusions: Short-term intravenous vancomycin can be safely and cost-efficiently administered in the deep vessels of the upper arm using the midline study device.

Purpose: The aim of this systematic review was to assess the efficacy of heparin flushing in the lock of central venous catheters., Methods: We searched MEDLINE and CINAHL databases. Eligible studies were randomized controlled trials evaluating the use of heparin versus normal saline or other solution in the flushing of central catheter among adult patients. No language restrictions were applied. Two reviewers independently screened titles and abstracts in order to identify relevant publications. The same two reviewers retrieved and evaluated full texts. Parameter estimates regarding catheter occlusion were pooled using network meta-analysis with Bayesian hierarchical modeling., Results: We identified 462 references. Eight studies were included. There was no evidence that heparin was more effective than normal saline in reducing occlusions. It was unclear whether urokinase and lepirudin were more effective than heparin in reducing occlusions. Vitamin C solution does not appear to prolong catheter patency., Conclusions: There is no evidence of a different effectiveness between heparin flushing and normal saline or other solutions in reducing catheter occlusions. Due to the little and inconclusive evidence available in this field, further studies might be necessary.

Background: Despite growing use, peripherally inserted central catheters (PICCs) are associated with risk of deep vein thrombosis (DVT). We designed a study to determine patient, provider and device factors associated with this outcome., Methods: This was a retrospective cohort study of adults who underwent PICC placement between 1 June 2009 to 30 June 2012. Symptomatic PICC-associated DVT was confirmed by ultrasound. Because PICCs are also recognized risk factors for lower-extremity DVT, lower-extremity DVT occurring while the PICC was in situ was included. Multivariable logistic and Cox-proportional hazards regression models were fit to examine the association between covariates specified a priori and PICC-DVT. Odds ratios (ORs) and hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were generated., Results: Of 966 unique PICC placements, 33 patients developed symptomatic PICC-associated DVT and 9 developed lower-extremity DVT, accounting for 42 thrombotic events. On bivariate analysis, recent diagnosis of cancer, interventional radiology placement, chemotherapy administration, number of lumens and PICC-gauge were associated with PICC-DVT. Following multivariable adjustment, recent cancer diagnosis (OR 1.95 [95% CI 1.01-3.76]) and PICC gauge (HR 2.21 [95%CI 1.04-4.70] and HR 3.56 [95%CI 1.31-9.66] for 5-Fr and 6-Fr PICCs, respectively) remained associated with thrombosis., Conclusions: Recent diagnosis of cancer and PICC gauge are associated with PICC-DVT. These findings have important clinical ramifications and suggest that placement of large gauge PICCs or PICCs in patients with cancer may provoke thrombosis. Improved policies and procedural oversights in these areas appear necessary to prevent PICC-DVT., (Published 2014. This article is a U.S. Government work and is in the public domain in the USA.)

Chylothorax is the accumulation of chyle in the pleural cavity as a result of damage to the lymphatic ducts. We treated a young man who was a kidney transplant recipient who had a prior internal jugular vein permanent catheter for hemodialysis, who developed dyspnea and hypoxemia. Chest radiography showed bilateral pleural effusion. Analysis of the white, milky, cloudy, odorless effusion fluid showed cell count > 500/μL; lymphocytes, 60%; total protein, 3.6 mg/dL; urea nitrogen, 45 mg/dL; creatinine, 90 μmol/L; triglycerides, above 2.2 mmol/L (repeatedly high); lactate dehydrogenase, 450 U/L (normal); and cultures, no growth. Magnetic resonance imaging showed thrombosis of the major neck veins, superior vena cava, and azygos vein. Treatment included pleural drains, gut rest, and dietary modification, octreotide, and warfarin. The chylothorax resolved with no relapse. In summary, chylothorax may occur in patients associated with thrombosis of major veins associated with a permanent dialysis catheter.

