Retained Central Venous Catheters in Pediatric Patients: Challenges, Mechanisms, and Surgical Strategies—A Narrative Review

ABSTRACT

Background

Long‐term central venous catheters (CVCs) play a critical role in the management of pediatric patients with chronic illnesses, particularly in oncology. These devices provide reliable vascular access for the administration of chemotherapy, total parenteral nutrition, antibiotics, blood products, and frequent blood sampling.

Objective

Review the etiology, complications, and management of retained long‐term central venous catheters in children.

Methods

This review analyzes existing literature and clinical experience to highlight mechanisms of catheter adherence and embolization, with a focus on pediatric‐specific challenges.

Results

Prolonged catheterization may lead to endothelial injury and fibrotic adherence of the catheter to the vessel wall. Catheter fracture with embolization is a rare but serious complication. Management includes surgical, endovascular, and conservative approaches. Pediatric‐specific ethical considerations are vital when fragments are left in situ.

Conclusion

Awareness of risk factors and timely intervention strategies can mitigate complications from retained CVCs. Further research is needed to understand the long‐term effects and improve clinical guidelines.

1. Introduction

Central venous access devices (CVADs) have revolutionized the care of pediatric patients with chronic and oncologic diseases. These devices facilitate the administration of chemotherapy, total parenteral nutrition (TPN), long‐term antibiotic therapy, blood transfusions, and enable frequent blood sampling while preserving peripheral veins. Their use has significantly reduced the need for repeated venipunctures, improving the overall patient experience and allowing for uninterrupted delivery of complex treatment regimens. The most often utilized CVADs in pediatric patients, in addition to catheters used for dialysis and apheresis, are tunneled catheters (such as Broviac and Hickman), implanted ports, and peripherally inserted central catheters (PICCs) [1]. The choice of device is usually guided by the duration of therapy, the type of medications to be administered, patient‐specific factors (including age and vascular anatomy), and expectable complications [2].

Despite the advantages offered by long‐term central venous catheters (CVCs), their use is not devoid of risks; indeed complications, such as catheter‐related bloodstream infections (CRBSIs), mechanical failures (e.g., dislodgement, fracture), and vascular thrombosis, are well‐documented [3, 4, 5].

However, one of the more insidious and underreported complications is the inability to safely remove the catheter at the end of its utility. When attempts to remove the catheter encounter unexpected resistance, it may be found that the catheter has adhered to the vessel wall. In more severe scenarios, the catheter may fracture during removal, resulting in an embolization of a distal segment within the vascular system [6].

Retained long‐term CVCs pose a unique challenge in pediatrics, as they require careful consideration of both short‐term and long‐term risks due to their smaller and delicate vascular anatomy, and the importance of long‐term sequelae after successful treatment of oncologic conditions, chronic diseases, or short bowel syndrome. Furthermore, the repeated need for venous access in relapsing or chronic disease contexts makes the preservation of vascular integrity an essential goal. Given the rare but significant impact of retained catheters, awareness of this complication, its prevention, and management are critical for all clinicians involved in pediatric care [7].

This article provides a thorough analysis of the clinical scenarios for catheter removal, the pathophysiological basis of catheter adherence, potential complications, and management strategies for retained or embolized catheters, while also addressing ethical considerations and proposing future research for pediatric patient safety and outcomes.

2. Indications for Central Venous Catheter Removal

The timely and appropriate removal of a central venous catheter is a critical step in the overall management of patients requiring long‐term vascular access. While CVCs are designed for prolonged use, they are not intended to remain in situ indefinitely, as prolonged indwelling times can increase the risk of complications [8]. The decision to remove a CVC should be based on clinical necessity, the resolution of the condition requiring access, or the development of complications that compromise the catheter's functionality or safety. Nevertheless, in cases where catheter removal is indicated but the device is still functional, not infected and central access remains necessary, especially in children with chronic medical conditions, a careful evaluation of the venous system should precede any retrieval attempt. These patients often have limited venous access due to multiple prior catheterizations, venous thrombosis, or vessel stenosis, which can significantly complicate the placement of a new catheter. In such situations, preserving existing access may take precedence, and conservative management or deferral of removal may be justified.

2.1. Infectious Complications

The most common indication for catheter removal is infection including:

• Exit site infections, characterized by erythema, swelling, pain, or purulent drainage at the catheter's skin exit point.

• Tunnel infections involving the subcutaneous tract through which the catheter is tunneled; it can progress from exit site infections or occur independently

• Pocket infections typically involve implanted ports where the infection affects the subcutaneous pocket housing the port reservoir.

• Catheter‐related bloodstream infections (CRBSIs) represent the most serious infectious complication. Usually associated with fever, bacteremia, and systemic inflammatory response, CRBSIs are particularly dangerous in immunocompromised pediatric patients and often necessitate catheter removal associated with targeted antimicrobial therapy [9, 10]. Furtherome, infections caused by high‐virulence organisms such as Staphylococcus aureus , Pseudomonas aeruginosa , or fungi generally mandate immediate catheter removal, given the high risk of sepsis and poor response to antibiotic therapy alone [11].

2.2. Thrombotic Complications

Catheter‐related thrombosis is another major indication for removal [12, 13]. Thrombus formation may occur within the catheter lumen (intraluminal thrombus), around the catheter tip (fibrin sheath), or in the adjacent vessel (catheter‐associated thrombosis). Symptoms can be subtle (such as resistance to flushing or absence of blood return) or more overt, including swelling, pain, or discoloration of the limb. Ultrasound or contrast‐enhanced imaging is typically used to confirm the presence of thrombus [14].

