{"markup":"\u003C?xml version=\u00221.0\u0022 encoding=\u0022UTF-8\u0022 ?\u003E\n    \u003Chtml version=\u0022HTML+RDFa+MathML 1.1\u0022\n    xmlns:content=\u0022http:\/\/purl.org\/rss\/1.0\/modules\/content\/\u0022\n    xmlns:dc=\u0022http:\/\/purl.org\/dc\/terms\/\u0022\n    xmlns:foaf=\u0022http:\/\/xmlns.com\/foaf\/0.1\/\u0022\n    xmlns:og=\u0022http:\/\/ogp.me\/ns#\u0022\n    xmlns:rdfs=\u0022http:\/\/www.w3.org\/2000\/01\/rdf-schema#\u0022\n    xmlns:sioc=\u0022http:\/\/rdfs.org\/sioc\/ns#\u0022\n    xmlns:sioct=\u0022http:\/\/rdfs.org\/sioc\/types#\u0022\n    xmlns:skos=\u0022http:\/\/www.w3.org\/2004\/02\/skos\/core#\u0022\n    xmlns:xsd=\u0022http:\/\/www.w3.org\/2001\/XMLSchema#\u0022\n    xmlns:mml=\u0022http:\/\/www.w3.org\/1998\/Math\/MathML\u0022\u003E\n  \u003Chead\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_itu2PgFdrjV-docKmLK8Jn5oXe_05RgvQh73eOhI_mE.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_at_symbol.js?nzoa82\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_article_reference_popup.js?nzoa82\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_I8yX6RYPZb7AtMcDUA3QKDZqVkvEn35ED11_1i7vVpc.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\n(function(i,s,o,g,r,a,m){i[\u0022GoogleAnalyticsObject\u0022]=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)})(window,document,\u0022script\u0022,\u0022\/\/www.google-analytics.com\/analytics.js\u0022,\u0022ga\u0022);ga(\u0022create\u0022, \u0022UA-15605596-27\u0022, {\u0022cookieDomain\u0022:\u0022auto\u0022});ga(\u0022set\u0022, \u0022page\u0022, location.pathname + location.search + location.hash);ga(\u0022send\u0022, \u0022pageview\u0022);ga(\u0027create\u0027, \u0027UA-189672-26\u0027, \u0027auto\u0027, {\u0027name\u0027: \u0027hwTracker\u0027});\r\nga(\u0027hwTracker.send\u0027, \u0027pageview\u0027);\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\njQuery.extend(Drupal.settings, {\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/55\\\/23\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/55\\\/23\u0022}],\u0022ac\u0022:{\u0022spmdc;14\\\/55\\\/23\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;14\\\/55\\\/23\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EMore cancer patient-specific data are needed to guide prevention and treatment of venous thromboembolism in patients with cancer. Longer-term treatment decision factors include bleeding risk and sex. Catheter removal in the event of thrombosis should be considered carefully. Direct oral anticoagulants are discouraged.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Epulmonary embolism\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Evenous thromboembolism\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecatheter-related thrombosis\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecancer\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emanagement\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ENew Insights in Treatment\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EStephan Moll, MD, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA, reviewed the decision-making process in treating patients with pulmonary embolism (PE) or venous thromboembolism (VTE).\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003ETreatment at the time of PE or VTE diagnosis is guided by how sick the patient is. Outpatient treatment is feasible for half of patients with PE and for those with deep vein thrombosis (DVT) who are mobile at the time of clinical assessment. Risk assessment scoring tools to assess PE-related 30-day mortality [Barra SNC et al. \u003Cem\u003EClin Cardiol.\u003C\/em\u003E 2013] include the Hestia criteria [Zondag W et al. \u003Cem\u003EJ Thromb Haemost.\u003C\/em\u003E 2011], which can assess patients with PE suitable for outpatient management irrespective of right ventricular function [Zondag W et al. \u003Cem\u003EJ Thromb Haemost.\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003ECatheter-directed thrombolysis of newly diagnosed DVT seems to lessen postthrombotic syndrome at the expense of increased risk of bleeding [Enden T et al. \u003Cem\u003ELancet.\u003C\/em\u003E 2012]. The ATTRACT trial [Vedantham S et al. \u003Cem\u003EAm Heart J.\u003C\/em\u003E 2013] is further assessing the value of catheter-directed thrombolysis.