Clinical management of peripherally inserted central catheters compared to conventional central venous catheters in patients with hematological malignancies: A large multicenter study of the <scp>REL</scp><scp>GROUP</scp> (Rete Ematologica Lombarda ‐ Lombardy Hematologic Network, <scp>I</scp>taly)
Authors: Nicola Stefano Fracchiolla, Elisabetta Todisco, Andrea Bilancia, Sara Gandolfi, Nicola Orofino, Francesca Guidotti, Valentina Mancini, Laura Marbello, Andrea Assanelli, Massimo Bernardi, Armando Santoro, Roberto Cairoli, Dario Consonni, Agostino Cortelezzi
Journal: American Journal of Hematology (2017)

Peripherally inserted central venous catheters (PICCs), implanted under ultrasound guidance in a peripheral vein (preferentially the basilic one), provide a mid-term central venous access, with low incidence of adverse events.1 Few studies have directly compared infectious adverse events (AEs) and thromboses in PICCs and conventional central venous catheters (cCVCs) in onco-hematologic patients.2-4 As REL (Rete Ematologica Lombarda-Lombardy Hematologic Network, Italy), we compared duration and complications, in particular infectious AEs and thromboses, in 464 PICCs and 441 cCVCs, implanted from January 2009 to December 2015, in 371 (PICCs) and 247 (cCVCs) consecutive patients (Table 1). The total in situ catheter days (CathDs) were 48 293 for PICCs and 9471 for cCVCs. Univariate analysis revealed that PICCs have a significantly longer duration (76 vs. 19 days, P < .0001) and catheter related AEs-free survival (P < .0001) (Supporting Information Figure 1A), significantly lower total AEs (40% vs. 71.6%, P < .0001) and infectious AEs, in particular fever of unknown origin/blood stream infections (21% vs. 55.6%, P < .0001), and significantly more catheter-related thromboses (8% vs. 1.36%, P < .0001). Nevertheless, this significance disappears when thromboses are normalized for 1000 CathDs (0.8 vs. 0.63 per 1000 CathDs, P = ns) (Table 1). Pathogens isolated from blood cultures specimens are reported in Supporting Information Table II. PICCs were removed less frequently following the occurrence of AEs of any type (28.4% vs. 35% for PICCs, P = .036), except for catheter-related thromboses, for which removal was more common in PICCs (6% vs. 1.3%, P < .001) (Table 1). Multivariate analysis adjusted for center, gender, diagnosis, and age, confirmed the significance of all outcomes differences except for the rate of removal following an AE (Supporting Information Figure 1B). Few studies have compared AEs in PICCs and cCVCs in onco-hematologic patients.5, 6 In a small series, no difference for catheter-related blood stream infections in PICCs compared to cCVCs was reported.5 A prospective study analyzing 1127 cCVCs, tunnelized CVCs, port-a-caths, and PICCs in oncologic and onco-hematologic patients (total CathDs 51 514), showed that PICCs were associated with lower catheter-related blood stream infections incidence (4.22/1000 PICC CathDs vs. 17.3/1000 cCVCs CathDs) for patients with hematological malignancies.4 In another study of 169 oncohematologic patients, a significantly lower catheter-related blood stream infections rate was reported for 84 PICCs (1.23/1000 CathDs) compared with 85 cCVCs (5.30/1000 CathDs).3 Our study analyzed infectious and thrombotic AEs in a large cohort of homogeneous onco-hematologic patients, covering an extensive observation period of nearly 60 thousand CathDs. In line with previous observations,5, 6 we found an incidence of thromboses both in PICC and cCVC groups comparable with the one reported. A higher incidence of catheter-related thromboses was demonstrable in PICC versus cCVC cohorts, but, notably, when normalized for 1000 CathDs, the difference was not statistically significant. This result underlines to the importance of correlating AEs to the catheters duration, a parameter that is not reported consistently in all available studies. Most importantly, infectious AEs are significantly lower in PICCs (2/1000 CathDs), compared with cCVCs (30/1000 CathDs) (P < .0001). Infectious AEs are comprehensive of fever of unknown origin and of all types of blood stream infections, including catheter-related ones, explaining the higher incidence of these adverse events in our study, evident in particular for cCVCs, compared to published data. Nevertheless, the observed increase of infectious AEs in cCVCs is dramatic. Thus, in our series of onco-hematologic patients at high risk of hemorrhagic and infectious AEs, PICC implant demonstrated to be a safe and effective alternative to cCVCs, exhibiting a longer life span and catheter-related AEs-free survival, a significantly lower rate of infectious AEs, and a significantly lower removal rate due to adverse events, without any increase of thromboses, when incidence is normalized for catheter duration. Authors are grateful to Dr. Giuseppe Rossi, chairman of the REL "Acute Leukemias" Committee for fruitful scientific discussions and critical review of the manuscript, to Pierina Monni for coordination of PICC/CVC nursing team at Hematology Unit Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico and to Dr. Enrica Morra, REL Scientific Coordinator, for her continuous scientific support to the project. Dr. A. Bilancia discloses employment with Bard SRL. Other authors have nothing to disclose. 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