Thromboembolism following removal of femoral venous apheresis catheters in patients with breast cancer

M. W. Saif1,*, S. F. Leitman2, G. Cusack1, M. Horne2, A. Freifeld1, D. Venzon2, A. PremKumar2, K. H. Cowan1, R. E. Gress1, J. Zujewski1 and C. Kasten-Sportes1

1 National Cancer Institute and 2 Clinical Center, National Institutes of Health, Bethesda, MD, USA

* Correspondence to:Dr M. W. Saif, University of Alabama at Birmingham, 263 Wallace Tumor Institute, 1530 3rd Avenue South, Birmingham, AL 35294-3300, USA. Tel: +1-205-934-0916; Fax: +1-205-934-1608; Email: wasif.saif{at}ccc.uab.edu


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Background: Apheresis catheters have simplified collection of peripheral blood stem cells (PBSC), but may be associated with thrombosis of the instrumented vessels. We performed a retrospective analysis to study the prevalence of thromboembolism associated with the use of femoral apheresis catheters in patients with breast cancer.

Patients and methods: Patients were participants in clinical trials of high-dose chemotherapy with autologous PBSC rescue. They underwent mobilization with either high-dose cyclophosphamide (n=21) or cyclophosphamide/paclitaxel (n=64), followed by filgrastim. Double lumen catheters (12 or 13 Fr) were placed in the femoral vein and removed within 12 h of the last apheresis procedure. Apheresis was performed using a continuous flow cell separator and ACD-A anticoagulant. Thromboembolism was diagnosed by either venous ultrasonography or ventilation-perfusion scan.

Results: Nine of 85 patients (10.6%) undergoing large volume apheresis with use of a femoral catheter developed thromboembolic complications. Pulmonary embolus (PE) was diagnosed in five and femoral vein thrombosis in four patients. Four of the five patients who developed PE were symptomatic; one asymptomatic patient had a pleural-based, wedge-shaped lesion detected on a staging computed tomography scan. The mean number of apheresis procedures was 2.4 (range one to four) and the mean interval between removal of the apheresis catheter and diagnosis of thrombosis was 17.6 days. In contrast, none of 18 patients undergoing apheresis using jugular venous access and none of 54 healthy allogeneic donors undergoing concurrent filgrastim-mobilized PBSC donation (mean 1.7 procedures/donor) using femoral access experienced thromboembolic complications.

Conclusions: Thromboembolism following femoral venous catheter placement for PBSC collection in patients with breast cancer may be more common than previously recognized. Healthy PBSC donors are not at the same risk. Onset of symptoms related to thrombosis tended to occur several weeks after catheter removal. This suggests that the physicians not only need to be vigilant during the period of apheresis, but also need to observe patients for thromboembolic complications after the catheter is removed. The long interval between the removal of apheresis catheter and the development of thromboembolism may have a potential impact on prophylactic strategies developed in future, such as the duration of prophylactic anticoagulation. Avoidance of the femoral site in breast cancer patients, and close prospective monitoring after catheter removal, are indicated.

Key words: apheresis, breast cancer, femoral apheresis catheters, malignancy, peripheral blood stem cell transplantation, thromboembolism


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Lack of adequate peripheral venous access for the performance of large-volume apheresis occurs in ~60% of cancer patients presenting for peripheral blood stem cell (PBSC) donation [1Go]. To facilitate the performance of apheresis, and to allow administration of chemotherapy, antibiotics, blood components and hyperalimentation, long-term indwelling central venous catheters are frequently used. However, catheter use has been associated with thrombotic complications. These complications occur in 4–42% of cancer patients with indwelling catheters and in 20% of patients undergoing autologous bone marrow transplantation [2Go–5Go].

Central venous catheters have greatly simplified the performance of apheresis in patients undergoing autologous PBSC collection. It is frequently necessary to process three to four blood volumes daily in order to collect an adequate stem cell dose [6Go, 7Go]. A constant blood inlet flow is required to obtain a stable mononuclear cell layer inside the device, so that mononuclear cell collection can proceed with the greatest efficiency. Moreover, high flow rates are required since apheresis requires withdrawal and return of a large volume of blood [8Go]. This constant and high flow rate is often achievable only with use of a large-gauge central venous catheter, particularly in patients who have previously received chemotherapy.

