Division of Vascular Surgery, University of Michigan Health System, Ann Arbor, Mich.
Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, Mich.
J Vasc Surg Venous Lymphat Disord. 2017 Sep;5(5):630-637. doi: 10.1016/j.jvsv.2017.03.018. Epub 2017 Jun 27.
Anticoagulation remains the standard of care for line-associated upper extremity deep venous thrombosis (UEDVT). This treatment carries the risk of hemorrhagic complications, possibly more so in surgical patients. Considering the low-risk profile of UEDVT-which is associated with fewer, less severe pulmonary emboli than lower extremity deep venous thrombosis-current UEDVT treatment guidelines may be overly aggressive. The goal of this study was to review outcomes of line-associated UEDVT in critically ill patients and to define the efficacy of current treatment protocols in pulmonary embolism (PE) prevention while avoiding hemorrhagic complications.
A retrospective review was performed of 193 consecutive patients admitted to the medical and surgical intensive care unit (ICU) at a tertiary care hospital between 2009 and 2014 diagnosed with acute line-associated UEDVT by duplex ultrasound. The examined treatment arms included anticoagulation with intent to reach therapeutic levels, prophylactic or subtherapeutic anticoagulation, and no anticoagulation. Primary outcomes included major hemorrhage (defined as any intracranial hemorrhage or any hemorrhage resulting in transfusion, ICU readmission, or death), PE, in-hospital mortality, total hospital length of stay (LOS), and ICU LOS.
Of the 10,907 patients, 161 (1.48%) were diagnosed with acute line-associated UEDVT, 81 of 6027 in the medical ICU (1.34%) and 80 of 4880 in the surgical ICU (1.64%), after exclusion of 32 patients with concurrent lower extremity deep venous thrombosis. In total, 122 patients (75.8%) received anticoagulation with intent to reach therapeutic levels, 23 (14.3%) received prophylactic anticoagulation, and 16 (9.94%) received no anticoagulation. Major hemorrhage was significantly more common than symptomatic PE in all patients (15.5% vs 4.97%; P < .001). A single fatal PE and two fatal hemorrhages were recorded across the series. There was no significant difference in in-hospital mortality (34.8% vs 16.7%; P = .726) or ICU LOS (33.1 vs 18.3 days; P = .739) for patients who developed major hemorrhage or symptomatic PE. On multivariate analysis, incidence of symptomatic PE was not significantly related to Acute Physiology and Chronic Health Evaluation III score (P = .963), anticoagulation regimen (P = .940), catheter type (P = .313), or bacteremia (P = .833).
Major hemorrhagic complications are more common than symptomatic PE after anticoagulation for line-associated UEDVT in ICU patients, raising concern that current treatment guidelines are too aggressive. These data necessitate further prospective investigation to determine the optimal treatment protocol for line-associated UEDVT in this critically ill cohort.
抗凝治疗仍然是上肢深静脉血栓形成（UEDVT）的标准治疗方法。这种治疗方法存在出血并发症的风险，在手术患者中可能更为严重。考虑到 UEDVT 的低风险特征——与下肢深静脉血栓形成相比，UEDVT 较少且更严重的肺栓塞（PE），目前的 UEDVT 治疗指南可能过于激进。本研究的目的是回顾重症监护病房（ICU）中与导管相关的 UEDVT 患者的结局，并确定当前预防 PE 的治疗方案在避免出血并发症方面的有效性。
对 2009 年至 2014 年间在一家三级医院的内科和外科 ICU 住院的 193 例连续确诊为急性导管相关 UEDVT 的患者进行了回顾性研究。检查的治疗组包括抗凝治疗以达到治疗水平、预防性或亚治疗性抗凝治疗和不抗凝治疗。主要结局包括大出血（定义为任何颅内出血或任何导致输血、ICU 再入院或死亡的出血）、PE、住院死亡率、总住院时间（LOS）和 ICU LOS。
在 10907 例患者中，161 例（1.48%）被诊断为急性导管相关 UEDVT，其中 6027 例在内科 ICU（1.34%），4880 例在外科 ICU（1.64%），排除 32 例同时患有下肢深静脉血栓形成的患者。共有 122 例（75.8%）患者接受抗凝治疗以达到治疗水平，23 例（14.3%）患者接受预防性抗凝治疗，16 例（9.94%）患者未接受抗凝治疗。在所有患者中，大出血的发生率明显高于有症状的 PE（15.5% vs. 4.97%；P<0.001）。在整个研究中，记录到一例致命性 PE 和两例致命性出血。发生大出血或有症状 PE 的患者住院死亡率（34.8% vs. 16.7%；P=0.726）或 ICU LOS（33.1 天 vs. 18.3 天；P=0.739）无显著差异。多变量分析显示，有症状的 PE 发生率与急性生理学和慢性健康评估 III 评分（P=0.963）、抗凝方案（P=0.940）、导管类型（P=0.313）或菌血症（P=0.833）无关。
在 ICU 患者中，与导管相关的 UEDVT 抗凝治疗后，大出血并发症比有症状的 PE 更常见，这引发了对目前治疗指南过于激进的担忧。这些数据需要进一步的前瞻性研究，以确定在这一重症患者群体中与导管相关的 UEDVT 的最佳治疗方案。
