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Vascular Access Devices Used During Harvest of Peripheral Blood Stem Cells: High Complication Rate in Patients with a Long-Term Dialysis Central Venous Catheter

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Vascular Access Devices Used During Harvest of Peripheral Blood Stem Cells: High Complication Rate in Patients with a Long-Term Dialysis Central Venous Catheter Bone Marrow Transplantation, (1999) 24, 793–797 1999 Stockton Press All rights reserved 0268–3369/99 $15.00 http://www.stockton-press.co.uk/bmt Vascular access devices used during harvest of peripheral blood stem cells: high complication rate in patients with a long-term dialysis central venous catheter E Johansson1, M Hansson2, A Solle´n Nilsson2 and P Engervall1 1Division of Haematology and Infectious Diseases, Department of Medicine, and 2Immunhemotherapy Unit, Division of Clinical Immunology and Transfusion Medicine, Karolinska Hospital, Stockholm, Sweden Summary: from the leukaphereses machine to the patient. However, many patients need a double lumen central venous dialysis PBSC harvesting requires good quality venous access. catheter (dCVC) to ensure harvesting. There are two differ- The efficacy and complication rate of the venous access ent categories of dCVC, the stiff dCVC for short-term use2 devices used during stem cell harvest in 101 consecutive and the softer silastic dCVC for long-term use.3 patients were examined. Four different categories of The long-term type of dCVC can also be used for routine venous access were used: (1) long-term dialysis central venous access, starting with delivery of chemotherapy for venous catheter (dCVC), (2) short-term dCVC, (3) per- the mobilisation of stem cells through the period of high- ipheral venous cannulae (PVC), and (4) PVC and con- dose chemotherapy until bone marrow recovery. Most ventional central venous catheter. The number of har- experience of long-term dCVCs has been collected in the vest occasions per patient or harvest days per occasion haemodialysis setting. The majority of reported compli- were similar between the various categories of access. cations leading to removal of the long-term dCVCs are Complications during harvest occurred in 13 out of 48 catheter-related infections (9–28%)4–7 and failure due to (27%) occasions using a long-term dCVC compared to poor flow rates or thromboses (5–30%).4,6–10 The published six out of 97 (6%) in the other three categories pooled experience on use of long-term dCVC for stem cell together (P Ͻ 0.01). Forty-two of the 101 patients harvesting is limited.3,11,12 received a long-term dCVC to facilitate the harvest. The In March 1993 we decided to use long-term dCVC for long-term dCVC was planned to stay in place and also stem cell harvesting and high-dose therapy in patients be used as a conventional i.v. line during the following unable to have peripheral venous cannulae (PVC) due to high-dose treatment. Twenty-one (50%) of the long- poor quality of the peripheral veins, with the intention of term dCVCs were removed due to complication. Thir- reducing the number of CVCs inserted in these patients. teen (31%) of the long-term dCVCs were usable The primary aim of this retrospective study was to esti- throughout the entire treatment period. In conclusion, mate the function and complication rate of long-term we recommend that PBSC harvesting is performed dCVCs used during harvesting and as a conventional intra- through peripheral venous catheters when practically venous line. Secondly, we evaluated efficacy and compli- possible, otherwise via short-term dCVC. cation rate during harvesting in all patients during the study Keywords: PBSC collection; harvest; central venous period, comparing four different categories of venous access; central venous catheter; complication; thrombosis accesses. In summary, half of the long-term dCVCs were removed due to complications and only one-third of the long-term dCVCs were usable throughout the entire treatment period. An increasing number of patients with various malignant disorders are undergoing high-dose therapy followed by autologous stem cells rescue as a part of their treatment.1 Patients and methods PBSC collected by leukapheresis has become the main cell source in recent years. The procedure requires a high blood flow through intravenous (i.v.) lines between patient and Leukaphereses performed between 1993 and 1996 apheresis machine. In some patients it is possible to use Between 1993 and 1996 101 patients were harvested on intravascular devices inserted in the peripheral arm veins, 145 occasions (each occasion consists of a varying number or to insert a femoral dialysis catheter. In other patients of harvests over a number of consecutive days (range 1–5 with a functional central venous catheter (CVC) already in days)), over 363 leukapheresis days. Patient characteristics place, this catheter can be used as the return line for blood are summarised in Table 1. In eight patients with CML, harvests were performed at the time of diagnosis and leu- kapheresed cells were saved as a back up to be used later Correspondence: E