When thrombosis is confirmed and associated with symptoms or the catheter is non‐functional, removal is often indicated. Anticoagulation may be used adjunctively, particularly if removal must be delayed due to clinical instability [15, 16].

2.3. Mechanical Complications

Mechanical issues include catheter breakage, disconnection, kinking, occlusion, or migration. These can lead to leakage of infused substances into surrounding tissues, risk of embolization, or loss of catheter function [17]. Mechanical malfunction that cannot be resolved with standard interventions (e.g., catheter repair kits, thrombolytic agents) generally warrants removal and replacement.

2.4. End of Therapy or Patient Preference

Once a patient completes the course of treatment requiring central access—such as the end of chemotherapy or long‐term antibiotic therapy—the catheter should be removed to minimize infection risk and preserve venous access for future use. Caregivers or older pediatric patients may request removal due to psychological burden, discomfort, or lifestyle limitations, but removal should not jeopardize clinical care [18].

2.5. Catheter Non‐Use and Dormancy

Catheters that are no longer actively used but are retained in situ for potential future use should be regularly assessed. Prolonged dormancy without proper maintenance (e.g., regular flushing) increases the risk of thrombotic occlusion or infection. Additionally, natural degradation of the catheter material over time—especially in long‐term placements—may compromise functionality, as observed in devices removed after a decade. In such cases, prophylactic removal may be appropriate, particularly if no near‐future use is anticipated.

In conclusion, while CVCs are invaluable tools in pediatric care, their continued presence must be justified by clear clinical benefits. Awareness of the indications for timely removal can help prevent avoidable complications and ensure optimal outcomes for pediatric patients [19].

3. Mechanisms of Catheter Adherence

The phenomenon of catheter adherence to the venous wall is a multifactorial process that evolves over time and reflects the host's biological response to a foreign body [20]. Although it is relatively rare, its clinical significance is considerable, especially when removal becomes necessary. Understanding the underlying mechanisms of adherence can aid clinicians in anticipating which patients are at higher risk and planning removal strategies accordingly.

3.1. Biological Basis of Adherence

The initial phase of catheter‐induced vascular injury begins with mechanical irritation of the endothelium [21]. Even in optimal placement, a catheter can cause localized turbulence of blood flow and repeated microtrauma to the inner lining of the vessel, activating endothelial cells and initiating a cascade of inflammatory processes. Subsequently, pro‐inflammatory cytokines and adhesion molecules are released, leading to leukocyte recruitment and platelet activation. These inflammatory mediators stimulate fibroblast proliferation and extracellular matrix deposition [22]. Over time, this results in the formation of fibrotic tissue that can encapsulate the catheter or anchor it to the vessel wall. This is further exacerbated in areas of stasis or poor catheter positioning, where local thrombosis may occur and undergo organization into fibrous tissue [23].

3.2. Fibroblastic Sheath Formation: Pathophysiological Basis and Clinical Relevance

The development of a fibroblastic sheath surrounding the intravascular portion of a central venous catheter is a well‐documented biological response to prolonged catheterization. It originates as early as 7–10 days after insertion and consists of a layered accumulation of fibrin, collagen, smooth muscle cells, and myofibroblasts, derived from endothelial injury and chronic low‐grade inflammation at the catheter‐blood interface [21]. The process is initiated by thrombin generation and platelet adhesion, which stimulate local fibroblast recruitment and extracellular matrix deposition. Over time, the initial fibrinous coating is gradually remodeled into a dense, collagen‐rich structure that may completely envelop the catheter and extend beyond its tip.

In long‐term indwelling catheters, the progressive incorporation of the foreign body into the venous endothelium can lead to intimalization, a process in which the catheter becomes partially or entirely embedded within a neointimal layer [24]. This phenomenon results from endothelial proliferation and migration over the catheter surface, mimicking the vessel's physiological response to injury. Once intimalized, the catheter can no longer be freely mobilized within the lumen and is instead structurally integrated into the vessel wall, sometimes forming a fibrous “cast” that adheres circumferentially to the catheter. This significantly increases the difficulty and risk associated with catheter removal, especially after several years of indwelling time [25].

From a clinical perspective, fibroblastic sheath and intimalization are not only mechanical obstacles but also predisposing factors for thrombosis and infection, since the sheath may act as a scaffold for microbial colonization and impair catheter function by obstructing flow or altering intraluminal dynamics. In pediatric patients, who may retain devices for many years due to chronic conditions, this phenomenon represents a major risk factor for catheter entrapment, fracture during traction, and iatrogenic vascular injury during removal.

3.3. Choice of Catheter Dimension and Material

Maintaining a catheter‐to‐vessel diameter ratio of one‐third is crucial for reducing complications and thrombosis risk [2]. Furthermore, the material composition of the catheter plays a crucial role in its interaction with the vascular endothelium [26]: polyurethane catheters are known for their stiffness and durability, making them resistant to kinking and suitable for high‐pressure infusions; however, this rigidity may contribute to increased endothelial irritation with a higher risk of fibrotic response [27, 28].

Silicone catheters, on the other hand, are more flexible and have a smoother surface texture, which is generally associated with lower rates of thrombogenicity and tissue reaction. Nonetheless, they are more prone to fracture and may degrade over time when exposed to certain infusive substances or environmental stressors [29, 30, 31, 32, 33]. The choice of material should therefore be individualized based on the anticipated duration of use and patient‐specific factors.