Purpose: Central venous catheters for maintenance hemodialysis (HD) are designed to attain the required dialysis dose through sustained high blood flow rates (BFR). The authors studied the immediate and long-term performance and complications of two twin-catheter systems, the Tesio catheter (TC) and the LifeCath Twin (LC), to inform clinical practice., Methods: This single-center randomized controlled parallel-group trial allocated 80 incident patients (1:1) to receive either a TC (MedComp) or LC (Vygon). Patients were dialyzed to target BFR 450 mL/min and followed up for 12 months. The primary outcome was achievement of target BFR during the first HD session. Secondary outcomes included thrombotic dysfunction, displacement and catheter-related infection. Catheter dysfunction was defined by a BFR ≤ 250 mL/min., Results: More LCs reached the primary endpoint (44% vs. 10%, p=0.001) delivering a higher BFR (mean 383±82 vs. 277±79 mL/min, p<0.001). Significant differences in BFR persisted until the fourth dialysis session. Rates of catheter-related bacteremia (0.40 vs. 0.51/1,000 catheter days, p=0.7) and exit site infection were similar between groups (0.24 vs. 0.09/1,000 catheter days, p=0.4). Overall rates of catheter dysfunction were 2.8/1,000 catheter days (95% CI 2.1-3.5), with no differences in thrombolytic lock use although the LC group required more thrombolytic infusions (6 vs. 0, p=0.01)., Conclusions: The LC can deliver greater BFRs in the first three HD sessions following insertion although this did not translate into differences in performance, dialysis adequacy or complication rates with long-term use. Both catheter types can consistently deliver high BFRs over an extended period of time.

Introduction: This study was conducted to compare catheter function, dialysis adequacy, and dialysis-related complications among patients receiving long-term dialysis via Palindrome catheter, Permcath catheter, and arteriovenous fistula (AVF) as vascular access., Materials and Methods: Forty-three patients undergoing dialysis with Permcath catheter, 49 with Palindrome catheter, and 56 with AVF were recruited. Urea clearance (KT/V), urea reduction rate, and the highest blood flow at the arteriovenous junction during dialysis were determined during the dialysis sessions. Catheter-related infection, catheter-associated thrombosis, and annual patency rate were also evaluated., Results: In patients using Permcath catheter for dialysis, the incidence of secondary renal injury (metabolic diseases, hypertension, and ischemic kidney diseases) was 73.1%, which was significantly higher than that in patients with AVF (51.5%; P = .001). In the Palindrome group, maximum blood flow, KT/V, urea reduction rate, and annual patency rate were significantly higher than those in the Permcath group, and the incidence of access-related infection was significantly higher than that in the AVF group. In the Palindrome group, the prevalence of thromboembolism was 30.6%, which was significantly lower than that in the Permcath group (46.5%), but higher than that in the AVF group (5.4%)., Conclusions: For dialysis patients, Palindrome catheter was superior to Permcath catheter and comparable with the AVF in terms of the maximum blood flow, dialysis adequacy, and annual patency rate. Dialysis with Palindrome catheter has a high infection rate and a high incidence of thromboembolism as in the dialysis with Permcath catheter.

The most complex patients requiring vascular access are those with bilateral central vein occlusions. Endovascular repair of the central lesions when feasible allow upper extremity use for access. When endovascular repair is not feasible, femoral vein transposition should be the next choice. When lower limb access sites have been exhausted or are contraindicated as in obese patients and in patients with peripheral arterial obstructive disease, a range of extrathoracic "exotic" extra-anatomic access procedures as the necklace cross-chest arteriovenous (AV) grafts, the ipsilateral axillo-axillary loops, the brachial-jugular AV grafts, the axillo-femoral AV grafts or even intra-thoracic ones as the right atrial AV bypasses represent the vascular surgeon's last resort. The selection among those extra-anatomical chest-wall procedures should be based upon each patient's anatomy or patient-specific factors.

