Primary Thromboprophylaxis in Patients With Malignancy and Central Venous Catheters

TRIM-Line is a double blind randomized controlled trial comparing rivaroxaban 10mg po daily vs placebo in patients with active cancer and indwelling CVC. This will involve 9 centers across Canada.

• Rivaroxaban 10 MG (Drug), also known as Placebo: Identical comparator drug

Primary outcomes

• Major VTE prevention [90 days (± 3 days) of randomization]: Number of Major VTE's in patient population
• Episodes of Major Bleeding [90 days (± 3 days) of randomization]: Number of participants who had a major bleed

Secondary outcomes

• Number of participants with Clinically Relevant Non-Major Bleeding (CRNMB) [90 days (± 3 days) of randomization]: As defined by ISTH
• Number of patients who had a fatal VTE [90 days (± 3 days) of randomization]: Fatal VTE
• Number of patients who benefitted from using the experimental intervention [90 days (± 3 days) of randomization]: Composite of major VTE and major bleeding
• PE [90 days (± 3 days) of randomization]: Incidental and Symptomatic
• Proximal CVC VTE [90 days (± 3 days) of randomization]: Incidental and symptomatic proximal (axillary vein or more proximal) upper extremity CVC-related DVT
• Distal CVC VTE [90 days (± 3 days) of randomization]: Incidental and symptomatic distal (brachial vein) or proximal (axillary vein or more proximal) upper extremity CVC-related DVT
• Proximal Lower extremity DVT [90 days (± 3 days) of randomization]: Incidental and symptomatic proximal (popliteal vein or more proximal) lower extremity DVT
• Distal Lower extremity DVT [90 days (± 3 days) of randomization]: Incidental and symptomatic distal or proximal (popliteal vein or more proximal) lower extremity DVT
• Number of participants with Unusual site thrombosis including: splanchnic vein (portal, splenic, superior mesenteric, inferior mesenteric, hepatic) cerebral vein, renal or gonadal vein thromboses [90 days (± 3 days) of randomization]: Unusual site thrombosis including: splanchnic vein (portal, splenic, superior mesenteric, inferior mesenteric, hepatic) cerebral vein, renal or gonadal vein thromboses
• Number of participants with Superficial upper or lower extremity vein thrombosis [90 days (± 3 days) of randomization]: Superficial upper or lower extremity vein thrombosis
• Number of participants with an arterial thromboembolic event including: MI, stroke, peripheral arterial disease [90 days (± 3 days) of randomization]: Arterial thromboembolic events defined as a diagnostically confirmed final clinical diagnosis of myocardial infarction, stroke or peripheral arterial disease involving the following arterial vascular beds: carotid, upper or lower extremity, gastrointestinal tract, liver, spleen, or kidney
• CVC Life-span [90 days (± 3 days) of randomization]: Life span of inserted CVC
• Number of patients with CVC occlusion occurring after the start of therapy, defined as an obstruction of the CVC lumen that prevents or limits the ability to flush, withdraw blood and/or administer solutions or medications. [90 days (± 3 days) of randomization]: CVC occlusion occurring after the start of therapy, defined as an obstruction of the CVC lumen that prevents or limits the ability to flush, withdraw blood and/or administer solutions or medications.
• Number of patients with CVC-related blood stream infection defined as the presence of bacteremia originating from the CVC according to the definition from the Centers for Disease Control and Prevention [90 days (± 3 days) of randomization]: CVC-related blood stream infection defined as the presence of bacteremia originating from the CVC according to the definition from the Centers for Disease Control and Prevention
• Number of participants who passed away during the trial [90 days (± 3 days) of randomization]: Overall mortality
• EQ-5D-5L Health-related quality of life [90 days (± 3 days) of randomization]: Health-related quality of life
• ICER [1 Year]: Incremental cost-effectiveness ratio (ICER) at one year

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Patients 18 years of age or older with a new or existing diagnosis of cancer and a CVC inserted in the last 72 hours.

Exclusion criteria:

1. CVC in place for >72 hours
2. Patient requires anticoagulation for other indications
3. Concomitant use of dual antiplatelet therapy
4. Major bleeding event in the last 4 weeks
5. Patients receiving concomitant systemic treatment with strong inhibitors of both CYP 3A4 and P-gp (such as cobicistat, ketoconazole, itraconazole, posaconazole, or ritonavir).
6. Known pregnancy or plan to become pregnant in next 3 months
7. Severe renal insufficiency (Creatinine clearance <30 mL/min (defined by Cockcroft-Gault) in the previous 3 months
8. Documented severe liver disease (e.g., acute clinical hepatitis, chronic active hepatitis or cirrhosis) in the previous 3 months
9. Known thrombocytopenia (platelet count < 50x 109/L) in the previous 3 months
10. Known allergy to rivaroxaban
11. Life expectancy <3 months
12. History of condition at increased bleeding risk including, but not limited to:

    1. cerebral infarction (hemorrhagic or ischemic), active peptic ulcer disease with recent bleeding, spontaneous or acquired impairment of hemostasis in the past 4 weeks.
    2. Chronic hemorrhagic disorder
13. Primary malignancy diagnosis of basal cell or squamous cell carcinoma of the skin only
14. Refused or unable to obtain consent

• Ikesaka R, Siegal D, Mallick R, Wang TF, Witham D, Webb C, Carrier M; Canadian Venous Thromboembolism Research Network (CanVECTOR). Thromboprophylaxis with rivaroxaban in patients with malignancy and central venous lines (TRIM-Line): A two-center open-label pilot randomized controlled trial. Res Pract Thromb Haemost. 2021 May 5;5(4):e12517. doi: 10.1002/rth2.12517. eCollection 2021 May. PMID 34027291
• Results publication: Wang TF, Ikesaka R, Mahe I, Hill D, Sperlich C, Tagalakis V, Shivakumar S, Leonard B, Cervi A, Kuruvilla P, Larose F, Matino D, Frosi Stella S, Seguin C, Al Raizah A, Le Gal G, Siegal DM, Delluc A, Mallick R, Lazo-Langner A, Wu C, Christopher D, Di Nisio M, Ageno W, Yazji B, Carrier M. Primary thromboprophylaxis in patients with malignancy and central venous catheters: TRIM-Line randomized controlled trial - Design and rationale. Thromb Haemost. 2026 Sep 21. doi: 10.1055/a-2963-4656. Online ahead of print. PMID 42767263

• Dr. Marc Carrier, Principal investigator, Ottawa Hospital Research Institute