Central Venous Catheters (CVCs) are one of the leading potential causes of an Upper Extremity Deep Vein Thrombosis (UEDVT) and the best way to reduce the risk of Upper Extremity DVTs is for the Vascular Access clinician to carefully place lines following the highest standards of care set by applicable nursing associations and societies.
An UEDVT is defined by a DVT (blood clot) in the peripheral veins of the arms. These veins include the basilic vein, brachial vein, cephalic vein, and other veins up to their junction to the axillary vein. These veins are accessed by the placement of CVCs such as Peripherally Inserted Central Catheters (PICCs) and Internal Jugulars (IJs) and non-CVCs such as Midlines. If a DVT is present or suspected in the affected extremity, the Vascular Access clinician should follow the American College of Chest Physicians (“CHEST”) guidelines to best manage the DVT. Since Midlines can present with an UEDVT, the Vascular Access clinician should also follow the same protocols. Some common symptoms of an UEDVT are swelling, redness, warmth and arm pain and, when present, should be evaluated.
How to reduce the risk of Upper Extremity DVTs during PICC or other CVC placement?
To reduce the risk of Upper Extremity DVTs during PICC or other CVC placement, the Vascular Access clinician should do the following:
- Ensure that the catheter to vein ratio is less than 45%. One of the best ways to measure the ratio is to use an Ultrasound machine (US) as it will measure the percentage of the vein that the catheter will reside in. The catheter diameter that best fits inside the vein is measured using a French scale for CVCs and a Gauge scale for IVs. In the case of a French scale, the diameter size increases with the catheter size as opposed to a Gauge scale where the diameter size is inversely proportional to the catheter size. For example, a 10 French catheter is exactly twice the size of a 5 French catheter, and a 22 Gauge catheter has a smaller diameter than a 14 Gauge catheter. (See picture of the catheter to vein ratio at the beginning of this article.) This picture shows the US calculating the catheter to vein ratio. In this case, the catheter size is a 4 French represented by the white circle, inside the vein, and the vein is represented by the black circle being measured by the US as shown by the dotted blue line around it.
- Place the PICC on the right side of the body versus the left side as the pathway of the PICC to the Superior Vena Cava (SVC) is a more direct and easier route for the catheter. If the PICC is placed on the left side, the PICC must travel across the body through the Left Innominate Vein to get to the SVC.
- Thread the PICC from the brachial/basilic vein into axillary vein instead of the cephalic vein. The pathway of the cephalic vein to the axillary vein is much more angled than the straight brachial/basilic vein pathway and, as a result, may decrease blood flow causing an increased risk of UEDTVs.
- Avoid “double stuffing” veins such as two catheters or a catheter and pacemaker wires into a single vein whenever possible as this decreases blood flow and can increase UEDVT risk.
- Place the catheter in the lower third (1/3) of SVC or Cavoatrial Junction (CAJ). This is the optimal placement as the upper SVC is thinner and can increase the risk of UEDVTs.
- Properly evaluate the patient to prevent unnecessary needle sticks as they can increase the risk of DVT.
What do the CHEST guidelines recommend to manage a placed CVC line in the presence Upper Extremity DVTs?
In the presence of UEDVTs, CHEST guidelines recommend the following:
- If a patient has an UEDVT in association with a placed CVC, and the line is no longer needed for treatment or therapy, the CVC should be removed unless the treating physician determines to treat the UEDVT through the line. In general, UEDVT treatment can commence prior to the line being removed.
- If a patient is symptomatic or in extreme pain or the placed CVC is non- functioning, the CVC should be removed. In general, UEDVT treatment can commence prior to the line being removed.
- If a patient has a confirmed UEDVT in association with a placed CVC and the line is still needed for therapy, that CVC should remain in place. In this case, CHEST recommends treating the UEDVT through the line, if necessary, such as by using IV anticoagulants, Heparin or other routes of anticoagulant therapies, and continue such treatment for at least 3 months or as determined by the managing physician. By pulling a CVC when therapy is still needed, the clinician can increase the risk of dislodging the clot and increase the risk of a DVT in the other arm or another location immediately or at a future time.
- Ensure that the patient does not use any kind of compression such as constrictive clothing, bandage or wrap on the arm in which the PICC is inserted. Any kind of compression on the patient’s arm or pathway of the PICC can decrease blood flow through the veins, therefore increasing risk of UEDVTs.
Why reduce the risk of having an UEDVT?
In general, DVTs can harm veins. Reducing the risk of having an UEDVT will not only help preserve the veins but the health of the patient. Veins are not renewable resources and damage to the veins can negatively impact the patient immediately or in the long term. In addition, complications from having a DVT can lead to Pulmonary Embolism (PE,) recurrent UEDVTs, and Post -Thrombotic syndrome (PTS) that can further harm the veins and the patient.
Vascular Wellness clinicians are well trained in managing the risk of UEDVTs. Not only do we follow all best practices, our clinicians are also trained in advanced vascular access procedures such as Small Bore Lines (e.g., Internal Jugular, Femoral and Axillary lines) and Large Bore Lines giving our clinicians additional tools and solutions for patients with risk of UEDVTs.