From the Guidelines
The removal of a venous sheath should be delayed until after initiation of anticoagulation in patients with symptomatic central venous line–related thrombosis who no longer require venous access or in whom the CVAD is nonfunctioning, as suggested by the American Society of Hematology 2018 guidelines 1. When removing a venous sheath, it is essential to follow a standardized protocol to minimize complications. The procedure should be performed by trained healthcare professionals.
Pre-removal assessment
- Assess the patient's coagulation status, ensuring that activated clotting time (ACT) is below 180 seconds or that sufficient time has passed since anticoagulation administration.
- Evaluate the patient's overall clinical condition and the presence of any contraindications for removal.
Removal procedure
- Position the patient supine and explain the procedure to reduce anxiety.
- Clean the insertion site with antiseptic solution and don sterile gloves.
- Apply gentle pressure 2-3 cm above the insertion site with two fingers of your non-dominant hand.
- With your dominant hand, grasp the sheath firmly and remove it in a slow, steady motion along the angle of insertion.
Post-removal care
- Immediately apply firm pressure to the site for at least 10-15 minutes or until hemostasis is achieved.
- For larger sheaths (>7 Fr) or in anticoagulated patients, pressure may need to be maintained longer.
- After achieving hemostasis, apply a sterile dressing and monitor the site for bleeding, hematoma formation, or signs of infection.
- The patient should remain on bed rest for 2-6 hours depending on sheath size and anticoagulation status, as recommended by the guidelines 1. This careful approach prevents complications such as bleeding, hematoma formation, vasovagal reactions, and air embolism while ensuring proper vessel closure after the invasive procedure.
Key considerations
- The optimal timing of removal is uncertain, but delaying removal until after 3 to 5 days of anticoagulation may reduce the risk of embolic phenomenon on CVAD removal, especially in children with known or potential right-to-left shunts 1.
- Pragmatic decisions, such as surgeon/operating suite availability, often determine the timing of CVAD removal.
- In cases where the thrombosis clinically extends/embolizes, despite adequate anticoagulation, the decision to remove or not remove a functioning CVAD must be made on an individual basis, considering factors such as availability of further vascular access and requirement for vascular access to treat the underlying condition successfully 1.
From the Research
Guidelines for Removal of Venous Sheath
The removal of a venous sheath is a critical procedure that requires careful consideration of various factors to minimize complications. The following guidelines are based on existing research:
- Patient Selection: Patients with higher systolic blood pressure and older age are more likely to experience complications during sheath removal 2.
- Removal Techniques: Different removal techniques, such as manual compression, C-clamp, and arterial vascular closure device, have comparable complication risks 2.
- Hemostasis: The use of procoagulant pads in combination with manual compression can decrease the time to hemostasis compared to manual compression alone 3.
- Coagulation Status: Abnormal coagulation status, such as the use of antiplatelet agents, can affect the time to hemostasis after sheath removal 4.
- Deployment Time: Reducing the deployment time of hemostatic devices from 30 minutes to 5 minutes does not increase the risk of bleeding or other vascular complications 5.
- Fibrin Sheath Disruption: Fibrin sheath disruption at the time of catheter removal or exchange does not appear to affect infectious outcomes in patients with catheter-related infections 6.
Key Considerations
When removing a venous sheath, healthcare professionals should consider the following key factors:
- Patient demographics and medical history
- Removal technique and hemostasis method
- Coagulation status and use of antiplatelet agents
- Deployment time of hemostatic devices
- Potential for fibrin sheath disruption and its impact on infectious outcomes
Complications and Risks
The removal of a venous sheath can be associated with various complications, including: