Clinical Study of Peripherally Inserted Central Catheter-Related Thrombosis and Its Influence on the Blood Flow Status of the Inserted Veins in Cancer Patients
目的 探讨肿瘤患者经外周静脉置入中心静脉导管（peripherally inserted central catheters, PICC）置管后2周内导管相关性血栓（PICC-related thrombosis, PICCRT）形成情况及其对置管静脉血流状态的动态影响，为实施血栓防控措施提供依据。 方法 2019年5月–2020年7月，前瞻性纳入四川大学华西医院PICC置管的实体肿瘤患者，用彩色多普勒超声仪检测患者置管后2周内PICCRT形成情况，根据是否发生PICCRT以及有无血栓相关症状和体征，分为无血栓组、非症状性血栓组和症状性血栓组。比较每个时点PICCRT患者检出情况，及其置管前1天和置管后2周内置管静脉的血管直径和血流速度。 结果 有173例患者完成试验，126例（72.8%）形成了PICCRT，且均发生在置管后1周内。其中非症状性血栓95例，症状性血栓31例。PICC置管前后，非症状性血栓组和症状性血栓组的血管直径均小于无血栓组，血流速度慢于无血栓组，且差异随着导管留置时间延长而持续增加，差异均有统计学意义。 结论 PICC置管时选择血管直径大、血流速度快的静脉穿刺置管，可能有助于降低PICCRT；置管后1周是预防PICCRT的重点干预时间。
- 经外周静脉置入中心静脉导管 /
- 导管相关性血栓 /
- 血管直径 /
Objective To investigate the clinical features of peripherally inserted central catheter (PICC)-related thrombosis (PICCRT) within 2 weeks after PICC placement in cancer patients and its dynamic influence on the blood flow status of veins inserted with catheter, and to provide support for implementing thrombosis prevention and control measures. Methods Between May 2019 and July 2020, patients who had solid tumors and who had PICC were prospectively enrolled at West China Hospital, Sichuan University. Scheduled color Doppler imaging was performed to examine the status of PICCRT formation at 8 points of time, with the first one conducted one day before the insertion of PICC and the other 7 completed within 2 weeks after the insertion of PICC. Then, based on whether patients had PICCRT, the patients were divided into two groups, a non-PICCRT group and a PICCRT group. The PICCRT group was further divided into two subgroups, an asymptomatic PICCRT group and a symptomatic PICCRT group, according to whether the patients had thrombosis-related symptoms and signs. Comparisons were made to study the incidence of PICCRT and the vascular diameter and the blood flow velocity in the veins inserted with catheters at different points of time in the patients of different groups. Results Among 173 cancer patients in the cohort, 126 (72.8%) developed PICCRT, all of which occurred within 1 week after PICC insertion. There were 95 cases of asymptomatic PICCRT and 31 cases of symptomatic PICCRT. Before and after PICC insertion, the vascular diameter of both the asymptomatic and symptomatic PICCRT groups was significantly smaller than that of the non-PICCRT group and the blood flow velocity was significantly slower than that of the non-PICCRT group, with the difference continuing to increase with the prolongation of catheter indwelling time. Conclusion Inserting catheters in veins with bigger vascular diameter and faster blood flow velocity may help reduce the incidence of PICCRT. The first week post catheter insertion is the key intervention period for the prevention of PICCRT.
表 1 PICC置管前后血流速度
Table 1. Blood flow velocity before and after PICC placement
Time Non-PICCRT group
(n=47, $\bar x \pm s$)
(n=95, $\bar x \pm s$)
(n=31, $\bar x \pm s$)
F* P d0 21.77±4.59 13.25±5.32 11.48±6.58 48.613 <0.001 d1 21.19±5.31 10.24±5.87 8.27±7.14 63.935 <0.001 d3 20.95±5.37 9.34±6.11 8.09±7.65 63.216 <0.001 d5 21.20±5.44 8.99±6.66 7.04±6.95 68.366 <0.001 d7 21.19±5.20 7.91±6.61 5.73±6.51 85.372 <0.001 d9 20.51±4.81 7.38±6.70 5.24±6.19 85.769 <0.001 d11 20.44±5.82 7.11±6.83 5.33±6.26 78.362 <0.001 d13 20.34±7.01 6.21±6.81 4.01±5.02 86.106 <0.001 F=1.717 P<0.001 F=18.643 P<0.001 F=7.486 P<0.001 Unit of blood flow velocity: cm/s. * Comparison among three groups: Non-PICCRT, asymptomatic PICCRT, and symptomatic PICCRT. Non-PICCRT vs. asymptomatic PICCRT, Fintergroup*time=15.368, P<0.001; symptomatic PICCRT vs. asymptomatic PICCRT, Fintergroup*time=25.664, P<0.001; symptomatic PICCRT vs. non-PICCRT, Fintergroup*time=4.564, P<0.001.
