Evaluation of the need for chest X-rays in the management of asymptomatic, intraluminal vascular access device occlusion in childhood cancer

Evaluation of the need for chest X-rays in the management of asymptomatic, intraluminal vascular access device occlusion in childhood cancer
Intraluminal vascular access occlusions are common complication during childhood cancer treatment. American College of Chest Physicians and the Canadian Vascular Access Association suggest that no imaging is required before thrombolysis in asymptomatic intraluminal VAD occlusion. However, some centres continue to include CXR due to concerns about administering TPA in broken or misplaced VAD and the risk of adverse bleeding events. The purpose of this research was to evaluate utility of routine CXRs prior to administering TPA for occluded VAD.
Retrospective, single centre chart review of oncology patients with line occlusions (partial or complete) leading to inability to aspirate and/or flush the line. Patients with symptomatic line occlusion (ex limb swelling) were excluded. All line occlusions were reviewed to see if CXR altered management. If so, these episodes were reviewed by a group of experts (oncologist, nurse practitioner, interventional radiologist, and thrombosis specialist) to review if administration of TPA could have resulted in harm.
85 patients experienced 123 episodes of VAD occlusion. 9 episodes of VAD occlusion were managed differently (line exchange, replace or removal) due to findings on CXR. After review by specialists only 2 episodes were thought to potentially cause harm if local TPA prior to CXR would have been instilled: port needle in wrong place and PICC broken internally. However the paper highlights the harm would not have been life threatening. The remaining 7 episodes were lines that had migrated.
Single centre study that uses interventional radiology to place lines. Retrospective study that may have missed some episodes. The potential risk of TPA instillation was assessed in a panel review which might not reflect what truly would have happened without the CXR.
This study supports the ACS statement that it is unneccessary to wait for CXR prior to local TPA administration as the CXR rarely alters management and potential harm of administering tPA in broken or misplaced line is low.

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