Many different types of catheters and sites of insertion have been used for PBSC collection. Thrombotic occlusion has been reported as a complication of apheresis in as many as 80% of subclavian catheters, whose tips are placed at the junction of the innominate vein and superior vena cava [9Go], and in 20% of inferior vena cava catheters [10Go]. The femoral site has been used less commonly due to concerns over infectious complications, in settings where catheters are in place for extended periods [11Go, 12Go]. However, placement of femoral catheters for a short duration decreases the risk of infection compared with longer duration placement [13Go, 14Go], and may be associated with a lower incidence of serious hemorrhagic events related to trauma of critical nearby structures. The femoral vein is increasingly regarded as an optimal short-term catheterization site in patients undergoing PBSC autotransplantation.

Patients with adenocarcinoma are known to be at increased risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). Since the prevalence of catheter-associated thromboembolism with short-term femoral vein catheters is not known, we performed a retrospective study of catheter-related thrombotic events in patients with breast cancer undergoing femoral vein catheterization to facilitate autologous PBSC collection.


    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Patients
Study subjects were enrolled in Institutional Review Board-approved National Cancer Institute protocols involving PBSC autotransplantation from January 1996 to January 2000. All patients were diagnosed with advanced breast cancer (stage III or stage IV) and participated in one of the following two studies.

Study 1
A pilot study of paclitaxel/cyclophosphamide and high dose melphalan/etoposide with autologous PBSC rescue for the treatment of metastatic and high risk breast cancer (n=92). PBSCs were collected during filgrastim-assisted recovery (10 µg/kg/day for 10–14 days) after at least three cycles of cyclophosphamide (2.7 g/m2) plus paclitaxel (160 mg/m2). Patients subsequently received high-dose melphalan and etoposide followed by PBSC infusion.

Study 2
Antimetabolite induction, high-dose alkylating agent consolidation and gene-modified PBSC infusion, followed by sequential paclitaxel and doxorubicin for stage IV breast cancer (n=27). The intent of this trial was to determine whether MDR1-modified PBSC could be expanded in vivo after non-ablative chemotherapy. Patients received methotrexate, leucovorin and 5-fluorouracil for two to four cycles, followed by three cycles of high-dose cyclophosphamide (4 g/m2). PBSC were collected during filgrastim-assisted recovery (10 µg/kg/day for 10–14 days) after the first cyclophosphamide cycle. High-dose thiotepa with PBSC rescue and daily filgrastim was then followed by four cycles of infusional paclitaxel and four cycles of doxorubicin [15Go].

Catheters
Femoral venous access was achieved by using a rigid polyurethane heparin-coated double-lumen catheter (12 or 13 Fr; Arrow International, Reading, PA, USA) initially designed for hemodialysis. For jugular venous access, a double-lumen Hickman catheter (12 Fr; Bard Access Systems, Salt Lake City, UT, USA) or a triple-lumen Pheres-Flow catheter (12 Fr, Horizon Medical Products, Manchester, GA, USA) was used. All catheters were placed under local anesthesia by a member of the vascular access device placement team, immediately prior to the start of leukapheresis. Informed consent for catheter placement was obtained in all cases. Catheters were inserted percutaneously into the femoral vein (right : left ratio, 4 : 1) using a modified Seldinger guide wire. They were sutured in place and the site was covered with sterile dressing. Following each apheresis session, the catheter ports were flushed with 5 ml of saline and 1.5 ml of heparin solution (Heparin Lock Flush, 100 U/ml; Abbott Laboratories, North Chicago, IL, USA) and then capped. The site of insertion was cleaned with alcohol and Betadine and covered with a sterile dressing. Catheters were removed within 12 h of the last apheresis procedure, when quantitation of the cellular content of the apheresis product was completed.

All patients were admitted as in-patients if more than one apheresis procedure was required. Prophylactic anticoagulation was not administered. Daily inspection of the insertion site for redness, tenderness, rash or leakage was performed by nursing staff. Occlusion of the catheter was suspected when inadequate blood flow rates or inability to withdraw blood were observed.