3.4. Elasticity and Its Relevance to Central Venous Catheters

The elasticity of a linear material is quantitatively expressed by Young's modulus (also referred to as the elastic modulus), which represents the ratio between the applied stress (force per unit area) and the resulting strain (relative deformation along the axis of force). Mathematically, it is defined as E = σ/ε = (F × L ₀)/(A ₀ × ΔL), where F is the applied force, A₀ the original cross‐sectional area, ΔL the change in length, and L₀ the initial length of the object (Figure 1). Materials with low Young's modulus, such as rubber, deform more easily under force, while those with high modulus values, like steel, show minimal deformation. In practical terms, the force required to stretch or compress a material increases proportionally with its Young's modulus. For instance, a silicone central venous catheter, characterized by a low modulus, requires minimal force to deform. However, once a metal guidewire is introduced into its lumen, the effective modulus of the system approximates that of the metal. As tension increases, the catheter's diameter progressively contracts until it matches the diameter of the wire, at which point further deformation is restricted. Consequently, a substantially greater force is necessary to rupture the catheter under these conditions.

FIGURE 1.

Stress–strain curve illustrating the mechanical properties of a material. The modulus of resilience (orange area) represents the energy absorbed in the elastic region, while the modulus of toughness (blue area) corresponds to the total energy absorbed before fracture. The yield strength marks the transition from elastic to plastic deformation. Ultimate strength is the maximum stress the material can withstand, and fracture indicates failure. Young's modulus is defined as the slope of the linear portion of the curve (stress/strain).

3.5. Duration of Catheterization

Time is a critical factor in the development of adherence [14, 21, 34]. Short‐term catheters (used for days to weeks) rarely exhibit strong adhesion to vessel walls [35]; in contrast, long‐term catheters (used for months to years) are at significantly higher risk of fibrotic encapsulation. Reports from histopathological studies of explanted catheters have shown significant vein wall thickening, pericatheter fibrosis, and even calcification around the catheter surface after prolonged use [36].

Moreover, repeated infections or thrombotic events around the catheter tip can accelerate the inflammatory process and promote faster adhesion [37]. Catheters that have remained unused or dormant for extended periods are also more susceptible, likely due to stagnant blood flow, thrombus formation, and absence of regular mechanical movement.

3.6. Vascular Site and Hemodynamic Factors

The anatomical site of catheter insertion may also influence the risk of adherence [21]: central veins with lower flow velocities (such as the subclavian or innominate veins) may be more prone to adhesion compared to higher flow areas like the superior vena cava [38]. In smaller children, vessel size and flow dynamics further increase susceptibility [39].

Additionally, the angle at which the catheter tip resides against the vessel wall may lead to localized areas of pressure necrosis or mechanical irritation, such as in cases of malpositioned catheters or where growth‐related anatomical alterations occur over time [40].

3.7. Imaging Evidence and Diagnosis

Detecting catheter adherence prior to removal remains a clinical challenge, since resistance to traction during an attempted removal may often represent the first indicator [20]. Doppler ultrasound can identify associated thrombus, but it is limited in assessing deeper central veins. Fluoroscopy with contrast injection through the catheter can delineate areas where contrast fails to track along the expected catheter path, suggesting tethering.

Advanced imaging such as contrast‐enhanced CT or MRI may be needed in complex cases, particularly when planning for surgical or interventional removal. The development of non‐invasive tools to assess catheter adherence remains an area of unmet clinical need.

3.8. Histopathological Insights

Post‐removal histological examination of catheters and surrounding tissues reveals key findings such as collagen‐rich fibrous tissue, endothelial hyperplasia, chronic inflammatory cell infiltration, and dystrophic calcification, supporting the notion that catheter adherence is a progressive, inflammatory‐fibrotic process with both mechanical and biological components [23].

In summary, catheter adherence is the final result of a complex interplay between mechanical forces, material properties, vascular biology, and host immune response. Awareness of these factors is crucial for clinicians managing long‐term CVADs, enabling better risk stratification, planning for removal, and development of preventive strategies such as material innovation and regular catheter surveillance.

4. Complications of Catheter Removal

Central venous catheter removal, often considered a minor procedure, can lead to significant complications, especially in pediatric oncology and hematology patients, and children dependent on long‐term parenteral nutrition, where catheter lifespan may exceed several years [7, 18, 41]. A seemingly routine extraction can reveal unexpected resistance, suggesting possible catheter adhesion or mechanical compromise. Understanding the spectrum of possible complications is vital for clinicians to prepare appropriately and respond rapidly when they occur (Table 1).

TABLE 1.

possible complications occurring during catheter removal.

Complication	Key features	Clinical implications	Management considerations
Catheterization	Incomplete catheter removal, often due to fibrin sheath formation, vessel wall adherence, or fracture	May remain asymptomatic or predispose to infection or embolization	Imaging to assess retained segment; surgical or interventional removal if symptomatic or mobile
Catheter fracture	Structural break in catheter, frequently at stress points (e.g., insertion site, hub)	Risk of intravascular embolization, infection, or obstruction	Inspect catheter post‐removal; imaging if fracture suspected; retrieval if embolized
Embolization	Intravascular migration of catheter or fragment (e.g., to pulmonary artery or heart)	Potential for arrhythmias, vascular occlusion, pulmonary symptoms	Prompt imaging (CXR, echocardiography, CT); interventional retrieval if accessible
Hemorrhagic and vascular complications	Unexpected bleeding, particularly if the catheter has eroded into the vessel wall or is adherent in such a way that its removal disrupts the endothelial lining and/or presence of coagulopathies (oncohematological diseases)	Risk of life‐threatening bleeding, possible necessity of surgical intervention; major risk in hematological malignancies	Doppler ultrasound, fluoroscopy, pre‐procedural blood test
Psychological impact	Fear and re‐experiencing trauma	Complications during removal reignite fear and trauma in children and their families	Clear communication, pre‐removal assessment, readiness to abort and re‐evaluate, skilled operator

4.1. Catheter Adherence to the Vessel Wall

As previously described in Section 3, this phenomenon is believed to result from chronic endothelial injury induced by long‐term catheter presence [21, 41], especially in those made of polyurethane compared to siliconic ones [42]. Resistance to traction is the initial indication of a catheter adhesion, which is frequently a silent process that has no effect on catheter function until removal is attempted. Forceful extraction in these cases may lead to catheter fracture, vessel laceration, hemorrhage, or even embolization of catheter fragments [20, 43].

