CICU/CCU Pathway for Management of
Acute Catheter-Related Venous Thromboembolism (VTE)
VTE Confirmed
Extremity ultrasound (US) and/or echocardiogram
Consult Cardiac Thrombosis team
Extremity ultrasound (US) and/or echocardiogram
Consult Cardiac Thrombosis team
Determine Medical Necessity of Catheter
Cardiac surgeon, CICU attending
Cardiac surgeon, CICU attending
Catheter Can Be Removed
Catheter Remains in Place
- Attending team consensus: CICU/CCU, Thrombosis, and Surgical
- Reviews eligibility for anticoagulation prior to removal
Assess Factors for High Bleeding Risk
Attending team consensus: CICU/CCU, Thrombosis, and Surgical
Attending team consensus: CICU/CCU, Thrombosis, and Surgical
- Active bleeding
- Coagulopathy, significant bleeding hx
- Recent surgery
- Age < 1 mo
Low Bleeding Risk
High Bleeding Risk
Risk benefit ratio
favors anticoagulation
favors anticoagulation
Risk outweighs anticoagulation
Initiate Enoxaparin
- Review lab results from previous 48 hrs
- CBC, PT/PTT, fibrinogen, creatinine
- Enoxaparin Clinical Practice Guideline
Repeat US at 1 wk
VTE progression: attending team consensus: CICU/CCU, Thrombosis, and SurgicalDischarge Planning
- Consider conversion to direct oral anticoagulants (DOACs) with Cardiac Thrombosis team
- Enoxaparin Discharge Planning with Case Management
Repeat extremity US, echocardiogram as indicated 6 wks from date of thrombus
VTE resolved or non-occlusive thrombus
VTE stable with occlusive thrombus
Thrombus progression
Assess for High Thrombosis Risk
Attending team consensus:
CICU/CCU, Thrombosis, and Surgical
Attending team consensus:
CICU/CCU, Thrombosis, and Surgical
VTE stable
or resolved
or resolved
Continue Anticoagulation
Repeat US 12 wks from date of thrombus
Repeat US 12 wks from date of thrombus
VTE progression
Discuss plan with Cardiac Thrombosis team
- Presence of central catheter
- Active infection
- Strong inherited thrombophilia
- Persistent pleural infusions
- Need for multiple catheterizations
Low risk
High risk
Discontinue Anticoagulation
Continue Anticoagulation
Therapeutic anticoagulation with future central catheters
Evidence
- Risks of Incident Venous Thromboembolism, Recurrent Thromboembolism, and Use of Antithrombotic Therapies, Among Children with Congenital Heart Disease Undergoing Cardiac Surgery: a Global Multicenter Analysis of Real-World Data
- Bleeding and Thrombosis in Pediatric Cardiac Intensive Care
- Effect of Anticoagulant Therapy for 6 Weeks vs. 3 Months on Recurrence and Bleeding Events in Patients Younger Than 21 Years of Age With Provoked Venous Thromboembolism: The Kids-DOTT Randomized Clinical Trial
- Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease
- Antithrombotic Therapy in Neonates and Children
- Bleeding and Thrombotic Emergencies in Pediatric Cardiac Intensive Care: Unchecked Balances
- Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Anticoagulation and Thrombolysis