Direct internal jugular vein incision for salvage of ‘stuck’ port catheters in pediatric leukemia: a single-center experience

Introduction

Background

Totally implantable venous access ports (TIVAPs) are essential for long-term venous access during pediatric acute lymphoblastic leukemia (ALL) chemotherapy (1,2). However, catheter-associated calcified fibroblastic sheaths often cause ’stuck catheters’ during removal, leading to failure of conventional extraction and risks of catheter fracture, vascular injury, or thromboembolism (3,4). Recent case-control and retrospective studies have confirmed that a diagnosis of ALL and prolonged catheter dwell time (>46 months) are independent risk factors for stuck port catheters in children. Crook demonstrated that 86% of stuck ports occurred in ALL patients, supporting the notion that children with ALL have an increased risk of difficult port removal (5,6).

Rationale and knowledge gap

Conventional traction and some interventional techniques are unsafe or ineffective in small pediatric vessels (7,8). Evidence on safe salvage surgery for stuck TIVAPs caused by organized thrombus in children remains limited.

Objective

This study aimed to investigate the etiology of difficult port removal and to evaluate the safety and efficacy of a direct internal jugular vein (IJV) incision for fibroblastic sheath dissection and port extraction in pediatric patients with ALL. We present this article in accordance with the PROCESS reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0315/rc).

Case presentation

Patient characteristics

Five pediatric ALL patients treated between January 2022 and December 2024 were retrospectively enrolled (Table 1). All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Ethics Committee of The First Affiliated Hospital of Gannan Medical University (approval No. LL8C-2025297). Publication of this case series and accompanying images was exempted from patient consent per the Institutional Ethics Committee. The cohort included one male and four females, aged 4–6 years (mean 5.4±0.8 years), weighing 17–27.5 kg (mean 22.0±4.1 kg). All patients had a pediatric-specific 6 Fr silicone TIVAP (B. Braun) implanted via the right IJV. Catheter indwelling time ranged from 25 to 44 months (mean 33.0±6.5 months). The interval between chemotherapy completion and planned port removal was 3–8 months (mean 4.5±1.2 months). Indications for removal included: completion of chemotherapy (≥3 months post-treatment with sustained remission), absence of infection, and no coagulation disorders.

Methods

Preoperative assessment

Imaging: all patients underwent preoperative color Doppler ultrasound (7.5–10 MHz), which confirmed catheter-associated calcified fibroblastic sheaths in the upper segment of the right IJV (1.5–3.0 cm from insertion) in all cases. Fibroblastic sheaths were hyperechoic and densely adherent to the catheter and the vessel wall (Figure 1A). Representative postoperative follow-up ultrasound findings are shown in Figure 1B. All sheaths were non-occlusive, and no patients had clinical symptoms of venous thrombosis.

Figure 1 Ultrasonographic evaluation of the right internal jugular vein. (A) Preoperative ultrasound showing hyperechoic organized thrombus (arrow) in the right IJV. (B) Postoperative (3-month) ultrasound demonstrating patent IJV flow without thrombus recurrence. IJV, internal jugular vein.

Laboratory tests: routine blood tests, coagulation profiles, and hepatic/renal function tests were performed, revealing no surgical contraindications.

Preoperative management: all patients received full-dose low-molecular-weight heparin (LMWH) (100 U/kg/day) for 3–4 weeks before surgery.

Surgical procedure

The procedure was a transjugular, direct-vision fibroblastic sheath dissection via a limited IJV incision.

• Anesthesia & positioning: general anesthesia with standard monitoring.
• Incision: a 1.5–2.5 cm longitudinal incision in the supraclavicular fossa along the IJV course (Figure 2).
• Exposure & dissection: the IJV was exposed via blunt dissection. Small tributaries were ligated to preserve the ansa cervicalis (specifically its superior and inferior roots as they course on the carotid sheath) and the vagus nerve (located within the carotid sheath posterolaterally).
• Vascular control: the IJV was gently lifted with a sling. Non-traumatic clamps were applied exclusively to the IJV itself, proximal and distal to the fibroblastic sheath. Clamp time was limited to <15 minutes (mean 8.3±2.1 minutes).
• Venotomy: a 0.5–1.0 cm longitudinal incision was made on the anterior venous wall.
• Fibroblastic sheath dissection & extraction: under direct vision, microforceps were used to dissect the calcified fibroblastic sheath from both the catheter surface and venous intima. The catheter and en bloc fibroblastic sheath were removed (Figure 3). The lumen was flushed with heparinized saline.
• Closure: the venotomy was closed continuously with 6-0 Prolene suture. Patency was confirmed by intraoperative ultrasound.

