PICCs Linked to Increase of Blood Clots in Children

Julie Jaffray, MD

New research from a conglomerate of children’s hospitals from across the nation is revealing use of peripherally inserted central catheters (PICCs) in children is associated with a significant increase in risk of blood clots compared to central venous catheters (CVCs).

A multicenter cohort study of more than 1900 newly placed PICCs or tunneled lines (TLs) indicated children between 6 months and 18 years of age were 8.5 times more likely to develop venous thromboembolism (VTE) if they received a PICC compared to a tunneled line.

“We can say definitively that patients who have PICCs have a much higher rate of thrombosis as well as central line associated bloodstream infections and catheter malfunctions when compared to TLs," said investigator Julie Jaffray, MD, of Children's Hospital Los Angeles and University of Southern California. "PICCs are not as benign as we once thought."

In response to an apparent increase in the incidence of VTE in children, investigators conducted the Clot Incidence Rates in Central Lines (CIRCLE) study, which was a prospective, observational cohort study comparing VTE in children with newly placed PICCs and TLs. A total of 1967 newly placed CVCs in a cohort of 1742 children were included in the analysis—all patients included in the study were from Children’s Hospital Los Angeles, Children’s Hospital of Philadelphia, Nationwide Children’s Hospital, and Texas Children’s Hospital.

The primary outcome measure of the study was the incidence rate and risk factors of CVC-related VTE in both PICCs and TLs in children. Secondary outcome measures of the study included the rate of central line associated bloodstream infections (CLABSIs) and catheter malfunctions between PICCs and TLs. Investigators pointed out participants diagnosed with a VTE, CLABSI and malfunction rates were compared prior to diagnosis.

Median age at CVC insertion was 6.4 years and the cohort of 1967 included 1047 males and 920 females. Investigators also pointed out caner was the predominate diagnosis of study subjects, accounting for 41% (n=802) of all subjects. Of the 1967 CVCs, 64% (n=1257) were PICCs and 36% (n=710) were TLs.

Investigators noted the most common type of TL placed during the study was a Port-a-cath® and the most common placement for TLs were the internal jugular vein (55%) and the subclavian vein (41%). In regard to PICCs, most were inserted into the basilic vein (56%) followed by the brachial vein (26%).

Upon analyses, investigators observed 94 of the 1967 CVCs included had a diagnosis of VTE within 6 months of insertion. Overall, the coincidence rate of catheter-related VTE in the study was 5.9±0.63%. Of the events to occur, 80% were in PICC with an incidence rate of 9.0±1.4%. In regard to TLs, the incidence rate as 2.9±0.64% and subjects with PICCs had a significantly higher risk of catheter-related VTE than subjects with TLs (HR=8.5, 95%CI: 3.1, 23, P<0.001).

Additionally, PICCs were found to be significantly more likely to have a CLABSI and CVC malfunction compared to TLs. Increased risk profiles were noted in patients with a previous history of VTE (HR=23, 95% CI: 4-127, P<0.001), multi-lumen CVC (HR=3.9, 95% CI: 1.8-8.9, P=0.003), and leukemia (HR=3.5, 95% CI: 1.3-9.0, P=0.031).

This study, titled “Peripherally Inserted Central Catheters Lead to a High Risk of Venous Thromboembolism in Children,” was published in Blood, a journal of the American Society of Hematology.