Introduction: Central venous catheters (CVC) related thrombosis (CRT) represents a well known complication in patients with acute myeloid leukemia (AML) receiving intensive chemotherapy but the efficacy of antithrombotic prophylaxis still remains controversial., Patients and Methods: We analyzed 71 consecutive AML patients whose CVC was inserted before each chemotherapy cycle for an overall number of 106 CVC placements. In 47/106 insertions, a prophylaxis with 100 IU/kg/day low molecular weight heparin (LMWH) was administered for 7 days after CVC insertion and additional 7 after CVC removal. This unconventional dose of LMWH, although higher than usual, appeared adequate for a short-course approach. LMWH was delivered regardless of the platelet (PLT) count once provided that it should have been maintained above 20 x 10(9)/L by transfusions., Results: Of 106 insertions, we observed 19 (18%) episodes of CRT, 58 (54%) of sepsis and 50 (47%) infections of CVC-exit site with no difference between LMWH and no-LMWH group. Occurrence of CRT was significantly associated with CVC-exit site infections (14/19, p=0.01) and sepsis (16/19, p=0.005) with no difference between LMWH and no-LMWH group. In multivariate analysis, both CVC-exit site infections and sepsis were confirmed to be independent risk factors for CRT development., Conclusion: Our retrospective study, although based on a small sample size, suggests that the occurrence of CVC-exit site infections and neutropenic sepsis following chemotherapy significantly increases the risk of CRT in AML, independently from the use of LMWH prophylaxis., (© 2013.)

Unlabelled: Upper extremity deep venous thrombosis (UEDVT) occurs either spontaneously, as a consequence of strenuous upper limb activity (also known as the Paget-Schroetter syndrome) or secondary to an underlying cause. Primary and secondary UEDVT differs in long-term sequelae and mortality. This review will focus on the clinical presentation, risk factors, diagnosis, and treatment strategies of UEDVT. In the period from January to October 2012 an electronic literature search was performed in the PubMed/MEDLINE database, and 27 publications were included., Clinical Presentation: swelling, pain and functional impairment are typical symptoms of UEDVT, although completely asymptomatic cases have been described. However life-threatening, massive pulmonary embolism (PE) can also be a sign of UEDVT., Risk Factors: for the primary condition anatomical abnormalities (Thoracic Outlet Syndrome, TOS) may dispose to the condition. Malignancy and therapeutic interventions are major risk factors for the secondary deep vein thrombosis in combination with the patient's characteristics, comorbidities and prior history of deep vein thrombosis., Complications: recurrent deep venous thrombosis, pulmonary embolism and Post Thrombotic Syndrome (PTS) are the major complications after UEDVT. PTS is a chronic condition leading to significant functional disability and impaired quality of life., Diagnosis: compression ultrasonography is noninvasive and the most frequently used objective test with a high accuracy in experienced hands. Treatment modalities and strategies: the treatment modalities include anticoagulation therapy, catheter-directed thrombolysis, surgical decompression, percutaneous transluminal angioplasty and stenting and they may be combined. However, the optimal treatment and timing of treatment remains controversial. Early diagnosis and treatment is essential to prevent PTS in primary UEDVT; however, there is no consensus on which treatment is the best. Anticoagulation is still considered the treatment of choice for at least 3-6 months, until Randomized Controlled Trials may have demonstrated otherwise.

