How to manage a non-functioning port?

From the Guidelines

To manage a non-functioning port, first attempt to flush the port with saline using a 10 mL syringe, and if resistance is encountered, consider using a thrombolytic agent such as alteplase (2 mg/2 mL) as recommended by the 2020 KDOQI clinical practice guideline for vascular access 1. When managing a non-functioning port, it is essential to identify the specific issue causing the dysfunction.

• Attempt to flush the port with saline using a 10 mL syringe to assess for resistance.
• If resistance is encountered, do not force the flush as this could cause complications.
• Try repositioning the patient by having them raise their arms, cough, or change positions, which may help dislodge any fibrin sheath or catheter tip occlusion. For thrombotic occlusions,
• instill an appropriate thrombolytic agent such as alteplase (2 mg/2 mL) into the port and allow it to dwell for 30-120 minutes before attempting to aspirate, as recommended by the 2020 KDOQI guideline 1.
• The use of alteplase is supported by the guideline, which suggests its effectiveness in restoring function to dysfunctional catheters due to thrombosis 1. If these measures fail,
• contact the interventional radiology team for potential port study with contrast to identify mechanical issues like catheter migration, pinch-off syndrome, or fibrin sheath formation. Regular port maintenance with proper flushing using 10 mL of normal saline followed by heparin (100 units/mL) after each use, or monthly if not in use, can help prevent occlusions by maintaining patency of the catheter lumen, as suggested by the clinical practice guidelines for vascular access 1.

From the FDA Drug Label

Restoration of function was assessed by successful withdrawal of 3 mL of blood and infusion of 5 mL of saline through the catheter If catheter function is not restored at 120 minutes after 1 dose of Cathflo Activase, a second dose may be instilled Across Trials 1 and 2,796 (68%) of 1043 patients with occlusions present for less than 14 days had restored function after one dose, and 902 (88%) had function restored after up to two doses The overall rate of catheter function restoration of 83% (257 of 310) was similar to that observed in Trial 2

To manage a non-functioning port, Alteplase can be used to restore function. The recommended dose is 2 mg in 2 mL for patients weighing ≥30 kg, and 110% of the internal lumen volume for patients weighing <30 kg. If catheter function is not restored after one dose, a second dose may be instilled. The overall rate of catheter function restoration is 83-88% after up to two doses 2, 2.

• Key steps for administration include:
  • Reconstituting the solution to a final concentration of 1 mg/mL
  • Instilling the appropriate dose into the occluded catheter
  • Assessing catheter function after 30 minutes and 120 minutes of dwell time
  • Administering a second dose if catheter function is not restored after the first dose
• Important considerations include:
  • Using Sterile Water for Injection for reconstitution
  • Avoiding Bacteriostatic Water for Injection
  • Not shaking the vial during reconstitution
  • Storing the reconstituted solution at 2-30°C (36-86°F) for up to 8 hours

From the Research

Managing a Non-Functioning Port

To manage a non-functioning port, several options are available, including catheter-directed thrombolysis. This approach involves using medications such as alteplase to dissolve blood clots that may be blocking the port.

Catheter-Directed Thrombolysis

• This method has been shown to be effective in treating peripheral arterial occlusions and venous thrombosis 3, 4.
• The use of low-dose alteplase has been found to achieve equivalent success rates with lower complication rates compared to higher doses 3.
• Catheter-directed thrombolysis can be used to treat subacute proximal venous thrombosis, with recombinant tissue plasminogen activator (rt-PA) being more effective than urokinase 5.

Technical Considerations

• The technique of infusion and the use of anticoagulation can affect the outcome of catheter-directed thrombolysis 4.
• Ultrasound-accelerated catheter-directed thrombolysis has been shown to be safe and effective in treating submassive pulmonary embolism 6.
• Patient selection and technical considerations are crucial in determining the success of catheter-directed therapy for pulmonary embolism 7.

Safety and Efficacy

• The safety and efficacy of catheter-directed thrombolysis have been demonstrated in several studies, with low complication rates and high success rates 3, 5, 6.
• The use of low-dose alteplase and standardized protocols can minimize the risk of adverse events 3, 6.