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EAt the time of diagnosis, the risk of mortality associated with PE can be assessed based on blood pressure, serum cardiac enzymes (troponin or brain natriuretic peptide levels), and right ventricle function [Meyer G et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2014; Jaff MR et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2011; Torbicki A et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2008]. Concerning PE, thrombolytic therapy is indicated only for high-risk patients, although the risks and benefits of thrombolytic therapy in younger patients with submassive PE (i.e., right heart strain plus cardiac enzyme positivity) remain unclear.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EAnother treatment decision at diagnosis is whether to use anticoagulation with low-molecular-weight heparin (LMWH) and warfarin or one of the non\u2013vitamin K antagonist oral anticoagulants (NOACs). NOACs are a good treatment choice for inpatient\/outpatient treatment of patients with mild to moderate VTE, and they should be discussed for patients receiving long-term warfarin. NOACs are not recommended for patients with renal impairment, appreciable liver disease, or heightened risk of bleeding, or for very underweight or severely obese patients. Low-molecular-weight heparin is still the gold standard in patients with cancer-associated DVT or PE.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EIn the early days following diagnosis, compression stockings had no benefit in preventing postthrombotic syndrome in a placebo-controlled study [Kahn SR et al. \u003Cem\u003ELancet.\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThe length of anticoagulant treatment (ie, 3 months vs long term) is weighed on an individual basis (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Longer-Term Anticoagulant TreatmentNOAC, non\u0026#x2013;vitamin K antagonist oral anticoagulant; VTE, venous thromboembolism.Reproduced with permission from S Moll, MD.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2099842582\u0022 data-figure-caption=\u0022Longer-Term Anticoagulant TreatmentNOAC, non\u0026#x2013;vitamin K antagonist oral anticoagulant; VTE, venous thromboembolism.Reproduced with permission from S Moll, MD.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11581\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003ELonger-Term Anticoagulant Treatment\u003C\/p\u003E\n               \u003Cp id=\u0022p-10\u0022\u003ENOAC, non\u2013vitamin K antagonist oral anticoagulant; VTE, venous thromboembolism.\u003C\/p\u003E\n               \u003Cp id=\u0022p-11\u0022\u003EReproduced with permission from S Moll, MD.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EIn the longer term, length of anticoagulation decision factors include whether a VTE was provoked by a major risk factor or was unprovoked (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E), and, in the intermediate-risk-of-recurrence group (ie, patients with VTE associated with minor risk factors, eg, minor surgery, minor immobility, and estrogen therapy), D-dimer and thrombophilia testing. A negative D-dimer (on and\/or off anticoagulation) predicts a lower risk of recurrence and pushes the patient up in the \u201crecurrence triangle\u201d; a positive D-dimer and finding of a strong thrombophilia push the patient down in the triangle, indicating a higher risk of recurrence.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Risk-of-Recurrence Triangle: How Long to Anticoagulate?DVT, deep vein thrombosis; PE, pulmonary embolism; VTE, venous thromboembolism.Reproduced with permission from S Moll, MD.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2099842582\u0022 data-figure-caption=\u0022Risk-of-Recurrence Triangle: How Long to Anticoagulate?DVT, deep vein thrombosis; PE, pulmonary embolism; VTE, venous thromboembolism.Reproduced with permission from S Moll, MD.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11584\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003ERisk-of-Recurrence Triangle: How Long to Anticoagulate?\u003C\/p\u003E\n               \u003Cp id=\u0022p-14\u0022\u003EDVT, deep vein thrombosis; PE, pulmonary embolism; VTE, venous thromboembolism.\u003C\/p\u003E\n               \u003Cp id=\u0022p-15\u0022\u003EReproduced with permission from S Moll, MD.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EFinally, patient education is important to optimize outcomes and patient satisfaction. The \u003Cem\u003EClot Connect\u003C\/em\u003E information resource (\u003Ca href=\u0022http:\/\/www.clotconnect.org\u0022\u003Ewww.clotconnect.org\u003C\/a\u003E) is a nonprofit educational program of the University of North Carolina for patients with DVT or PE and health care professionals looking after them.