Objective: The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere/CryoLife Inc, Eden Prairie, Minn) has provided an innovative means to obtain hemodialysis access for patients with severe central venous occlusive disease. The outcomes of this novel treatment modality in a difficult population have yet to be clearly established., Methods: A retrospective review of HeRO graft placement from June 2010 to January 2012 was performed. Patient hemodialysis access history, clinical complexity, complications, and outcomes were analyzed. Categoric data were described with counts and proportions, and continuous data with means, ranges and, when appropriate, standard deviations. Patency rates were analyzed using life-table analysis, and patency rate comparisons were made with a two-group proportion comparison calculator., Results: HeRO graft placement was attempted 21 times in 19 patients (52% women), with 18 of 21 (86%) placed successfully. All but one was placed in the upper extremity. Mean follow-up after successful placement has been 7 months (range, 0-23 months). The primary indication for all HeRO graft placements except one was central vein occlusion(s) and need for arteriovenous access. Patients averaged 2.0 previous (failed) accesses and multiple catheters. Four HeRO grafts (24%), all in women, required ligation and removal for severe steal symptoms in the immediate postoperative period (P < .01 vs men). Three HeROs were placed above fistulas for rescue. All thrombosed <4 months, although the fistulas remained open. An infection rate of 0.5 bacteremic events per 1000 HeRO-days was observed. At a mean follow-up of 7 months, primary patency was 28% and secondary patency was 44%. The observed 12-month primary and secondary patency rates were 11% and 32%, respectively. Secondary patency was maintained in four patients for a mean duration of 10 months (range, 6-18 months), with an average of 4.0 ± 2.2 thrombectomies per catheter., Conclusions: HeRO graft placement, when used as a last-resort measure, has been able to provide upper extremity access in patients who otherwise would not have this option. There is a high complication rate, however, including a very high incidence of steal in women. HeRO grafts should continue to be used as a last resort., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Paget-Schroetter syndrome, or an upper-extremity deep venous thrombosis (UEDVT), occurs in young people after strenuous repetitive activity involving the upper extremity. The long-term morbidity and mortality of this condition is similar to the effects of lower-extremity DVT and therefore, its early diagnosis and treatment are essential., Objectives: This case report describes Paget-Schroetter syndrome (effort thrombosis) diagnosed at the bedside by Emergency Physician performed ultrasound., Case Report: This is a case report of an uncommon but potentially dangerous disease that carries high morbidity if not diagnosed and treated early. Emergency Physicians should be aware of this condition in any young patient who presents with upper-extremity complaints with a history of repetitive use. Although the role of ultrasound in the diagnosis of lower-extremity DVT is well described, this case report is unique because it illustrates the diagnosis of Paget-Schroetter syndrome completed at the bedside., Conclusion: This article presents the case and discusses the incidence, potential causes, predisposing factors, diagnostic modalities, and the course of treatment for this particular diagnosis., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: Whether an anticoagulant prophylaxis is needed for patients with cancer with a central venous catheter is a highly controversial subject. We designed a study to compare different prophylactic strategies over 3 months of treatment., Methods: We performed a phase III prospective, open-label randomized trial. After the insertion of a central venous access device, consecutive patients with planned chemotherapy for cancer were randomized to no anticoagulant prophylaxis, low molecular weight heparin [low molecular weight heparin (LMWH); with isocoagulation doses], or warfarin 1 mg/day. Treatments were given over the first 3 months. Doppler ultrasound and venographies were performed on days 1 and 90, respectively, or sooner in case of clinical presumption of thrombosis., Results: A total of 420 patients were randomized, and 407 were evaluable. Forty-two catheter-related deep vein thrombosis (DVT) occurred (10.3 %), 20 in those with no anticoagulation, 8 in those receiving warfarin, and 14 in those receiving LMWH. Nine additional non-related catheter deep vein thrombosis (CDVT) occurred. Anticoagulation significantly reduced the incidence of catheter-related DVT (p = 0.035) and catheter non-related DVT (p = 0.007), with no difference between warfarin and LMWH. Safety was good (3.4 % of attributable events) but compliance with randomized prophylaxis was lower than expected., Conclusions: Prophylaxis showed a benefit regarding catheter-related and non-catheter-related DVT with no increase in serious side effects.