Apheresis
Collections were initiated when the white cell count first exceeded 4 x 109/l or when a measurable population of CD34 + cells (>20 cells/µl) was found in the circulating blood during daily flow cytometric monitoring. Apheresis was performed using a CS-3000 Plus continuous-flow cell separator (Baxter Healthcare, Deerfield, IL, USA) with acid citrate dextrose formula A (ACD-A) anticoagulant at a 1 : 12 to 1 : 13 ratio with whole blood. Inlet blood flow rates ranged from 50 to 85 ml/min. The minimum targeted stem cell dose was 2 x 106 CD34+ cells/kg. Attempts were undertaken to limit any single collection to <5 h.

Study design
Thromboembolic events were detected by retrospective review of medical records, protocol toxicity records and imaging studies of patients with breast cancer enrolled in two high-dose chemotherapy trials. The relevant records of all patients who had undergone central venous catheter placement to facilitate PBSC collection were examined The medical records and follow-up information on all healthy allogeneic donors undergoing PBSC donation with use of a femoral catheter (12 or 13 Fr; Arrow International) during the same period were also reviewed.

Diagnosis of DVT and PE
The diagnoses of DVT and PE were confirmed with venous ultrasound and ventilation-perfusion scan, respectively. The occurrence of thrombosis in the catheterized femoral vein, in the absence of thrombosis in the contralateral vein, was considered a positive finding. Patients who had bilateral femoral thrombosis were noted but not included in the calculations of catheter-associated thrombosis. Not only symptomatic patients but also patients with radiological imaging consistent with pulmonary thromboembolism (PTE) were also included. A computed tomography (CT) scan finding suggesting PTE such as a wedge-shaped defect was followed by a V/Q scan to further confirm the diagnosis and differentiate from a pulmonary metastatsis.

Statistical methods
The significance of differences between populations was determined using Fisher's exact test.


    Results
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
One hundred and three patients underwent apheresis to collect PBSC for autologous transplantation, 82 of whom participated in study 1 and 21 in study 2 (Table 1). Sixty-four of the patients in study 1 underwent femoral venous catheter placement while 18 were treated using internal jugular venous access. All 21 patients in study 2 underwent femoral venous catheterization. Several patients required more than one type of catheter and/or more than one catheter site. Two patients had two different types of catheters in the jugular location simultaneously, and another two underwent apheresis using both a jugular and a femoral catheter (these subjects are included in the femoral catheter group). Thus, a total of 85 patients underwent femoral catheter placement to facilitate apheresis.


View this table:
[in this window]
[in a new window]
 
Table 1. Demographic characteristics of study subjects

 
Symptomatic femoral vein thrombosis, confirmed by ultrasonography, developed in four of 85 patients (4.7%) who underwent femoral venous catheter placement. PE was diagnosed in an additional five of these 85 patients (5.9%), four of whom were symptomatic, with the diagnosis confirmed by ventilation-perfusion scan, and one of whom had a pleural-based, wedge-shaped lesion detected on restaging CT scan (Table 2). This CT scan finding was followed by a V/Q scan to confirm the diagnosis of PE. Ultrasonography of the extremities was not performed in all patients with PE. The overall incidence of symptomatic thrombosis was thus eight of 85 (9.4%), while the incidence of all catheter-associated thrombotic events, detected retrospectively, was nine of 85 (10.6%). None of these nine patients had a personal or family history of thrombosis or a history of a hereditary thrombophilic condition. No patient was receiving anticoagulant therapy at the time of diagnosis of the thrombotic event and none had any intercurrent illnesses other than advanced breast cancer. The mean age of patients who developed thromboembolic disease was 49 years (range 37–71), and did not differ from that of patients without thrombosis. Thirty-seven percent of all patients had received chemotherapy, hormonal therapy and/or radiation therapy for the treatment of breast cancer prior to study enrollment.


View this table:
[in this window]
[in a new window]
 
Table 2. Characteristics of patients who developed thromboembolic complications

 
All patients tolerated their apheresis procedures well. The mean number of apheresis procedures per patient was 2.4 (range 1–4), and did not differ in those who developed versus those who did not develop symptomatic thrombosis. The longest duration a catheter was in place was 4 days. The average inlet blood flow rate for all procedures was 70 ml/min (range 55–85), and the mean volume processed was 16.8 l of blood per procedure. There were no interruptions in procedures or decreases in blood flow rate due to catheter-related flow problems. Reductions in flow rate were occasionally necessitated by the development of citrate-related symptomatic hypocalcemia. Intravenous calcium gluconate infusion resulted in prompt response in such cases. The only other catheter-related complication was occasional bleeding at the insertion site following removal of the catheter. No catheter-related infections were encountered.

