Palliative care in cancer: Which central venous access devices are associated with higher complication rates?

A systematic review and meta-analysis by researchers from the University of Hong Kong has shown that the use of peripherally inserted central catheters (PICCs) is associated with a higher rate of complications than central lines in terminally ill cancer patients with central venous access devices (CVADs) for palliative care. No conclusions were reached regarding the use of totally implanted ports (PORTs), as no studies on PORTs were eligible for analysis.

Palliative care in cancer patients often requires CVADs, such as PICCs and central lines, for total parenteral nutrition (TPN), intravenous (IV) fluid replacement and blood product transfusion. Single-lumen PORTs are preferred for long-term intermittent chemotherapy, especially in patients with solid tumours, while double-lumen PORTs are used in patients undergoing bone marrow transplantation or infusion of noncompatible medications and fluid. [Int J Lab Hematol 2007;29:261-278; CA Cancer J Clin 2008;58:323-346] “However, lack of evidence-based guidelines has led to diverse CVAD selection in palliative care across medical centres. [To improve the decision-making process,] we conducted this study to compare rates of complications associated with different types of CVADs in terminally ill cancer patients receiving palliative care,” the researchers wrote.

The researchers screened articles published by 30 April 2023 on PubMed, Embase, Scopus, Cochrane Library, CINAHL, Google Scholar and trial registries. Included in the meta-analysis were five studies on complication rates of CVADs (PICCs, n=4; central lines, n=1) in palliative care of terminally ill cancer patients published between 2010 and 2021. Newcastle-Ottawa quality assessment indicated that all selected studies were of high quality with low bias risks (total score, 7–9). [Cancers 2023;15:4712]

The meta-analysis involved 327 patients (mean age, 68.4 years; male, 55 percent), with gastrointestinal cancer (47.7 percent) being the most prevalent primary cancer. Other primary cancer types included genitourinary cancer (14.1 percent) and hepatobiliary and pancreatic cancer (12.5 percent). The most common indications for CVAD insertion were TPN (84.7 percent) and IV fluid replacement (75.5 percent).

Results showed that a higher rate of overall complications (ie, catheter-related bloodstream infection [CRBSI] and thromboembolism [TE]) was associated with PICCs (random effects model: pooled estimate, 7.02 percent; 95 percent confidence interval [CI], 0.27–19.10; I², 74 percent) compared with central lines (1.44 percent; 95 percent CI, 0.30–4.14) (p=0.002).

PICCs were also associated with a higher risk of CRBSI (random effects model: pooled estimate, 2.03 percent; 95 percent CI, 0.00–9.62; I², 61 percent) vs central lines (0.96 percent; 95 percent CI, 0.12–3.41) (p=0.046). There was a trend towards an increased TE risk with PICCs (random effects model: pooled estimate, 2.10 percent; 95 percent CI, 0.00–12.22; I², 78 percent) vs central lines (0.48 percent; 95 percent CI, 0.01–2.64) (p=0.061).

Other complications including thrombophlebitis (two cases), bleeding (eight cases) and self-removal of lines (seven cases) were reported in two studies on PICCs involving 68 patients.

No studies on PORTs were eligible for analysis. “Terminally ill cancer patients are typically unsuitable candidates for insertion of PORTs, a procedure that often involves general anaesthesia or IV sedation,” the researchers explained.

“Our study provides insights into selecting optimal CVADs in palliative care of terminally ill cancer patients,” they highlighted. “Additional considerations include patients’ life expectancy, physicians’ expertise, clinic or hospital facilities, available resources, and cost-effectiveness [of CVADs], which should be discussed with patients and their caregivers.”

“Further research on complication profiles of CVADs is warranted to establish recommendations for CVAD use in palliative care [for cancer patients],” the researchers added.