Catheter Damage, Embolism, Repair, and Exchange

Core Standards

Standard 1: Preventative strategies must be implemented to maintain catheter integrity and reduce the risk of catheter damage across all care settings.

Standard 2: Prior to undertaking any catheter repair or exchange procedure, clinicians must perform a comprehensive assessment of the patient’s risk-to-benefit ratio and ongoing vascular access requirements.

Prevention of Catheter Damage

1.1 Fundamental Principles of Catheter Preservation

Maintaining catheter integrity requires attention to mechanical, procedural, and patient-related factors throughout the device’s lifespan. The following practices form the foundation of catheter damage prevention.

Syringe Selection and Flushing Technique. When assessing VAD function, clinicians should use a syringe with a minimum 10-mL diameter barrel. This larger syringe size generates lower pressure per unit of force applied, reducing the risk of catheter rupture. Under no circumstances should force be applied against resistance during flushing or aspiration, as this creates excessive intraluminal pressure that may compromise catheter integrity (Wouters et al., 2019; Canadian Vascular Access Association, 2019).

Power Injection Protocols. Contrast media power injections must be limited exclusively to VADs and add-on devices that carry explicit manufacturer labeling indicating suitability for power injection. Using devices not rated for high-pressure injection significantly increases the risk of catheter rupture and subsequent complications (Saijo et al., 2019).

Guidewire and Catheter Management During Insertion. During the insertion process, clinicians must never withdraw the catheter or guidewire backward through the introducer needle. The needle bevel presents a sharp edge capable of shearing the wire or catheter material, potentially creating fragments that may embolize. Continuous control of the guidewire throughout the procedure is essential to prevent inadvertent wire embolism (Kassar et al., 2017).

Mechanical Stress Reduction. Catheters should be protected from stretch forces, repeated bending at the same location, and friction. For devices with integrated clamps, rotating the clamp position along the catheter prevents continuous pressure on a single segment, which can weaken the material over time (Wouters et al., 2019).

1.2 Anatomical Considerations for Insertion Site Selection

The selection of insertion site significantly influences long-term catheter integrity. For implanted vascular access port placement, ultrasound-guided internal jugular vein cannulation is preferred over subclavian approaches when clinically feasible. The subclavian approach carries inherent risk of pinch-off syndrome, a mechanical complication occurring when the catheter becomes compressed between the clavicle and first rib. When subclavian insertion is necessary, care must be taken to avoid acute catheter angulation at the internal jugular vein entry point (Kridis et al., 2019; Li et al., 2017).

1.3 Long-Term Surveillance

For patients with long-dwelling CVADs, including implanted ports, annual chest radiograph assessment should be considered to evaluate catheter position and structural integrity. Clinical evidence suggests that younger patient age, femoral catheter placement, and extended dwell times are associated with increased catheter fracture risk (Ai et al., 2020; Kridis et al., 2019).

1.4 Procedural Precautions During Insertion and Removal

Multiple opportunities for inadvertent catheter damage exist during insertion and removal procedures. Clinicians must exercise vigilance to avoid accidental puncture of the catheter with needles or scalpels, application of excessively tight sutures that may compromise catheter integrity, positioning CVADs in locations prone to mechanical compression, incorrect attachment of catheters to port bodies, and excessive traction against resistance during removal (Matton et al., 2022).

1.5 Patient and Caregiver Education

Comprehensive education for patients, caregivers, and all members of the healthcare team is essential for catheter preservation. Educational content should address the prohibition against flushing or infusing against resistance, avoidance of sharp objects near the catheter, prevention of pulling or tension on the external catheter segment, use of gauze padding when applying clamps (if a designated clamping sleeve is unavailable), rotation of clamp placement to distribute mechanical stress, protection of external catheters with appropriate clothing, and avoidance of friction from items such as backpacks, shoulder straps, stiff collars, or jewelry.

