The research status of central venous catheterization-associated thrombosis: a bibliometrics analysis

Introduction

Central venous catheterization is a common, simple, and safe treatment for many critically ill patients, as well as those undergoing chemotherapy. It can also be used to monitor large venous and right heart pressures to provide accurate information for assessing patient conditions and the effect of treatments (1,2). Central venous catheters can be implanted through medium and large veins that can be accessed through punctures on the body surface. For example, the subclavian vein, internal jugular vein, external jugular vein, and cephalic vein can be used to access the superior vena cava, while the femoral vein and the saphenous vein can be used to access the inferior vena cava. Indeed, the catheter can eventually reach the right heart (3). However, because patients undergoing central venous catheterization are often critically ill, or in a hypercoagulable state due to factors such as infection, inflammation, malignancy, or require long-term catheterization, the risk of venous thrombosis is significantly increased (4-6). Moreover, venous thrombosis associated with central venous catheterization is often asymptomatic and difficult to detect early (7-9). The risks of central venous catheterization-associated thrombosis include cancer, advanced age, commodities, long hospitalization, lack of sports, venous nutrition, central venous catheters insertion in the subclavian vein, left-sided central venous catheters insertion, longer duration of catheter, catheter-to-vein ratio >0.45, and type of central venous catheters (10). Once the thrombosis is formed, it can easily enter the pulmonary circulation through the venous blood flow, resulting in pulmonary embolism that can endanger the patient’s life (11,12). Due to the huge number of patients using central venous catheters in recent years, the incidence of thrombosis has significantly increased. A previous study summarized that catheter-related thrombosis constituted 10% of all deep venous thrombosis (DVT) in adults and 50–80% of all DVTs among children (10). Research regarding thrombosis after central venous catheterization has mainly focuses on several aspects, including mechanisms of action, prevention, early diagnosis, and treatment (10,13). However, the current state of research in this field is unclear. Therefore, this study adopted bibliometrics to analyze the current research status of thrombosis related to central venous catheterization, so as to provide an updated reference for researchers.

Methods

Data source and search strategy

Science Citation Index Expanded (SCI-E) database was the most used database for bibliometrics analysis. English literatures published in the SCI-E database in the Web of Science Core Collection (WOSCC) from inception of database to December 31, 2021 were searched using the topic search strategy. The search terms were “central venous catheter” and “thrombosis”.

Analysis

The final results of the literature search were exported in plain text format to form source files for analysis. The CiteSpace software was used to analyze the source files. The dimensions of the analysis included the following: the number of publications in each year; the number of publications in each country and the collaborations between countries; the number of articles published by each institution and the collaborations between institutions; the number of articles published by each author and the collaborations between authors; the number of articles published by each journal; the use of keywords; and the number of times each country, institution, author, or journal was cited. The CiteSpace software was also used to draw the co-occurrence maps between countries, institutions, authors, and keywords.

Statistical analysis

The CiteSpace software was used to count the number and percentage of documents. No comparative analysis between groups was performed and thus, no statistical tests were conducted and no P values were set.

Results

General information

In this study, a total of 3,011 related research literature records were retrieved, of which 201 were classified as duplicates and deleted. Finally, a total of 2,810 literatures were included. These literatures were cited a total of 29,920 times, and the average number of citations per literature was 10.65 and the h-index was 79. Among these documents 2,218 were original articles, 383 were reviews, 146 were conference papers, 83 were conference abstracts, 72 were editorial materials, 53 were online publications, 33 were letters, 18 were notes, 2 were book chapters, 2 were corrections, and 1 was a retraction (Table 1). The number of publications in this field generally showed an annual increasing trend (Figure 1), dominated by disciplines such as peripheral vascular disease, as well as hematology and oncology (Figure 2). The number of citations also showed an obvious increasing trend annually (Figure 3).

Figure 1 The annual publication of literatures related to central venous catheterization-associated thrombosis.

Figure 2 The distribution of literatures according to research discipline.

Figure 3 The annual citation of literatures related to central venous catheterization-associated thrombosis.

