Part 5: Special Populations, Device Removal, Patient Education, and Quality Metrics

1. Special Populations in Oncology Vascular Access

1.1 Pediatric Oncology

1.1.1 Device Selection

Implanted ports are the preferred vascular access device for children with cancer requiring long-term treatment, based on evidence demonstrating lower venous thromboembolism and infection rates compared to tunneled catheters and PICCs.¹²³

Specific Pediatric Considerations:

• Catheter sizing: Use the smallest French size that accommodates the treatment plan. Common pediatric port catheter sizes range from 5 Fr to 8 Fr.
• Growth and tip migration: Children grow, which can cause secondary catheter tip malposition over time. Periodic chest radiographs (at minimum annually) should monitor catheter tip position relative to the cavoatrial junction. Device exchange may be required during prolonged treatment courses spanning years.⁴
• Repeated PICC insertions: In pediatric patients, repeated PICC insertions in the same arm have been associated with increased risk and accelerated progression of symptomatic thrombosis. This cumulative risk should factor into device selection decisions.¹
• Sedation and anesthesia: Port placement in young children typically requires general anesthesia. Port access for treatment may require procedural sedation or anxiolytic premedication in younger children, along with topical anesthetic cream.
• Activity restrictions: School-age children and adolescents should receive age-appropriate guidance regarding physical activity. Contact sports are generally discouraged with externalized catheters (PICCs, tunneled catheters). With implanted ports (deaccessed), most physical activities including swimming are permitted after full wound healing.

1.1.2 Pain Management for Port Access in Children

Pain management is a critical aspect of pediatric port care:⁴⁵

• Topical anesthetic cream: EMLA (lidocaine 2.5%/prilocaine 2.5%) or LMX (liposomal lidocaine 4%) should be applied to the port site 30–60 minutes before access as standard practice
• Vapocoolant spray: May provide rapid anesthesia as an adjunct or alternative
• Non-pharmacologic strategies: Child life specialist involvement, distraction techniques (electronic devices, guided imagery, music therapy), positioning for comfort (allowing the child to sit in a parent’s lap), and age-appropriate procedural preparation
• Needle phobia or severe anxiety: Consider anxiolytic premedication (e.g., midazolam) per institutional protocol for children with significant procedural distress despite topical anesthesia and distraction

1.1.3 Flushing Protocols in Pediatric Oncology

Flushing volumes and heparin concentrations are adjusted for pediatric patients:⁴⁶

1.1.4 Thrombosis Prevention and Management in Pediatric Oncology

• Implanted ports are preferred over PICCs and tunneled catheters for reducing VTE risk in children with cancer¹²
• Routine thrombophilia screening is not recommended for pediatric patients with catheter-associated DVT¹
• Pharmacologic VTE prophylaxis in pediatric oncology remains an area of limited evidence; some data suggest prophylactic anticoagulation may decrease CAT risk without increasing bleeding complications in specific subgroups¹
• Treatment of confirmed CAT follows adult principles: anticoagulation for a minimum of 3 months, with catheter retention if the device is functional and needed

1.2 Elderly Oncology Patients

1.2.1 Device Selection Considerations

The growing population of elderly cancer patients presents specific challenges for vascular access:⁷

• Skin fragility: Aging skin is thinner, more friable, and more susceptible to medical adhesive-related skin injury (MARSI). Silicone-based skin protectants or barrier films should be applied before dressing and securement device application.
• Subcutaneous tissue loss: Reduced tissue over the port body may increase the risk of port erosion through the skin. Low-profile port designs may be preferred.
• Cardiovascular comorbidities: Higher prevalence of pacemakers, defibrillators, and aortic disease may influence insertion site and approach. Contralateral placement to cardiac devices is typical.
• Cognitive impairment: Patients with dementia or significant cognitive decline may not be able to report symptoms of complications (pain, swelling) or participate in self-care. Increased clinician surveillance and caregiver involvement are essential.
• Functional status: Performance status (ECOG) and prognosis should influence device selection. A patient with limited life expectancy and palliative treatment goals may benefit from a PICC (easier placement and removal) rather than a port requiring surgical procedures.
• Polypharmacy and anticoagulation: Elderly patients frequently take anticoagulants and antiplatelet agents, requiring careful coordination for device placement and removal.
• Falls risk: Externalized catheters (PICCs, tunneled catheters) may be caught during falls, resulting in dislodgement or damage. Ports may be safer in patients at high fall risk.