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EKeeping the Pipes Open in Cancer\u003C\/h2\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EWilliam Geerts, MD, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, spoke on the management of catheter-related thrombosis (CRT) in patients with cancer. Central venous catheters (CVCs; peripherally inserted central catheters, midline catheters, tunneled and nontunneled central catheters, and implanted ports) are used in \u0026gt;\u200925% of inpatients and more than half of those receiving intensive care. Increasingly, the approach is used for outpatients. Resulting CRT includes formation of a pericatheter sheath of fibrin, intraluminal thrombosis, and superficial or deep venous thrombosis (\u003Ca id=\u0022xref-fig-3-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F3\u0022\u003EFigure 3\u003C\/a\u003E) [Baskin JL et al. \u003Cem\u003ELancet.\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F3\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Types of ThrombosisReproduced with permission from W Geerts, MD.Adapted from Baskin JL et al. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet. 2009;374:159\u0026#x2013;169.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2099842582\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Types of ThrombosisReproduced with permission from W Geerts, MD.Adapted from Baskin JL et al. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. \u0026amp;lt;em\u0026amp;gt;Lancet\u0026amp;lt;\/em\u0026amp;gt;. 2009;374:159\u0026#x2013;169.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 3.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F3.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 3.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/55\/23\/F3.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11587\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 3.\u003C\/span\u003E \n               \u003Cp id=\u0022p-18\u0022 class=\u0022first-child\u0022\u003ETypes of Thrombosis\u003C\/p\u003E\n               \u003Cp id=\u0022p-19\u0022\u003EReproduced with permission from W Geerts, MD.\u003C\/p\u003E\n               \u003Cp id=\u0022p-20\u0022\u003EAdapted from Baskin JL et al. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. \u003Cem\u003ELancet\u003C\/em\u003E. 2009;374:159\u2013169.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EThe resulting pathophysiology can involve local venous injury at the insertion site, venous injury and diminished blood flow due to fibrin deposition, and mural thrombosis. CRT is uncomfortable and anxiety producing; necessitates catheter removal and replacement, which increase the risk of infection; can require anticoagulant treatment with its associated risks; and increases health care costs. CVCs are associated with an approximately 7-fold increase in the risk of upper extremity vein thrombosis [Joffe HV et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2004], which are asymptomatic in up to 60% of cases.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003ECatheter-related risk factors of CRT include the type of CVC, catheter size and composition, number of lumens, catheter insertion site and technique, and length of use. Patient- or therapy-related risk factors include the type and extent of cancer, chemotherapy, prior CRT or CVC, and infection. Peripherally inserted central catheters are associated with a greater risk of CRT [Chopra V et al. \u003Cem\u003ELancet.\u003C\/em\u003E 2013], especially with increasing catheter size [Evans RS et al. \u003Cem\u003EChest.\u003C\/em\u003E 2010], and major complications in patients with cancer.\u003C\/p\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EWhen CRT is present, a catheter should not be removed just because of thrombosis; indications for removal are failure to function, suspected infection, or because it is not needed [Debourdeau P et al. \u003Cem\u003EJ Thromb Haemost.\u003C\/em\u003E 2013; Kovacs MJ et al. \u003Cem\u003EJ Thromb Haemost.\u003C\/em\u003E 2007]. Treatment can involve intermediate- or full-dose LMWH, full-dose LMWH, and direct oral Xa or IIa inhibitor. CRT prevention is not achieved using flushes with heparinized saline or warfarin. Instead, avoidance of catheter use if possible, use of the smallest catheter, catheter insertion by experts using ultrasound guidance, and anticoagulant prophylaxis are prudent in patients with cancer.