Investigating Central Venous Access Practice and Catheter-Associated Deep Vein Thrombosis

Research study background

Children undergoing surgery for congenital heart disease (CHD) represent one of the highest-risk pediatric populations for developing hospital-associated deep vein thrombosis associated with central venous catheter placement. This clinical challenge is compounded by the fact that catheter-associated deep vein thrombosis (CA-DVT) carries severe secondary risks in these patients. Intracardiac shunting can lead to paradoxical arterial embolism, and venous thromboses can cause permanent vascular complications that limit future cardiac catheterization, vascular access and long-term surgical options.

Despite these high stakes, current clinical practice relies heavily on low-quality, often conflicting evidence and expert recommendations. While some institutions have developed localized protocols, there is a distinct lack of data regarding how these strategies differ across institutions on a national scale. The team initiated this research to systematically map these practice variations and establish a baseline for multi-institutional quality improvement.

John S. Kim, MD, leads the Cardiac Thrombosis Clinic at Children’s Hospital Colorado and is a leading member on the multicenter consortium of institutional experts in CA-DVT and congenital heart disease. For this study, the team developed and planned a survey and administered it across the Pediatric Cardiac Critical Care Consortium (PC4) institutions.

Recognizing the critical gap in standardized anticoagulation and line-management data, the research team from the PC4 designed a rigorous 35-question electronic survey instrument. This instrument underwent strict face, content and internal consistency and validity testing across multiple institutions before national distribution.

Study results

The team analyzed responses from 45 respondent PC4 centers and found that:

• 71% of centers (n = 32) had a prophylactic anticoagulation protocol.
• Only 2 of the 45 respondent centers utilized a protocol for proactive screening for CA-DVT.
• Only 64% of centers (29/45) treated CA-DVT for a duration of 6 to 12 weeks (the currently recommended standard of care).
• Internal jugular central vein catheters (CVC) were the most common primary access for children undergoing heart surgery — 73% (33/45) for infants 1 to 12 months of age and 89% (40/45) for patients 1 to 18 years of age.
• Significant variability in CVC-type selection was reported in neonates (<30 days of age).
• Although some centers avoid upper extremity peripherally inserted central catheter placement in patients with single ventricle CHD, this study found that about half of centers still utilized this location for central venous access both prior to and after stage 2 palliation for single ventricle CHD (58% avoided and 53% accessed the upper extremity veins).

Clinical implications

“The definitive takeaway is the striking, lack of consistency in practice across specialized centers,” Dr. Kim says. “Significant practice variation exists in every single domain of CA-DVT prevention, surveillance and management. Despite the presence of some evidence and expert consensus guidelines for treatment duration of CA-DVT, even this practice varies widely across major cardiac centers”

Protocol gaps

While 71% of surveyed centers use a prophylactic anticoagulation protocol, only 53% have an established, structured protocol for treating a confirmed CA-DVT.

Guideline nonadherence

Only 62% of centers consistently follow the standard, evidence-based recommendation to treat CA-DVT. Nearly one-third of centers default to shorter, unstudied treatment windows (e.g., 4 to 6 weeks or ceasing therapy immediately upon image-confirmed thrombus resolution).

Practice implications

The research team is on the cusp of achieving their overarching goal of employing the PC4 network to perform a quality improvement initiative. Their hope is to understand the true incidence of CA-DVT by instituting a protocol for proactive ultrasound screening of central venous catheters after heart surgery for infants, the highest risk population identified in the research. Ultimately, they hope to reduce clinical variance in practice and reduce thrombosis-associated morbidity in critically ill cardiac patients.