How should I manage two non‑patent peripherally inserted central catheters on the third day of therapeutic anticoagulation?

Management of Non-Patent Dual Catheters After Three Days of Anticoagulation

Remove both non-functioning catheters after a short course (3–5 days) of anticoagulation therapy, as current guidelines clearly state that non-functional catheters warrant removal regardless of anticoagulation duration. 1

Immediate Decision Algorithm

Your catheters meet the criteria for removal because they are non-functioning (not patent). The ESMO guidelines explicitly state that if the CVC is non-functioning, a short course (3–5 days) of anticoagulation therapy is recommended followed by catheter removal. 1 Since you are already on day 3 of anticoagulation, you have met the minimum threshold for safe removal.

Key Decision Points for Catheter Retention vs. Removal

Criteria that must ALL be met to justify keeping a thrombosed catheter in place: 1

• Distal catheter tip is correctly positioned (at SVC-right atrium junction)
• Catheter is functional (good blood reflux and infusion capability)
• Catheter is mandatory or vital for the patient
• No fever or signs of infected thrombophlebitis

Your catheters fail the second criterion (functionality), which automatically mandates removal. 1

Anticoagulation Management

• Continue therapeutic anticoagulation with LMWH for a minimum of 3–6 months total from the initial diagnosis of catheter-related thrombosis, not from the date of removal. 1

• After catheter removal, you may transition from LMWH to warfarin if prolonged LMWH is refused or impossible, though LMWH alone is preferred as it is more effective and has lower bleeding risk. 1

• In severe renal impairment, use unfractionated heparin rapidly followed by vitamin K antagonist (possibly as early as day 1). 1

Thrombolytic Therapy Consideration

Do NOT use thrombolytic agents (alteplase, urokinase, streptokinase) as first-line therapy for catheter-related thrombosis, as they carry a greater risk of recurrent thrombosis compared to anticoagulation alone. 1 Thrombolytics may only be considered in specialized units for poor clinical tolerance (vena cava syndrome) and absence of contraindications. 1

The FDA-approved alteplase (Cathflo Activase) is indicated for restoring function to occluded catheters, but this applies to intraluminal occlusion (clot within the catheter lumen), not mural thrombosis (clot in the vein around the catheter). 2 Given that your catheters remain non-patent after 3 days of systemic anticoagulation, thrombolytic instillation is unlikely to restore function and is not recommended as first-line therapy. 1

Planning for Future Central Access

• Evaluate the superior vena cava network status by CT scan or Doppler ultrasonography before placing any new catheter to assess vessel patency and identify thrombosis. 1

• Avoid placing new catheters in veins with recent thrombosis (within 30 days), as this significantly increases risk of recurrent complications. 3, 4

• For patients requiring long-term central access (>6 weeks), strongly consider tunneled catheters or implantable ports instead of PICCs, as these have substantially lower complication rates for extended use. 3 PICCs have higher thrombosis rates (5.8%) compared to tunneled CVCs (1.7%) in oncology patients. 1

• Right-sided insertion should be favored for any new catheter, as left-sided placements carry higher DVT incidence. 1

Monitoring After Removal

• Monitor for signs of pulmonary embolism, which occurs in 5–14% of upper extremity venous thrombosis cases. 1

• Watch for progressive symptoms or recurrent thrombosis, which occurs in approximately 2–5% of cases. 1

• Assess for post-thrombotic syndrome development, which affects 10–28% of patients with upper extremity DVT. 1

Common Pitfalls to Avoid

• Do not continue attempting to salvage non-functional catheters beyond 3–5 days of anticoagulation, as this delays definitive management and increases infection risk without improving outcomes. 1

• Do not stop anticoagulation after catheter removal—the minimum duration is 3–6 months regardless of catheter status. 1

• Do not place new catheters without imaging the venous system first, as unrecognized thrombosis or stenosis will lead to immediate failure of the new device. 1

• Avoid assuming both catheters failed for the same reason—evaluate each insertion site and vessel separately for infection, malposition, or anatomical factors. 1