Akl Elie A, Vasireddi Srinivasa Rao, Gunukula Sameer, Yosuico Victor E D, Barba Maddalena, Sperati Francesca, Cook Deborah, Schünemann Holger
Department of Medicine, State University of New York at Buffalo, ECMC CC-142, 462 Grider Street, Buffalo, NY, USA, 14215.
Cochrane Database Syst Rev. 2011 Apr 13(4):CD006468. doi: 10.1002/14651858.CD006468.pub4.
Central venous catheter (CVC) placement increases the risk of thrombosis in cancer patients. Thrombosis often necessitates the removal of the CVC, resulting in treatment delays and thrombosis related morbidity and mortality.
To evaluate the efficacy and safety of anticoagulation in cancer patients with a CVC.
We searched The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (January 1966 to February 2010; accessed via OVID), EMBASE (January 1980 to February 2010; accessed via OVID) and ISI the Web of Science (1975 to February 2010). We handsearched conference proceedings, checked references of included studies and used the "related article" feature within PubMed.
Randomized controlled trials (RCTs) comparing any dose of unfractionated heparin (UFH), low molecular weight heparin (LMWH), vitamin K antagonists (VKA), or fondaparinux to no intervention or placebo or comparing two different anticoagulants in cancer patients with a CVC.
Two authors independently extracted data from each included study and resolved their disagreements by discussion.
Of 8187 identified citations, we included 12 RCTs enrolling 3611 patients and assessing either prophylactic dose heparin or low dose VKAs. Prophylactic dose heparin was not associated with a statistically significant effect on death (relative risk (RR) = 0.85; 95% confidence interval (CI): 0.53 to 1.37), symptomatic deep venous thrombosis (DVT) (RR = 0.54; 95% CI: 0.28 to 1.05) asymptomatic DVT (RR = 0.81; 95% CI: 0.64 to 1.02), major bleeding (RR = 0.68; 95% CI: 0.10 to 4.78), thrombocytopenia (RR = 0.85; 95% CI: 0.49 to 1.46), or infection (RR = 0.91; 95% CI: 0.49 to 1.68). Similarly, low dose VKAs were not associated with a statistically significant effect on death (RR = 0.97; 95% CI: 0.82 to 1.15), symptomatic DVT (RR = 0.63; 95% CI: 0.35 to 1.11) or major bleeding (RR = 6.93; 95% CI: 0.86 to 56.08). However, they were associated with a statistically significant reduction in asymptomatic DVT (RR = 0.42; 95% CI: 0.28 to 0.61). Studies comparing heparin to VKA found no effects on any of the outcomes of interest.
AUTHORS' CONCLUSIONS: We found no statistically significant effect of heparin or VKA on the outcomes of interest. However, the findings did not rule out clinically important benefits and harms. Patients with cancer with CVCs considering anticoagulation should balance the possible benefit of reduced thromboembolic complications with the possible harms and burden of anticoagulants.
中心静脉导管（CVC）置管会增加癌症患者发生血栓形成的风险。血栓形成常常需要拔除CVC，从而导致治疗延误以及与血栓形成相关的发病率和死亡率。
评估抗凝治疗在置有CVC的癌症患者中的疗效和安全性。
我们检索了Cochrane对照试验中心注册库（CENTRAL，Cochrane图书馆，2010年第1期）、MEDLINE（1966年1月至2010年2月；通过OVID检索）、EMBASE（1980年1月至2010年2月；通过OVID检索）以及科学引文索引（1975年至2010年2月）。我们手工检索了会议论文集，检查了纳入研究的参考文献，并利用了PubMed中的“相关文章”功能。
随机对照试验（RCT），比较任何剂量的普通肝素（UFH）、低分子量肝素（LMWH）、维生素K拮抗剂（VKA）或磺达肝癸钠与不干预或安慰剂，或者比较置有CVC的癌症患者中两种不同的抗凝剂。
两位作者独立从每项纳入研究中提取数据，并通过讨论解决分歧。
在8187条检索到的引文中，我们纳入了12项RCT，共3611例患者，评估了预防性剂量肝素或低剂量VKA。预防性剂量肝素对死亡（相对危险度（RR）=0.85；95%置信区间（CI）：0.53至1.37）、有症状的深静脉血栓形成（DVT）（RR = 0.54；95% CI：0.28至1.05）、无症状DVT（RR = 0.81；95% CI：0.64至1.02）、大出血（RR = 0.68；95% CI：0.10至4.78）、血小板减少症（RR = 0.85；95% CI：0.49至1.46）或感染（RR = 0.91；95% CI：0.49至1.68）均无统计学显著影响。同样，低剂量VKA对死亡（RR = 0.97；95% CI：0.82至1.15）、有症状的DVT（RR = 0.63；95% CI：0.35至1.11）或大出血（RR = ６.93；95% CI：0.86至56.08）也无统计学显著影响。然而，它们与无症状DVT的统计学显著减少相关（RR = 0.42；95% CI：0.28至0.61）。比较肝素与VKA的研究未发现对任何感兴趣的结局有影响。
我们发现肝素或VKA对感兴趣的结局无统计学显著影响。然而，这些结果并未排除临床上重要的益处和危害。考虑进行抗凝治疗的置有CVC的癌症患者应权衡减少血栓栓塞并发症的可能益处与抗凝剂可能带来的危害和负担。
