Vascular Access Device Occlusion

Prevention, Assessment, and Management

Definition of Patency

A vascular access device (VAD) is considered patent when the clinician can successfully flush all catheter lumens without encountering resistance, following confirmation of blood return from each lumen. Establishing patency through this dual confirmation—aspiration followed by flushing—represents the standard for verifying device functionality prior to therapeutic use.

1.2 Guiding Philosophy for Occlusion Management

When occlusion occurs, catheter salvage should be prioritized over removal whenever clinically appropriate. The selection of catheter-clearing agents must be guided by systematic assessment of the probable occlusion etiology. If initial interventions fail to restore function and the device remains clinically necessary, escalation pathways should be pursued, including consultation with vascular access specialty teams, radiographic evaluation of catheter tip positioning and flow dynamics, and pharmaceutical consultation to determine occlusion causation.

Occlusion Prevention

Effective prevention requires attention to multiple domains of VAD management. Clinicians should adhere to evidence-based flushing and locking protocols, as inadequate maintenance remains a primary contributor to occlusive complications.

2.1 Mechanical Prevention

Catheter dislodgement—whether partial or complete—significantly increases occlusion risk. Appropriate securement techniques must be employed consistently to maintain catheter position and prevent migration that can predispose to thrombotic or mechanical obstruction.

2.2 Chemical Incompatibility Prevention

Incompatible mixing of intravenous solutions and medications represents a preventable cause of catheter occlusion. Clinicians should verify compatibility whenever two or more drugs or solutions are administered together, whether combined in the same container, given as intermittent short-term infusions, delivered via manual injection, or infused concomitantly through the same VAD. Pharmacist consultation or reference to evidence-based compatibility databases is essential when compatibility status is uncertain. In the absence of documented compatibility data, the mixture should be treated as incompatible (Gorski, 2018; Canadian Vascular Access Association, 2019).

Medications and solutions with elevated precipitation risk warrant particular vigilance. Alkaline agents such as phenytoin, diazepam, ganciclovir, acyclovir, ampicillin, imipenem, and heparin may precipitate when mixed inappropriately. Acidic preparations including vancomycin and parenteral nutrition formulations pose similar concerns. The combination of ceftriaxone with calcium gluconate is specifically contraindicated. Parenteral nutrition solutions containing elevated calcium and phosphate concentrations carry inherent mineral precipitation risk (Gorski, 2018; Cancer Nurses Society of Australia, 2021).

Between infusions, a gentle pulsatile flush using 10 mL of preservative-free 0.9% sodium chloride should be performed. Pediatric and neonatal patients, as well as those with fluid restrictions, require appropriately reduced volumes. When multiple incompatible infusions are necessary, separate catheter lumens should be utilized when available.

2.3 Lipid-Related Occlusion Prevention

Administration of lipid-containing infusions creates potential for lipid residue accumulation within the catheter lumen. When lipid residue buildup is suspected, preventive strategies such as increased flushing frequency should be implemented proactively (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019).

Clinical Assessment of Occlusion

3.1 Signs and Symptoms

Clinicians should maintain vigilance for indicators of potential VAD occlusion, which may manifest as inability to withdraw blood or sluggish blood return; sluggish flow, resistance to flushing, or complete inability to flush the lumen or infuse fluid; frequent occlusion alarms triggered on electronic infusion pumps; visible swelling or solution leaking at the infusion site; and, in hemodialysis central vascular access devices, absent or insufficient blood flow return (Gorski, 2018; Canadian Vascular Access Association, 2019; Ullman et al., 2020).

3.2 Patency Verification Protocol

Before administering any solution through a VAD, patency should be confirmed through aspiration for blood return followed by flushing each lumen with preservative-free 0.9% sodium chloride. When aspiration fails to yield blood return, clinicians should conduct a comprehensive site and clinical assessment. Alternating gentle aspiration with gentle instillation of small saline volumes may be attempted with appropriate caution (Cancer Nurses Society of Australia, 2021; Giordano et al., 2015).

If standard aspiration proves unsuccessful but the catheter flushes without difficulty, using a smaller-barrel syringe for blood withdrawal may improve results. Smaller syringes generate reduced negative pressure during aspiration, potentially facilitating blood return in partially obstructed lumens (Canadian Vascular Access Association, 2019).

