Increased Risk of PICC Line Thrombosis in Acute Promyelocytic Leukemia.

Introduction: Central venous access catheters are being used at increasing rates in the practice of hematology. Although significant complication rates in patients with solid tumors exist, studies have shown a lower incidence of complications in hematology patients. Recently, we noted an increased incidence of percutaneously inserted central catheters (PICC line) thrombosis in patients with acute promyelocytic leukemia (APL).

Methods: We undertook an evaluation of the medical records of all adult patients with acute leukemia (AL) from the year 1995 to 2005 at our two hematology centers. All indwelling catheters (of which most are PICC lines) at our institutions are inserted by interventional radiologists under fluoroscopic visualization. The catheters are flushed with saline and heparin prophylaxis was not routinely used during this evaluation period. All thrombotic episodes were diagnosed based on clinical and ultrasound duplex studies. Data was collected in reference to catheters, thrombotic and infectious complications, and relationship to diagnosis and treatment.

Results: Of 368 evaluated patients with a central venous catheter and AL, there were 23 incidents of clinically apparent catheter thrombosis (6.2%). The subgroup incidence of catheter thrombosis was nine of 237 (3.8%) patients with acute myelogenous leukemia not including APL (AML), seven of 104 patients (6.7%) with acute lymphoblastic leukemia (ALL), half of the ALL episodes were associated with catheter sepsis, and seven of 25 (28%) with APL. Comparison of the APL group with the AML group is significant at p < 0.03.

Conclusion: There appears to be an increased incidence of PICC line thrombosis in APL patients. This may be secondary to the institution of all trans retinoic acid (ATRA) treatment and the thrombophillia of APL. In ALL patients the slightly raised incidence may be due to the thrombophillia of asparaginase or the increased infectious complications of high dose steroids associated with ALL treatment. Based on these findings we would recommend heparin prophylaxis for APL patients with central venous access lines. Following this evaluation we instituted heparin prophylaxis for newly diagnosed APL patients and found no evidence of clinically apparent thrombosis in 8 consecutive patients. There were no episodes of increased bleeding in these 8 APL patients. Further analysis of the data will be presented.