Therefore, any resistance encountered should prompt a halt to the procedure and further imaging to assess the catheter's course and possible points of fixation. Real‐time detection of malposition, looping, or vascular adhesion can be achieved by using transthoracic ultrasound to examine the position of the catheter and guidewire in the right atrium or superior vena cava. Additionally, techniques including contrast‐enhanced ultrasound (CEUS) and intracavitary electrocardiogram (IC‐ECG) have been verified for real‐time catheter tip localization, with an accuracy of approximately 95.8%. Real‐time fluoroscopy is still necessary, though, to assess catheter course and fixation, particularly when adhesion or entrapment is suspected. It guarantees safe manipulation during removal attempts and offers direction during operations [44, 45, 46].

4.2. Catheter Fracture

Another significant risk is fracture during removal, which may be the result of the catheter material's fragility after protracted indwelling, manufacturing defects, or operator‐induced stress during manipulation. Fractures may lead to distal embolization or the retention of a portion of the catheter within the vessels.

The clinical implications of catheter fracture depend on the location of the retained fragment. If the break occurs near the insertion site, retrieval might be possible with minimal intervention. Nevertheless, the likelihood of severe complications (such as pulmonary embolism, endocarditis, or arrhythmias) increases significantly if the catheter segment embolizes distally into the central venous system [7, 47]. These circumstances frequently require the cooperation of cardiothoracic surgeons or interventional radiologists [48, 49, 50].

4.3. Embolization or Retention of Catheter Fragments

Catheter fragment embolization is a rare but potentially life‐threatening complication. Detached fragments can migrate through the venous system and lodge in the pulmonary arteries, right atrium, or even the right ventricle [51, 52, 53]. In rare cases of cardiac defects with intracardiac shunting, fragments could potentially enter systemic circulation, increasing the risk of stroke or peripheral embolism.

The clinical presentation depends on the size and location of the fragment. While many cases are asymptomatic and discovered incidentally during unrelated imaging, symptomatic patients may experience chest pain, dyspnea, palpitations, syncope, or hemodynamic instability. In the former situation knowing the implanted catheter length is of utmost importance, allowing the clinicians to promptly identify discrepancies upon removal and raise early suspicion for silent or delayed fragment embolization, which may otherwise go unnoticed until complications arise [54].

Due to the uncertain long‐term consequences of retained intravascular foreign bodies, it is recommended that embolized fragments be retrieved whenever feasible, particularly in pediatric patients. Occasionally, only part of the catheter is removed, leaving a residual segment in situ. This can occur due to unnoticed breakage during extraction or operator decision in the context of severe adhesion. In such cases, the proximal portion is often excised, and the distal fragment left inside the vessel with or without securing measures. The decision to leave a fragment in place should only be made after thorough multidisciplinary discussion, considering the potential for infection, thrombosis, or interference with future vascular access.

4.4. Hemorrhagic and Vascular Complications

Unexpected bleeding during catheter removal can occur if the catheter erodes into the vessel wall or disrupts the endothelial lining. Major hemorrhage may require surgical intervention and be life‐threatening. Patients with coagulopathies or thrombocytopenia, common in pediatric oncology, are at higher risk.

Injury to the vessel itself, such as dissection or rupture, though uncommon, must be considered, especially when high resistance is encountered. Pre‐removal imaging such as Doppler ultrasound or fluoroscopy may help anticipate such risks in long‐term catheterized patients (Figures 2 and 3).

FIGURE 2.

Chest x‐ray (A) and coronal CT scan (B) showing a retained fragment of a central venous catheter (CVC) in the upper mediastinum (red oval). The catheter fragment is clearly visible on the chest radiograph and corresponds to a linear radiopaque structure located anterior to the trachea on the CT scan.

FIGURE 3.

Representative images from a case of difficult removal of a totally implantable venous access device (TIVAD) after prolonged in situ dwell time. (A) Explanted device showing the port chamber, catheter, and multiple adherent fibrin sleeves retrieved along the tract. (B) Macroscopic detail of a fibrin sheath strongly adherent to the catheter wall, contributing to resistance during traction. (C) Close‐up of the distal catheter segment with areas of external fibrosis and encasement, suggesting long‐standing tissue incorporation. (D) Proximal catheter section with evident signs of discoloration and material degradation, indicating chronic biomechanical stress.

4.5. Psychological Impact

The removal of a catheter, especially when complicated or unsuccessful, can have a psychological impact on pediatric patients and their families. Many children associate the device with their illness journey, and unexpected issues during removal can reignite fears or trauma related to hospitalization. Clear communication, pre‐procedural preparation, and psychological support are essential, particularly when unexpected complications occur.

In summary, the removal of long‐term CVCs in pediatric patients must be approached with care and forethought. Pre‐removal assessment, gentle technique, and readiness to abort and re‐evaluate when complications are suspected are hallmarks of safe clinical practice. Understanding the mechanisms and manifestations of potential complications enables clinicians to respond quickly and appropriately, reducing the risk of long‐term harm.