Mean time between removal of the apheresis catheter and diagnosis of a thromboembolic event was 17.6 days (range 2–35). Similarly, mean time elapsed between the last dose of chemotherapy and diagnosis of thromboembolism was 14 days. Average leukocyte counts on the first day of apheresis and on the day the thromboembolic event was diagnosed were 26 300 and 2351/µl, respectively. Average platelet counts on the first day of apheresis and on the day of diagnosis of the thromboembolic event were 27 000 and 170 000/µl, respectively. During the same period as these events, January 1996 to January 2000, none of 54 healthy allogeneic donors (38 males and 16 females, mean age 38.3 years, mean number of apheresis procedures 1.7) developed symptomatic thromboembolic events following filgrastim-mobilized PBSC donation using femoral venous access (Table 1).

Comparison of the two breast cancer treatment groups revealed that the proportion of patients developing thromboembolic events, four of 21 (19%) in the group undergoing stem cell mobilization with cyclophosphamide alone, was not significantly different from that of the group undergoing mobilization with cyclophosphamide plus paclitaxel, five of 64 (8%) (P=0.08). However, the occurrence of thrombosis in patients who underwent PBSC collection using femoral access (nine of 85) was significantly greater than in cases where jugular access alone was used (zero of 18 patients) (P <0.05). Lastly, thrombosis occurred significantly more often in patients with breast cancer donating for autologous use (nine of 85) than in healthy subjects donating for allogeneic use (zero of 54) (P=0.02).


    Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Large-volume leukapheresis generally refers to procedures in which >15 l of blood, or three blood volumes, are processed. Such procedures are increasingly used to obtain progenitor cells for autologous transplantation. Approximately 60% of patients with cancer who need such procedures do not have adequate peripheral venous access [1Go]. Use of central venous catheters has simplified this problem by providing dual-channel, rigid-walled appliances with large lumina that allow very high blood flow rates, thus decreasing the time required per procedure while maintaining a high efficiency of collection [16Go, 17Go]. However, use of such catheters is associated with risks. These include hemorrhage or other local trauma at the time of catheter insertion or removal, infection, and thrombosis. The risk of thrombosis is greatest in long-term indwelling catheters. Our study demonstrates that this risk may be considerable with short-term non-tunneling catheters as well, particularly if placed in the femoral location.

Placement of femoral catheters was initially discouraged, due to an increased incidence of bacteremia when such applicances were left in place for a long time, as in hemodialysis [11Go]. However, the short-term nature of the catheter requirement for PBSC collection, the increasing discomfort and hemorrhagic risk of large bore catheters placed in the subclavian location, the lack of pneumothorax risk and lack of need for radiographic confirmation of correct placement, all combined to make femoral access an increasingly attractive option for temporary apheresis access. The absence of catheter-related bacteremia in our study patients, and the fact that a transplantable number of progenitor cells could be collected in one or two sessions in >90% of patients, confirm these expectations.

A surprisingly high incidence of symptomatic venous thrombosis was detected in our study, despite the short-term nature of the catheter use. More than 10% of all patients (nine of 85) developed thrombosis, 9% (eight of 85) experienced symptomatic events and nearly 6% (five of 85) developed PE. Although thrombotic occlusion has been reported as a complication of apheresis in a high proportion of long-term catheters, reaching 80% with subclavian [9Go] and 20% with inferior vena cava [10Go] catheters, the incidence of PE was markedly higher in our study than in prior studies of long-term indwelling catheters (subclavian or internal jugular, 0.2% [18Go]). Even more surprisingly, our data suggest that thrombotic complications can develop long after the removal of the apheresis catheter, in contrast to prior studies in which thrombosis was detected while the catheter was still in the blood vessel [17Go–19Go]. Furthermore, it is likely that our study design, a retrospective chart review, underestimated the true incidence of thrombosis, in that only symptomatic cases were detected, and prospective surveillance studies were not performed.

