Great topic. Thanks again for the great discussion. Nice slides Dr. Patel!! really appreciate.

1. Question: So what is the verdict on prophylactic catheter exchanges? Beyond the problem of being stuck if left for long time, is there a time limit on the integrity of catheter material? If so, what is it?

2. Comment: Catheters could be stuck in soft tissues also (in the tunnel). I have had 2 patients that I could not remove catheter after dissecting the cuff, proceeded with a cut down at the IJ/Venotomy, was able to pull the intravascular portion of catheter out - then dissected the catheter from the other side of tunnel. Once the intravascular portion is removed, it is much safer. This issue could happen if catheter was tunneled very superficially (dermis).

In another patient when the intravascular portion was stuck, pulling the catheter at the venotomy (after a cut down as above) gave a better traction for removal - than pulling from the exit site - my observations..

Thank you.
Suresh (UC Davis, Sacramento CA)

There really is no verdict on prophylactic catheter exchanges, and no published data that I am aware of. This approach was mentioned at a national meeting a few years ago, by a very experienced interventionalist who does utilize this approach.

For me, if there is a long-term catheter in place, I don’t usually want to touch it if it is working well.

But the concept of a “prophylactic exchange” is provocative. This could be of benefit if it prevents a thoracotomy, but could be detrimental if you somehow instigate a catheter infection by exchanging the catheter.
I’ve had some catheters that have been in for years that came out easily, and some that have been in for just a few months that are challenging to remove. It’s impossible to predict which ones will have issues – but in general, the longer that it’s in, the more likely it will be adherent to the central veins.

The endoluminal dilation technique works really well. As mentioned in the presentation, when it doesn’t work, I can generally leave the balloon inflated at the suspected adherence site and pull the shaft of the balloon to focus gentle traction at that adherence site. This is similar in concept to your description of the ventomoy site cut-down to allow a more proximal focus of traction. This has always worked for me, and fortunately I have yet to have a patient require a thoracotomy.

I am not aware of any data on the “lifespan” of a catheter. Most develop some sort of dysfunction over time that necessitate an exchange at some point. Older generations of catheters had more issues with clamps or hubs cracking – but I don’t see that issue as much with more modern catheters. When we did see broken clamps and hubs, I’ve always been more in favor of replacing the entire catheter rather than repair it, to provide a “fresh” catheter. But that has been just my preference.

I’ve never encountered any other “breakdown” of the catheters otherwise.

Thank you very much for the comprehensive response Dr. Patel. This has helped me to make decisions on a patient. Thank you again.

Daniel makes a good point that there is no evidence to guide whether to prophylactically exchange a catheter based upon its length of service. It is important to pause on this point a bit. When there is no evidence to support a practice, it is improper to subject a patient to an invasive procedure that has known risks until a study is done to demonstrate benefit. My opinion would be that this needs to be studied, but until that is done purely prophylactic catheter exchange should not be a part of clinical patient care.

Daniel makes a good point that there is no evidence to guide whether to prophylactically exchange a catheter based upon its length of service. It is important to pause on this point a bit. When there is no evidence to support a practice, it is improper to subject a patient to an invasive procedure that has known risks until a study is done to demonstrate benefit. My opinion would be that this needs to be studied, but until that is done purely prophylactic catheter exchange should not be a part of clinical patient care.

Totally agree with Tim.
In our experience, the rate of tethered catheter is less 1/1000 (and not 1/100), hence, subjecting patient to unnecessary procedures should not be recommended.
The ballon technique works (and most practical) as long as u use a low profile balloon as discussed. One added feature to this technique, is that we have used a Tuohy hemostasis valve at the TDC luer (to prevent back bleeding or even air sucking) as we are manipulating the balloon and wire through the catheter lumen. We filibusters at times the hang up is at the venotomy rather than within the central veins, hence, dilating with the 6mm balloon through the entire length of the catheter (except tunnel) is recommended. A pre (via TDC) and post (via a sheath over the wire) balloon dilation is a given.
Cutting the TDC at the venotomy level and burying it (after clamping it with a hemostasis clip, a tie would have been appropriate) in a very frail, elderly patient with decreased longevity, is very appropriate. We did that in only 1 instance.
Tony Samaha