5. Catheter Embolization: Clinical Implications

Catheter embolization represents a rare but potentially severe complication in the management of long‐term central venous access devices, particularly in the pediatric population [55]. Embolization can result from catheter fracture during removal attempts, mechanical fatigue of the catheter material over time, or inadvertent cutting or disconnection during medical procedures. The clinical consequences of an embolized catheter fragment are highly variable and depend on multiple factors including the size of the fragment, its final location, and the patient's underlying clinical status.

5.1. Pathophysiology and Mechanism

Catheter embolization typically occurs when mechanical stress (whether due to removal, kinking, or degradation) leads to a break in the catheter structure [3]. The fragment, no longer anchored, can migrate via the bloodstream, following venous return to the right heart and pulmonary vasculature. In pediatric patients, especially those with congenital heart defects, there is even a possibility of paradoxical embolism into the systemic circulation if intracardiac shunts are present.

The embolized segment can act as a nidus for thrombus formation or infection. Moreover, the prolonged presence of foreign material within the cardiac chambers or pulmonary arteries may induce local inflammation, fibrosis, and endocardial damage. These effects can be insidious, manifesting months or even years after the embolic event [56].

5.2. Common Sites of Embolization

The most frequent anatomical sites where embolized catheter fragments are identified include:

• Pulmonary arteries: Often asymptomatic, but large fragments may obstruct blood flow and cause ventilation‐perfusion mismatch [48].

• Right atrium and right ventricle: Can provoke arrhythmias, particularly if the fragment is mobile or irritates the conduction system [53].

• Subclavian and brachiocephalic veins: Fragments here may cause localized thrombosis or remain clinically silent.

• Systemic arterial system (in rare cases): Possible in the presence of right‐to‐left cardiac shunts; emboli may lodge in the brain, limbs, or kidneys, potentially leading to stroke or organ ischemia.

5.3. Clinical Presentation

Many embolic events are clinically silent, particularly in children, and discovered incidentally during imaging for unrelated issues. When symptoms are present, they may include chest pain or tightness, palpitations or new‐onset arrhythmias, shortness of breath or hypoxemia, hemodynamic instability in severe cases, and neurological symptoms in the case of paradoxical embolism. The timing of presentation may be acute (during or shortly after catheter removal) or delayed [49].

5.4. Diagnostic Workup

Prompt and accurate localization of the embolized fragment is essential. The diagnostic approach typically includes:

• Chest radiography: Useful for initial screening and may identify radiopaque fragments

• Echocardiography: Transthoracic or transesophageal echocardiography can visualize intrathoracic fragments, particularly within the heart.

• CT angiography: Offers precise localization and can detect small fragments in the pulmonary vasculature.

• MRI: May be used when high‐resolution soft tissue contrast is required, although its use is limited in acutely unstable patients.

Intraoperative fluoroscopy is invaluable during retrieval procedures to guide instrument placement and confirm fragment capture [57, 58].

5.5. Management Options

Once an embolized fragment is identified, a decision must be made whether to retrieve it or [59]. Retrieval is generally recommended in the pediatric population due to their long life expectancy and unknown risks of chronic foreign body retention. The preferred approach in most cases is endovascular retrieval [60, 61], while surgical retrieval is indicated when endovascular methods fail or are not feasible. Open surgical approaches such as sternotomy may be required for fragments lodged in cardiac chambers [43].

Conservative management may be considered for small, asymptomatic fragments in non‐critical locations, particularly when retrieval would pose excessive risk [62].

5.6. Risks and Complications of Retrieval

Retrieval procedures, though generally safe in experienced hands, carry risks that include vessel perforation or dissection, hemorrhage, fragment migration during attempted capture, arrhythmias during manipulation within the heart, sedation or anesthesia‐related complications in children.

5.7. Long‐Term Considerations in Pediatrics

In children, the long‐term implications of retained catheter fragments are not well studied. Potential concerns include: chronic inflammation and granuloma formation, risk of late infection or endocarditis, interference with future vascular or cardiac procedures, and psychological stress on patients and families aware of the retained object.

These considerations often tip the balance toward retrieval even in the absence of acute symptoms. Longitudinal follow‐up is recommended, ideally through structured registries or surveillance programs.

5.8. Ethical and Family Communication Considerations

When embolization occurs, clear and compassionate communication with the family is essential. The implications must be explained, including diagnostic findings, treatment options, risks of intervention versus observation, and expected outcomes. Shared decision‐making should be encouraged, with full documentation of discussions and informed consent for any intervention undertaken.

In conclusion, catheter embolization, while rare, represents a clinically important event that necessitates prompt recognition and an individualized, patient‐centered response. Advances in imaging and interventional techniques have improved outcomes, but prevention through careful catheter management and removal protocols remains paramount.

6. Management Strategies

The management of retained or adherent CVCs in pediatric patients demands a thorough understanding of the pathophysiology and the possible therapeutic options, with a delicate balance between minimizing procedural risk and achieving complete resolution of the complication. Decision‐making should be multidisciplinary, requiring collaboration among pediatric surgeons, interventional radiologists, hematologists, anesthesiologists, and critical care specialists. The choice of strategy depends on multiple factors, including the clinical urgency, anatomical location of the catheter, extent of adhesion, availability of resources, and long‐term prognosis of the patient.