In contrast to our findings, two prior studies of short-term femoral catheterization for autologous PBSC collection revealed a lower incidence of thrombotic events, although study methods differed (Table 3). Shariatmadar and Noto [16Go] retrospectively reviewed the records of 63 cancer patients who underwent 101 PBSC collections via femoral access. No thrombotic complications were encountered. The longest duration of catheter placement was 6 days. Adorno et al. [17Go] prospectively studied 147 cancer patients undergoing 488 PBSC collections using dual-lumen femoral access. Mobilization was with granulocyte colony-stimulating factor alone or in combination with chemotherapy. All patients received systemic anticoagulation with low molecular weight heparin and ultrasound examination was routinely performed after removal of the catheter. Seven of 147 patients (4.8%) developed thrombosis as evidenced by ultrasound carried out immediately after catheter removal. Although this experience is similar to the rate of symptomatic femoral thrombosis found in the current study, no episodes of PE were seen. It is possible that differing diagnoses (hematologic malignancy versus adenocarcinoma) or treatment regimens, varying methods of patient follow-up, differing techniques of catheter placement or removal, or different types of catheters could explain these divergent findings. Our study data argue against a strong effect of catheter type, however, in that the same femoral catheter that was associated with a 10% incidence of thrombosis in breast cancer patients did not result in symptomatic thrombosis when placed in the jugular location in breast cancer patients, or when placed in the femoral location in healthy allogeneic donors. This suggests a unique and increased risk for catheter-related thrombosis in patients with advanced breast cancer undergoing short-term femoral vein catheterization. It is possible that the sustained immobility and obligate bed-rest necessitated by sequential daily 4–5 h apheresis procedures using femoral access are responsible for this increased risk. Patients with jugular access were not obligated to observe strict bed-rest between procedures, or to be strictly immobile during lengthy apheresis procedures. Healthy donors were younger, had their catheters in place for significantly shorter periods of time, did not have systemic disease or sustained immobility and were not receiving chemotherapy.


View this table:
[in this window]
[in a new window]
 
Table 3. Comparison of three studies of femoral apheresis access in cancer patients

 
The thrombogenic nature of indwelling venous catheters is well known. It is postulated that fibrin sleeves are formed on such catheters and present a nidus for thrombus propagation and embolization at the time of catheter removal [18Go]. Other factors may contribute to catheter-related thromboembolic complications, including endothelial injury due to mechanical trauma or chemotherapy, local and systemic coagulation abnormalities, and underlying malignancy. The association of cancer and thrombosis is well described and certain neoplasms, including breast cancer, are strongly associated with an increased frequency of thromboembolic events [20Go]. In addition, the chemotherapeutic and hormonal agents used to treat breast cancer are associated with damage to vascular endothelium, lowered levels of endogenous anticoagulants (protein C, protein S and antithrombin III) and an increased incidence of thrombosis, in both the adjuvant and metastatic setting [21Go–29Go]. The higher doses of chemotherapy used in PBSC transplantation may thus result in a prothrombotic state. Indeed, autologous transplantation is reported to lead to changes in the fibrinolytic system, tissue factor activity, Factor VIII activity, anticardiolipin antibodies and fibrinogen levels, which further contribute to this prothrombotic state. Thrombotic complications are reported in up to 20% of patients undergoing autologous marrow transplantation [30Go, 31Go]. A foreign thrombogenic surface (catheter) introduced into this environment even for a relatively short period of time may thus pose a compounded risk for thrombosis.

The role of growth factors in promoting thrombus formation is unclear. Enhanced neutrophil-endothelial cell interactions and aggregation of ‘sticky’ neutrophils at catheter tips, where they can cause damage to vascular endothelium, have been hypothesized [26Go]. The role of platelets in catheter thrombosis is also unclear. Previous investigators have found a longer thrombus-free survival in patients whose catheter was placed when their platelet count was <80 K as compared with the presence of a higher platelet count in the patients who developed thrombosis [32Go]. Thrombocytopenia at the time of catheter placement may delay thrombus formation, which becomes evident only days to weeks later when the platelet count returns to normal [32Go]. The development of clinical thrombosis days to weeks after catheter placement in the majority of our subjects, at a time when chemotherapy-induced thrombocytopenia had resolved, supports this mechanism as evidenced by an average platelet count of 27 K on day 1 of apheresis and 170 K on the day of diagnosis of a thromboembolic event.

Systemic anticoagulation and use of antiplatelet agents have both been recommended as prophylactic measures to reduce the incidence of thrombosis in central venous catheter placement for PBSC collection. Haire et al. [32Go] reported a significant reduction in inferior vena cava catheter occlusion rates with aspirin 325 mg daily. In contrast, Adorno et al. [17Go] found a 4.8% (seven of 147) incidence of femoral thrombosis with use of prophylactic low molecular weight heparin.

