Incidence And Characteristics Of Double Lumen Induced Central Venous Catheter-Related Thromboembolism In Hemodialytic Patients

Citation : Margaret Merlyn Tjiang, Dimas Arsana Prayoga. Incidence And Characteristics Of Double Lumen Induced Central Venous CatheterRelated Thromboembolism In Hemodialytic Patients Medicinus. 2020 October; 8(3): 111-116


Introduction
Central venous catheters (CVCs) is an indwelling device that is peripherally inserted into a central vein, most commonly the internal jugular, subclavian or femoral and advanced until the terminal lumen resides within the inferior vena cava, superior vena cava or right atrium. 1 CVCs are frequently used for several indications including cancer treatment, diagnostic monitoring, parenteral nutrition, hemodialysis, and administration of fluids, blood products or medication. Potential complications of catheter related thrombosis (CRT) are thromboembolism in 10% to 15%, interruption of venous flow 10%, infection and catheter occlusion. 2,3 Hemodialysis patient related to long-term vascular access, double lumen catheters often used for hemodialysis patient to reduced the infection rate, however, the other complication such as thrombosis remain a problem. 4 There are several risk factors for the development of CRT including patient factors such as hypercoagulable states (malignancy, sepsis, critical illness, renal failure, inherited thrombophilias, use of certain drugs), catheter type (increased lumen diameter such as double lumen CVC) and insertion process (multiple insertion attempts, tip located above the junction between the SCV and atrium). 2 The pathophysiology are related to Virchow's triad of endothelial damage, stasis and hypercoagulability, described as the components involved in thrombus formation. 3 Intravenous catheters may cause endothelial trauma and are often placed in patients who are hypercoagulable, leading to venous thrombosis. 5 Catheterrelated thromboembolism can be symptomatic or asymptomatic.
The incidence of catheter-related asymptomatic thromboembolism is 27% to 66% and symptomatic catheter-related thromboembolism is 0% to 28%. 6 And if left untreated, it can contribute to decreased quality of life and can be fatal. Double lumen catheter induced CVCs thrombosis has not been paid into proper attention in developing countries such as Indonesia.

Methods
This is a retrospective cohort study conducted in General Teaching Hospital in a suburban area Indonesia. Data was taken from the medical records from January 2018 to January 2019. Inclusion criteria were patients who had undergone hemodialysis using double lumen catheter. The baseline characteristics and incidence of catheter induced thrombosis was noted using a structured questionnaire. CVCs thrombosis was confirmed using D-dimer and compression ultrasonography.

Results
A total of 408 patients were included in our study. The mean age of the patients was ± 49.3 years. There were 192 (47.1%) male patients. The double lumen catheter was mostly placed in the jugular vein (60%), followed by subclavian vein (25%) and femoral vein (15%) ( Table 1).
Four (1.1%) patients had deep vein thrombosis after about one month of double lumen catheter placement. Out of four patients, two of the patients were male. In all these four patients, the double lumen catheter was inserted in the femoral vein. Any other significant risk factors for thrombosis other than double lumen catheter insertion not found. Out of these four patients, one of them passed away. All patients were treated using heparin.

Discussion
Over 150 years ago, the German pathologist Rudolph Virchow postulated that thrombus formation and propagation resulted due to abnormalities in 3 areas namely; blood flow, vessel wall and blood components (Figure 1). Catheter insertion is a risk for thrombosis due to its damage to the endothelial wall, and contribution to stasis. [7][8][9] There are also several catheterrelated risk factors for development of thrombosis such as catheter tip location, number of lumens, prior catheterization at same puncture site, prolonged catheter dwell time, catheter related infection and more than one insertion attempt. 10,11 There has been evidence on larger diameter catheters and increased thrombosis risk in recent literature. [12][13] Catheter to vessel ratio (CVR) defined as the indwelling space or area consumed or occupied by an intravascular device inserted and positioned within a venous or arterial blood vessel. In 2016, new practice recommendations stated that the CVR is below 45% of the vessel diameter. 14 Larger lumens caused larger endothelial damage. Injury to endothelium is accompanied by loss of protective molecules and expressioin of adhesive molecules, procoagulant activites and mitogenic factors leading to development of thrombosis. 15 Majority of CRT are asymptomatic which can make identificatioin difficult. The clinical features may be fairly self-evident such as arm or neck swelling and discomfort or venous distension. In some cases, patient may experience atypical symptoms such as jaw or shoulder pain, headache, erythema of limb, phlebitis, localised numbness and pain. 7 Consensus opinion for the treatment of CRT is systemic anticoagulation such as low molecular wight heparin (LMWH) for minimum of three months. 7,16 Based on current guidelines, anticoagulation for the routine prevention of CRT is not recomended, although it is expected that vast maority of critical care patients will receive LMWH or low dose heparin (1 mg/ day) as standard care prophylaxis without increase in bleeding risk. 17,18 In our study, one patient passed away. We hope that in the future prophylactic anticoagulation can be given to high risk patients in order to avoid such major complications.
Limitations of our study are we only took data from the past one year since this is still a preliminary study. Another limitation is that this is a retrospective study. There are many factors that may impact thrombosis, it is difficult to account for all confounding variables with this study design. Further recommendations are we suggest study with prospective methods and larger studies are required.

Conclusion
The incidence of double lumen catheter induced thrombosis is low (1.1%) in patients undergoing hemodialysis. However, further larger study is needed to confirm and find the associating factors.

Acknowledgement
The abstract of this study has been presented as a poster in the International Society on Thrombosis Haemostatis 2019 in Melbourne, 8

Endothelial Damage
Catheter insertion