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPrevention and Treatment of Cancer-associated Thrombosis (CAT)\u003C\/h2\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EAgnes Lee, MD, MSc, University of British Columbia, Vancouver, British Columbia, Canada, discussed strategies for the prevention and treatment of VTE in patients with cancer.\u003C\/p\u003E\n         \u003Cp id=\u0022p-25\u0022\u003EInpatient anticoagulant prophylaxis is prudent, if there are no contraindications [Lyman et al. \u003Cem\u003EJ Clin Oncol.\u003C\/em\u003E 2013; Kahn SR et al. \u003Cem\u003EChest.\u003C\/em\u003E 2012; Mandala M et al. \u003Cem\u003EAnn Oncol.\u003C\/em\u003E 2011], for several reasons: the risk of thrombosis is high for patients with various malignancies, most are admitted to hospital for another acute condition like infection, mobility is likely to be reduced, and VTE is associated with significant morbidity and mortality. Of note, although VTE risk is reduced by anticoagulant therapy, up to one-third of hospitalized patients have contraindications for prophylactic anticoagulation [Zwicker JI et al. \u003Cem\u003EJ Clin Oncol.\u003C\/em\u003E 2014]. Patients with cancer who are in one or more of the following categories likely will benefit from prophylaxis: aged\u2009\u2265\u200970 years, body mass index\u2009\u2265\u200930 kg\/m\u003Csup\u003E2\u003C\/sup\u003E, reduced mobility, prior VTE, an acute medical condition, and current hormone therapy [Kahn SR et al. \u003Cem\u003EChest.\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-26\u0022\u003EIn acutely ill patients in general, parenteral anticoagulants (eg, enoxaparin, dalteparin, and fondaparinux) can reduce the risk of VTE during hospitalization [Cohen AT et al. \u003Cem\u003EBMJ.\u003C\/em\u003E 2006; Leizorovicz A et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2004; Samama MM et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 1999]. Prophylaxis with direct oral anticoagulants apixaban or rivaroxaban is noninferior to LMWH, but it increases bleeding [Cohen AT et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2013; Goldhaber SZ et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2011], with no information yet available specifically for patients with cancer. Available data support the use of LMWH, but randomized controlled trials specifically involving patients with cancer are needed to better define the risk\u2013benefit balance.\u003C\/p\u003E\n         \u003Cp id=\u0022p-27\u0022\u003ERegarding extended prophylaxis following hospital discharge, clinical trials have not yet indicated the overall benefit of the strategy, due to the risk of increased bleeding (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E) [Cohen AT et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2013; Goldhaber SZ et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2011; Hull RD et al. \u003Cem\u003EAnn Intern Med.\u003C\/em\u003E 2010].\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/11590\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/11590\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11590\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-28\u0022 class=\u0022first-child\u0022\u003EExtended Prophylaxis Increases Major Bleeding.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-34\u0022\u003EApixaban, rivaroxaban, edoxaban, and dabigatran have proven noninferior to treatment with vitamin K antagonists in the prevention of VTE [Agnelli G et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2013; Hokusai-VTE Investigators. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2013; Schulman S et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2009; EINSTEIN DVT and PE. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2010 and 2012]. While data suggest that these direct oral anticoagulants provide a benefit similar to that of conventional treatment in highly selected patients with cancer [Vedovati MC et al. \u003Cem\u003EChest.\u003C\/em\u003E 2014], their use is discouraged in this population. Drug clearance can be affected by renal dysfunction and hepatic metastases, and drug\u2013drug interactions can diminish treatment efficacy and increase the risk of bleeding, and these drugs have not been compared with LMWH, the standard-of-care therapy for cancer-associated thrombosis.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/55\/23.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzoa82\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzoa82\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzoa82\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}