Our study shows that short-term femoral venous catheters for PBSC collection in patients with advanced breast cancer are not as safe as previously thought. Prospective non-invasive monitoring at the time of catheter removal and close clinical follow-up for several weeks after catheter removal are indicated. We also suggest that the physicians need to be vigilant during the period of apheresis for thromboembolic complications as well as observe these patients for such complications after the catheter is removed. The long interval between the removal of apheresis catheter and the development of thromboembolism may have a potential impact on prophylactic strategies developed in future, such as the duration of prophylactic anticoagulation. Our data also suggest that in this population, jugular rather than femoral catheterization may be preferable. In addition, healthy allogeneic donors do not appear to be at the same risk for catheter-related thrombosis as patients with breast cancer.

Received for publication September 26, 2003. Revision received April 30, 2004. Accepted for publication May 3, 2004.


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
1. Haire WD, Lieberman RP, Lund GB et al. Translumbar inferior vena cava catheters: safety and efficacy in peripheral blood stem cell transplantation. Transfusion 1990; 30: 511–515.[CrossRef][ISI][Medline]

2. Conlan MG, Haire WD, Lieberman RP et al. Catheter-related thrombosis in patients with refractory lymphoma undergoing autologous stem cell transplantation. Bone Marrow Transplant 1991; 7: 235–240.[ISI][Medline]

3. Lazarus HM, Lowder JN, Herzig RH. Occlusion and infection in Broviac catheters during intensive cancer therapy. Cancer 1983; 52: 2342–2348.[ISI][Medline]

4. Lokich JJ, Becker B. Subclavian vein thrombosis in patients treated with infusion chemotherapy for advanced malignancy. Cancer 1983; 52: 1586–1589.[ISI][Medline]

5. Kaye CG, Smith DR. Complications of central venous cannulation. BMJ 1988; 297: 572–573.[ISI][Medline]

6. Comenzo RL, Vosburgh E, Weintraub LR et al. Collection of mobilized blood progenitor cells for hematopoietic rescue by large-volume leukapheresis. Transfusion 1995; 35: 493–497.[CrossRef][ISI][Medline]

7. Smolowicz AG, Villman K, Tidefelt U. Large-volume apheresis for the harvest of peripheral blood progenitor cells for autologous transplantation. Transfusion 1997; 37: 188–192.[CrossRef][ISI][Medline]

8. Haire WD, Stephens LC, Kotulak GD et al. Double-lumen inferior vena cava catheters for peripheral stem cell apheresis and transplantations. Transfus Sci 1995; 16: 79–84.[ISI][Medline]

9. Haire WD, Edney JA, Landmark JD, Kessinger A. Thrombotic complications of subclavian apheresis catheters in cancer patients: prevention with heparin infusion. J Clin Apheresis 1990; 5: 188–191.[Medline]

10. Bozzetti F, Scarpa D, Terno G et al. Subclavian venous thrombosis due to indwelling catheters: a prospective study on 52 patients. JPEN J Parenter Enteral Nutr 1983; 7: 560–562.[Abstract]

11. Oliver MJ, Callery SM, Thorpe KE et al. Risk of bacteremia from temporary hemodialysis catheters by site of insertion and duration of use: a prospective study. Kidney Int 2000; 58: 2543–2545.[CrossRef][ISI][Medline]

12. Bambauer R, Mestres P, Pirrung KJ. Frequency, therapy, and prevention of infections associated with large bore catheters. ASAIO J 1992; 38: 96–101.[Medline]

13. Hahn U, Goldschmidt H, Salwender H et al. Large-bore central venous catheters for the collection of peripheral blood stem cells. J Clin Apheresis 1995; 10: 12–16.[ISI][Medline]

14. Lee JH, Klein HG. Collection and use of circulating hematopoietic progenitor cells. Hematol Oncol Clin North Am 1995; 9: 1–22.[ISI][Medline]

15. Moscow JA, Huang H, Carter C et al. Engraftment of MDR1 and NeoR gene-transduced hematopoietic cells after breast cancer chemotherapy. Blood 1999; 94: 52–61.[Abstract/Free Full Text]