6.1. Conservative Management and Observation

In select cases, particularly when a retained fragment poses no immediate threat and the patient is asymptomatic, conservative management may be appropriate [7]. This may include leaving the catheter or a fragment in situ with careful clinical and radiological monitoring. Such decisions are more commonly made in adult populations; however, in pediatrics, they necessitate particularly thoughtful consideration due to concerns regarding long‐term risks, such as infection, thrombosis, and future vascular access compromise.

Careful documentation and family counseling are essential. Follow‐up protocols should be clearly defined, typically including periodic Doppler ultrasound, chest radiography, or even CT angiography. The risks and benefits of leaving a fragment must be revisited over time, especially as the child grows and anatomical relationships change.

6.2. Gentle Traction and Manual Techniques

If mild resistance is encountered during routine catheter removal, a standard first‐line approach involves pausing the procedure, re‐evaluating the situation, and attempting gentle, sustained traction. It is critical to avoid applying forceful or repetitive pulling, which significantly increases the risk of catheter fracture and embolization.

This maneuver may be facilitated by ensuring the patient is fully relaxed under general anesthesia, allowing vasodilation and reduction of muscular tension that may contribute to resistance. In certain cases, warming the area locally or using gentle external massage along the catheter path may also aid release.

6.3. Use of Intraluminal Guidewire or Dilator Techniques

When external traction fails, intraluminal techniques may be employed. One common method involves inserting a stiff guidewire or dilator through the catheter lumen, advancing it to the tip, and applying a gentle push or rotational maneuver [41], in order to mechanically disrupt fibrous adhesions from within the catheter, dislodging it from the venous wall. However, excessive pressure must be avoided since this could damage the vessel or rupture the catheter. During such procedures, fluoroscopic guidance is highly recommended to monitor the catheter's behavior and avoid complications [41, 48].

6.4. Surgical Cutdown and Venotomy

If minimally invasive techniques fail, surgical exposure of the catheterized vessel may be warranted. This involves a small incision over the catheter entry site, followed by careful dissection to isolate the vein and catheter; a venotomy is then performed to access the catheter internally and release any adhesions directly.

This method allows controlled removal while minimizing the risk of distal embolization. However, it is limited by the depth and extent of adherence: catheters adherent far along their course or at central locations may not be accessible. Furthermore, the surgical approach is usually performed under general anesthesia and requires postoperative monitoring for complications such as hematoma or infection.

6.5. Endovascular Retrieval Techniques

Endovascular techniques represent the mainstay in the management of fractured or embolized catheter fragments. Through fluoroscopic or ultrasound guidance, interventional radiologists use loop snares, retrieval baskets, and endovascular forceps introduced through a femoral or jugular venous access (Figure 4).

FIGURE 4.

Radiographic and angiographic sequence documenting central venous catheter (CVC) rupture, embolization, and endovascular retrieval. (A) Chest radiograph showing the fractured and embolized distal fragment of the CVC projecting over the superior vena cava and right cardiac chambers. (B) Fluoroscopic image showing endovascular retrieval maneuvers using a gooseneck snare to engage the embolized catheter fragment. (C, D) Sequential fluoroscopic images demonstrating successful capture of the catheter fragment with the snare. (E) Completion angiographic image demonstrating retrieval of the catheter fragment through a transfemoral venous route, with no residual foreign body or vascular complication.

The choice of instrument and approach depends on the location, size, and mobility of the fragment: snare techniques are highly effective for free‐floating fragments with a well‐visualized end, while retrieval baskets may be more appropriate for fragments lodged in wider vascular spaces such as the right atrium [63]. Intravascular ultrasound (IVUS) may be used in complex or high‐risk cases to enhance visualization and precision.

Endovascular retrieval is generally safe but not without risks, including vessel trauma, arrhythmias, embolization during manipulation, or incomplete retrieval. The procedure may be further complicated in children due to the smaller vessel size and the need for sedation.

6.6. Open Surgical Retrieval and Sternotomy

In rare and extreme cases, such as embolization of a fragment into the cardiac chambers or pulmonary arteries with associated symptoms or hemodynamic compromise, open surgical retrieval may be necessary. This typically involves a median sternotomy and direct visualization of the heart and great vessels [64]. The procedure carries significant morbidity and requires cardiopulmonary bypass in some instances.

Open retrieval should be reserved for life‐threatening situations or when less invasive techniques have failed. Preoperative planning with advanced imaging (echocardiography, cardiac CT/MRI) is essential.

6.7. Hybrid Approaches and Multidisciplinary Planning

In complex cases, a hybrid approach combining multiple techniques may be employed. For example, a catheter that is adherent proximally but has a free distal segment may be approached with both surgical cutdown and endovascular snaring. Such strategies require careful preoperative planning, including imaging, anesthesia coordination, and the presence of both surgical and interventional teams.

In conclusion, the management of retained long‐term central venous catheters in children requires a nuanced, tiered approach that progresses from the least invasive to the most invasive options. Each strategy has its risks and benefits, and no single technique is appropriate for all cases. Prevention through careful catheter management, regular monitoring, and early planning for removal remains the most effective strategy. When complications arise, timely recognition and a coordinated response are key to minimizing morbidity and preserving vascular integrity.

7. Pediatric Considerations

The management of retained or embolized CVCs in children is inherently more complex than in adults, not only due to anatomical and physiological differences but also because of long‐term implications and ethical considerations unique to the pediatric population. As previously mentioned, complications during removal of the catheter, which is itself a symbol of the illness, may reignite fears or trauma related to hospitalization.

Children are not just “small adults”: their vascular system is more fragile, their growth potential poses specific challenges for long‐term retention of intravascular foreign material, and the psychosocial aspects of medical interventions often carry a profound impact on both the patient and their family.