Purpose: To describe a single institutional experience with translumbar tunneled dialysis catheters (TDC) and compare outcomes between patients with normal and abnormal body mass index (BMI)., Materials and Methods: Translumbar TDCs placed between January 2002 and July 2011 were reviewed retrospectively. There were 33 patients; 18 had a normal BMI<25, and 15 had an abnormal BMI>25. Technical outcome, complications, indications for exchange or removal, and BMI were recorded. Catheter dwell time, catheter occlusion rate, frequency of malposition, and infection rates were collected., Results: There were 92 procedures (33 initial placements) with 7,825 catheter days. The technical success rate was 100%. Two minor (2.2%) and three major (3.3%) complications occurred. The complication rate did not differ significantly between patients with a normal BMI and patients with an abnormal BMI. Median catheter time in situ (interquartile range) for all patients was 61 (113) days, for patients with normal BMI was 66 (114) days, and for patients with abnormal BMI was 56 (105) days (P = .9). Primary device service intervals for all patients, patients with normal BMI, and patients with abnormal BMI were 47 (96) days, 63 (98) days, and 39 (55) days (P = .1). Secondary device service intervals for all patients, patients with normal BMI, and patients with abnormal BMI were 147 (386) days, 109 (124) days, and 409 (503) days (P = .23). Catheter-related central venous thrombosis rate was 0.01 per 100 catheter days (n = 1)., Conclusions: Translumbar TDC placement can provide effective hemodialysis in patients with limited venous reserve regardless of the patient's BMI. An abnormal BMI (>25) does not significantly affect complication rate, median catheter time in situ, or primary or secondary device service interval of translumbar TDCs., (Copyright © 2013 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: Despite the increasing use of central venous catheters (CVC) for hemodialysis in clinical practice, the role of CVC in thrombus development is poorly understood. This work aims at defining new methods and protocols for assessing the micromorphology and composition of thrombi formed into tunneled and non-tunneled hemodialysis CVC removed from patients. 
, Methods: Twenty-nine CVCs were collected and the microscopic features of intra-luminal thrombi were quantified by scanning electron microscopy (SEM) and visualized by two photon laser scanning microscopy (TPLSM). 
, Results: SEM quantification showed that fibrin was the most abundant structure in CVC thrombi. Specifically, the median micromorphologic composition of the surface layer resulted in: 42.6% of fibrin plaque, 16.3% of fibrin network, 0.4% of fibrin fibers, 9.3% of platelets, 10.3% of erythrocytes and 1.7% of white blood cells. TPLSM showed that sub-surface layers were instead composed by smaller amounts of fibrin and platelets and higher amounts of blood cells.
, Conclusions: Integration of SEM and TPLSM was found to be an excellent tool for characterizing thrombi in hemodialysis CVC removed from patients. Protocols and techniques presented here may be useful in the development and testing of new strategies for limiting thrombus formation on vascular access because of CVC.

Despite recommendations by various national guidelines advocating arteriovenous fistulae as the access of choice in patients undergoing hemodialysis (HD), the use of central venous catheters (CVCs) remains widespread among both incident and prevalent HD patients. Unfortunately, long-term use of CVCs is fraught with complications, which are a major cause of morbidity and death in this patient population. Complications include a high rate of infections, as well as thrombus and sheath-related mechanical dysfunction. This review addresses prevention and management of noninfectious catheter-related dysfunction.

During the last two decades the prevalence of patients needing chronic renal replacement therapy has increased progressively. Furthermore, the dialysis population has significantly changed. Patients are older, have multiple comorbidities, and have a particularly high cardio-vascular risk. Therefore, the prerequisites for the formation of fistulae have become worse. Many centres (including our own) have formed interdisciplinary vascular access teams to provide an optimal service for these patients. Herein, we review recent studies regarding the diagnostic and therapeutic approaches for access failure. As many clinical decisions remain opinion -based we also include our personal approach resulting from regular interdisciplinary board meetings.

