The Journal of Vascular Access

Staphylococcus aureus (SA) is a prominent pathogen that frequently causes catheter-related bloodstream infections (CRBSIs) in hemodialysis patients with tunneled central lines. The guidelines’ key recommendation for managing SA-induced CRBSIs is to remove the infected catheter. In real life, however, this may be hindered by logistical or clinical problems (e.g. unavailability of surgical rooms, incarcerated catheters, catheter-associated thrombosis). Furthermore, an interventional approach may expose patients to complications, such as those related to the procedure itself or the development of central vein stenoses. Prospective observational studies seem to support the possibility of preserving the infected line in case of early pathogen identification and CRBSI management with empirical large-spectrum antibiotics, followed by targeted treatment once the antibiogram is available. Further options for the treatment and prevention of SA-induced infections are becoming available, leading to a rapidly evolving therapeutic scenario. This review aims to perform a multidisciplinary revision of the available evidence and current unsolved problems, focusing on future perspectives for the management and prevention of SA-induced CRBSIs in hemodialysis patients.

Background A collapse phenomenon associated with stenoses was observed during Doppler ultrasound (DUS) examinations in arteriovenous fistulas (AVFs). Aim To investigate the influence of the phenomenon over the diagnosis of stenosis, its prevalence and cause. Method Comparison of luminal diameters before and during downstream compression of the efferent vein (DCEV); retrospective cross-sectional analysis of the prevalence; and theoretical analysis based on cardiovascular physiology and flow mechanicals and analysis of pressure gradients. Results DCEV increased the luminal diameter at the phenomenon sites from 1.64 ± 0.78 mm to 4.03 ± 1.42 mm ( p < 0.0001). The prevalence of the phenomenon was 11.3% (25) between 221 different AVFs and 16.6% (25) between 150 AFVs with stenoses. Pressure gradients in systole (147.9 ± 67.15 mmHg) and diastole (66.74 ± 37.7 mmHg) indicated intraluminal low pressures at the phenomenon sites. Conclusions The collapse phenomenon can simulate AVF stenoses ⩾50% in DUS examinations, have an important and high prevalence between AVFs with stenoses and is compatible with the Venturi effect.

Background Intracavitary ECG (IC-ECG) for central venous access devices (CVADs) tip location is one of the most significant innovations in the field of venous access in recent years. Despite there is evidence demonstrating its effect in improving outcomes, data regarding its cost-effectiveness are still scarce. Methods We conducted a retrospective observational study at a tertiary care Italian hospital comparing IC-ECG versus fluoroscopy plus postprocedural chest X-ray (CXR) and IC-ECG versus postprocedural CXR for port and peripherally inserted central catheters (PICC) tip location respectively. The primary outcome was to assess the impact of the adoption of IC-ECG versus radiological tip location on annual cost reduction. Results Between January 1st and December 31st, 2022, 1722 medium-long term CVADs (753 ports and 969 PICC) were placed at the authors’ Vascular Access Center. Costs of single port insertion using fluoroscopy plus CXR or IC-ECG for tip location were €921,04 and €351,42 respectively, with a net saving of €569,62 per procedure in favor of IC-ECG. Costs of a single PICC insertion using postprocedural CXR and IC-ECG for tip location were €364,38 and €320,85 respectively, with a net saving of €43,53 per procedure in favor of IC-ECG. Costs related to primary malpositioning were also calculated, being €926,17 and €52.962,63 for port and PICC respectively. Based on the authors’ annual volume of CVAD placements, annual savings by utilizing IC-ECG instead of fluoroscopy for port tip location and IC-ECG instead of post procedural CXR for PICC tip location, were €425.836,58 and €92.361,97 respectively, with an overall net total saving of €518.198,55. Conclusion Utilizing IC-ECG instead of X-ray guidance (CXR or fluoroscopy) for medium and long term CVAD tip location (PICC and port) has resulted in significant cost reduction. This strategy should strongly be considered for improving the cost-effectiveness of CVADs implantation.

