Prophylaxis or peril? Rethinking catheter-related thrombosis prevention in home parenteral nutrition

Catheter-related thrombosis (CRT) is a consequential complication in patients receiving long-term home parenteral nutrition (HPN), compromising central venous access, nutrition support and, in some cases, survival. Yet whether routine prophylactic anticoagulation should be used to prevent CRT remains a clinical dilemma: although thrombosis prevention may preserve venous access, anticoagulation introduces bleeding risk, monitoring demands, added treatment burden, lifestyle restrictions, and cost. Proponents cite the relatively high incidence and clinical consequences of CRT, supported by observational data suggesting reduced thrombosis risk with prophylaxis. Opponents emphasize bleeding risks, lack of randomized controlled trial (RCT) evidence, and the improved safety of modern catheter care without anticoagulation. Consequently, practice varies widely, from routine anticoagulation to selective, risk-based approaches. This review critically evaluates the arguments on both sides, drawing on evidence from adult and pediatric cohorts. Beyond clinical outcomes, it considers the quality-of-life implications that daily anticoagulation imposes on an already complex HPN regimen. Routine anticoagulation in HPN sits at the intersection of prevention and harm: it may be appropriate for selected high-risk patients, but it is not a one-size-fits-all solution. An individualized, multidisciplinary approach, balancing thrombotic and bleeding risk alongside patient preference, is essential. Future research, including RCTs and predictive risk tools, is needed to refine patient selection and optimize strategies to preserve the venous lifelines sustaining HPN.