Background: Patients with acute leukemia and in particular, acute promyelocytic leukemia (APL), are felt to be at high risk for developing venous thromboembolism. The presence of central venous catheters (CVCs) increases this risk; however, reports have varied regarding the frequency of this complication. Current guidelines do not recommend the routine use of prophylactic anticoagulation for patients with CVC., Methods: We suspected an increased incidence of CVC thrombosis in patients with APL and therefore conducted a retrospective survey of 473 patients who were treated for acute leukemia at our institution., Results: The overall rate of symptomatic CVC thrombosis was 6.8%. We found a significantly (P < 0.001) increased rate of symptomatic CVC thrombosis (32%) in patients with APL as compared with patients with acute lymphocytic leukemia and acute myeloid leukemia (6.4% and 4%, respectively). CVC thrombosis was most prevalent following induction treatment and was associated with higher platelet counts in patients with APL. Following this observation, 13 additional newly diagnosed patients with APL were treated with low molecular weight heparin prophylaxis during the recovery phase after chemotherapy. None had a thrombotic event., Conclusions: Although our treatment group was small, we suggest considering prophylaxis for CVC thrombosis during platelet recovery after induction treatment in patients with APL., (© 2013 John Wiley & Sons A/S.)

Paget-Schroetter syndrome, or primary upper extremity deep vein thrombosis, is a relatively rare condition for which various treatment protocols have been proposed. No randomized controlled trials exist to guide management, and treatment must be tailored to the individual. This report describes a case of a 39-year-old man with chronic clavicular malunion from multiple clavicular fractures who presented with Paget-Schroetter syndrome. The thrombus occluded the right axillary, brachial, and subclavian veins. Attempted thrombolytic therapy was unsuccessful, and decompressive surgery was used to avoid postphlebitic complications and regain functionality of the upper extremity. Rather than first rib resection, claviculectomy with thrombectomy and subclavian vein repair was performed., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: We reviewed our strategies during the last decade for deep vein thrombosis (DVT) of the upper extremity due to thoracic outlet syndrome (TOS) andthe lower extremity., Methods: Between 1998 and 2011, we treated 31 patients with 18 subclavian DVTs and 13 iliac DVTs. Management included catheter-directed thrombolysis compared to mechanical thrombolysis (MT; post 2006). Prior to 2006, patients with TOS were treated with total excision of the first rib compared to excision of the anterior half of the rib. Patients were followed up with serial duplex ultrasounds., Results: There was no major morbidity and no mortality in these 31 patients. Three patients developed recurrent DVT but maintained patency after further treatment., Conclusion: Use of MT has led to shorter treatment duration and length of hospital stay. Limiting first rib resection to the anterior half of the rib shortened operative time. Patients requiring stents had excellent long-term patency rates.

Unlabelled: Deep vein thrombosis (DVT) is a common complication following spinal cord injury (SCI). Although DVT of the upper extremity is much less common than DVT of the lower extremities, the risk of pulmonary embolism following upper-extremity DVT should not be disregarded., Method: Case report., Findings: A bilateral upper-extremity DVT developed in a 51-year-old woman with SCI (central cord syndrome) being followed in our rehabilitation clinic. Medical treatment resulted in improvement in the clinical status of the patient as well as the regression in the thrombus., Conclusion: In patients with SCI, DVT should be kept in mind in the presence of pain and edema in the upper extremities, and prophylactic DVT treatment should be considered.