1.2.2 Skin Care in Elderly Patients

• Use alcohol-free adhesive removers to minimize skin stripping during dressing changes
• Apply skin barrier films before dressing application
• Consider foam-bordered TSM dressings for patients with very fragile skin
• Monitor for MARSI at each dressing change and adjust products as needed
• Minimize tape use; prefer engineered securement devices over tape-based methods

1.3 Thrombocytopenic Patients

Thrombocytopenia is common throughout oncology treatment, arising from chemotherapy-induced myelosuppression, bone marrow infiltration by tumor, or treatment with targeted agents.⁸

1.3.1 CVAD Insertion During Thrombocytopenia

• Ultrasound-guided insertion minimizes the number of access attempts and reduces bleeding risk
• Post-procedure monitoring for hematoma formation should be intensified in thrombocytopenic patients
• For port placement, ensure adequate hemostasis before wound closure; consider fibrin sealant if available

1.3.2 CVAD Maintenance During Thrombocytopenia

• Noncoring needle insertion and removal at the port site may cause localized bleeding; apply firm pressure after needle removal in patients with low platelets
• Dressing changes should be performed gently to avoid disrupting fragile tissue and blood vessels
• Monitor for hematoma formation at the insertion site
• Avoid unnecessary catheter manipulation to reduce risk of bleeding

1.3.3 CVAD Removal During Thrombocytopenia

• PICC removal is generally safe at platelet counts ≥20,000/µL with manual pressure application
• Tunneled catheter removal may require platelet transfusion support if the count is <50,000/µL, given the non-compressible subclavian/jugular venotomy site
• Port removal (surgical) typically requires platelet count ≥50,000/µL
• For all device removals in thrombocytopenic patients, plan for extended pressure application at the access site

1.4 Patients on Anticoagulation Therapy

1.4.1 Coordination of Anticoagulation with CVAD Procedures

Clinical Notes:

• The above timing recommendations are general guidelines; institutional protocols and individual patient risk assessment should guide decisions
• In cancer patients, the risk of thrombotic events during anticoagulation holds must be balanced against procedural bleeding risk
• Bridging anticoagulation strategies should follow institutional protocols and cancer-specific VTE guidelines
• For patients on LMWH for cancer-associated VTE, brief holds for CVAD procedures are generally well-tolerated with low thrombotic risk

1.4.2 Ongoing CVAD Care in Anticoagulated Patients

• Monitor insertion sites more closely for bleeding or hematoma
• Document anticoagulation status at each CVAD assessment
• Use caution during dressing changes and catheter manipulation
• Heparin lock solutions are generally safe in patients on systemic anticoagulation; however, some institutions omit heparin locks in fully anticoagulated patients to avoid confusion regarding heparin exposure

1.5 Patients with Hematologic Malignancies

Patients with leukemia, lymphoma, and myeloma face unique challenges:⁸⁹

• Prolonged cytopenias: Multi-week neutropenia and thrombocytopenia during induction chemotherapy for acute leukemia
• Frequent multi-lumen access: Need for simultaneous chemotherapy, blood products, antibiotics, and TPN favors tunneled multi-lumen catheters
• Stem cell transplant: Dedicated tunneled catheter for conditioning, transplant, and engraftment management (typically dual or triple lumen)
• High CLABSI rates: Hematologic malignancy patients have the highest CLABSI rates among all oncology populations; maximum CLABSI prevention bundle compliance is essential
• Mucositis-associated bacteremia: Gastrointestinal mucosal barrier injury allows translocation of enteric organisms, particularly viridans group streptococci and gram-negative bacilli. This may mimic or coincide with CRBSI.

2. Device Removal Criteria and Procedures

2.1 Indications for CVAD Removal

Definitive Indications:

Relative Indications (Clinical Judgment Required):

2.2 Post-Treatment Port Retention vs. Removal

A common clinical decision in oncology practice is whether to remove an implanted port after completion of active cancer treatment. Multiple professional society guidelines address this question:⁴⁵¹⁰

Factors Favoring Port Retention:

• High risk of cancer recurrence requiring future treatment
• Ongoing need for surveillance imaging with IV contrast (power-injectable port)
• Ongoing supportive care needs (transfusions, hydration)
• Patient preference to keep the device as “insurance” against relapse
• Limited vascular access that would make future device placement challenging

Factors Favoring Port Removal:

• Low recurrence risk and no anticipated future need
• Complications with the current device (infection history, thrombosis)
• Patient discomfort, anxiety, or body image concerns
• Device at or near end of expected service life (manufacturers typically warrant ports for 3–5 years, though many function far longer)
• Patient desire for psychological closure after cancer treatment
• Risk of long-term complications with prolonged dwell: infection, thrombosis, catheter tip migration, catheter fracture, port erosion

Counseling Approach:

Patients should be informed that retained ports require ongoing maintenance flushing (every 4–12 weeks per institutional protocol) and periodic assessment. The risks of both retention and removal should be discussed, and the decision should be made collaboratively with the patient and oncology team.¹⁰

2.3 PICC Removal Procedure

PICC removal is a bedside procedure that does not require anesthesia or sedation:¹¹

