Chapter 15

Catheter and Port Removal: Techniques and Follow-Up Care

Janice Newsome

Jaime Tisnado

The use of central venous catheters has increased dramatically over the past 20 years. These devices now are considered essential in providing dependable venous access for both acute and chronically ill patients. Whereas much emphasis is placed on the insertion and management of central catheters, little attention has been given to their removal, and this task is often assigned to junior physicians or nurses who are inexperienced in removal procedures. This chapter discusses the techniques for removal of the various types of venous catheters and ports; briefly mentions the complications of catheter removal; and provides therapeutic measures to deal with infected catheters, tunnels, and pockets.

Once the decision is made to remove a catheter or port either because an infection clearly has occurred, because infection is suspected to be present, or because the vascular access is no longer needed, the patient is counseled about what to expect during the removal procedure and thereafter. Informed consent is not routinely obtained for a simple catheter removal unless another catheter is going to be inserted or an associated procedure will be performed. Some operators may wish to obtain consent, however, particularly if the catheter being removed was placed initially by someone else. Necessary equipment for catheter removal includes a cut-down tray and a small table with basic instruments. A bed that allows placement of the patient in a head-down position (Trendelenburg) is ideal although not required. This special bed is not routinely available in most radiology departments. Removals are done in any suitable room, not necessarily in the angiographic laboratory; so the laboratory can be used for other purposes.

REMOVAL OF TUNNELED CATHETERS

Tunneled catheters should be removed when they are infected or no longer needed. In general, the longer a catheter has been in place, the more difficult the removal may be; however, this is not necessarily true. In fact, some infected catheters or ports will slide out easily regardless of how long they have been in place. Some patients develop thick scar tissue and cheloid very rapidly. We have seen patients in whom removal of a catheter placed a few weeks earlier was rather difficult.

The skin over the catheter exit site, the tunnel, and the area overlying the entrance site into the vein is prepared using Povidone–iodine (7.5–10%) or alcohol. Sterile drapes and towels are placed to establish a sterile field. Adequate local anesthesia is obtained with lidocaine, with or without epinephrine, and infiltrated in the soft tissues, making sure that the entire subcutaneous tunnel and the skin over the site of entry into the vein are well anesthetized. Special care must be taken not to puncture the catheter during the administration of local anesthetic because bleeding may follow if the catheter is damaged. Initially, the catheter is released from the skin at the exit site by cutting the anchoring sutures, if present. If the catheter was placed recently, that is, less than 2 weeks ago, removal requires little dissection, but this is not always true.

The patient should be instructed to suspend respiration temporarily to prevent the serious risk of air embolism, which may occur if the patient takes a deep inspiration as the catheter exits the vein. The catheter is grasped with one hand, at or near the hub, and pulled slowly and steadily to ensure that the force of traction follows the path of the tunnel. Excessive force or tension must be avoided because the catheter may rupture, with resultant bleeding in the tunnel or fragment embolization. The operator must immediately hold pressure at the venous insertion site with the other hand as soon as the catheter exits the vein at the puncture site. In certain cases, such as infection, care should be taken to prevent contamination of the catheter if the tip is needed for culture. Hemostasis usually is achieved by holding gentle pressure on the vein for about 10 minutes. Elevation of the head of the bed more than 30 degrees may help with hemostasis.

During pulling the catheter, enough tension must be applied to release the catheter free of the remaining granulation and scar tissue; however, care must be taken not to apply so much tension that the catheter breaks. Some large catheters, such as dialysis (12–14 F) catheters, are quite sturdy, and a great deal of tension can be applied during removal, but these catheters can rupture. The smaller 7 to 10 F tunneled catheters, especially Silastic catheters, will break with the application of even a little tension. When the catheters break, they usually tear on the hub side of the Dacron cuff. This is a serious situation that requires prompt action because brisk bleeding into the subcutaneous tract may occur and air embolization into the venous system is likely. The catheter must be compressed immediately. If the procedure was being done unassisted, one must get help immediately because it is impossible to hold pressure over the catheter while dissecting the tract. Once the bleeding has been controlled with compression, another incision should be made at the venous entry site or over the subcutaneous tunnel near this site. Using a hemostat, blunt dissection is done until the underlying catheter is seen and retrieved. The catheter must be clamped to stop bleeding from its torn end. The clamped catheter should then slide easily out of the vein as pressure is applied at the venous puncture site. When hemostasis is obtained, the remaining segment of catheter with the Dacron cuff may be dissected free through the new skin incision.