Clamps should only be applied at designated clamping sleeves when present. Luer-lock connectors must be attached to catheter hubs with care to prevent cross-threading or excessive torque that may damage the connection point (Wouters et al., 2019; Canadian Vascular Access Association, 2019; Gnannt et al., 2017).

Recognition and Assessment of Catheter Damage

2.1 Clinical Indicators of Catheter Compromise

Catheter damage and potential embolism should be suspected when assessment reveals any of the following findings: visible catheter damage or fractured hub components, fluid leakage at the insertion or exit site, catheter dysfunction manifesting as inability to aspirate blood or frequent infusion pump alarms, localized pain or swelling along the CVAD pathway during infusion, paresthesia in the ipsilateral arm, abnormal radiographic findings, respiratory distress or new-onset arrhythmias.

Importantly, patients may remain asymptomatic despite significant catheter damage. Research indicates that as many as 20% of catheter fragments are missed on standard radiographic studies, emphasizing the need for high clinical suspicion (Kridis et al., 2019; Matton et al., 2022).

2.2 Sites of Catheter Separation

Catheter integrity assessment must include evaluation of all potential separation points. Structural failure may occur at the lumen-hub junction, external connections and add-on devices, and internal junctions (particularly the septum-outflow tubing connection in implanted ports).

Separation at any of these sites may result in infiltration of infusates, bleeding, or in severe cases, exsanguination. All connections must be verified as secure. During hemodialysis procedures, all connections must remain visible throughout the treatment session to enable continuous assessment (Kridis et al., 2019).

2.3 Assessment Following Difficult Removal

When VAD removal proves difficult or in the presence of catheter dysfunction, comprehensive patient assessment must be performed to evaluate for catheter damage and potential catheter, air, or thrombotic embolism. This assessment should be documented and appropriate interventions initiated as indicated (Kassar et al., 2017).

2.4 Recognition of Pinch-Off Syndrome

Pinch-off syndrome represents a specific and potentially serious complication affecting catheters inserted via the subclavian vein. Early recognition is critical to prevent catheter fracture and embolization.

Clinical indicators of pinch-off syndrome include resistance during flushing or infusion that resolves with postural changes (such as rolling the shoulder, raising the arm, or moving the neck), blood return that varies with patient positioning, frequent or intermittent occlusion alarms, infraclavicular pain, discomfort during flushing or infusion, swelling at the insertion site, and any clinical finding that changes with arm or shoulder movement.

When pinch-off syndrome is suspected, radiographic confirmation should be obtained. The radiology requisition must specifically indicate “rule out pinch-off syndrome” to ensure proper arm positioning during the examination, as standard positioning may not reveal the compression (Kassar et al., 2017; Alizade et al., 2019; Li et al., 2017; Syltern et al., 2020).

Management of Catheter Damage

3.1 Immediate Response

Upon discovery of catheter damage—whether ballooning, fracture, rupture, or hub cracking—timely management is essential to prevent serious complications including catheter fracture and embolization, air embolism, hemorrhage, catheter-lumen occlusion, catheter-associated bloodstream infection (CABSI), and treatment interruption or failure.

The immediate response protocol requires stopping all infusions immediately, then clamping or sealing the damaged catheter between the exit site and the damaged area. This may be accomplished by closing an existing clamp, applying an additional clamp, covering the damaged area with occlusive dressing material, or folding and securing the external segment. The catheter must be clearly labeled “Do Not Use” pending definitive management (Wouters et al., 2019; Gnannt et al., 2017; Salonen et al., 2019; Chan et al., 2019).

3.2 Treatment Options

Three primary management strategies exist for damaged catheters, each with distinct advantages and considerations.

Catheter Repair. Repair procedures may extend catheter longevity, preserve limited vascular access sites, and potentially reduce infection risk compared to catheter exchanges. This option is particularly valuable in patients with challenging vascular anatomy or limited access options (Salonen et al., 2019; Chan et al., 2019).