Not sure how “filibuster” came about in my comment! It should be: we find….
Sorry
Tony Samaha

I have seen 2 catheters :"stuck" to the SVC in 20 years, and after my IR colleague and I both failed to get them out had to resort to an "endovascular thoracic surgeon".
This situation is so fleetingly rare (in my experience) as to be an oddity - to propose "prophylactic replacement" on this basis is something I could not support.
Moreover, tissue ingrowth into the fiber cuff is the element of cuffed catheters that seals the tunnel and prevents skin flora from migrating down into the blood stream - the element that reduces risk of bacteremia and catheter sepsis. To DELIBERATELY disrupt this effective safety mechanism for light or spurious reasons would most likely cause more morbidity than it would prevent, not to mention the costs of procedures done without a recognized indication.
By all means conduct a randomized, double blinded trial, IF you can find an IRB who would sanction such speculation, AND if you can convince patients to submit to a schedule of procedures they might not need.

Agee with the expert consensus here - no apparent role for routine prophylactic exchanges in all patients.

Unfortunately there never will be any reasonable studies here, due to the relatively rare nature of this. So we are left to using our own judgment here. I agree with all the points above.

The question arises on what do you do after you are able to get a stuck catheter out. Presumably these issues happen to catheter dependent patients who will still need a catheter after you have removed it.

With successful removal with endoluminal ballon dilation, I have no apprehension about exchanging the catheter in the same spot. We have a femoral catheter patient who always requires dilation during her exchanges- which happen on average every 2-3 years when the catheter stops working. Fortunately ballon dilation has worked every time for her, without any apparent long-term consequences.

For any of you with catheter-dependent patients requiring a thoracotomy, where did you put the new catheter?

Do you replace it back in the same spot and risk another thoracotomy in the future? Do you go femoral?

Will your thoracic surgeon still send you a Christmas card every year if you put it back in the chest?

If you do go back into the chest after a thoracotomy, does a prophylactic exchange seem like a reasonable approach in this unique situation?

Unfortunately no good data here, and hopefully with the endoluminal technique we won’t encounter this issue as much in the future.

I agree with Tony and others that the "tethered" catheter is an infrequent phenomenon, especially with the newer catheters made from copolymers of polyurethane and polycarbonate. It was more frequent with the silicone catheters such as the early twin catheters of Canaud and Tesio. if they were used for years of dialysis. Dr. Beathard suggested that if an SVC catheter could not be removed, it could be cut just above the entry point to the jugular vein, and left in place without need for tying it off or clamping it. There's no pressure gradient from the SVC to the SQ tissue in most patients, and the catheter will quickly clot off. inside the vein the catheter has probably been separated from the bloodstream and incorporated into the vein wall by the overlying fibrous sheath, so infection is unlikely (just like with old pacemaker wires).. I tried this approach in two patients that had 5 year-old silicone Tesio catheters,, and it worked without any complications..
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I agree with Tony and others that the "tethered" catheter is an infrequent phenomenon, especially with the newer catheters made from copolymers of polyurethane and polycarbonate. It was more frequent with the silicone catheters such as the early twin catheters of Canaud and Tesio. if they were used for years of dialysis. Dr. Beathard suggested that if an SVC catheter could not be removed, it could be cut just above the entry point to the jugular vein, and left in place without need for tying it off or clamping it. There's no pressure gradient from the SVC to the SQ tissue in most patients, and the catheter will quickly clot off. inside the vein the catheter has probably been separated from the bloodstream and incorporated into the vein wall by the overlying fibrous sheath, so infection is unlikely (just like with old pacemaker wires).. I tried this approach in two patients that had 5 year-old silicone Tesio catheters,, and it worked without any complications..
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