The patient must stop breathing momentarily while the catheter is being removed to prevent air embolism. The operator must promptly compress the venous puncture site, which is usually apparent on examination of the scar of the healed puncture site. Once hemostasis is achieved, antibiotic ointment may be applied to the exit wound and an airtight occlusive dressing placed over the site and left there for 2 to 3 days. If the exit site is large, a single interrupted stitch must be placed; otherwise, Steri-strips are used to close the skin. Tunneled catheters placed in the femoral vein are removed in a similar fashion (Fig. 15–1).

On occasion, during tension and pulling of the catheter, the Dacron cuff may be separated off the catheter and remain in the subcutaneous tissue. The cuff is left there because it is of no clinical significance and nothing needs to be done. If for cosmetic or other reasons (infected tunnel) cuff removal is desired, a direct cut-down over the region of the retained cuff may be needed for the cuff to be removed.

REMOVAL OF SUBCUTANEOUS PORTS

Ports must be removed by an experienced operator. A surgical cut-down tray is required. The skin over the pocket, the subcutaneous tunnel, and the venous puncture site are prepped with povidone-iodine (7.5–10%) and alcohol. Sterile towels and drapes are placed to create a sterile surgical field. Adequate local anesthesia is obtained using generous amounts of 1% buffered (with sodium bicarbonate) lidocaine. Care must be taken not to puncture the catheter within the tunnel while injecting the local anesthetic. Ideally, if a special table is available, the patient can be placed in a Trendelenburg position with the head turned away from the working site. A no. 10 or 15 scalpel is used to make an adequate skin incision over the previous scar, which will result in only one scar with better cosmetic results. Forceps are used to elevate and separate the tissues directly over the port. Using blunt and sharp dissection with scissors and scalpels, the scar tissue, which usually surrounds and encases the port, is released. Additional dissection may be needed to release scar tissue often found at the port stem /catheter lock as well as at the proximal portion of the tunnel. Dissection along the tunnel is rarely needed to free the catheter because the Silastic catheter is biocompatible and does not promote scar tissue. The catheter is withdrawn from the vein and tunnel easily. Once the port and catheter are free, the patient is instructed to suspend respirations to prevent air embolism. The catheter is grasped distal to the connection with the port and withdrawn in a slow, steady manner. To achieve hemostasis, the venous puncture site must be compressed for 10 minutes as soon as the catheter tip exits the vein. Dry gauze can be placed inside the pocket and pressure applied for hemostasis. The gauze is removed and the pocket examined to ensure that it is “dry” and no hematoma is forming. If bleeding sites are noted, they should be ligated or controlled. Absorbable sutures are placed to approximate the deeper subcutaneous tissues and, depending on the operator’s preferences, buried subcutaneous running absorbable sutures or simple interrupted nonabsorbable sutures are used to close the skin. Antibiotic ointment can be applied to the wound, and an airtight dressing is left in place for 2 to 3 days.

Besides bleeding, one of the most common and feared complications of catheter and port removal is air embolism. The signs and symptoms may be nonspecific, and the diagnosis can be made based on clinical assumption, often after an unsuspected transient cardiopulmonary collapse or neurologic dysfunction has occurred. Few documented cases are reported in the literature of air embolism during placement of central venous catheters,^1–4 and even fewer documented cases are reported of air embolism during catheter removal.^5–8 Breathing during removal by uncooperative patients is the cause. Also, if a fibrin sheath is present along the catheter tract in the tunnel, the sheath can be a pathway for air to enter the venous system if prompt hemostasis is not performed.

After removal of a central venous catheter, regardless of the site, a short tract between the skin and the vein may stay patent momentarily. The tract, if large enough, can allow air to enter the venous system during inspiration. Enough air to cause embolism and cardiorespiratory collapse can enter the venous system in one inspiration. For this reason, it is critical that patients suspend respiration during the withdrawal phase of catheter removal until firm pressure is maintained on the vein to occlude the puncture site. It has been reported that a tract diameter of 4.5 mm needed to insert a 14 F catheter can allow conduction of 200 cc of air in 1 second, according to Poiseuille’s law.⁷ The documented lethal amount of injected air in humans is 70 to 105 cc per second.¹ If the embolized air is trapped in the right ventricle, it may produce right ventricular obstruction, resulting in acute right heart failure, shock, and death.

