DISCUSSION

Many cancer patients require CVCs for a safe and effective delivery of chemotherapeutic drugs. At our hospital, 2131 PICC and PC devices were placed in 3180 cancer patients over a two-year period, from 2017 to 2019. A total of 777 devices were inserted in 874 CRC patients. Metastatic and advanced CRCs are usually treated with continuous infusions of 5-FU using CVCs. Home chemotherapy has been carried out more often since the approval of FOLFIRI and FOLFOX. Consequently, complications involving CVCs and 5-FU pumps more frequent.8 In comparison to patients with PICC lines, those with PCs demonstrated lower incidence rates of overall complications (7% versus 52%, p < 0.001) and late complications (4% versus 45%, p<0.001). Among the late complications in the PICC group, the rate of CVC-associated eczema reached 45%. Most complications (85%) occurred outside the -hospital, due to incompliance with the nurses’ instructions. Only 15% of patients with CVC-associated eczema used dressing for sensitive skin, especially in summer. Unlike PICCs, PCs do not require dressing after needles’ extraction; thus, the incidence of CVC-associate eczema in the PC group is only 0.29%. Furthermore, additional hospital visits are required for patients with PICC as they require frequent dressing changes. PICC and PC insertion procedures were performed in a sterile room and by experienced clinicians who were trained and certified. When performed under strict sterile conditions and under radiological guidance, PICC insertions demonstrated higher insertion success rates and lower procedure related complications, especially with late complications, such as thrombosis or CRBSI. For convenience, 23 patients (35%) preferred the placement of PICCs in the upper left arm rather than the upper right arm. These were performed despite informing the patients that PICC insertions on the right have lower rates of related complications.9

As a common complication of CVCs, infection is the major cause of their removal.10 The results of our study (66%) were similar to the previous reports, where we found that 1.5% of PICCs’ implantations had CRBSI, which was slightly higher than the 1.1% CRBSI rate in previous studies.11 Therefore, we evaluated the economic and clinical impacts of catheter-related complications in China. As one of the most significant catheter-related complications, CRBSI is associated with high additional costs. The relationship between hospitalization costs and length was analyzed in previous studies.12–16 In this study, the cost of CRBSI treatments and the second replacements for PICC and PC were US $551.4 versus US $1346, respectively. Except for catheter removal, antibiotic therapy should be another option if the patient has no clinical signs of sepsis.


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In some studies on CVCs, the symptomatic deep venous thrombosis rates were up to 9.3% in adults.17 In our study, 4 cases of catheter-related thrombosis were confirmed by doppler ultrasound connected with clinical symptoms of venous thrombosis which required anticoagulation treatment. All 3 (4.6%) cases of catheter-related thrombosis in patients with PICC were diagnosed as upper extremity deep venous thrombosis (UEDVT) by vascular ultrasound. It is worth mentioning that a study on PICCs implantation in tumor patients has shown that the incidence of UEDVT ranges from 4% to 50%.18,19 All twelve cases of CVCs’ malfunction did not render the line ineffective, such as the impossibility of injection and/or aspiration, but had made them difficult. According to the“Catheter Injection and Aspiration” (CINAS) classification scheme, we scored 6 2IN1ASI catheters’ malfunctions, 4 IN2ASI catheters’ malfunctions and 2 catheters with a IN2AS2 malfunction. CINAS is designed to describe the function of the catheter and to distinguish patients with good catheters’ function from the terms “injection” and “aspiration”.20

Another common complication was occlusion. One out of four cases of PICC occlusion was removed due to the failure of intravenous thrombolysis with urokinase, and that was removed under radiological guidance. Several studies confirmed that the occurrence rates of catheter malposition and re-implantation without ultrasound guidance were approximately 1.9–2.3%.21–24 Ideally, the tip of the catheter should terminate in the SVC upstream of the right atrium. In our study, only 2 cases in the PC group were mispositioned and the tip of the catheter was located in the right atrium, which showed adaptation to higher blood flow velocity, but was associated with a higher risk of cardiac complications such as cardiac tamponade and atrial thrombosis.25,26 Bleeding rates of 0.5–1.6% were shown to be associated with CVC insertion and tranexamic acid (TA) has been shown to clearly reduce excessive bleeding at the wound insertion site27,28 and the occurrence rate of hematoma and excessive bleeding from insertion site in the PC group (0.7% versus 4%, p=0.003) and (0 versus 1.3%, p=0.032). Although there are no definite conclusions in our study as to whether tranexamic acid will increase the risk of catheter-related thrombosis (p=0.426), Chornenki NLJ, Um KJ demonstrated that tranexamic acid does not increase the risk of thrombosis, and the occurrence of arterial thrombosis has been reduced since the introduction of TA.29,30 In our study, 401 patients with PC devices (57%), who accepted hemostatic prophylaxis, just after the insertion, had fewer complications compared to those without hemostatic prophylaxis (0.7% versus 5.7%, p < 0.001) (Table 4). During the period of our study, the mean of additional cost of hemostatic infusion was $4.6.

Table 4

In this study, we compared the relative cost-effectiveness of using PICCs and PCs. With the exception of the monthly mean of maintenance costs, the monthly mean of therapeutic complications costs, device insertion and removal, the overall cost for patients with a PCs were all higher compared to those of patients with PICCs. As the maintenance cost increased over time, the total cost of a PC will be lower than that of a PICC and without any insurance. However, the yearly overall cost of a PC is twice the cost of a PICC when compensation from medical insurance is considered.

There were some limitations, such as lifestyle issues relating to CVC that were not sufficiently explored in our study. We also aimed at ruling out all factors that may affect the incidence of complications, due to the retrospective nature of the study. For instance, random grouping may not be possible, which results in minor biases and requires additional studies.

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