Countries

The CiteSpace V software was used to analyze the information regarding countries of publication and a visualization map was generated (Figure 4). The results of the analysis showed that a total of 113 countries appeared in these documents, and there were 529 collaborations among these countries. The top 5 countries with the largest number of published papers in this field are USA, Italy, Canada, Germany, and China (Table 2). The top 5 countries with the highest centrality score reflecting the number of foreign collaborations are USA, Italy, UK, Canada, and Spain (Table 3).

Figure 4 The country visualization map. The nodes in the figure are represented by circles. The larger the circle, the more literatures from that country. The line between the circles represents that any two countries involved in a particular publication. The denser the connections, the more collaborations in that country. As can be seen from the figure, USA, Italy, UK, Canada, and other countries have more connections with other countries, while China has published a large number of documents, with fewer connections to other countries.

Institutions

The CiteSpace V software was used to analyze the research institutions associated with the published literatures and a visualization map was generated (Figure 5). The results of the analysis revealed that a total of 482 research institutions appeared in these documents, and there were 2,731 collaborations between institutions. The literature volume analysis demonstrated that the top 5 institutions with the largest number of publications in this field are McMaster University, University of Toronto, Hospital of Sick Children, Mayo Clinic, and University of Michigan (Table 4). The top 5 institutions with the highest centrality scores are McMaster University, Johns Hopkins University, University of Toronto, University of Michigan, and University of Washington (Table 5).

Figure 5 The institutional visualization map. The nodes in the figure are represented by circles. The larger the circle, the more literatures from that institution. The line between the circles represents two institutions appearing in a document at the same time, and the denser the connection, the more collaborations from that institution. The figure shows many connections (cooperation) between several institutions, but the sums between institutions are distributed in clusters, suggesting that cooperation between institutions may be limited to the same country.

Authors

Analysis using CiteSpace demonstrated that the cooperation between authors was mainly limited to the same team or research institution (Figure 6). The top 5 authors with the most publications are Mauro Pittiruti, Vineet Chopra, Julie Jaffray, Maureen Andrew, and Guy Young (Table 6). However, all had lower centrality scores, reflecting lower cooperation between authors (Table 7). Authors are often cited by the same literatures (Figure 7, Tables 8,9).

Figure 6 The author co-authorship visualization map. Each circle (or point) in the graph represents an author, and the larger the circle, the greater the number of articles published by the author. In the figure, the authors are gathered in groups, and each group represents a common research institution (or team). There are also links between clumps, representing collaborations with authors from other research institutions.

Figure 7 The author co-citation visualization map.

Journals

The 2,810 articles included in this study were published from 608 journals, of which the top 5 journals with the most published articles were Journal of Vascular Access, Thrombosis Research, Journal of Vascular and Interventional Radiology, Journal of Thrombosis and Haemostasis, and Journal of Parenteral and Enteral Nutrition. These top 5 journal published a total of 388 articles, accounting for 13.81% of the total literature (Table 10). The top 5 most cited journals were Chest, New England Journal of Medicine, Journal of Clinical Oncology, Thrombosis Haemostasis, and Lancet (Table 11). The highest cited centrality score was from British Medical Journal (Table 12).

Keywords

CiteSpace V software was used to analyze the keywords used in these included documents and a keyword co-occurrence map was constructed. The results demonstrated that these documents used a total of 482 keywords, and the number of times that any 2 keywords appeared in 1 document at the same time was 2,731 times (Figure 8). The top 5 keywords with the highest frequency were “thrombosis”, “central venous catheter”, “complication”, “risk factor”, and “deep venous thrombosis” (Table 13). The keyword with the highest centrality score was “infection” (Table 14). Burst analysis was conducted on the keywords with high frequency, and the results revealed that the use of high-frequency keywords showed obvious annual changes (Figure 9).

Figure 8 The keyword co-occurrence map.

Figure 9 The top 25 keywords with the strongest citation bursts.

