Low incidence of catheter-related complications in patients with advanced pulmonary arterial hypertension undergoing continuous epoprostenol infusion.

Epoprostenol (EPO) improves hemodynamics and survival in patients with advanced pulmonary arterial hypertension (PAH) by vessel dilatation and inhibiting platelet aggregation. 1 3 However, it requires continuous infusion and may lead to catheter-related complications (CRCs) (infection, thromboembolism, or bleeding). In patients with indwelling central venous catheters, the incidence of catheter infection varies from 0.3 to 9.1 infections per 1,000 patient-days. 4 6 The incidence of local infection in EPO users is 0.49 per patient-year and that of catheter-related bloodstream infection is 0.09 per patient-year. 3 We sought to investigate incidence and determinants of CRC in patients with advanced PAH who required long-term central venous access for EPO infusion. Records of 65 consecutive patients who were given an EPO infusion were reviewed retrospectively from 1998 to 2008. All patients underwent surgical implantation of a cuffed catheter (Hickman; CR Bard, Inc) for EPO infusion. During a median follow-up period of 6.4 years (interquartile range, 3.3-8.8), 27 patients (41.5%) developed catheter-related tunnel infection. Only fi ve patients (7.6%) developed central venous catheter-related bloodstream infection (0.03 per 1,000 catheterdays), and there were no thromboembolic or bleeding complications. The univariate logistic regression analysis showed that severity of disease, concurrent receipt of steroid therapy, and presence or absence of diabetes were not related to development of catheter-related infection (CRI), whereas patients who received a catheter on the left side of the chest (longer indwelling catheter) (OR, 2.72; 95% CI, 1.16-8.28) or wounds that were covered with dressings (OR, 2.85; 95% CI, 1.16-9.08) had a high tendency to develop CRI ( Table 1 ). The lower incidence of CRI in patients with advanced PAH than that in patients without PAH may occur because many patients with PAH are often very motivated to learn about their disease, participate in their treatment, and take extra precautions to improve their quality of life and survival. In addition, other reasons may include the fact that few patients with PAH have received chemotherapy leading to neutropenia and the antiplatelet effect of EPO itself. Guidelines by the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention listed as unresolved the issue that no recommendation can be made regarding the necessity for any dressing on well-healed exit sites of long-term cuffed and tunneled central venous catheters. 7 Continuous EPO infusion is associated with some limi tations, including infection, but the benefi ts are becoming increasingly relevant in the ambulatory setting. Prospective investigation is warranted. Toshiyuki Nagai , MD Shun Kohsaka , MD Toshihisa Anzai , MD Tsutomu Yoshikawa , MD Keiichi Fukuda , MD Toru Sato , MD Tokyo, Japan