# Ipsilateral pull-through technique using a handmade loop snare catheter for difficult port catheter removal

## TL;DR

A new technique using a handmade loop snare helps remove difficult-to-remove venous access device catheters that stick to blood vessel walls.

## Contribution

A modified ipsilateral pull-through technique using a handmade loop snare is introduced for challenging TIVAD catheter removal.

## Key findings

- The ipsilateral pull-through technique successfully removed difficult TIVADs in 7 out of 8 patients.
- One complication was catheter fracture observed on follow-up imaging.
- The median procedure time was 60 minutes with a long median indwelling duration of 2473 days.

## Abstract

Removal of an adhered indwelling catheter in a totally implantable venous access device (TIVAD) can occasionally be challenging, particularly after prolonged implantation. The purpose of this paper is to present a modified endovascular technique for difficult TIVAD removal and to highlight its clinical relevance in cases where the catheter is firmly adhered to the vessel wall, making standard removal methods challenging.

Between December 2015 and April 2025, a total of 3347 TIVADs were implanted, and 367 removal procedures were conducted. Among these, 355 (96.7%) catheters were successfully removed using the standard technique. Three (0.8%) were removed using the push-in techniques, and one (0.3%) was removed using the contralateral pull-through combined with the sheath-twist technique. In 8 (2.2%), the ipsilateral pull-through technique was required after failure of the initial approaches. The ipsilateral pull-through technique was performed using an introducer sheath and a handmade loop-snare constructed from a guidewire and a seeking catheter. Patient characteristics and procedural data were collected for analysis.

The ipsilateral pull-through technique was successfully used to remove difficult-to-remove TIVADs in 7 of 8 patients. In the remaining patient, the indwelling catheter was firmly adhered to the segment extending from the innominate vein to the superior vena cava, where antegrade flow was absent and numerous collateral vessels were present. Although the occlusion was successfully crossed, catheter removal was aborted due to severe pain and concerns about potential superior vena cava rupture. One procedure-related complication was observed: catheter fracture on follow-up computed tomography in one of the seven successful cases. No other complications were observed. The subclavian vein, innominate vein, and superior vena cava were patent on follow-up computed tomography performed for cancer evaluation. The median indwelling duration in this cohort was 2473 days (interquartile range [IQR], 2017–3002 days), and the median procedure time was 60 min (IQR, 45.8–74.8 min).

The ipsilateral pull-through technique is a useful method to detach adhered catheters during difficult TIVAD removal.

Level 3, Retrospective Study.