Catheter Exchange. Exchange over a guidewire is associated with reduced risk of technical insertion complications such as pneumothorax, hemothorax, and arterial puncture compared to de novo insertion. However, catheter exchange may carry higher thrombosis rates. Exchange should not be performed when infection is suspected in patients meeting criteria for catheter removal, specifically those with sepsis, hemodynamic instability, or persistent bacteremia beyond 72 hours of appropriate antimicrobial therapy. Of particular note, PICC exchanges have been associated with a two-fold increased risk of thrombosis compared to non-exchanged catheters (Gnannt et al., 2017; Park et al., 2018; Chopra et al., 2018; Calderwood, 2023).

Catheter Removal and Replacement. Complete removal with subsequent new catheter placement at a different site may be indicated based on clinical circumstances (Kridis et al., 2019; Gnannt et al., 2017; Li et al., 2017; Zens et al., 2019; Chan et al., 2019; Chopra et al., 2018; Pabon-Ramos et al., 2019; Rus et al., 2017).

3.3 Risk-Benefit Analysis

Selection among management options requires systematic evaluation of multiple factors.

Patient-related considerations include age, venous integrity and available vascular access options, current clinical condition (with particular attention to immunocompromise, burns, transplant status, or confirmed/suspected infection), and patient and healthcare team preferences.

Therapy-related considerations include the remaining duration of required infusion therapy and the characteristics of prescribed infusates, particularly osmolarity and vesicant potential.

Catheter-related considerations include the current catheter location (particularly femoral placement), patency status, external catheter length, catheter material composition, extent of potential microbial exposure due to damage, anticipated changes in tip position following repair, proximity of damage to the exit site (repairs are generally contraindicated when damage occurs within 3.0 cm of the exit site or when less than 2.5-5.0 cm of undamaged catheter remains proximal to the bifurcation), persistent leakage following repair attempts, and history of previous repairs or exchanges.

Certain clinical situations generally contraindicate repair or exchange in favor of removal, including sepsis, endocarditis, and suppurative thrombophlebitis (Wouters et al., 2019; Gnannt et al., 2017; Salonen et al., 2019; Zens et al., 2019; Chan et al., 2019; Chopra et al., 2018).

3.4 Post-Procedure Requirements

Following catheter repair (if the CVAD was withdrawn during the damage event or repair procedure) or catheter exchange, tip location must be confirmed radiographically or through other appropriate imaging technology before initiating or resuming prescribed therapies (Canadian Vascular Access Association, 2019).

When repair or exchange proves unsuccessful or inappropriate, collaboration with the healthcare team is required to arrange catheter replacement or removal as clinically indicated.

Post-procedural monitoring must include surveillance for catheter-related infection, persistent or new leakage, migration of any metallic components (such as repair stents), occlusion, and thrombosis (Gnannt et al., 2017; Salonen et al., 2019; Chan et al., 2019; Chopra et al., 2018).

Catheter and Guidewire Embolism

4.1 Clinical Presentation

Catheter or guidewire embolism should be suspected when patients exhibit palpitations or cardiac arrhythmias, dyspnea, cough, or thoracic pain, particularly when these symptoms cannot be attributed to the patient’s primary disease or known comorbidities. Notably, some patients with catheter fragment embolization remain asymptomatic initially, with damage manifesting gradually over extended periods of device use (Kassar et al., 2017; Matton et al., 2022).

4.2 Post-Removal Inspection

Following catheter or guidewire removal, the device must be examined for damage and potential fragmentation. The removed length should be compared to the documented inserted length. Any discrepancy or visible damage necessitates chest radiograph or further imaging evaluation to assess for retained fragments (Canadian Vascular Access Association, 2019).

4.3 Emergency Management of Confirmed or Suspected Embolism

When catheter or guidewire embolism is confirmed or strongly suspected, immediate intervention is required.