Figure 2 Schematic of the incision site in the supraclavicular fossa. (A) Anatomical landmarks of the lower neck and supraclavicular region. (B) Planned longitudinal incision in the supraclavicular fossa along the IJV course for direct venous exposure. IJV, internal jugular vein.

Figure 3 Intraoperative image of the en bloc thrombus (A,C) and extracted catheter (B,D).

Postoperative management and follow-up

Patients received prophylactic LMWH (100 U/kg/day) for 3 days postoperatively. Venotomy patients required 6 hours of bed rest and 24 hours of neck immobilization, with monitoring for bleeding and respiratory compromise.

Follow-up was conducted at 1 week, 1 month, and 3 months postoperatively. Clinical assessment included:

• Neck range of motion [full active/passive assessment per American Academy of Orthopaedic Surgeons (AAOS) guidelines];
• Age-appropriate Visual Analog Scale (VAS) for neck pain;
• Systematic cranial nerve and upper extremity neurologic function assessment [per International Society for Pediatric Vascular Surgery (ISPVS) guidelines];
• Cosmetic outcome evaluation using the Vancouver Scar Scale;
• Color Doppler ultrasound to assess IJV patency.

Results

All five procedures were completed successfully with complete en bloc removal of the catheter and calcified fibroblastic sheath. No perioperative complications (hematoma, infection, vascular injury, or thromboembolism) occurred.

Operative time ranged from 35 to 60 minutes (mean 45.5±8.7 minutes), and intraoperative blood loss was 3–10 mL (mean 6.2±2.1 mL). Postoperative hospital stay was 2–3 days (mean 2.3±0.5 days).

At the 1–3 months follow-up, all patients exhibited VAS pain scores of 0; full neck range of motion (≥90° anterior flexion, ≥70° posterior extension, ≥80° bilateral rotation, ≥45° lateral flexion); no neurologic deficits; excellent cosmetic outcomes (Vancouver Scar Scale score ≤2); ultrasound-confirmed patent IJV flow with no evidence of sheath recurrence or venous stenosis (Figure 1B).

Discussion

Key findings

This case series demonstrates that catheter-associated fibroblastic sheaths are the principal cause of difficult port removal in pediatric patients with long-term TIVAPs and ALL. The Procedure proved highly safe and effective, with minimal blood loss, short operative times, and no complications in our cohort.

Pathophysiological clarification: fibroblastic sheath vs. catheter-related thrombosis (CRT)

Acute CRT arises from the vessel wall and does not adhere firmly to the catheter, rarely causing extraction difficulty. By contrast, fibroblastic sheaths are concentric connective tissue layers surrounding the catheter, often calcifying and becoming tightly adherent with long-term indwelling, leading to difficult removal and unresponsiveness to anticoagulation (9). In the present study, histopathological examination confirmed dense collagenous tissue with focal calcification, consistent with calcified fibroblastic sheaths.

Comparison with similar research

Our technique of direct IJV incision offers distinct advantages over both blind traction and interventional methods, particularly in small pediatric vessels—

Balloon-assisted techniques: this technique achieves minimally invasive disruption of fibrous adhesions and calcifications via sequential intraluminal balloon dilation, avoiding venotomy and perivascular tissue injury. It is associated with minimal blood loss, short procedural time, and same-day discharge (10).

Sheath-assisted dissection: this technique employs a dedicated retrieval sheath set for dissection and removal through the original vascular access, without requiring an additional venous incision, thus reducing surgical trauma (11).

Endovascular snaring/angiographic assistance: this technique percutaneously accesses vessels (e.g., femoral vein) and retrieves fractured or migrated catheter fragments under Digital Subtraction Angiography (DSA) guidance, avoiding thoracotomy or venotomy for foreign body removal. It is particularly suitable for high-risk situations involving catheter drift into the heart or pulmonary artery, with minimal invasiveness (12,13).

