Impact of catheter removal timing and an ultrasound/DSA-guided stratified management strategy on outcomes of difficult PICC removal in malignant tumor patients: A single-center retrospective study of 61 cases

Objective To evaluate the impact of catheter removal timing and an ultrasound/digital subtraction angiography (DSA)-guided stratified management strategy on outcomes in malignant tumor patients experiencing difficult peripherally inserted central catheter (PICC) removal. Methods Clinical data of 61 malignant tumor patients with difficult PICC removal, treated in the Department of Vascular Surgery at Tianjin First Central Hospital between January 2022 and March 2026, were retrospectively analyzed. Patients were divided into two groups based on the timing of initial conventional catheter removal: Group A (n = 25, Non-deferred removal group) and Group B (n = 36, Deferred removal group). Outcomes of catheter removal (success rate, failure rate, and fracture rate) were compared between the two groups. For patients with failed conventional catheter removal, ultrasound and DSA evaluations were performed, followed by guidewire-assisted removal or surgical venotomy. This workflow established a decision-making pathway for stratified management. Results The success rate of initial conventional catheter removal was significantly higher in Group B than in Group A [77.78% (28/36) vs. 40.00% (10/25), P < 0.05], while the failure rate of catheter removal was significantly lower in Group B [22.22% (8/36) vs. 60.00% (15/25), P < 0.05]. No statistically significant difference was observed in catheter fracture rates between Group A and Group B [8.00% (2/25) vs. 8.33% (3/36), P > 0.05]. Among the 15 patients in Group A who failed initial conventional removal, 2 patients with catheter fracture proceeded directly to ultrasound/DSA evaluation and subsequent stratified management; the remaining 13 patients without catheter fracture underwent a second conventional removal attempt between 1 and 7 days later, resulting in successful removal in 8 cases and persistent failure in 5 cases;The cumulative success rate of conventional catheter removal success in Group A including the initial and secondary conventional removal was 72.00% (18/25).Overall, among the 61 patients, conventional catheter removal succeeded in 46 cases and failed in 15 cases (9 without catheter fracture and 6 with catheter fracture). Overall conventional removal success rate of the 61 patients was 75.41% (46/61).All 15 patients who failed conventional catheter removal underwent ultrasound/DSA evaluation and subsequent stratified management. Imaging revealed that guide-wire-assisted removal was suitable for the 9 cases without catheter fracture; Among 6 patients without catheter deformation, the success rate guidewire-assisted catheter removalreached 5/6 (83.33%). 3 patients presented with severe catheter deformation; The catheter luminal deformation prevented the guide wire from passing through the deformed catheter lumen. Partial catheter wall rupture occurred in 2 catheters during repeated guide-wire insertion attempts, and complete catheter fracture occurred in one case. A total of 10 patients underwent surgical venotomy, and all catheters were successfully retrieved. The final overall non-surgical success rate for catheter removal across all 61 patients was 83.61% (51/61), with the remaining 10 patients successfully managed via surgery. No postoperative complications such as infection, bleeding, or upper limb dysfunction occurred, achieving successful catheter removal in all patients. Based on these findings, a four-level decision-making pathway was constructed, incorporating timing selection for conventional removal, ultrasound/DSA imaging assessment, and subsequent selection between guide-wire-assisted removal and surgical venotomy. Conclusion In this retrospective cohort, delaying initial conventional catheter removal (by 1–7 days) is associated with a higher initial success rate without increasing the risk of catheter fracture. The ultrasound/DSA-guided four-level decision-making pathway derived from these findings (Timing selection for conventional removal→imaging assessment→guide-wire-assisted removal→surgical venotomy) provides a clinical reference for individualized, stratified management of difficult PICC removal in malignant tumor patients.