Furthermore, it has been reported that in humans the foramen ovale may remain patent in 10 to 24% of the population.⁹ Therefore, if a patient has a patent foramen ovale, serious and catastrophic arterial air embolism can occur. Air in the left ventricle can migrate into the carotid arteries, causing cerebral air embolism.

In addition, air can enter the venous system directly through the catheter, especially if it becomes disconnected from the intravenous line or if the hub of the catheter is open or incompletely locked. The sound of sucking air through the catheter or tract is highly suggestive of air embolism. Fluoroscopy and other radiologic examinations, such as chest radiographs, computed tomography, or echocardiogram, may show air embolized in the heart or brain. Prompt recognition of air emboli is critical to allow therapeutic intervention. Patients should be given 100% oxygen immediately. Embolized air can produce right ventricular outflow obstruction, acute right-sided heart failure, and shock. If the embolized air remains in the right side of the heart, immediately place the patient in the left lateral decubitus position with the patient’s left side down (Durant) and the head down (Trendelenburg) to allow blood to flow out of the right ventricle into the pulmonary outflow tract and preventing obstruction.¹⁰ Furthermore, the air can be trapped in the right atrium, and a catheter can be inserted into the right side of the heart and the air aggressively aspirated (as much as possible) to prevent the serious sequelae.¹¹

Pulmonary Embolism

Pericatheter thrombus is a common complication of long-term indwelling central venous catheters. It is estimated that 42 to 100% of venous catheters become covered by a fibrin sheath.¹² During withdrawal of the catheters, thrombi and fibrin may be stripped from the catheter and embolize into the lungs. These pulmonary emboli are usually small and of no clinical significance in most patients, unless they have a borderline pulmonary reserve. Furthermore, if the patient has a patent foramen ovale, the emboli can gain access to the left ventricle and embolize into the carotid circulation, leading to a stroke. Moreover, it was recently reported that the sleeve surrounding the catheters is not a true fibrin sleeve but, rather, an organized cellular–collagen tissue covered by endothelium.¹²

It is important to know that the cellular–collagen sleeve can be present as early as 24 hours, be complete in 1 week, and last up to 10 months after catheter removal. This process may play an important role in the withdrawal occlusion of veins. Some investigators have suggested the prophylactic use of aspirin, and even oral warfarin, to decrease the incidence of catheter-related venous thrombus formation, as is almost routinely done for arterial thrombus prevention.¹³ Other researchers have found no correlation between thrombus formation, duration of catheterization, type of catheter used, or regimen of anticoagulation with heparin, either therapeutic or low-dose.¹⁴

The incidence of infectious complications differs significantly with the different types of catheters. There is a higher infection rate in nontunneled catheters. The incidence of infection of tunneled catheters is as high as 10 to 30%.^15,16 The infection rate for Hickman catheters is 1.9 per 1000 catheter days when a radiologist places the catheter and 4.0 per 1000 catheter days when a surgeon places the catheters.¹⁷

Subcutaneous ports have lower infection rates, ranging from 0.03 to 0.1 per 1000 catheter days.¹⁸ On the other hand, PICCs have infection rates of 3.1 per 1000 catheter days.¹⁵ The diagnosis of catheter-related infection can be difficult. Subtle clinical signs, such as unexplained leukocytosis, low-grade fever, or an isolated positive blood culture, might be the only feature of a raging infection. Unfortunately, the frequently used parameters for diagnosing a catheter infection are nonspecific. Pain, local erythema, and swelling may be more significant indicators of catheter infection than other clinical and laboratory parameters.¹⁹

The treatment for a catheter-related infection depends on the extension of the process. Exit-site infections are the easiest to diagnose and usually present with tenderness and erythema about 1 cm around the exit site. Occasionally, a purulent exudate may be present. These infections can be treated successfully with local measures and antibiotics.

Tissue disruption of the port pocket or tunnel and tenderness and cellulitis over the port or along the tunnel indicate a serious infection or abscess. The port or tunneled catheter must be removed. Pus or cloudy fluid should be cultured and intravenous antibiotics started. The pocket must be opened and thoroughly irrigated with saline and packed with iodoform gauze twice daily until the drainage has stopped. The pocket eventually will heal by secondary intention. If the tunnel is infected, the skin over the tunnel can be incised and the tunnel drained. Alternatively, the tunnel can be enlarged, irrigated, and packed from both ends with gauze twice daily until drainage stops and eventually heals by secondary intention as the gauze is progressively withdrawn.