This article reports a critically ill patient with extremity fractures caused by a traffic accident. Given the severity of the patient’s condition and the specific nature of the fractures, after a thorough evaluation of the fracture sites, a midline catheter was placed in the affected side’s upper arm through ultrasound guidance as a vascular access solution. The catheter was safely retained for 63 days, completing the entire treatment cycle without any related complications, providing stable and reliable vascular access support for the patient’s overall treatment. This case demonstrates the feasibility of using midline catheters in critically ill patients with extremity fractures, offering new perspectives and references for the selection of vascular access in these patients.

Objective To evaluate the clinical impact of residual thrombus at the anastomotic site during surgical thrombectomy and endovascular intervention for arteriovenous graft (AVG) thrombosis. Methods This retrospective, single-center cohort study reviewed 203 consecutive cases of vascular access thrombosis treated between January 2015 and December 2023. Among them, 43 cases of AVG thrombosis with a first-time occlusion and successful revascularization were included for analysis. A per-protocol analysis focusing on postintervention outcomes was conducted among patients who underwent surgical thrombectomy and/or endovascular intervention. Residual anastomotic thrombus was assessed on intraoperative final angiography. All cases were divided into those with residual anastomotic thrombus and those without. The primary outcome measure was postintervention assisted primary patency (PAPP). In addition, hazard ratios of each variable for postintervention patency were evaluated using univariate and multivariate analysis. Results All 43 patients were divided into two groups: 12 patients (27.9%) with residual anastomotic thrombus and 31 patients (72.1%) without residual anastomotic thrombus. During a median follow-up period of 19 months, PAPP was significantly lower in cases with residual anastomotic thrombus than those without (residual thrombus: 38.1% at 90 days, 19.1% at 180 days, and 19.1% at 365 days; non-residual thrombus: 93.2% at 90 days, 85.7% at 180 days, and 74.6% at 365 days; log-rank p < 0.0001). There was no significant difference in postintervention secondary patency between cases with residual anastomotic thrombus and those without (residual thrombus: 75.0% at 90 days, 65.6% at 180 days, and 65.6% at 365 days; non-residual thrombus: 96.8% at 90 days, 96.8% at 180 days, and 93.1% at 365 days; log-rank p = 0.148). Multivariate analysis identified residual thrombus as an independent risk factor for PAPP (hazard ratio 5.57; 95% confidence interval 2.40–12.93; p < 0.0001), as well as variables including endovascular intervention. Conclusion AVG thrombosis with residual thrombus at the anastomotic site during intervention showed significantly lower PAPP than those without. Residual anastomotic thrombus may be a relevant factor associated with patency outcomes, and further prospective evaluation is warranted to assess its utility as a treatment endpoint of intervention for AVG thrombosis.

Internal jugular vein (IJV) cannulation is one of the most commonly used procedure in intensive care units and hemodialysis setting. With ultrasound-guided cannulations, the incidence of complications has significantly decreased. We report a patient who developed vertebro-jugular fistula post internal jugular vein cannulation and was successfully treated with a stent graft placed using an endovascular technique. In the literature, very few similar cases have been reported so far.

Background Hemodialysis requires reliable vascular access, and arteriovenous fistulas (AVF) are preferred for their superior patency and fewer complications. However, AVF failure remains high, with 50% becoming nonfunctional within 2 years. Inflammatory biomarkers can contribute to AVF failure, yet the specific biomarkers involved remain to be identified. Aim We aim to determine the prognostic significance of inflammatory biomarkers in predicting primary AVF failure in hemodialysis patients. Methods The electronic search was performed in different databases: PubMed, Embase, and Cochrane Library, from inception to June 2024. Statistical analysis was performed using R software 4.3.1. A random-effects model was employed to compute mean differences (MD) and risk ratios (RR) with 95% confidence intervals (CI) for continuous and binary endpoints. The results were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guideline. Results A total of 15 studies, encompassing 1809 patients with a mean age of 62 years, were included. Over follow-up ranging from 6 weeks to 26 months, we did not observe a significant difference in the levels of monocyte chemotactic protein 1 (MCP-1; 12.15 pg/mL; 95% CI −14.26 to 38.56; p = 0.37), tumor necrosis factor alpha (TNF-α; 0.90 pg/mL; 95% CI −38.77 to 40.57; p = 0.96) and white blood cells (WBC; 0.31 g/L; 95% CI −0.05 to 0.66; p = 0.09) between the group experiencing AVF maturation and those facing AVF failure. However, there was a significant elevation in C-reactive protein (CRP) levels in the AVF failure group (2.89 mg/L; 95% CI 0.31–5.47; p = 0.03). Conclusions Despite the increased CRP values within the AVF failure cohort and the significance noted in individual studies, our investigation did not find discernible effects attributable to other inflammatory and fibrotic biomarkers.