Johansson, Division of Haematology and Infectious diseases, Department of Medicine, Karolinska Hospital, S-171 76 Stock- during blast crisis. The remaining 93 patients were planned holm, Sweden for PBSC rescue at the time of harvest. Received 23 December 1998; accepted 13 May 1999 Venous access routes used during harvest were divided Venous catheters for harvest of PBSC E Johansson et al 794 Table 1 Characteristics of 101 patients who underwent leukaphereses Leukapheresis procedure and of 42 patients in whom a long-term dCVC was inserted Collection of peripheral stem cells was performed by apher- 101 patients 42 patients with esis nurses, using a COBE Spectra blood cell separator who underwent a long-term (Cobe, Lakewood, CO, USA) on standard settings of the leukapheresis dCVC automated program (presently software version 5.1) which has been upgraded regularly since the beginning of the Female/Male (n) 52/49 24/18 study. Unless otherwise stated, at least 10 l of blood were Age, median, range (years) 50 (16–66) 48 (17–61) Diagnosis (n) processed during each procedure, aiming at a steady flow Acute leukaemia 26 10 rate of 50–60 ml/min and a collection rate of р1.5 ml/min. Chronic myelocytic leukaemia 19 6 All complications requiring special action during the apher- Multiple myeloma 21 8 eses were documented by the apheresis nurses. Lymphoma 22 12 Solid tumour 11 6 Amyloidosis 2 – Use and care of long-term dCVCs dCVC = dialysis central venous catheter. dCVC dressings were changed twice a week in accordance with the findings of a previous study.13 The exit site was aseptically cleaned with chlorhexidine (5%) and a trans- parent dressing was used. All parenteral therapy including into four categories: (1) long-term dCVC, (2) short-term medications, fluid therapy, blood products, peripheral stem dCVC, (3) PVC and (4) PVC and conventional CVC. cells and total nutrient admixtures were given via the long- In 66 of the 145 (46%) harvest occasions, patients had term dCVC. Daily blood samples were also taken. Two poor quality peripheral veins and dCVCs were inserted to three-way stopcocks with a 10-cm extension tube were con- facilitate the harvest procedure. In 18 of these 66 harvest nected to the long-term dCVC. The inner stopcock was occasions (16 patients), patients received a short-term changed at the time of the dressing change and the outside dCVC (Mahurkar; Quinton Instruments). In the remaining stopcock was changed once a day, most often directly after 48 of these 66 harvest occasions (37 patients) PBSC were blood sampling. New caps were put on after every event. collected through long-term, tunneled, dual-lumen dCVC The insertion site was inspected daily through the trans- (PermCath; Quinton Instruments). Venous access could, in parent dressing to identify early signs of infection. To the same patient, differ from one harvest occasion to maintain function between use, each lumen was primed another, depending on the quality of the peripheral veins with 1.3 ml or 1.4 ml of heparin (5000 IU/ml). Before each at the time of harvest. use the indwelling heparin was aspirated. Impaired blood flow/occlusion Patients with a long-term dCVC In long-term dCVCs with signs of occlusion (ie total failure During the study period 42 patients received a long-term of infusing or when it was possible to infuse but not to dCVC (Table 1). Thirty-seven of these 42 patients mobil- aspirate) saline flushes were administered. Fibrinolytic ther- ised stem cells and were subsequently harvested. The long- apy (t-PA, Actilys; Boehringer Ingelheim) was used if cath- term dCVCs were surgically installed under aseptic con- eter dysfunction persisted after mechanical manipulation. ditions in an operating theatre. Patients with a platelet count Suspicion of catheter-related deep venous thrombosis was Ͻ × 9 50 10 /l received prophylactic platelet transfusions confirmed either by X-ray or Doppler examination. Verifi- before catheter insertion. Catheter placements are shown in cation of a venous dCVC-related thrombosis resulted in Table 2. Thirty-one of the 42 (74%) patients had a history immediate catheter removal. None of the patients received of having had one to four previous CVCs. prophylactic oral anticoagulants. Infection Table 2 Localisation of 42 long-term dialysis central venous catheters The decision to remove a long-term dCVC due to infection, was made by the physician in charge. During neutropenia Vein No. all patients received prophylactic antifungal and antiviral therapy with fluconazole 50–200 mg once daily and acyclo- Internal jugular vir 200 mg five times daily, respectively. Prophylactic anti- right 7 left 9 biotic therapy was not given. External jugular right 12 left 10 Statistics Subclavia right 3 Catheter survival analysis was calculated using the Kaplan– Saphena magna Meier life table method for estimating survival. Catheter right 1 survival times were recorded in completed days. Nominal data were compared using the Fisher’s exact test. Differ- Venous catheters for harvest of PBSC E Johansson et al 795 ences in group proportions were assessed by the Mann– geons.
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