16. Shariatmadar S, Noto TA. Femoral vascular access for large-volume collection of peripheral blood progenitor cells. J Clin Apheresis 1998; 13: 99–102.[CrossRef][ISI][Medline]

17. Adorno G, Zinno F, Bruno A et al. Femoral catheters: safety and efficacy in peripheral blood stem cell collection. Int J Artif Organs 1999; 22: 710–712.[ISI][Medline]

18. Malatinsky J, Faybik M, Samuel M, Majek M. Surgical, infectious and thromboembolic complications of central venous catheterization. Resuscitation 1983; 10: 271–281.[CrossRef][ISI][Medline]

19. Volkow P, Tellez O, Vazquez C et al. A single, double lumen high-flow catheter for patients undergoing peripheral blood stem cell transplantation. Experience at the National Cancer Institute in Mexico. Bone Marrow Transplant 1997; 20: 779–783.[CrossRef][ISI][Medline]

20. Sack JH, Levin J, Bell WR. Trousseau's syndrome and other manifestations of chronic disseminated coagulopathy in patients with neoplasms: Clinical, pathophysiologic, and therapeutic features. Medicine (Baltimore) 1977; 56: 1–37.[ISI][Medline]

21. Doll DC, Yarbo JW. Vascular toxicity associated with anti-neoplastic agents. Semin Oncol 1992; 19: 580–596.[ISI][Medline]

22. Nicholson GL, Custead SE. Effects of chemotherapeutic drugs on platelet and metastatic tumor cell-endothelial cell interactions as a model for assessing vascular endothelial integrity. Cancer Res 1983; 45: 331–336.

23. Rogers JS, Murgo AJ, Fontana JA. Chemotherapy for breast cancer decreases plasma protein C and protein S. J Clin Oncol 1988; 6: 276–281.[Abstract]

24. Cantwell BMJ, Carmichael J, Ghani SE. Thromboses and thromboemboli in patients with lymphoma during cytotoxic chemotherapy. BMJ 1988; 297: 179–180.[ISI][Medline]

25. Levine MN, Gent M, Hirsh J. The thrombogenic effect of anticancer drug therapy in women with stage II breast cancer. N Engl J Med 1988; 318: 404–407.[Abstract]

26. Stephens LC, Haire WD, Schmit-Pokorny K et al. Granulocyte macrophage colony stimulating factor: high incidence of apheresis catheter thrombosis during peripheral stem cell collection. Bone Marrow Transplant 1993; 11: 51–54.

27. Love RR, Surawicz TS, Williams EC. Antithrombin III level, fibrinogen level, and platelet count changes with adjuvant tamoxifen therapy. Arch Intern Med 1992; 152: 317–320.[Abstract]

28. Pritchard KI, Peter J, Paul N. Thromboembolic complications related to chemotherapy in a NCI Canada randomized trial of tamoxifen versus tamoxifen plus chemotherapy in post-menopausal women with axillary node positive receptor positive breast cancer. Proc Am Soc Clin Oncol 1989; 8: 25.

29. Mamby CC, Love RR, Feyzi JM. Protein S and protein C level changes with adjuvant tamoxifen therapy in postmenopausal women. Breast Cancer Res Treat 1994; 30: 311–314.[ISI][Medline]

30. Natazuka T, Kajimoto K, Ogawa R et al. Coagulation abnormalities and thrombotic microangiopathy following bone marrow transplantation from HLA-matched unrelated donors in patients with hematological malignancies. Bone Marrow Transplant 1998; 21: 815–819.[CrossRef][ISI][Medline]

31. Qasim W, Gerritsen B, Veys P. Anticardiolipin antibodies and thromboembolism after BMT. Bone Marrow Transplant 1998; 21: 845–847.[CrossRef][ISI][Medline]

32. Haire WD, Lieberman RP, Lund GB et al. Translumbar inferior vena cava catheters: experience with 58 catheters in peripheral stem cell collection and transplantation. Transfus Sci 1990; 11: 195–200.[CrossRef][ISI][Medline]





This Article
Abstract
Full Text (PDF)
E-letters: Submit a response
Alert me when this article is cited
Alert me when E-letters are posted
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
Google Scholar
Articles by Saif, M. W.
Articles by Kasten-Sportes, C.
PubMed
PubMed Citation
Articles by Saif, M. W.
Articles by Kasten-Sportes, C.