表 2 PICC置管前后血管直径
Table 2. Vascular diameter before and after PICC placement
Time Non-PICCRT group
(n=47, $\bar x \pm s$)
(n=95, $\bar x \pm s$)
(n=31, $\bar x \pm s$)
F* P d0 5.69±0.65 4.27±0.80 4.19±0.92 57.055 <0.001 d1 5.65±0.64 4.19±0.82 4.03±0.77 66.250 <0.001 d3 5.58±0,66 3.97±0.78 3.71±0.87 83.542 <0.001 d5 5.54±0.71 3.82±0.98 3.54±1.16 61.109 <0.001 d7 5.48±0.80 3.75±0.99 3.47±1,13 59.251 <0.001 d9 5.40±0.71 3.60±1.09 3.35±1.09 59.904 <0.001 d11 5.40±0.67 3.54±1.08 3.33±1.09 64.507 <0.001 d13 5.35±0.71 3.50±1.08 3.24±1.20 60.723 <0.001 F=3.622
Unit of vascular diameter: mm.*Comparison among three groups: Non-PICCRT, asymptomatic PICCRT, and symptomatic PICCRT. Non-PICCRT vs. asymptomatic PICCRT, Fintergroup*time=16.627, P<0.001; symptomatic PICCRT vs. asymptomatic PICCRT, Fintergroup*time=20.155, P<0.001; symptomatic PICCRT vs. Non-PICCRT, Fintergroup*time=8.142, P<0.001.
 BERTOGLIO S, FACCINI B, LALLI L, et al. Peripherally inserted central catheters (PICCs) in cancer patients under chemotherapy: a prospective study on the incidence of complications and overall failures. J Surg Oncol,2016,113(6): 708–714. doi: 10.1002/jso.24220  WALSHE L J, MALAK S F, EAGAN J, et al. Complication rates among cancer patients with peripherally inserted central catheters. J Clin Oncol,2002,20(15): 3276–3281. doi: 10.1200/JCO.2002.11.135  TREROTOLA S O, STAVROPOULOS S W, MONDSCHEIN J I, et al. Triple-lumen peripherally inserted central catheter in patients in the critical care unit: prospective evaluation. Radiology,2010,256(1): 312–320. doi: 10.1148/radiol.10091860  NIFONG T P, MCDEVITT T J. The effect of catheter to vein ratio on blood flow rates in a simulated model of peripherally inserted central venous catheters. Chest,2011,140(1): 48–53. doi: 10.1378/chest.10-2637  宋燕伶, 何金爱, 刘胤佃, 等. PICC导管/静脉直径比最佳临界值的研究. 中国护理管理,2017,17(6): 737–742. doi: 10.3969/j.issn.1672-1756.2017.06.005  SHARP R, CUMMINGS M, FIELDER A, et al. The catheter to vein ratio and rates of symptomatic venous thromboembolism in patients with a peripherally inserted central catheter (PICC): a prospective cohort study. Int J Nurs Stud,2015,52(3): 677–685. doi: 10.1016/j.ijnurstu  TREZZA C, CALIFANO C, IOVINO V, et al. Incidence of fibroblastic sleeve and of catheter-related venous thrombosis in peripherally inserted central catheters: a prospective study on oncological and hematological patients. J Vasc Access,2021,22(3): 444–449. doi: 10.1177/1129729820949411  CHOPRA V, FALLOUH N, MCGUIRK H, et al. Patterns, risk factors and treatment associated with PICC-DVT in hospitalized adults: a nested case-control study. Thromb Res,2015,135(5): 829–834. doi: 10.1016/j.thromres.2015.02.012  YI XL, CHEN J, LI J, et al. Risk factors associated with PICC-related upper extremity venous thrombosis in cancer patients. J Clin Nurs,2014,23(5/6): 837–843. doi: 10.1111/jocn.12227  LIU Y, GAO Y, WEI L, et al. Peripherally inserted central catheter thrombosis incidence and risk factors in cancer patients: a double-center prospective investigation. Ther Clin Risk Manag,2015,11: 153–160. doi: 