1. Verify the indication for removal with the care team
2. Place the patient supine with the arm at or below heart level
3. Perform hand hygiene; don clean gloves
4. Remove the dressing and securement device
5. Inspect the insertion site; note external catheter length
6. Instruct the patient to exhale slowly during catheter withdrawal (reduces risk of air embolism)
7. Slowly and steadily withdraw the catheter; never forcefully pull against resistance
8. If resistance is encountered, stop and reassess. Possible causes include:
   • Vasospasm (apply warm compresses and reattempt after several minutes)
   • Fibrin sheath adherence
   • Catheter knotting (rare; requires radiographic evaluation)
   • Venous thrombosis encasing the catheter (requires imaging and possible anticoagulation before reattempt)
9. Measure the removed catheter length and compare to documented insertion length to confirm complete removal
10. Apply pressure to the insertion site with sterile gauze for 3–5 minutes (longer in anticoagulated or thrombocytopenic patients)
11. Apply a sterile occlusive dressing; leave in place for 24–48 hours
12. Instruct the patient to keep the site clean and dry; report any bleeding, swelling, or signs of infection
13. Document the procedure, catheter length, site condition, and patient tolerance

Critical Safety Points:

• Never cut a PICC to facilitate removal — this risks catheter embolization
• If the catheter breaks during removal, clamp the remaining external portion, apply a tourniquet above the insertion site, place the patient supine in Trendelenburg, and obtain urgent imaging to locate the retained fragment. Interventional radiology retrieval is required.
• Air embolism prevention: Position the patient flat or in Trendelenburg; have the patient exhale or perform Valsalva during final withdrawal; apply an occlusive dressing immediately

2.4 Tunneled Catheter Removal Procedure

Tunneled catheter removal requires sufficient force to disrupt the tissue ingrowth around the Dacron cuff:¹¹

1. Position the patient supine
2. Perform skin antisepsis over the exit site and subcutaneous tunnel
3. Administer local anesthetic at the exit site and along the palpable tunnel
4. Make a small incision over the cuff if tissue ingrowth is mature (>2–4 weeks post-insertion)
5. Use blunt dissection to free the cuff from surrounding tissue
6. Once the cuff is freed, apply gentle, steady traction to withdraw the catheter
7. If resistance is encountered after cuff dissection, consider imaging to evaluate for catheter fixation
8. Verify complete catheter removal by measuring against documented insertion length
9. Apply pressure to the exit site and tunnel incision for 5–10 minutes
10. Close the incision if needed (typically steri-strips are adequate)
11. Apply sterile dressing

2.5 Port Removal Procedure

Port removal is a surgical procedure requiring sterile technique and local or general anesthesia:¹⁰¹¹

1. Pre-procedure: Verify coagulation status (platelets ≥50,000/µL, INR ≤1.5); hold anticoagulants per protocol; obtain informed consent
2. Prepare the port site with CHG-alcohol antisepsis
3. Inject local anesthetic along the prior incision line and around the port pocket
4. Make an incision along the original port placement scar (or new incision if scar is not favorable)
5. Dissect to the port pocket; free the port body from surrounding fibrous capsule
6. Identify and dissect along the catheter from the port body toward the venotomy site
7. Apply gentle traction to deliver the catheter from the vein
8. Verify complete catheter removal — inspect the catheter tip; if the tip is absent or the catheter appears shorter than expected, obtain immediate imaging to evaluate for a retained fragment
9. Achieve hemostasis in the pocket and venotomy site
10. Close the incision in layers
11. Apply a sterile dressing
12. Post-procedure wound care instructions for the patient

Complications of Port Removal:

• Retained catheter fragment (catheter may fracture during removal, particularly with prolonged dwell time or fibrous encasement)
• Bleeding (particularly in anticoagulated or thrombocytopenic patients)
• Wound infection
• Pneumothorax (rare)
• Damage to adjacent structures

Risk factors for difficult removal include prolonged dwell time, catheter fibrosis, and ports implanted in the forearm.¹⁰

3. Patient and Caregiver Education

3.1 Pre-Insertion Education

Before CVAD placement, patients and caregivers should receive education addressing:⁴⁵¹²

• The type of device being placed and why it was selected
• The insertion procedure, including what to expect during and after
• Expected appearance of the device and insertion site after placement
• Activity restrictions during the healing period (typically 1–2 weeks for PICCs; 2–4 weeks for ports and tunneled catheters before full activity)
• Routine care and maintenance requirements
• How the device will be used for treatment
• Signs and symptoms of complications requiring prompt medical attention
• Who to contact with questions or concerns (24/7 contact information)

Education provided before insertion has been shown to decrease patient anxiety and improve knowledge retention.¹²

3.2 Ongoing Patient Education Topics

For All CVAD Types:

Additional Topics for Home Infusion Patients:

3.3 Port-Specific Patient Education

For Patients with Implanted Ports:

• Explanation of the port anatomy (reservoir, catheter, septum) using diagrams or models
• How the port is accessed (noncoring needle through the skin into the septum)
• Importance of having the port accessed only by trained clinicians using noncoring needles
• Maintenance flush schedule when not receiving treatment (every 4–12 weeks per institutional protocol)
• Signs of port complications: port pocket swelling, skin breakdown over the port, pain, difficulty with access
• Activities permitted when the port is deaccessed (swimming, bathing, most sports) vs. restrictions when accessed
• Carrying a port identification card (includes device manufacturer, model, and whether it is power-injectable)
• MRI compatibility information per manufacturer specifications
• Importance of informing all healthcare providers about the port before any medical procedure, imaging study, or emergency department visit⁴¹²

3.4 Post-Treatment Education (Survivorship)

When treatment is completed, education should address:¹⁰

• Whether the CVAD will be retained or removed, and the rationale
• If retained: ongoing maintenance requirements (flushing schedule, annual surveillance)
• If removed: wound care after removal, expected healing timeline, and when to resume all activities
• Long-term follow-up plan
• Potential late complications of CVAD dwell (if retained): infection, thrombosis, catheter fracture, tip migration
• Instructions to report any new symptoms related to the CVAD site, even months or years after treatment completion

4. Quality Metrics and Surveillance

4.1 CLABSI Surveillance

CLABSI is a nationally reportable quality metric and a critical focus of oncology quality programs:²³

Surveillance Metrics:

Standardized Infection Ratio (SIR):

Many institutions report the CLABSI Standardized Infection Ratio, which compares observed infections to a nationally predicted number based on facility type and patient population. Oncology units should track SIR trends over time with the goal of maintaining an SIR ≤1.0 (at or below the national baseline).³

4.2 Catheter-Associated Thrombosis Surveillance

4.3 Device Complication and Utilization Metrics

4.4 Patient Experience Metrics

4.5 Quality Improvement Framework

An effective CVAD quality program in oncology incorporates:²³¹³

1. Multidisciplinary governance: A vascular access committee or governance structure including oncologists, vascular access specialists, infusion nurses, infection preventionists, interventional radiologists, and patient representatives
2. Standardized policies and procedures: Evidence-based protocols for device selection, insertion, maintenance, and complication management, reviewed and updated at minimum annually
3. Competency validation: Initial and ongoing competency assessment for all clinicians involved in CVAD insertion and management, including hands-on skills verification
4. Data collection and analysis: Prospective surveillance with regular review of complication rates, bundle compliance, and outcomes
5. Benchmarking: Comparison of institutional outcomes against national benchmarks (NHSN data, published oncology-specific rates)
6. Root cause analysis: Investigation of serious CVAD-related events (CLABSI clusters, severe extravasation, catheter embolization) with implementation of corrective actions
7. Education and feedback: Regular dissemination of surveillance data to frontline clinicians; targeted education when performance gaps are identified
8. Technology evaluation: Systematic assessment of new products and technologies (antimicrobial catheters, novel securement devices, thromboresistant materials) with evidence-based adoption decisions
9. Patient engagement: Incorporating patient education, shared decision-making in device selection, and patient-reported outcomes into the quality framework

4.6 Audit Tool: CVAD Maintenance Compliance

The following audit checklist may be adapted for institutional use to assess compliance with CVAD maintenance standards during observational audits:

5. Emerging Topics and Future Directions

5.1 Antimicrobial and Antithrombotic Catheter Technologies

Catheter surface modifications including hydrogel coatings, drug-eluting surfaces, antimicrobial impregnation, and hydrophilic or hydrophobic polymer technologies represent an evolving area of research. While some products have shown promise in reducing infection and thrombosis rates, confirmatory clinical trials with adequate sample sizes in oncology populations are needed before broad adoption can be recommended.¹¹⁴

5.2 Extended Maintenance Flushing Intervals

The trend toward extending port maintenance flushing intervals (from monthly to every 8–12 weeks or even every 3 months) reflects growing evidence that less frequent flushing does not compromise port patency and reduces patient burden. Further prospective studies are underway to define the upper limits of safe flushing intervals.⁵

5.3 Point-of-Care Ultrasound for Ongoing CVAD Assessment

Expanding use of point-of-care ultrasound by infusion nurses and vascular access specialists for routine CVAD assessment — including catheter tip surveillance, thrombosis screening, and troubleshooting — represents a growing practice that may improve early complication detection.⁷

5.4 Machine Learning for Risk Prediction

Machine learning approaches incorporating patient demographics, cancer characteristics, laboratory values, and device factors show potential for improved prediction of CVAD-related thrombosis and other complications. These tools may enable individualized risk stratification to guide prophylactic interventions.¹

References