3.3 Alternative Patency Assessment

Circumstances exist where blood return assessment may be contraindicated or persistently unsuccessful. In hemodynamically unstable patients dependent on vasopressor delivery, for example, patency evaluation may require alternative approaches. Assessment parameters in such scenarios include ongoing clinical response to infusing medications, absence of resistance during flushing, site evaluation findings, and patient symptom reports.

When blood return remains absent or unassessable, the frequency of site assessment for complications such as infiltration and extravasation should be increased. If a peripheral intravenous catheter without confirmed blood return is being used for vesicant administration, transition to a more appropriate VAD or central vascular access device should be planned when clinically feasible. Central vascular access device occlusion requires prompt evaluation and treatment; if patency cannot be restored, consultation with the provider regarding removal and replacement is indicated.

Systematic Occlusion Evaluation

4.1 Identifying the Cause

Thorough assessment of the infusions, injections, flushing procedures, and other events preceding occlusion is essential for determining etiology and selecting appropriate intervention.

4.2 External Mechanical Causes

External mechanical factors should be ruled out or resolved first, requiring assessment of the entire infusion system from the administration set to the insertion site beneath the dressing. Specific assessment points include the securement device or suture for catheter constriction, kinked or clamped catheters or administration sets, obstructed or malfunctioning filters or needleless connectors, changes in external catheter length, and malposition of implanted port access needles.

When external factors are suspected, add-on devices should be removed and catheter patency assessed by attaching a syringe directly at the hub before applying new add-on devices. External kinks may resolve with catheter repositioning and sterile dressing reapplication. Malpositioned or occluded implanted port access needles require replacement (Gorski, 2018; Canadian Vascular Access Association, 2019; Denton et al., 2016; Kumwenda et al., 2018).

For withdrawal occlusions (inability to obtain blood return despite ability to infuse), short-term resolution may be attempted through patient repositioning such as raising the arm, having the patient cough, or instructing deep breathing to alter catheter position within the vessel. Persistent or recurrent withdrawal occlusion warrants further investigation (Cancer Nurses Society of Australia, 2021; Giordano et al., 2015).

Catheter damage indicators including bulging, leaking, or swelling along the central vascular access device pathway require assessment, with repair or replacement as indicated.

4.3 Internal Mechanical Causes (Central Vascular Access Devices)

Internal mechanical causes specific to central vascular access devices include pinch-off syndrome, secondary catheter malposition, catheter-associated deep vein thrombosis, implanted vascular access port failure, and kinking related to tissue and vascular anatomy. Movement of the head and neck may cause kinking in catheters inserted via the internal or external jugular vein.

Pinch-off syndrome should be suspected when external catheter length has changed, when the patient reports arm or shoulder discomfort, when arrhythmias are observed, or when rolling the shoulder or raising the ipsilateral arm is required to allow flow or obtain blood return. Testing involves gently flushing the catheter with 10 mL of preservative-free 0.9% sodium chloride (reduced volumes for pediatric and neonatal patients) while asking the patient to raise the ipsilateral arm and roll the shoulder backward. If flow demonstrates dependence on arm position, pinch-off syndrome should be investigated through appropriate radiographic studies (Ast & Ast, 2014).

Suspected malposition, pinch-off syndrome, or catheter damage requires provider collaboration for management.

4.4 Thrombotic Occlusion

Thrombotic occlusion should be suspected when visible blood appears in the catheter or add-on devices, when blood cannot be aspirated, or when flow becomes sluggish. Thrombotic occlusions may be intraluminal, arising from fibrin or clot formation within the catheter, or extraluminal, related to fibrin tail, fibrin sheath or sleeve formation, or mural thrombus (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019; Gorski, 2018).

4.5 Chemical Occlusion

Chemical occlusion should be suspected based on the types of medications or solutions administered, the duration of drug contact within the catheter, any visible precipitate observed in the catheter or administration set, infusion rate history, dilution properties and sequences, light exposure, and flushing frequency.

Calcium phosphate precipitation risk increases when calcium or phosphate concentrations in parenteral nutrition solutions are elevated, in fluid-restricted parenteral nutrition formulations, or when the calculated calcium phosphate solubility product falls below 75 mmol²/L² (Zheng et al., 2019).

Lipid residue occlusion should be suspected when infusing total nutrient admixture containing lipid concentration greater than 10%. If thrombolytic therapy proves unsuccessful in restoring patency, chemical occlusion should be considered as the likely etiology (Zheng et al., 2019; Canadian Vascular Access Association, 2019).

4.6 Contrast Studies

For persistent or recurring unresolved central vascular access device occlusion, contrast study should be considered to evaluate catheter integrity, position, and flow dynamics (Canadian Vascular Access Association, 2019; Ullman et al., 2020).