Background Autologous arteriovenous fistulae (AVF) are the vascular access (VA) of choice for most hemodialysis (HD) patients. Creating multidisciplinary VA teams (MDT) may improve access-related outcomes and patient survival. This study aims to evaluate our center’s MDT impact on matured AVFs. Methods A retrospective case-control analysis was performed, comparing our center’s incident HD patients from years 2022 and 2019. An MDT was created in 2021. Patient data was collected from their electronic health record. The primary outcome was the VA typology used for HD initiation. Secondary outcomes were the prevalence of functioning AVFs 12 months after HD initiation and 24-month patient mortality. Clinical predictors of mortality were derived from a combined-year Cox proportional hazard regression model. Results One hundred and sixty-nine and 184 incident HD patients were included from 2022 and 2019, respectively. There were no significant differences regarding demographic variables, comorbidities, prior nephrology and VA appointments, patients with VA constructed, and the number of non-programmed HD initiations. The number of patients starting HD with a matured AVF was higher in 2022 (50.9% vs 37.5%, p = 0.011), regardless of demographic variables and comorbidities. The number of functioning AVFs at the 12th month of HD was also greater in 2022 (85.2% vs 76.6%, p = 0.041). The cumulative number of AV interventions until 12 months post-HD was similar between years, with fewer AV construction surgeries in 2022 ( p < 0.001). Primary patency ( p = 0.020) and secondary patency ( p < 0.001) were higher in 2022. The 24-month cumulative mortality was lower in 2022 (17.8% vs 27.2%, p = 0.041), with no significant differences regarding the categorized cause of death. In our combined-cohort multivariable analysis, previous myocardial infarction (HR 1.86, p = 0.034) and dementia (HR 2.61, p = 0.016) were predictors of 24-month mortality. VA construction (HR 0.36, p = 0.013) was a negative predictor. Conclusion In our center, the MDT creation was associated with a significantly increased number of matured AVFs at HD initiation and after 12 months of HD. Twenty-four-month patient mortality was lower post-MDT creation.

Parenteral nutrition (PN) is a vital treatment for critically ill newborns. Inserting a central venous catheter in a neonate to administer PN and other solutions and drugs incompatible with the peripheral route is crucial and is an urgent procedure. Dislocation or loss of the central vascular catheter implies the placement of a new device, and the inability to insert it may become a clinical emergency in this vulnerable population. We describe the insertion technique of an ultrasound-guided non-tunneled centrally inserted central catheter (CICC) placed in an extremely low-weight and extremely preterm neonate, adapting materials used for placing vascular access devices in the superficial veins of neonates.

Vascular access (VA) maintenance is challenging in complex dialysis patients, where patient-centered approaches are decisive. Arteriovenous grafts (AVGs) provide an alternative for those unsuitable for autogenous arteriovenous fistula (AVF). However, AVFs and AVGs are prone to complications such as stenosis, aneurysm, and thrombosis, leading to dysfunction and morbidity in these patients. This report focuses on the journey of an extraordinary longevity of a 15-year-old AVG in a 54-year-old female patient, detailing multiple interventions required to maintain its patency. The case also underscores the role of a multidisciplinary team in achieving long-term success.

