Vascular Access Devices: A Retrospective Review Amongst Patients Treated at the Ottawa Hospital with Induction Chemotherapy for Acute Leukemia.

As part of the care of patients with acute leukemia, central vascular access is important in order to safely and reliably deliver chemotherapy, antibiotics, blood products and nutrition as needed. Two examples of these vascular access devices are peripherally inserted central venous catheters (PICC) and Hickman^® catheters (Bard Access Systems, Inc., Salt Lake City, Utah). Each has its set of unique benefits and weaknesses. Some are related to the location where they enter the vascular system but others such as risk of infection, device occlusion or incidence of deep vein thrombosis (DVT) are less clear between devices.

Patients included in this study had a diagnosis of acute leukemia (lymphoblastic [ALL] or myeloid [AML]) between September 1996 and April 2009, had a central venous access device inserted (PICC or a Hickman^®), received induction chemotherapy and survived at least 20 days. In that time period, the method of insertion of both devices has changed since January 1^st 2007. Prior to this date, a specially trained nurse using palpation inserted the PICC at the patient's bedside into veins located in the antecubital fossa (PICC-palp). After this date, the same nursing team began inserting PICCs using ultrasound guidance and modified seldinger technique into veins proximal to the antecubital fossa (PICC-U/S). Hickman^® catheters, previously inserted in the operating room by a surgeon (H-Surg), since January 1^st 2007 have been inserted in the angiographic suite by an interventional radiologist (H-IR). The four groups were analyzed for differences in basic demographics. Comparisons between the four devices included the presence of cellulitis at the catheter exit site and whether or not there was an infection accompanied at the site, confirmed bacteremia, the need to administer a thrombolytic agent to unblock the device, a DVT around the device, and whether or not the line had to be removed. The four groups were compared for differences using the Kruskal-Wallis Test for continuous variables and the chi-square test for categorical variables.

147 patients were identified. 55 had a Hickman^® catheter (18 H-Surg and 37 H-IR) and 92 had a PICC (69 PICC-palp and 23 PICC-U/S). The median age (range) within the four groups H-Surg, H-IR, PICC-palp, and PICC-U/S were 54 (20-72), 52 (17-69), 51 (18-73), 56 (19-73), respectively. Males made up 49-56% of each group. ALL ranged between 6 and 9% within each group. The only significant difference between the four groups was whether they were inserted from the right or left side with 89-100% of the Hickman^® catheters being inserted on the right vs. 59-74% of the PICCs being inserted on the right (p<0.0001). The most significant improvements from H-Surg to H-IR catheters are the reduction in catheter exit site cellulitis accompanied by exit site infections (27.8% to 5.4%, p=0.04) and in bacteremia counts (72.2% to 27.0%, p=0.01). There were no statistically significant findings from PICC-palp to PICC-U/S; however, the most clinically relevant improvements showed decreases in cellulitis and DVT cases from 60.9% to 39.1% (p=0.07) and 24.6% to 8.7% (p=0.07), respectively. H-IR catheters were shown to outperform PICC-U/S in DVT cases (0.0% vs. 8.7%), and the need to administer a thrombolytic agent (8.1% vs. 69.6%, p<0.0001). upon comparing PICCs vs. Hickman^® catheters, the number of catheter exit site cellulitis cases were fewer in the PICC catheters (55.4% vs. 76.4%, p=0.01); however, Hickman^® catheters prevailed over PICCs when comparing cases of DVT (0.0% vs. 20.7%) and the need to administer a thrombolytic agent (5.5% vs. 59.8%, p<0.0001). The difference in catheter removal across all four groups was similar ranging from 24-33%.

Despite small sample groups it appears that both vascular access devices have shown improvements from pre to post 2007 insertion methods. Patients treated at the Ottawa Hospital with intensive chemotherapy for acute leukemia currently appear to demonstrate less complications with Hickman^® catheters, inserted by interventional radiologists, compared to PICCs, especially in the most clinically relevant spheres (i.e. bacteremia, incidence of DVT and need for thrombolytic agents to unblock the catheter). This suggests that Hickman^® catheters provide a more reliable central vascular access in these patients. A larger sample size or a randomized control trial would be needed to confirm these observations.

No relevant conflicts of interest to declare.