Treatment and Catheter Clearance

5.1 Interdisciplinary Collaboration

The patient’s medication record should be reviewed in collaboration with pharmacy services to determine the appropriate intervention and catheter clearance agent selection (Gorski, 2018).

5.2 Treatment of All Affected Lumens

In multilumen central vascular access devices, all catheter lumens demonstrating partial, withdrawal, or complete occlusion require treatment. An occluded lumen should never be left untreated simply because another lumen remains functional. Prolonged fibrin formation within untreated lumens constitutes a risk factor for catheter-associated bloodstream infection (Doellman et al., 2015; Gorski, 2018).

5.3 General Principles

Excessive force should be avoided when instilling catheter clearance agents to minimize risk of catheter damage. Prompt resolution of suspected thrombotic occlusion or occlusion of unknown etiology improves thrombolytic efficacy in central vascular access devices and may avoid or delay the need for catheter replacement (Canadian Vascular Access Association, 2019; Nephrology CEN & Canadian Hemodialysis Access Coordinators Network, 2015; Kumwenda et al., 2019).

5.4 Thrombolytic Therapy for Thrombotic Occlusion

Before initiating thrombolytic therapy, risks and benefits should be assessed. Circumstances warranting consideration of catheter removal or replacement rather than thrombolysis include contraindications to thrombolytic agents and patients with catheter-associated sepsis due to candidemia or Staphylococcus aureus infection (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019).

5.4.1 Tissue Plasminogen Activator Administration

Tissue plasminogen activator (tPA, alteplase) should be instilled into the catheter lumen according to manufacturer directions for use. If the initial attempt is unsuccessful, one additional attempt may be made (Cancer Nurses Society of Australia, 2021; Giordano et al., 2015; Gnannt et al., 2019; Steere et al., 2018).

Thrombolytic administration for catheter occlusion is appropriate across all healthcare settings, including community and long-term care environments. All infusions should be stopped prior to and during thrombolytic agent dwell time when possible, particularly when treating suspected fibrin tail or sheath, to optimize thrombolysis and facilitate contact between the thrombolytic agent and thrombus or fibrin on both intraluminal and extraluminal catheter surfaces (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019; Gorski, 2018; Scott et al., 2017).

Lower doses of tPA (such as 1 mg/mL) have demonstrated effectiveness in lumens requiring 1 mL or less volume, and cryopreserved aliquots have shown efficacy. However, randomized controlled trials are needed to definitively establish alternate dosing efficacy (Giordano et al., 2015; Scott et al., 2017; Jafari et al., 2018; Massmann et al., 2015; Mendes et al., 2015; Sapienza & Ciaschini, 2015).

For neonatal and pediatric patients weighing 30 kg or less, the instilled volume should equal 110% of the catheter priming volume (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019; Da Costa et al., 2019).

5.4.2 Alternative Thrombolytic Agents

Alternative agents including urokinase, reteplase, tenecteplase, and alfimeprase have demonstrated effectiveness in smaller studies. Additional safety data and comparative research are recommended to establish relative efficacy, safety profiles, and cost considerations among different thrombolytic agents (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019; Kumwenda et al., 2018; Kennard et al., 2017; Anderson et al., 2013; Chang et al., 2017; Pollo et al., 2016; Ragsdale et al., 2014; Song et al., 2017; Yang et al., 2023).

5.4.3 Alternative Administration Methods

For persistent or recurring occlusions not resolved by standard instillation, alternative methods may be considered: the push method administered over 30 minutes; low-dose infusion relative to patient weight delivered over 30 minutes to 3-4 hours; or dual syringe and implanted port access needle techniques (Canadian Vascular Access Association, 2019; Kumwenda et al., 2018, 2019; Ragsdale et al., 2014; Yang et al., 2023).

5.4.4 Dwell Time

Thrombolytic agents should remain in the catheter lumen for the duration specified in manufacturer directions for use or as defined by organizational policies, procedures, and practice guidelines.

5.4.5 Thrombolytic Use in Midline Catheters

Limited retrospective evidence supports tPA use for managing thrombotic occlusions in midline peripheral catheters. Off-label thrombolytic use for midline catheter restoration should proceed with caution and only after careful assessment of continued vascular access need and exclusion of catheter malfunction from other causes. Potential etiologies requiring exclusion before considering thrombolysis include vessel thrombus (evidenced by leaking at the insertion site), infiltration or extravasation (assessed through swelling, discoloration, subcutaneous fluid on ultrasound, and pain evaluation), and catheter malposition resolvable through repositioning (such as migration into a vein valve or lodging against the vessel wall). When these causes have been excluded and occlusion within or at the catheter tip is determined to be the etiology, tPA administration may be considered according to provider order when supported by organizational practice (Hawes, 2020; Rizk et al., 2022).

5.5 Catheter Clearance Agents for Chemical Occlusion

Suspected chemical occlusion from medication precipitate or lipid residue may be addressed using catheter-clearance agents instilled based on catheter lumen priming volume and allowed to dwell for 20 to 60 minutes.

For acidic drug precipitates (pH 1-5), L-cysteine 50 mg/mL or 0.1 N hydrochloric acid have been utilized. Alkaline drug precipitates (pH 9-12) may respond to sodium bicarbonate 8.4% or sodium hydroxide 0.1 mmol/L. Parenteral nutrition and calcium phosphate precipitates have been treated with sodium hydroxide 0.1 mmol/L as first-line therapy or L-cysteine hydrochloride 50 mg/mL (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019; Gorski, 2018; Giordano et al., 2015; Zheng et al., 2019).

Lipid residue has been addressed with sodium hydroxide 0.1 mmol/L or 70% ethanol. Systematic review evidence suggests sodium hydroxide may be more effective than ethanol, though trial research and observational studies have yielded mixed findings (Canadian Vascular Access Association, 2019; Gorski, 2018; Giordano et al., 2015; Zheng et al., 2019; Nephrology CEN & Canadian Hemodialysis Access Coordinators Network, 2015; LaRusso et al., 2021; Mokha et al., 2017; Wolf et al., 2018).

Repeat instillation of the catheter-clearance agent may be performed one additional time if necessary (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019).

5.6 Post-Treatment Protocol

Following appropriate dwell time of any catheter clearance agent, degradation products must be aspirated and discarded prior to flushing the lumen to assess restored patency.

Evidence supporting more than two doses of thrombolytic therapy is limited. Before considering additional thrombolytic doses, further assessment as described in the following section is recommended.

Management of Unresolved Occlusion

When catheter patency cannot be restored through standard interventions, alternative approaches should be considered.

6.1 Advanced Interventions

Radiography may be employed to rule out catheter tip malposition. Referral to interventional radiology enables contrast study evaluation or procedural interventions including internal snare removal of fibrin, ablation of implanted central vascular access devices, catheter exchange with fibrin sheath disruption, or central venous angioplasty (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019; Zheng et al., 2019; Pabon-Ramos et al., 2019).

6.2 Thrombosis Evaluation

Collaboration with the healthcare team and vascular access specialty services (when available) is essential for investigation to rule out catheter-associated thrombosis. Venous thrombosis is a significant predictor of thrombolytic instillation treatment failure (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019; Ullman et al., 2020; Steere et al., 2018).

6.3 Catheter Removal

When all restoration efforts prove unsuccessful, catheter removal may become necessary. Alternative vascular access planning should proceed as clinically indicated.

Post-Thrombolysis Monitoring

Patients who have received thrombolytic therapy require monitoring for signs of catheter-related infection or catheter-related thrombosis. Clinicians should recognize that bacteria may adhere to thrombi within and around central vascular access devices, creating potential for infection development (Cancer Nurses Society of Australia, 2021; Canadian Vascular Access Association, 2019; Ullman et al., 2020; Steere et al., 2018).

Quality Improvement and Outcomes Monitoring

8.1 Outcome Tracking

Outcomes requiring systematic monitoring include known and suspected occlusion causes, treatment success and failure rates, and other relevant metrics. Barriers to implementing occlusion prevention strategies and interventions should be identified, with appropriate strategies developed to address them through policy development, procedural refinement, and clinician education and training programs.

8.2 Advancing Technology

Improvements in catheter materials may reduce complications including occlusion and thrombosis. In patient populations experiencing elevated occlusion or thrombosis incidence, consideration may be given to devices constructed from novel or alternative materials as a preventive strategy. Definitive trial evidence is required before recommending routine or widespread adoption of such technologies (Moureau et al., 2022).

References

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This clinical guideline is provided as an educational resource. Clinical decisions should always be made in consultation with institutional policies, individual patient assessment, and current evidence-based practice. This document is intended for licensed healthcare professionals.

Document Version: 1.0 Last Updated: January 2026