Vascular Access for Therapeutic Apheresis Policy

1. Policy Statement

It is the policy of this organization that all vascular access for therapeutic apheresis procedures shall be selected, placed, maintained, and monitored according to evidence-based clinical criteria that account for procedure type, patient anatomy, acuity, developmental status, and institutional resources, ensuring safe and effective extracorporeal blood processing while minimizing preventable vascular access complications.

2. Purpose

This policy exists to:

• Establish a systematic clinical decision framework for vascular access device selection in therapeutic apheresis
• Define technical requirements for peripheral and central vascular access in apheresis procedures
• Specify appropriate catheter sizing for adult and pediatric apheresis patients
• Standardize catheter maintenance and locking protocols between apheresis sessions
• Identify contraindicated access types and mitigate associated patient safety risks
• Guide clinicians in managing implanted apheresis ports for patients requiring long-term treatment

3. Scope

This policy applies to:

• All licensed clinicians who place, access, or maintain vascular access devices for therapeutic apheresis
• Inpatient and outpatient apheresis settings within this organization
• Adult and pediatric patients undergoing centrifugation-based or filter-based apheresis procedures
• All departments providing therapeutic apheresis services, including hematology, nephrology, neurology, and stem cell transplantation programs

4. Policy Requirements

4.1 Clinical Decision Framework for VAD Selection

4.1.1 Clinicians shall evaluate multiple interconnected factors when determining the most suitable vascular access approach for apheresis, including:

• The type of apheresis procedure (centrifugation-based or filter-based)
• Evaluation of superficial and deep peripheral venous anatomy
• Patient acuity level
• Expected duration and frequency of treatments
• Care setting (inpatient versus outpatient)
• Patient preferences
• Underlying disease processes
• Institutional resource availability

4.1.2 Clinicians shall be aware that geographic practice patterns show notable variation in preferred access methods. Peripheral venous access predominates in European clinical settings, whereas CVADs remain the primary approach across North America, South America, and Central America. This awareness shall inform institutional benchmarking and quality improvement activities.

4.2 Peripheral Vascular Access

4.2.1 Rationale and Patient Selection

4.2.1.1 Peripheral venous access shall be considered as a first-line option in appropriate candidates. Evidence indicates that peripheral catheter insertion carries fewer complication risks compared to central venous catheterization for apheresis procedures, potentially reducing the overall need for CVADs in suitable patients.

4.2.1.2 Ultrasound guidance shall be used to enhance peripheral intravenous catheter placement success rates in apheresis candidates whenever ultrasound capability is available.

4.2.2 Technical Requirements

4.2.2.1 Standard peripheral apheresis procedures shall employ two separate PIVCs: one catheter serving as the access or withdrawal site for blood entering the apheresis circuit, and the second catheter facilitating return of processed cells and replacement fluids to the patient.

4.2.2.2 Single-needle configurations may be used for patients with severely limited venous access; however, clinicians shall inform the patient and apheresis team that substantially increased procedure duration will result.

4.2.2.3 Catheter selection for peripheral access shall favor large-gauge devices. Dialysis-style cannulas or PIVCs ranging from 16 to 20 gauge shall be used to provide adequate flow characteristics.

4.2.2.4 The antecubital fossa shall be the preferred insertion site for the withdrawal catheter. The basilic or cephalic veins in the forearm represent viable alternatives for the withdrawal catheter. The return line may be placed in smaller-caliber veins when necessary.

4.2.3 Alternative Peripheral Approaches

4.2.3.1 In rare circumstances where upper extremity vessels prove unsuitable, direct femoral vein venipuncture may be considered as a salvage option. This technique shall be performed only by qualified clinicians familiar with the technique and its associated risks, and shall be documented in the medical record with clinical justification.

4.2.4 Pediatric Considerations for Peripheral Access

4.2.4.1 Peripheral access for apheresis shall not be routinely recommended in young children due to vessel size limitations. Older children and adolescents with adequate venous development may undergo peripheral apheresis when individual patient assessment supports this approach.

4.2.4.2 For neonates requiring apheresis, appropriately sized central venous catheters shall be used, consistent with published evidence for this population.

4.3 Central Vascular Access Devices

4.3.1 Device Characteristics for Apheresis

4.3.1.1 Central venous catheters designated for dialysis applications shall be the preferred central access option for therapeutic apheresis. These devices deliver reliable blood flow rates, tolerate high negative pressures generated during blood withdrawal, and provide appropriate lumen diameter for procedural demands.

4.3.1.2 Adult patients shall require catheter sizes of at least 11.5 French (Fr) to achieve adequate flow for therapeutic apheresis.

4.3.2 Pediatric Catheter Sizing

4.3.2.1 Catheter selection in pediatric patients shall match device size to patient weight and vessel dimensions using the following evidence-based sizing recommendations for nontunneled or tunneled cuffed CVADs:

• Patients weighing less than 10 kg: catheter sizes of 6.0 to 7.0 Fr
• Patients weighing 10 to 30 kg: catheter sizes of 6.0 to 8.0 Fr
• Patients weighing 30 to 50 kg: catheter sizes of 8.0 to 10.0 Fr
• Patients weighing more than 50 kg: adult-sized devices of 11.5 Fr or larger

4.3.2.2 In all pediatric cases, direct assessment of vessel diameter shall inform final catheter selection in addition to weight-based sizing guidelines.