However, all the above interventional approaches are only effective for CRT or loose catheter fragments and cannot dissolve, dissect, or resect fibroblastic sheaths. In contrast, a direct IJV incision allows complete resection of the entire fibroblastic sheath under direct visualization, the only reliable method to resolve sheath-induced catheter entrapment. This approach achieves definitive one-stage removal with high safety and no radiation exposure, making it the preferred salvage strategy for pediatric patients with difficult port removal due to fibroblastic sheaths (7,14,15).

Explanations of findings

The small diameter and thin wall of the pediatric IJV make it susceptible to endothelial injury. Protracted chemotherapy, particularly with agents like asparaginase that induce a hypercoagulable state, further promotes thrombosis. The resulting thrombi organize into a rigid, adherent sheath, rendering conventional traction ineffective and hazardous (14,15).

Notably, our pediatric cohort developed this complication within 25–44 months, which is much earlier than observed in adults. In our study, a uniform 6 Fr TIVAP was used for all patients, without strict adherence to the recommended 1:3 catheter-to-vessel diameter ratio. Two of the five patients had a ratio below this threshold, resulting in relative catheter oversizing. Such a diameter mismatch may cause persistent endothelial irritation and injury, thereby promoting fibroblastic proliferation and sheath formation.

Management of deep/distal catheter adherence

All cases in our series involved adherence limited to the proximal IJV segment. For deeper or distal adherence, we recommend the following stepwise approach:

• Initial approach: initiate gentle, sustained traction with slow rotation of the catheter for 5–10 minutes. If unsuccessful, and if multiple consecutive intraoperative attempts fail, we proceed directly to a direct IJV venotomy given the calcified nature of the sheath.
• Brachiocephalic vein adherence: extend the proximal IJV incision superiorly to expose the brachiocephalic vein junction under direct vision.

Superior vena cava or intracardiac segment adherence: multidisciplinary consultation is recommended. Endovascular approaches—such as snare retrieval and angioplasty/stenting—are commonly the first-line strategy and have been widely documented to achieve high technical success rates for retrieving dislodged catheter fragments or relieving venous obstruction (16). Combined endovascular-open surgical approaches are reserved for refractory cases when endovascular attempts fail, while median sternotomy is only required in extremely rare scenarios.

Applicability to other central venous access sites

For subclavian vein stuck catheters, the controlled venotomy technique can be safely adapted using a modified supraclavicular approach with a small transverse incision above the clavicle to expose the proximal subclavian vein. For femoral vein stuck catheters, endovascular techniques are first-line, with open venotomy reserved only as a last resort due to higher risks of deep vein thrombosis and surgical site infection.

Proposed standardized management pathway

We have developed a five-phase standardized management pathway for suspected ‘stuck’ TIVAPs, encompassing mandatory preoperative assessment, etiology-specific preconditioning, site-specific standard removal attempts, an escalation protocol for failed removal, and standardized postoperative care, with the detailed algorithm presented in Figure 4.

Figure 4 Concise standardized management pathway for suspected ‘stuck’ TIVAPs. IJV, internal jugular vein; IR, interventional radiology; TIVAPs, totally implantable venous access ports.

Strengths and limitations

This study is limited by its retrospective, single-center design and small sample size (n=5). Larger, multicenter prospective studies are needed to validate long-term outcomes. Importantly, we emphasize that direct IJV venotomy should never be the first-line approach and should only be considered after all conservative and minimally invasive techniques have failed.

Conclusions

Calcified fibroblastic sheaths are the primary cause of difficult port removal in pediatric ALL. Direct IJV incision allows safe, complete, and visualized resection of fibroblastic sheaths, representing a reliable last-resort salvage procedure with favorable outcomes. To enhance patient safety, we emphasize standardized port maintenance, preoperative ultrasound screening, and the timely adoption of this surgical approach when standard removal fails.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PROCESS reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0315/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0315/prf

Funding: This work was supported by the Regional Science Foundation Project of the National Natural Science Foundation of China (grant No. 82460560); General Program of Jiangxi Natural Science Foundation Committee (grant No. 20242BAB25523); Science and Technology Project of Jiangxi Provincial Health Commission (grant No. 202410057); Guided Science and Technology Project of Ganzhou Science and Technology Bureau (grant No. GZ2024ZSF183).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0315/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Ethics Committee of The First Affiliated Hospital of Gannan Medical University (approval No. LL8C-2025297). Publication of this case series and accompanying images was exempted from patient consent per the Institutional Ethics Committee.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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