Summary of recommendations by clinical guidelines on the prevention and treatment of CRT
| Guideline . | Prevention . | Treatment . |
|---|---|---|
| ACCP 201244 , 201649 * | In outpatients with cancer and indwelling CVAD, suggest against routine prophylaxis with LMWH or LDUH (grade 2B) or VKAs (grade 2C). | In patients with acute UEDVT: |
| Recommend parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) over no anticoagulation (grade 1B). | ||
| Suggest LMWH or fondaparinux over IV UFH (grade 2C) and over SC UFH (grade 2B). | ||
| Suggest anticoagulant therapy alone over thrombolysis (grade 2C). | ||
| If thrombolysis is administered, recommend the same intensity and duration of anticoagulant therapy compared with nonthrombolysis patients (grade 1B). | ||
| Suggest that the CVAD not be removed if it is functional and there is an ongoing need for the catheter (grade 2C). | ||
| If CVAD is removed, 3 mo of anticoagulation is recommended over a longer duration of therapy in noncancer patients (grade 1B). The same approach is suggested in cancer patients (grade 2C). | ||
| If CVAD is not removed, anticoagulation is recommended over stopping after 3 mo of treatment in cancer patients (grade 1C). The same approach is suggested in noncancer patients (grade 2C). | ||
| American Society of Clinical Oncology 201345 | In cancer patients with CVADs: | In cancer patients with CRT: |
| Routine thromboprophylaxis is not recommended. | t-PA is recommended to restore patency and preserve catheter function. | |
| Routine CVAD flushing with saline is recommended. | CVAD removal is recommended if thrombosis does not respond to fibrinolytic therapy or if fibrinolytic or anticoagulation therapy is contraindicated. | |
| Data are insufficient to recommend routine thrombolytics to prevent catheter occlusion. | 3-6 mo of anticoagulant therapy with LMWH or LMWH followed by warfarin (INR, 2.0-3.0) is recommended for treatment of symptomatic CRT. | |
| European Society for Medical Oncology 201548 † | In cancer patients with CVADs: | In cancer patients with CRT: |
| Routine thromboprophylaxis is not recommended. | LMWH is preferred over VKA (grade II, A). | |
| Prophylaxis with thrombolytic agents is not recommended (grade I, A). | Anticoagulation treatment should be continued for the length of time the catheter is in use (grade III, C). | |
| Saline flushing is recommended (grade III, C). | If CVAD is nonfunctional, the CVAD should be removed after a short course (3-5 d) of anticoagulation (grade I, A). | |
| LMWH alone or LMWH followed by warfarin should be used for a minimum of 3-6 mo (grade I, C). | ||
| After treatment of CRT, prophylactic doses of anticoagulation should be continued as long as the CVAD remains indwelling (grade I, C). | ||
| Thrombolytic therapy is not routinely recommended (grade I, B). | ||
| International Guideline 201346 ‡ | In cancer patients with CVADs: | In cancer patients with CRT: |
| Routine thromboprophylaxis is not recommended (grade 1A). | Anticoagulation is recommended for a minimum 3 mo. | |
| Catheters should be inserted on the right side, in the jugular vein, with catheter tip in the junction of the SVC and the right atrium (grade 1A). | LMWHs are suggested but VKA can also be used. | |
| CVAD removal is not required if functional, well positioned, and not infected. | ||
| Whether or not the CVAD is removed, no standard approach in terms of duration of anticoagulation is established (best clinical practice). | ||
| National Comprehensive Cancer Network 201347 § | In cancer patients with CVADs: | In cancer patients with CRT: |
| Routine thromboprophylaxis is not recommended (grade 2A). | Anticoagulation is recommended for as long as the CVAD remains indwelling. | |
| If the CVAD is removed, at least 3 mo of anticoagulation is recommended. | ||
| Consider CVAD removal if symptoms persist, if the CVAD is nonfunctional, or if it is no longer necessary. | ||
| Consider catheter-directed thrombolysis in select cases. |
| Guideline . | Prevention . | Treatment . |
|---|---|---|
| ACCP 201244 , 201649 * | In outpatients with cancer and indwelling CVAD, suggest against routine prophylaxis with LMWH or LDUH (grade 2B) or VKAs (grade 2C). | In patients with acute UEDVT: |
