Central venous catheter thrombosis

Question 1

You are asked to review a 64-year-old-woman on the ward. She has been nil by mouth and receiving total parenteral nutrition (TPN) for two weeks via a right subclavian vein central line. The treatment was started for an anastomotic leak after a Whipple procedure for pancreatic cancer. She has noticed swelling of her whole right arm over the last 24 hours. What is the most likely diagnosis and appropriate management?

Answer 1

Impression
Given the patients central line emplacement and acute symptoms of upper limb swelling, I am mostly concerned about a central venous catheter thrombosis. This is supported by several risk factors for thrombosis formation according to Virchow’s triad: recent surgery, bed-bound, malignancy. The main Concern is that this could lead to pulmonary embolism.

Ddx

• infective: line sepsis, cellulitis, necrotising fasciitis
• TPN leakage into surrounding tissue
• haematoma
• new DVT

Question 2

CVC thrombosis - Assessment

Answer 2

Assessment

• Call for senior help, arrange urgent vascular review
• Assess HD stability for evidence of PE, compromise

Question 3

CVC thrombosis - History

Answer 3

History

• would want to review patient notes for details of their ongoing management, recent surgery, plans for discharge, and any NFRs/ACDs in place, details of the catheter itself
• Sx: sudden vs gradual onset, pain and SOCRATES, when started, course of the swelling, paraesthesia/numbness
• REDS: fever, tachycardia/palpitations, chest pain (pleuritic),
• Medications, allergies
• Rest of medical history as pertinent

Question 4

CVC thrombosis - Examination

Answer 4

Examination

• General appearance + vitals
• inspection: line, surrounding skin, distribution of swelling (consistent with venous occlusion rather than arterial), assess for any mechanical obstruction,
• cardiorespiratory examination
• ensure neurovascularly intact in the upper limb

Question 5

CVC thrombosis - Investigations

Answer 5

Investigations
Key/diagnostic:
- Duplex ultrasound: looking for evidence of DVT: (non-compressibility, abnormal/absent blood flow, echogenic within vessel lumen, location of thrombus and extent. Can also assess for mechanical defects of the CVC
- Contrast venography (CT/MRI) - gold standard for assessing venous system for DVT, only performed if not identified on US.

• Bloods: FBC, UEC, LFT, Coags, ESR/CRP, ?blood cultures if septic, D-DImer if indicated
• imaging: consider CTPA/V/Q scan is suspicious of PE and indicated by Wells criteria

Question 6

CVC thrombosis - Management

Answer 6

Management
Goals:
- intervene immediately for any HD instability as per A to E approach, call for senior help, potentially ICU/ED disposition, Theatres for acute mx

Supportive

• analgesia
• regular monitoring of obs
• discontinue TPN infusion through CVC, consider its removal if would benefit patient (altho keep if access is difficult, isn’t infected, is in right position, and there is an ongoing need for it

Definitive

• anticoagulation: heparin infusion, monitor aPTT till in therapeutic range, can do sub-cut clexane (enoxaparin)
• consider thrombolysis (limited indications)
• further surgical intervention such as venous filter