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How I treat central venous access device–related upper extremity deep vein thrombosis

Anita Rajasekhar and Michael B. Streiff

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  • RE: The evidence for DOACS in patients with cancer associated thrombosis
    • Gwynivere Davies, Hematologist University of Calgary, Calgary, AB, Canada
    • Other Contributors:
      • Alejandro Lazo-Langner, Hematologist- Thrombosis
      • Michael J. Kovacs, Hematologist- Thrombosis

    Dear authors,
    We read with interest your “How I Treat” article on catheter related thrombosis (CRT). As this complication is increasingly recognized, a thorough review of the literature was beneficial, especially in managing challenging cases such as cancer associated thrombosis (CAT). When reviewing the ACCP 2016 guidelines and evidence supporting direct oral anticoagulant (DOAC) use for CRT, we think it is crucial to emphasize the lack of prospective data supporting DOAC use for CAT.
    Subgroup analysis of the original EINSTEIN trials in this population indicated recurrent venous thromboembolism (VTE) and clinically relevant bleeding risks of 5% and 14% with rivaroxaban vs. 7% and 16% in the enoxaparin/vitamin K antagonist (VKA) arm, with reduced major bleeding rates, although it is important to remember these were highly selected patients (1). This led to widespread introduction of DOACs for CAT in certain centres (2), including patients with upper extremity VTE or CRT who were retrospectively analyzed, showing an impressive 3.6% rate of line dysfunction and 2.4% risk of major bleeding (3). However, only 64% of patients completed 3 month follow up. Our group has performed two prospective studies on oral anticoagulation for CRT in patients with cancer, first low molecular weight heparin (LMWH) bridged with VKA with no recurrences and 4% major bleeding (4), and more recently a study of rivaroxaban monotherapy demonstrating a 1.4% recurrence risk, including a fat...

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    Conflict of Interest:
    G. Davies has no conflicts of interest to declare. A. Lazo-Langner has received honoraria and/or research funding from Pfizer, Bayer, LEO Pharma, Daiichi Sankyo and Alexion. M. Kovacs has received honoraria and grant/research funds from Pfizer, Daiichi Sankyo Pharm and LEO Pharma, and honoraria from Bayer.