7.1. Anatomical and Physiological Considerations

Pediatric patients, especially infants and young children, present unique challenges due to the smaller diameter of their central veins and the ongoing growth of their vascular system. Catheters placed in early life may shift position as the child grows, potentially altering their relationship to surrounding tissues and increasing the likelihood of adherence to vessel walls.

Additionally, pediatric patients are more vulnerable to the hemodynamic consequences of vascular complications. A thrombus or retained catheter segment in a central vein can more easily lead to flow obstruction, increased central venous pressure, or even superior vena cava syndrome in severe cases. These risks demand greater caution and monitoring during both placement and removal of CVCs.

7.2. Growth and Development

One of the most significant concerns regarding retained catheter fragments in children is how they will interact with the child's natural growth since they may gradually migrate, become enveloped by new tissue, erode into nearby structures, or serve as a nidus for infection or thrombosis. Furthermore, any retained intravascular object could interfere with future diagnostic imaging (e.g., MRI artifact), limit vascular access options for future therapies, or even complicate surgical procedures in later life.

7.3. Future Medical Needs and Access Planning

Pediatric patients, especially those with chronic illnesses, often require multiple long‐term vascular accesses throughout their lifetime; therefore, preservation of venous capital is essential. A retained fragment may compromise future access sites or preclude use of a preferred vein, thereby increasing procedural complexity and morbidity in future catheter placements.

This long‐term perspective often motivates clinicians to favor retrieval, even in the absence of immediate complications, if safe and feasible, while a pediatric series by Bautista et al. reported no complications for retained fragments, suggesting that the benefit of close follow‐up may outweigh the possible hindrance of retrieval [61].

7.4. Psychosocial Impact on Patients and Families

Beyond the physical considerations, the psychosocial implications of a retained catheter or its complications are not negligible. Children may experience anxiety related to the presence of a foreign body, especially if they associate it with past illness or hospitalization. Parents may feel guilt, fear, or a sense of helplessness, particularly if the catheter was associated with a traumatic medical experience [65].

7.5. Documentation and Long‐Term Follow‐Up

In any case where a catheter fragment is retained or a complication arises, meticulous documentation is essential. This includes a clear summary of:

• Clinical rationale for retention versus retrieval.

• Family discussions and informed consent.

• Imaging findings and procedure details.

• Follow‐up plan, including timelines and responsible clinicians.

Long‐term surveillance strategies should be tailored to the patient's condition and the fragment's location. A structured follow‐up pathway may include serial imaging, clinical evaluations, and specialist consultations. Milbrandt et al. stated that in asymptomatic patients a yearly chest x‐ray and eco‐Doppler ultrasound are recommended. However, even in the absence of a directly referenced protocol for peripheral fragments, clinical reasoning should guide the correct timing of follow‐up: monitoring every week through chest X‐ray and ultrasound and gradually extending surveillance to 3–6 months and, if stability is confirmed, yearly controls. Oppositely, in case of symptomatic patients or migrated fragments, immediate evaluation and retrieval must be performed [65]. These strategies help ensure that any delayed complication is promptly identified and addressed.

7.6. The Role of Multidisciplinary Teams

Pediatric vascular access management is ideally delivered within the context of a multidisciplinary team [14], including pediatric surgeons, hematologists/oncologists, interventional radiologists, infectious disease specialists, anesthesiologists, and mental health professionals. This collaborative model ensures that all aspects of the child's care (clinical, technical, psychosocial, and ethical) are integrated into a coherent, compassionate management plan [18].

In conclusion, pediatric patients with retained or embolized CVCs require a highly individualized approach that extends beyond the immediate technical challenge. Their care must be informed by an understanding of their unique anatomical, developmental, and psychosocial needs, and grounded in a commitment to shared decision‐making and long‐term outcome optimization.

8. Future Directions and Recommendations

Despite advances in CVAD materials, placement techniques, and maintenance protocols, the management of retained and embolized catheters remains a complex clinical challenge. Particularly in pediatric populations, where long‐term outcomes and cumulative procedural exposure must be carefully considered, further progress is needed on multiple fronts—clinical, technological, educational, and regulatory.

8.1. Standardized Protocols for Catheter Removal

One of the most pressing needs is the development and implementation of evidence‐based, standardized protocols for catheter removal, particularly for long‐term devices. These protocols should include:

• Pre‐removal assessment tools to identify patients at risk of catheter adherence (e.g., duration in situ, material type, previous infections or thromboses).

• Guidelines for imaging prior to removal in high‐risk patients.

• Stepwise procedures outlining escalating approaches (from gentle traction to surgical referral) in the presence of resistance.

Inclusion of standardized protocols in institutional policies and national pediatric oncology guidelines could ensure more consistent, safer practices across care settings.

8.2. Registry Development and Data Collection

Retained and embolized catheters are rare, making it difficult to gather robust data from single centers. National or international registries would allow pooling of data, enabling more accurate determination of incidence, risk factors, long‐term outcomes, and effectiveness of different management strategies.

Such registries should collect detailed information on:

• Patient demographics.

• Type and duration of catheter.

• Complication type and location.

• Management strategy employed.

• Procedural outcomes and complications.

• Long‐term follow‐up and sequelae.

This data could inform predictive models and risk stratification tools that support personalized care.

8.3. Innovation in Catheter Design and Materials

Current CVAD materials have known limitations. Polyurethane offers strength but increases endothelial irritation, while silicone is more biocompatible but less durable. Innovations should aim for materials that combine mechanical resilience with minimal inflammatory potential.

