How should a tunneled dialysis catheter be removed?

Tunneled Dialysis Catheter Removal: Technical Approach

Remove tunneled dialysis catheters using the modified cut-down method at the bedside, which involves local anesthesia, incision at the exit site, dissection to expose and remove the Dacron cuff, and controlled catheter extraction under direct visualization.

Removal Technique

Modified Cut-Down Method (Preferred Approach)

The modified cut-down method is the safest technique for tunneled catheter removal, eliminating serious complications observed with simple traction methods. 1

• Apply local anesthesia at the catheter exit site 1, 2
• Make a small incision at the exit site to expose the subcutaneous tunnel 1
• Dissect down to visualize and remove the Dacron cuff under direct vision 1, 2
• Extract the catheter in a controlled manner once the cuff is freed 1
• Close the incision with sutures and apply sterile dressing 1

Alternative: Simple Traction Method (Higher Risk)

The traction method involves pulling the catheter out without surgical dissection, but this carries risk of cuff retention (6.5% of cases) and potential serious complications including catheter fracture and embolization 1, 2. This method should be avoided in favor of the modified cut-down approach. 1

Clinical Indications for Removal

Mandatory Removal Scenarios

• Confirmed catheter-related bacteremia with positive blood cultures, especially if patient remains symptomatic >36 hours despite appropriate antibiotics 3
• Staphylococcus aureus bacteremia from any tunneled catheter 3
• Tunnel tract infection with drainage 3
• Clinical instability or sepsis 3, 4
• Gram-negative bacilli bacteremia (high treatment failure rate if catheter retained) 3, 4
• Candida species bloodstream infection (remove within 72 hours) 3

Catheter Salvage May Be Considered

• Exit site infection alone without systemic symptoms or positive blood cultures can be treated with topical/parenteral antibiotics without removal 3
• Coagulase-negative staphylococcal bacteremia in stable patients with limited venous access may be managed with guidewire exchange plus 3 weeks of systemic antibiotics, but only if patient becomes afebrile within 48 hours and has no tunnel involvement 3, 5

Safety Considerations

Anticoagulation Management

Patients on aspirin, clopidogrel, or warfarin can safely undergo bedside catheter removal without discontinuing antiplatelet therapy. 6

• In a cohort where 68% of patients were on antiplatelet or anticoagulant therapy, bleeding complications occurred in only 2% of cases 6
• No routine reversal of anticoagulation is required for this procedure 6

Common Pitfalls

• Cuff retention occurs in 6.5% of removals and is significantly associated with outpatient removal (p=0.007) 2
• Outpatient removals require extra vigilance to ensure complete cuff extraction 2
• Simple traction without visualization risks catheter fracture and retained fragments 1

Post-Removal Management

Timing of New Access Placement

• Do not place new permanent vascular access until blood cultures remain negative for at least 48 hours after completing antibiotic therapy 3, 5
• If immediate dialysis access is needed, place a temporary non-tunneled catheter at a different anatomical site 4

Wound Care

• Apply sterile dressing to the exit site 1
• Monitor for post-removal site infection 4

Training and Competency

Bedside tunneled catheter removal by nephrologists (including fellows in training) demonstrates 99% success rates with <2% complication rates. 2, 6, 7

• This procedure should be part of standard nephrology training curricula 6, 7
• Supervised removal by trainees is safe and facilitates timely patient care 6, 7
• The modified cut-down technique is straightforward to teach and perform 1