4.3.3 Contraindicated and Alternative Central Access Options

4.3.3.1 Peripherally inserted central catheters (PICCs) shall not be used for therapeutic apheresis. Their smaller gauge and higher failure rates make them inappropriate for this application.

4.3.3.2 Midline catheters represent an emerging option that may deliver sufficient flow rates for apheresis in select cases. Institutions utilizing midline catheters for apheresis shall ensure that new midline devices are used for each procedure and that strict adherence to manufacturer specifications is maintained.

4.3.4 Catheter Maintenance: Locking Solutions

4.3.4.1 CVAD patency between apheresis sessions shall be maintained using high-concentration heparin or sodium citrate locking solutions.

4.3.4.2 Clinicians shall maintain heightened awareness for heparin-induced thrombocytopenia (HIT), particularly in patients with multiple myeloma undergoing stem cell harvesting via apheresis catheter for autologous hematopoietic stem cell transplantation. An elevated HIT frequency of approximately 4% has been identified in this population, attributable to repeated heparin exposure through catheter flush and lock procedures.

4.3.4.3 When HIT is suspected or confirmed, heparin-containing locking solutions shall be discontinued and alternative non-heparin locking agents shall be used. Hematology consultation shall be obtained as clinically indicated.

4.4 Implanted Vascular Access Ports for Long-Term Treatment

4.4.1 Indications and Device Design

4.4.1.1 Implanted vascular access ports shall be considered for patients requiring extended courses of therapeutic apheresis. Standard ports designed for intermittent chemotherapy infusion shall not be substituted for apheresis-specific ports. Only ports with engineering modifications supporting the high-flow demands of extracorporeal blood processing shall be used for therapeutic apheresis.

4.4.2 Complication Surveillance

4.4.2.1 Clinicians managing implanted apheresis ports shall maintain active surveillance for long-term complications, including infectious complications, thrombotic catheter occlusion, device migration, and formation of fibrin sheaths or intraluminal sludge.

4.4.2.2 Suspected complications shall receive prompt clinical evaluation and intervention. Surveillance protocols shall be incorporated into routine port management workflows.

4.4.3 Access and Verification Procedures

4.4.3.1 Before initiating apheresis through an implanted port, clinicians shall verify proper device positioning and confirm appropriate access needle selection based on port design specifications. Apheresis ports may have unique access requirements that differ from conventional ports, and clinicians shall be familiar with those specifications prior to accessing the device.

4.5 Arteriovenous Access: Contraindication

4.5.1 Arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) shall not be used as the primary vascular access for therapeutic apheresis. Despite their widespread use in hemodialysis, these access types demonstrate substantially elevated failure rates for apheresis procedures.

4.5.2 When a patient with an existing AVF or AVG requires therapeutic apheresis, alternative vascular access shall be established for the apheresis procedure. Clinicians shall document the rationale for access selection in the medical record.

5. Compliance

5.1 Key Performance Indicators

• Percentage of apheresis procedures in adult patients using catheters of at least 11.5 Fr for central access (target: ≥95%)
• Rate of PICC use for therapeutic apheresis (target: 0%)
• Rate of AVF/AVG use as primary apheresis access (target: 0%)
• Incidence of catheter-related complications (infection, occlusion, migration) in apheresis patients with implanted ports
• Rate of ultrasound guidance use for peripheral PIVC placement in apheresis candidates (target: ≥90%)
• Incidence of HIT among multiple myeloma patients undergoing apheresis catheter-based stem cell harvesting, tracked and reported quarterly
• Documentation compliance for catheter selection rationale in pediatric apheresis patients (target: ≥95%)

5.2 Enforcement

Non-compliance with this policy shall be addressed through established institutional performance improvement processes, including documentation review, peer feedback, and escalation to department leadership and the Vascular Access Governance Committee. Serious safety events resulting from contraindicated access use shall be subject to formal root cause analysis.

6. Exceptions

Exceptions to this policy require documented clinical justification by the ordering or proceduralist clinician and, where feasible, prospective review by the Vascular Access Governance Committee or a designated clinical leader. In emergent situations where the standard of care cannot be immediately met, the exception shall be documented retrospectively with a plan for transition to compliant access at the earliest safe opportunity.

7. Related Documents

• Vascular Access Device Selection and Insertion Policy
• Central Vascular Access Device Tip Location Policy
• Implanted Vascular Access Ports Policy
• Vascular Visualization Technology Policy
• Flow Control Devices Policy
• Aseptic Non Touch Technique (ANTT) Policy
• Hand Hygiene Policy
• Informed Consent for Vascular Access Policy
• Competency and Competency Validation Policy

8. Revision History