Patient Positioning. Place the patient in the left lateral decubitus position with Trendelenburg positioning unless contraindicated by conditions such as elevated intracranial pressure, recent eye surgery, or severe cardiac or respiratory disease.

Activity Restriction. Minimize patient movement, particularly of the involved limb.

Supportive Care. Provide reassurance to the conscious patient while preparing for emergency intervention.

Emergency Notification. Immediately summon emergency medical assistance.

Fragment Migration Prevention. Applying pressure over the target vein at the involved limb may reduce the likelihood of fragment migration. When embolization is directly observed, immediate tourniquet application proximal to the site should be considered.

Definitive Management. The healthcare team must be notified promptly. Percutaneous interventional or surgical procedures are typically required for fragment retrieval to prevent further complications (Alizade et al., 2019; Canadian Vascular Access Association, 2019; Li et al., 2017; Salonen et al., 2019; Chopra et al., 2018).

Catheter Repair Procedures

5.1 Equipment and Technique

Catheter repair must be performed using the manufacturer’s catheter-specific repair kit according to the provided directions for use. When a device-specific repair kit is unavailable, alternative strategies such as catheter exchange or removal with replacement should be considered rather than attempting improvised repairs (Salonen et al., 2019; Zens et al., 2019; Chan et al., 2019).

5.2 Infection Prevention

Surgical Aseptic Non-Touch Technique (Surgical-ANTT) must be maintained throughout all catheter repair procedures to minimize the risk of catheter-associated infection.

5.3 Post-Repair Protocol

Following repair, the catheter must not be used for the time period specified in the manufacturer’s repair instructions to allow adequate bonding of adhesive components between catheter segments. Prior to resuming catheter use, patency must be confirmed and the repair site inspected for any evidence of leakage (Salonen et al., 2019; Zens et al., 2019; Chan et al., 2019).

5.4 Ongoing Assessment

Regular assessment of repaired catheters is essential to confirm the ongoing integrity of the repair and identify developing problems. Clinicians and patients should be informed that repaired catheters may not retain the same structural strength as the original intact catheter (Salonen et al., 2019).

5.5 Repair Failure Management

When catheter repair fails, catheter exchange or replacement should be considered following a systematic risk-benefit analysis as outlined in Section 3.3 (Gnannt et al., 2017).

Catheter Exchange Procedures

6.1 General Principles

Routine exchange of functioning CVADs without evidence of local or systemic complications is not indicated and should be avoided (Chopra et al., 2018).

6.2 Indications for Exchange

Catheter exchange, including exchange of tunneled, cuffed catheters and implanted vascular access ports, may be considered when there is no evidence of active infection (Saleh et al., 2017).

In situations involving actual or suspected catheter-related infection (excluding septic shock or metastatic infection) where vascular access options are limited, CVAD exchange may be considered with specific precautions. Use of antimicrobial-impregnated, coated, or bonded catheters should be considered, along with administration of prophylactic antimicrobials. Limited evidence suggests that hemodialysis catheter revision utilizing a new tunnel and exit site while maintaining the same venotomy site may result in lower infection rates compared to standard catheter exchanges (Saleh et al., 2017).

6.3 Procedural Technique

Surgical-ANTT must be maintained throughout the exchange procedure. Specific techniques to reduce the risk of air embolism during catheter exchange must be employed, including appropriate patient positioning, use of aerostatic sheaths when available, and meticulous attention to maintaining closed-system technique during the over-the-wire exchange (Hsu & Trerotola, 2015).

6.4 Post-Exchange Monitoring

Following catheter exchange, monitoring must include assessment for bleeding or hematoma at the exit site, signs of infection, and recurrence of catheter malfunction (which may indicate an intact fibrin sheath compromising the new catheter) (Syltern et al., 2020).

References

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Document Version: 1.0 Last Reviewed: January 2026 This guideline should be reviewed and updated as new evidence becomes available.