10.2147/TCRM.S73379  WANG G, LU Y, WU C, et al. The clinical features and related factors of PICC-related upper extremity asymptomatic venous thrombosis in cancer patients: a prospective study. Medicine (Baltimore),2020,99(12): e19409. doi: 10.1097/MD.0000000000019409  RAJASEKHAR A, STREIFF M B. How I treat central venous access device-related upper extremity deep vein thrombosis. Blood,2017,129(20): 2727–2736. doi: 10.1182/blood-2016-08-693671  宋燕伶, 何金爱, 刘胤佃, 等. 置管静脉/导管直径比例对PICC相关性静脉血栓的影响. 护理研究,2017,31(12): 1470–1473. doi: 10.3969/j.issn.1009-6493.2017.12.019  陈江琼, 张杰, 康楠, 等. 超声造影在经外周静脉穿刺中心静脉置管相关性血栓诊断中的应用价值. 中华血管外科杂志,2017,2(2): 122–126. doi: 10.3760.cma.j.issn.2096-1863.2017.02.011  SONG X, LU H, CHEN F, et al. A longitudinal observational retrospective study on risk factors and predictive model of PICC associated thrombosis in cancer patients. Sci Rep,2020,10(1): 10090. doi: 10.1038/s41598-020-67038-x  傅麒宁, 吴洲鹏, 孙文彦, 等. 《输液导管相关静脉血栓形成中国专家共识》临床实践推荐. 中国普外基础与临床杂志,2020,27(4): 412–418. doi: 10.7507/1007-9424.202001030  WALL C, MOORE J, THACHIL J. Catheter-related thrombosis: a practical approach. J Intensive Care Soc,2016,17(2): 160–167. doi: 10.1177/1751143715618683  CHEN Y, CHEN H, YANG J, et al. Patterns and risk factors of peripherally inserted central venous catheter-related symptomatic thrombosis events in patients with malignant tumors receiving chemotherapy. J Vasc Surg Venous Lymphat Disord,2020,8(6): 919–929. doi: 10.1016/j.jvsv.2020.01.010  AHN D H, ILLUM H B, WANG D H, et al. Upper extremity venous thrombosis in patients with cancer with peripherally inserted central venous catheters: a retrospective analysis of risk factors. J Oncol Pract,2013,9(1): e8–e12. doi: 10.1200/JOP.2012.000595  Al-ASADI O, ALMUSARHED M, ELDEEB H. Predictive risk factors of venous thromboembolism (VTE) associated with peripherally inserted central catheters (PICC) in ambulant solid cancer patients: retrospective single Centre cohort study. Thromb J,2019,17: 2. doi: 10.1186/s12959-019-0191-y  JONES D, WISMAYER K, BOZAS G, et al. The risk of venous thromboembolism associated with peripherally inserted central catheters in ambulant cancer patients. Thromb J,2017,15: 25. doi: 10.1186/s12959-017-0148-y  KANG J R, LONG L H, YAN S W, et al. Peripherally inserted central catheter-related vein thrombosis in patients with lung cancer. Clin Appl Thromb Hemost,2017,23(2): 181–186. doi: 10.1177/1076029615595880  ITKIN M, MONDSHEIN J I, STAVIOPOULOS S W, et al. Peripherally inserted central catheter thrombosis-reverse tapered versus nontapered catheters: a randomized controlled study. J Vasc Interv Radiol,2014,25(1): 85–91.e81. doi: 10.1016/j.jvir.2013.10.009  崔其亮, 谢亦农, 梁伟翔, 等. 彩色多普勒检测新生儿外周穿刺置入中心静脉导管对血流动力学的影响. 中国实用儿科杂志,2004,19(10): 599–601. doi: 10.3969/j.issn.1005-2224.2004.10.008  NITESCU P, LARSSON N, ERIKSSON E, et al. Disturbances of blood-flow velocity in the dorsal veins of the hand after vein cannulation and cannula fixation in the anaesthetised patient. Acta Anaesthesiol Scand,1990,34(2): 120–125. doi: 10.1111/j.1399-6576.1990.tb03055.x