| Recommend parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) over no anticoagulation (grade 1B). | ||
| Suggest LMWH or fondaparinux over IV UFH (grade 2C) and over SC UFH (grade 2B). | ||
| Suggest anticoagulant therapy alone over thrombolysis (grade 2C). | ||
| If thrombolysis is administered, recommend the same intensity and duration of anticoagulant therapy compared with nonthrombolysis patients (grade 1B). | ||
| Suggest that the CVAD not be removed if it is functional and there is an ongoing need for the catheter (grade 2C). | ||
| If CVAD is removed, 3 mo of anticoagulation is recommended over a longer duration of therapy in noncancer patients (grade 1B). The same approach is suggested in cancer patients (grade 2C). | ||
| If CVAD is not removed, anticoagulation is recommended over stopping after 3 mo of treatment in cancer patients (grade 1C). The same approach is suggested in noncancer patients (grade 2C). | ||
| American Society of Clinical Oncology 201345 | In cancer patients with CVADs: | In cancer patients with CRT: |
| Routine thromboprophylaxis is not recommended. | t-PA is recommended to restore patency and preserve catheter function. | |
| Routine CVAD flushing with saline is recommended. | CVAD removal is recommended if thrombosis does not respond to fibrinolytic therapy or if fibrinolytic or anticoagulation therapy is contraindicated. | |
| Data are insufficient to recommend routine thrombolytics to prevent catheter occlusion. | 3-6 mo of anticoagulant therapy with LMWH or LMWH followed by warfarin (INR, 2.0-3.0) is recommended for treatment of symptomatic CRT. | |
| European Society for Medical Oncology 201548 † | In cancer patients with CVADs: | In cancer patients with CRT: |
| Routine thromboprophylaxis is not recommended. | LMWH is preferred over VKA (grade II, A). | |
| Prophylaxis with thrombolytic agents is not recommended (grade I, A). | Anticoagulation treatment should be continued for the length of time the catheter is in use (grade III, C). | |
| Saline flushing is recommended (grade III, C). | If CVAD is nonfunctional, the CVAD should be removed after a short course (3-5 d) of anticoagulation (grade I, A). | |
| LMWH alone or LMWH followed by warfarin should be used for a minimum of 3-6 mo (grade I, C). | ||
| After treatment of CRT, prophylactic doses of anticoagulation should be continued as long as the CVAD remains indwelling (grade I, C). | ||
| Thrombolytic therapy is not routinely recommended (grade I, B). | ||
| International Guideline 201346 ‡ | In cancer patients with CVADs: | In cancer patients with CRT: |
| Routine thromboprophylaxis is not recommended (grade 1A). | Anticoagulation is recommended for a minimum 3 mo. | |
| Catheters should be inserted on the right side, in the jugular vein, with catheter tip in the junction of the SVC and the right atrium (grade 1A). | LMWHs are suggested but VKA can also be used. | |
| CVAD removal is not required if functional, well positioned, and not infected. | ||
| Whether or not the CVAD is removed, no standard approach in terms of duration of anticoagulation is established (best clinical practice). | ||
| National Comprehensive Cancer Network 201347 § | In cancer patients with CVADs: | In cancer patients with CRT: |
| Routine thromboprophylaxis is not recommended (grade 2A). | Anticoagulation is recommended for as long as the CVAD remains indwelling. | |
| If the CVAD is removed, at least 3 mo of anticoagulation is recommended. | ||
| Consider CVAD removal if symptoms persist, if the CVAD is nonfunctional, or if it is no longer necessary. | ||
| Consider catheter-directed thrombolysis in select cases. |
LDUH, low-dose unfractionated heparin; SC, subcutaneous; t-PA, tissue plasminogen activator; UFH, unfractionated heparin.
Levels of evidence and grades of recommendation adapted from the ACCP-modified GRADE approach.75
Levels of evidence and grades of recommendation adapted from the Infectious Diseases Society of America-US Public Health Service Grading System.
Levels of evidence and grades of recommendations are based on the international GRADE approach.76,77
Levels of evidence and grading of recommendations are based on the NCCN categories of evidence and consensus.47