Discussion

The results of this study demonstrated that in the SCI-E database, the literatures related to thrombosis after central venous catheterization were mainly published after 1990. The number of published literatures generally showed an increasing trend, and the number of citations also increased year by year. These documents are mainly from developed countries in Europe and North America, including USA, UK, Italy, and France, with the majority of collaborations occurring in these countries. However, cooperation between institutions tended to be limited to the same country, and cooperation between authors tended to be within the same institution. The analysis showed that although specialized journals in the field of vascular medicine and thrombosis published more articles, the top comprehensive journals were cited more frequently. Keyword analysis showed that in recent years, research on thrombosis after central venous catheterization was more targeted and focused on evidence-based medicine.

Catheter related thrombosis can be divided into tunneled or non-tunneled catheters, peripherally inserted central catheter (PICC), implanted ports, and dialysis catheters (14). Among them, PICC-related thrombosis accounts for about 80% of all catheter-related thrombosis in tumor patients (15). In a multicenter prospective study of 477 cancer patients who received a total of 50,841 catheter-days, 9 patients (1.9%) developed symptomatic upper extremity deep vein thrombosis (16). In another study, Lu et al. included 86 studies for a meta-analysis and demonstrated that the incidence of PICC-related venous thrombosis was 2.29% (17). In another study by Jones et al., catheter-related deep vein thrombosis occurred in 5.5% of PICC patients (18). It should be noted that these patients received standard catheter irrigation and heparinization after PICC implantation and may also have a degree of asymptomatic deep vein thrombosis. Furthermore, PICC increased the risk of symptomatic catheter-related thrombosis by 26% compared with other central venous catheterization methods (11). This may possibly be related to the longer indwelling time of the PICC (19). Central venous catheters via the subclavian, internal jugular, and femoral veins are generally indwelling for a shorter period of time, especially after extensive PICC development. Therefore, these locations are less likely to form blood clots.

Despite the era of aggressive prophylaxis, some patients develop catheter-related thrombosis after central venous catheterization. In a systematic review study, Leung et al. analyzed the results of 25 reports and found that most of the studies considered age, malignancy, diabetes, obesity, chemotherapy, thrombophilia, and previous thrombosis as risk factors for tube-related thrombosis (20). Another study has reported that associated risk factors include successful catheterization after multiple procedures [odds ratio (OR) =2.61; 95% confidence interval (CI): 1.12 to 6.05] and fluorouracil-containing chemotherapy (OR =4.27; 95% CI: 1.3 to 14.07). Risk factors for venous thromboembolism include fluorouracil-containing chemotherapy (OR =4.54; 95% CI: 1.63 to 12.61), male sex (OR =2.03; 95% CI: 1.04 to 3.93), and increased white blood cells (OR =1.12; 95% CI: 1.00 to 1.26) (18). Of course, compared with other central venous catheterization methods, PICC also increases the risk of catheter-related thrombosis, which may be related to the large amount of fluid infusion that fills the inner port of the catheter and the distant blood stagnation (13). To reduce multiple catheter placement attempts, ultrasound guidance can be used, thereby reducing the risk of thrombosis (21,22). Other risk factors include insertion of the catheter on the left side of the body (23), catheter diameter, catheter tip location, catheter indwelling time, and type of catheter (10).

Regarding the management of catheter-related thrombosis, current opinions are relatively consistent. Anticoagulation therapy is often administered to stabilize the thrombus, which is then resolved by the body’s thrombolytic system. In general, catheter-related deep vein thrombosis requires about 3 months of treatment. Initial treatment can be with intravenous anticoagulants or subcutaneous anticoagulants, and after a certain period of time, it can be gradually converted to oral anticoagulants (24). Once the patient starts anticoagulation, the catheter does not need to be removed until necessary (25).

This report presents the current research status in this field, including the distribution of countries, research institutions, researchers, and journals. The results of the keyword analysis may lead to changes in relevant research priorities. There were some limitations to this bibliometric study. First, the overall situation and changing trend of clinical research was not fully examined. Furthermore, the study failed to distinguish the different types of thrombosis after central venous catheterization. Nonetheless, these findings suggested that future research should focus on the prevention, early diagnosis, and treatment of asymptomatic central venous catheter-related thrombosis.

Acknowledgments

Funding: None.

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-22-1552/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: J. Teoh)