Background: Hemodialysis patients who have exhausted all of the conventionally used veins for vascular access, including arteriovenous fistula, arteriovenous graft, and traditional catheter access sites, present a challenge to the treating physician. Transhepatic and translumbar inferior vena cava catheters have been used in these patients who have no other access site option. The objective of the study was to examine our experience with translumbar and transhepatic approach for catheter-based hemodialysis access in patients who have exhausted all other options., Methods: A retrospective review was performed from June 2000 to May 2011 of all patients who underwent transhepatic or translumbar inferior vena cava catheter placement for the purpose of hemodialysis. Data abstracted included previous access procedures, duration of use and patency of dialysis catheters, catheter-related complications, and mortality., Results: Seven patients were identified. Four patients underwent transhepatic access and three underwent translumbar access. Five patients were female and two were male. The mean age was 44 years. The etiology of renal failure was diabetes in four patients, congenital hypoplastic kidneys in two patients, and acute glomerulonephritis in one patient. A mean of 14 (range: 11-18) dialysis access procedures were performed before catheter placement by transhepatic/translumbar interventions. The initial device service interval for all patients ranged from 15 to 658 days, with a mean of 295 days and a median of 245 days. Total access site service interval ranged from 15 to 790 days, with a mean of 380 days and a median of 245 days., Conclusion: Translumbar and transhepatic venous access is a viable long-term alternative route for catheter-based hemodialysis access in patients who have exhausted conventional options., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To determine the outcomes of percutaneous interventions for prolonging the patency of the Hemodialysis Reliable Outflow (HeRO) device., Materials and Methods: Between January 2007 and August 2011, 73 percutaneous interventions were performed on 26 HeRO devices in 25 patients. The graft was implanted in the upper arm with the outflow catheter tip in the superior vena cava or right atrium. Procedural reports, angiographic images, and clinical notes were retrospectively reviewed. The primary and secondary patency rates after intervention were calculated using the Kaplan-Meier method., Results: The mean time from HeRO implantation to initial dysfunction or thrombosis was 171 days. In 60 (82%) procedures, the HeRO device was thrombosed. An intragraft stenosis was the most common lesion identified (59%; n = 43) followed by an arterial anastomosis stenosis identified in 18% (n = 13). In 22% (n = 16) of procedures in which the HeRO device was thrombosed, an underlying cause was not identified after thrombectomy. The 3-, 6-, and 12-month primary patency rates after intervention were 47%, 37%, and 26% for first-time interventions. The secondary patency rates were 80%, 70%, and 64%. The only complication was pulmonary embolism resulting in death 2 days after HeRO thrombectomy., Conclusions: Percutaneous interventions on thrombosed and failing HeRO devices yielded acceptable primary and secondary patency rates after intervention in these patients with few, if any, alternatives for hemodialysis access., (Copyright © 2013 SIR. Published by Elsevier Inc. All rights reserved.)

Paget Schroetter Syndrome (PSS) or "effort thrombosis" is a rare form of primary upper extremity deep vein thrombosis often seen in individuals with anatomic variants involving the thoracic outlet and exacerbated by repetitive microtrauma to the subclavian vein. Diagnosis can be made with ultrasound and confirmed with MR venography or conventional venography. We report a case of PSS in a young male athlete who was treated with pharmacologic and mechanical thrombolysis.

Cardiovascular implantable electronic devices (CIEDs) are frequently utilized for management of cardiac dysrhythmias in patients with chronic kidney disease or end-stage renal disease receiving hemodialysis. The survival benefit from use of implantable cardioverter defibrillators in patients with CKD or ESRD is not as clear as in the general population, particularly when used for primary prevention of sudden cardiac death. Transvenous CIED leads are associated with central vein stenosis resulting in significant adverse consequences for existing or future arteriovenous access. Venous hypertension from CIED lead-related central vein stenosis is a challenging clinical problem and may require repeated percutaneous interventions, replacement of the CIED, or creation of alternative arteriovenous access. Infections associated with transvenous CIED leads are more frequent and associated with worse outcomes in patients with renal disease. Epicardial CIED leads or other nontransvenous devices may reduce complications of both central venous stenosis and endovascular infection in these vulnerable patients. Consensus recommendations are offered for avoidance and management of complications arising from the use of CIEDs and arteriovenous hemodialysis access., (© 2012 Wiley Periodicals, Inc.)

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., Objectives: 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]., Conclusion: 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., (© 2012 International Society on Thrombosis and Haemostasis.)