Promising directions include:

• Hydrophilic coatings to reduce protein adsorption and thrombosis.

• Anti‐adhesive surface treatments to resist fibrotic encapsulation.

• Biodegradable or bioresorbable components designed to safely dissolve over time.

• Embedded sensors to monitor catheter position, function, or signs of infection.

Partnerships between clinicians, biomedical engineers, and device manufacturers will be essential to bring these innovations to clinical practice.

8.4. Preventive Strategies and Surveillance

Proactive catheter management may help prevent complications related to retention. Strategies may include:

• Scheduled reassessment of catheter need, especially after treatment completion.

• Regular flushing protocols and thrombosis surveillance.

• Early imaging in cases of suspected dysfunction.

• Preemptive removal of dormant catheters when no short‐term use is anticipated.

Additionally, surveillance imaging before elective removal—especially in long‐term catheters—could help identify early signs of adherence and inform procedural planning.

8.5. Training and Simulation‐Based Education

Proper training of healthcare professionals is essential to prevent complications. Simulation‐based training modules for catheter removal can improve recognition of resistance and appropriate escalation. Interdisciplinary simulation exercises may also help teams prepare for rare but serious scenarios like catheter embolization or surgical retrieval.

Educational efforts should be incorporated into pediatric surgery, hematology/oncology, interventional radiology, and critical care fellowship programs. Continuing medical education (CME) offerings can help keep experienced clinicians current with evolving guidelines and technologies.

8.6. Family Engagement and Communication Tools

Decision‐making in pediatric care must always involve the child's caregivers. Tools such as decision aids, animated explainer videos, and consent checklists can help families better understand the risks and options related to retained or embolized catheters.

Long‐term care plans should also be shared with primary care physicians and future treating specialists to ensure continuity of surveillance and minimize duplication of interventions.

8.7. Policy and Accreditation Standards

Incorporating best practices into hospital accreditation standards could incentivize institutions to prioritize catheter safety. For example:

• Tracking and reporting of catheter retention events.

• Credentialing for staff who perform CVAD removals.

• Institutional support for multidisciplinary vascular access teams.

Such measures could improve patient safety and align with broader quality improvement efforts.

8.8. Research Priorities

There are several important unanswered questions that merit further study:

• What is the true incidence of catheter adherence and embolization in pediatric patients?

• What are the long‐term outcomes of retained catheter fragments in children?

• How do different catheter materials influence adherence over time?

• Can biomarkers or imaging modalities predict catheter adhesion pre‐removal?

Funding agencies and research collaboratives should prioritize multicenter studies to address these knowledge gaps.

In summary, future efforts must emphasize prevention, innovation, and collaboration. By improving our understanding of retained catheter complications and refining our management tools and systems, we can optimize both immediate and long‐term outcomes for pediatric patients requiring central venous access.

9. Conclusion

Retained long‐term CVCs in pediatric patients, whether due to fibrotic adherence or intravascular embolization, represent a clinically significant and multifaceted challenge. While rare, these complications carry the potential for serious immediate consequences (such as infection, thrombosis, and embolic events) as well as long‐term implications, including interference with future vascular access, psychological burden, and unknown risks associated with the retention of foreign bodies over a growing child's lifetime.

The management of retained CVCs necessitates a careful, individualized approach informed by clinical context, patient age, catheter characteristics, and anticipated future needs. Conservative, minimally invasive, and surgical strategies all have roles depending on the specific scenario. Equally important is proactive prevention: careful attention to catheter care, appropriate timing of removal, and the use of risk‐stratified protocols can substantially reduce the likelihood of complications.

A multidisciplinary team is essential to provide holistic care, combining the expertise of pediatric surgeons, interventional radiologists, oncologists, anesthesiologists, nurses, and psychosocial support professionals. Families must be engaged in shared decision‐making with full access to understandable information and ongoing support.

Moving forward, there is an urgent need for more research, particularly into the long‐term outcomes of retained catheters in children, predictive tools to assess removal risks, and innovations in catheter material science that reduce adherence or make removal safer. National and international registries, standardized removal protocols, and increased training will all contribute to improving the safety and quality of care.

Ultimately, the goal is to ensure that the lifesaving benefits of central venous access are delivered with the highest possible safety, minimizing complications and supporting the long‐term health and well‐being of pediatric patients. Through ongoing attention to prevention, education, innovation, and patient‐centered care, we can reduce the burden of retained CVCs and enhance outcomes for vulnerable children.

Author Contributions

Alessandro Crocoli: conceptualization of the review, clinical perspective, data interpretation, manuscript drafting and final revision. Alice Gismondi: literature review, data synthesis, manuscript drafting. Tommaso Domenico D'Angelo: literature review, data interpretation, manuscript revision. Chiara Grimaldi: contribution to vascular access aspects, critical revision of the manuscript. Giorgio Persano: clinical data interpretation, manuscript review. Cristina Martucci: contribution to pediatric oncology aspects, manuscript review. Giovanni Rollo: contribution to surgical management sections, manuscript review. Giorgia Romano: contribution to manuscript revision and formulation of the novelty statement, critical intellectual input. Gian Luigi Natali: contribution to interventional radiology aspects, manuscript review. Giulia Cassanelli: contribution to endovascular management sections, manuscript review. All authors read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Funding

This work was supported by the Italian Ministry of Health with “Current Research funds”. This study did not receive other types of grants from funding agencies in the public, commercial, or nonprofit sectors.

Ethics Statement

The present study received authorization for publication from the scientific board in the authors' institution.

Consent

Written informed consent was obtained from the minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.