Shin H Stella, Towbin Alexander J, Zhang Bin, Johnson Neil D, Goldstein Stuart L
Division of Pediatric Nephrology, Emory University, 2015 Uppergate Dr. NE, Atlanta, GA, 30322, USA.
Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Pediatr Radiol. 2017 Nov;47(12):1670-1675. doi: 10.1007/s00247-017-3915-9. Epub 2017 Jul 6.
Peripherally inserted central catheters (PICCs) can lead to development of venous thrombosis and/or stenosis. The presence of venous thrombosis and/or stenosis may preclude children with chronic medical conditions from receiving lifesaving therapies, from hemodialysis in end-stage renal disease to total parenteral nutrition in short bowel syndrome. Several adult studies have found an association between PICCs and venous thrombosis and/or stenosis, but none has evaluated for this association in children.
To determine the incidence of venous thrombosis and/or stenosis after PICC placement and identify factors that increase the risk of venous thrombosis and/or stenosis after PICC placement in children.
We conducted a retrospective review of children ages 1-18 years with a PICC placed between January 2010 and July 2013 at our center, and included those who had at least one vascular imaging study of the ipsilateral extremity (Doppler ultrasound, venogram or MR angiogram) after PICC placement. Logistic regression was applied to determine risk factors for development of venous thrombosis and/or stenosis.
One thousand, one hundred and ten upper extremity PICCs were placed, with 703 PICCs in the right and 407 PICCs in the left. Eight hundred fifty-one imaging studies (609 Doppler ultrasounds, 193 contrast venograms and 49 MR angiograms) were performed in 376 patients. The incidence of venous thrombosis and/or stenosis in the imaged cohort was 26.3%. PICC laterality, insertion site, duration, patient height to PICC diameter ratio, and number of PICCs per patient were not associated with development of venous thrombosis and/or stenosis. Additionally, primary diagnosis and symptoms at the time of imaging did not predict findings of venous thrombosis and/or stenosis. However, patients exposed to non-PICC central venous catheters (CVC) were more likely to develop venous thrombosis and/or stenosis (odds ratio 1.95, 1.10-3.45).
More than a quarter of the vascular imaging studies performed in this study cohort showed previously unknown venous thrombosis and/or stenosis, irrespective of PICC laterality, insertion site, duration and size and the number of PICCs. A history of CVC was associated with a nearly two-fold increase in risk of venous thrombosis and/or stenosis after PICC placement. We suggest that PICCs and CVCs should be placed judiciously in all children, but especially in those with lifelong medical conditions who are more likely to incur direct consequences from limited vascular access.
经外周静脉穿刺中心静脉置管（PICC）可导致静脉血栓形成和/或狭窄。静脉血栓形成和/或狭窄的存在可能使患有慢性疾病的儿童无法接受挽救生命的治疗，从终末期肾病的血液透析到短肠综合征的全胃肠外营养。几项成人研究发现PICC与静脉血栓形成和/或狭窄之间存在关联，但尚无研究评估儿童中的这种关联。
确定PICC置管后静脉血栓形成和/或狭窄的发生率，并确定增加儿童PICC置管后静脉血栓形成和/或狭窄风险的因素。
我们对2010年1月至2013年7月在本中心进行PICC置管的1至18岁儿童进行了回顾性研究，纳入了那些在PICC置管后至少进行过一次同侧肢体血管成像检查（多普勒超声、静脉造影或磁共振血管造影）的儿童。应用逻辑回归分析确定静脉血栓形成和/或狭窄发生的危险因素。
共置入1110根上肢PICC，其中右侧703根，左侧407根。376例患者进行了851次成像检查（609次多普勒超声、193次静脉造影和49次磁共振血管造影）。成像队列中静脉血栓形成和/或狭窄的发生率为26.3%。PICC的置入侧、穿刺部位、留置时间、患者身高与PICC直径之比以及每位患者的PICC数量与静脉血栓形成和/或狭窄的发生无关。此外，成像时的主要诊断和症状并不能预测静脉血栓形成和/或狭窄的结果。然而，曾接受非PICC中心静脉导管（CVC）置管的患者更易发生静脉血栓形成和/或狭窄（比值比1.95，1.10 - 3.45）。
本研究队列中超过四分之一的血管成像检查显示存在此前未知的静脉血栓形成和/或狭窄，与PICC的置入侧、穿刺部位、留置时间、尺寸以及数量无关。有CVC置管史会使PICC置管后静脉血栓形成和/或狭窄的风险增加近两倍。我们建议，在所有儿童中，尤其是那些患有终身疾病且更可能因血管通路受限而产生直接后果的儿童，应谨慎进行PICC和CVC置管。
