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A blood clot can form around a central line, such as a port or a PICC. Signs include a swollen, painful or red arm, neck or face, swollen veins on the chest, or a line that will not flush or give blood. An ultrasound scan confirms it. It is treated with blood thinners for at least three months, and the line can often stay in if it still works and is not infected.
Symptomatic catheter-related thrombosis (CRT) is reported in about 4 to 8% of people with cancer and lines (ESMO 2015), and many more clots are found on screening. Signs are often non-specific; the first is often difficulty aspirating or infusing, with local pain, redness, swelling or oedema. Doppler ultrasound is the usual first test [III, A]; venography or other imaging follows when ultrasound is normal but suspicion remains or central occlusion is suspected [III, A].
ITAC (2022, guidance) recommends anticoagulation for at least 3 months and for as long as the catheter is in place, suggesting LMWH, and notes that LMWH, DOACs and VKAs have not been compared directly in CRT. The catheter can stay if it is functional, well positioned and not infected, with symptoms resolving under close surveillance. ESMO (2015) adds that where the line is no longer needed or long-term anticoagulation is contraindicated, 3 to 5 days of anticoagulation before removal is recommended [I, A], and that the line should come out if symptoms progress or the clot extends into the superior vena cava. Routine anticoagulant prophylaxis against CRT is not recommended (ITAC 1A); right-sided jugular insertion with the tip at the cavoatrial junction is (1B), and ITAC suggests ports over PICCs where a central line is needed (guidance).
Why: Line clots often cause vague symptoms; a line that stops working can be the first sign.
“Frequently in clinical practice, the first signs are: difficulty aspirating or infusing through the lumen of the catheter, and complaints of local pain or a burning sensation during injection.”
Why: Ultrasound is quick, painless and finds most line clots.
“Although venography is considered the gold standard for the diagnosis of CRT, Doppler ultrasound is usually carried out [III, A], because it is readily available and non-invasive (sensitivity 56%–100%; specificity 94%–100%)”
ESMO (Annals of Oncology, Sousa et al.) 2015 · [III, A]
Why: Ultrasound cannot see the veins inside the chest well.
“In patients with suspected CRT and a normal ultrasound, or suspected central venous occlusion, venography or alternative imaging should be carried out [magnetic resonance imaging, computed tomography (CT), gadolinium-enhanced magnetic resonance venography or contrast-enhanced CT] [III, A]”
ESMO (Annals of Oncology, Sousa et al.) 2015 · [III, A]
Why: Treatment stops the clot growing or travelling to the lungs while the line, which caused it, is still there.
“For the treatment of symptomatic catheter-related thrombosis in patients with cancer, anticoagulant treatment is recommended for a minimum of 3 months and as long as the central venous catheter is in place; in this setting, LMWHs are suggested and direct comparisons between LMWHs, direct oral anticoagulants, and vitamin K antagonists have not been made (guidance).”
Why: Removing a working line is often unnecessary, and a new line carries its own risks.
“In patients with cancer and with catheter-related thrombosis, the central venous catheter can be kept in place if it is functional, well positioned, and not infected, with good resolution of symptoms under close surveillance while anticoagulation therapy is administered.”
Why: A short course first lowers the chance that pulling the line dislodges the clot.
“When the CVC is no longer necessary, or if long-term anticoagulation is contraindicated, a short course (3–5 days) of anticoagulation therapy is recommended before removing the catheter, in order to avoid clot embolisation [I, A]”
Why: A spreading clot despite treatment, or one in the main vein to the heart, outweighs the value of keeping the line.
“Additionally, if symptoms progress or the blood clot extends into the SVC, the CVC should be removed.”
Why: In trials the bleeding risk outweighed the small reduction in clots for most people.
“Use of anticoagulation for routine prophylaxis of catheter-related thrombosis is not recommended (grade 1A).”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Confirm with Doppler ultrasound (ESMO 2015 [III, A]); anticoagulate for at least 3 months and while the line remains, LMWH suggested (ITAC 2022, guidance); keep a functional, well-positioned, uninfected line; anticoagulate 3 to 5 days before removing a line that is no longer needed (ESMO [I, A]); no routine prophylaxis (ITAC 1A). The two sources differ on what follows removal: ITAC sets 3 months as a minimum while the catheter is in place; ESMO says the length after removal is uncertain and 3 months is usually advised [I, C]. Neither has trial data comparing DOACs with LMWH for line clots.
International Initiative on Thrombosis and Cancer (ITAC), endorsed by the ISTH (Lancet Oncology, Farge et al.) 2022 · ESMO (Annals of Oncology, Sousa et al.) 2015
Where it differs: After the treatment course, continues anticoagulation at a prophylactic dose until the catheter is removed.
Evidence: ESMO 2015 recommends continuing at a prophylactic dose while the catheter is in place [I, C]; ITAC 2022 recommends treatment for as long as the catheter is in place without specifying a step-down dose.
ESMO (Annals of Oncology, Sousa et al.) 2015 · International Initiative on Thrombosis and Cancer (ITAC), endorsed by the ISTH (Lancet Oncology, Farge et al.) 2022
Where it differs: Treats the line clot with apixaban, rivaroxaban or edoxaban.
Evidence: Not compared directly with LMWH in CRT (ITAC 2022). ESMO 2015 said there were no data for the newer oral anticoagulants in CRT at the time.
International Initiative on Thrombosis and Cancer (ITAC), endorsed by the ISTH (Lancet Oncology, Farge et al.) 2022 · ESMO (Annals of Oncology, Sousa et al.) 2015
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Doppler ultrasound as the usual diagnostic test | [III, A] | ESMO (Annals of Oncology, Sousa et al.) 2015 |
| Short anticoagulation before removing a line that is no longer needed | [I, A] | ESMO (Annals of Oncology, Sousa et al.) 2015 |
| About 3 months of anticoagulation after removal “According to the severity of thrombosis, 3 months of therapy is usually advised, with some authors suggesting even shorter courses [I, C]” | [I, C] | ESMO (Annals of Oncology, Sousa et al.) 2015 |
| Anticoagulation for at least 3 months and while the line is in place, LMWH suggested | guidance | International Initiative on Thrombosis and Cancer (ITAC), endorsed by the ISTH (Lancet Oncology, Farge et al.) 2022 |
| No routine anticoagulant prophylaxis for CRT | 1A | International Initiative on Thrombosis and Cancer (ITAC), endorsed by the ISTH (Lancet Oncology, Farge et al.) 2022 |
| Right-sided jugular insertion with the tip at the cavoatrial junction “Catheters should be inserted on the right side, in the jugular vein, and the distal extremity of the central catheter should be located at the junction of the superior vena cava and the right atrium (grade 1B).” | 1B | International Initiative on Thrombosis and Cancer (ITAC), endorsed by the ISTH (Lancet Oncology, Farge et al.) 2022 |
| Implanted ports suggested over PICCs where a central line is needed “In patients requiring central venous catheters, we suggest the use of implanted ports over peripherally inserted central catheter lines (guidance).” | guidance | International Initiative on Thrombosis and Cancer (ITAC), endorsed by the ISTH (Lancet Oncology, Farge et al.) 2022 |
Shares Implanted port access, flushing and care in adults having cancer treatment, Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Implanted port access, flushing and care in adults having cancer treatment, Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Implanted port access, flushing and care in adults having cancer treatment, Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Implanted port access, flushing and care in adults having cancer treatment, Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Implanted port access, flushing and care in adults having cancer treatment, Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Peripherally inserted central catheters (PICC lines), Central venous access (port, PICC line).
Shares Peripherally inserted central catheters (PICC lines), Central venous access (port, PICC line).