Background Totally Implantable Venous Access Devices (TIVADs) are commonly used for intravenous chemotherapy administration and may remain in place depending on the likelihood of disease relapse. Regular flushing is required to maintain patency, although there is no established consensus on the optimal interval between maintenance sessions, with some clinicians extending or omitting the procedure. While TIVADs are generally well-accepted, patients may experience physical discomfort or psychological stress, which are assessed through Patient Reported Outcomes (PROs). This study aims to evaluate the complete TIVAD experience, from insertion to removal, with a particular focus on the maintenance period, as part of the Port REMoval Outcomes (PREMO) study. Methods A cross-sectional survey was conducted at University Hospitals Leuven, Belgium between 2019 and 2022. Adult patients with chest TIVADs, planned for an elective removal, completed the Leuven Patient Reported Experiences at Port Removal (Leuven PREP) a self-reported, self-developed 27-item questionnaire. Results A total of 100 oncology patients completed the questionnaire, with a mean age of 60.9 years and a median TIVAD duration of 2093 days. Most patients reported low insertion pain (median NRS score = 2), while emotional and psychological impacts were generally minimal, with only 1% expressing constant fear. Local discomfort was mentioned, with 24.5% reporting a bump and 12% experiencing pain during needle insertion; 10% experienced frequent cosmetic issues. TIVAD maintenance adherence was limited to 70.7% following the flushing regimen, and 61.2% found extending the maintenance period valuable. The removal procedure was well-received, with 60.2% reporting it was better than expected, and overall patient satisfaction was high, with a median score of 8/10. Conclusion Patients expressed high satisfaction with low impact on comfort, psychological state and physical well-being. Maintenance experiences varied, highlighting the need for further investigation and a validated comprehensive questionnaire. Registration number NCT03948958.

Aim To retrospectively review the efficacy and safety of ultrasound-guided Femoseal vascular closure device in antegrade common femoral artery puncture after peripheral arteries revascularization. Methods We reviewed the hemostatic outcome achieved with DUS guided FemoSeal in patients undergoing antegrade common femoral artery accesses for percutaneous lower limbs revascularization using 6- to 8-Fr vascular sheaths. Exclusion criteria were known bleeding or coagulation disorder, previous femoral artery punctures within 1 month and/or previous common femoral artery vascular interventions. Primary endpoint was technical success. Secondary endpoints were access complications and need for reintervention. Results A total of 301 patients (250 M; 51 F) were included in the study. Technical success was achieved in 99%. One pseudoaneurysm (0.3%) developed in the first post-operative day and was treated with Human Thrombin Injection. Two more pseudoaneurysms were found during follow-up at the first 1 month US scan. Two conversions to manual compression occurred. Conclusion The use of ultrasound-guided FemoSeal VCD in antegrade CFA puncture demonstrated high technical success and a low complication rate. These findings suggest that it is a safe and effective option for achieving hemostasis in patients undergoing percutaneous lower limb revascularization. Further studies with larger cohorts and longer follow-up may help confirm these results and refine patient selection criteria.

Background Distal transradial access (dTRA) has received extensive attention and has gradually become an alternative access for cardiac interventions. However, with the widespread use of dTRA, access complications such as distal radial artery occlusion (dRAO), haematoma, pseudoaneurysm and arteriovenous fistula (AVF) have been reported. In this study, we report a case of AVF after dTRA and review the related literature. Case report A 54-year-old female, who underwent percutaneous coronary intervention (PCI) 2 years ago, was admitted to the hospital with discomfort in her thumb. On admission, a mass was found at the puncture site, and ultrasound revealed a fistula between the distal radial artery (DRA) and the cephalic vein (CV). The patient was treated with manual compression for 2 h. Three months later, the mass was smaller than before, the symptoms had resolved and the fistula was found to have closed on repeat ultrasound. Conclusion Understanding the mechanisms underlying the occurrence of AVF and the principles guiding the treatment of the potential risks associated with AVF after dTRA is important and allows for the effective prevention of AVF and accurate prognostic prediction.

Background Needle-free connectors (NFCs) are closure systems for vascular catheters largely used because effectively reduce needlestick incidents. They are classified based on their impact on the fluid column within the catheter as positive (fluid displacement into the vein), negative (fluid displacement back from the vein into the catheter), neutral (minimal displacement), or anti-reflux (equipped with additional anti-reflux valve). Each category has specific usage and clamping procedures. This study aimed to evaluate the backflow volume (BV) when different NFC categories and clamping sequences are used with a peripherally inserted central catheter (PICC) and a Midline catheter (MC). Methods In this bench study, four types of NFCs with different flow displacement behavior were studied. Each NFC was evaluated using two different catheters: a 4 Fr × 60 cm single-lumen catheter (PICC), and a 4 Fr × 25 cm single-lumen catheter (MC). The experimental model simulated the physiological blood pressure of the superior vena cava. Three operators performed specific sealing sequences for each combination of NFC and catheter. After that, the BV (mm ³ ) inside the catheter for every NFC was assessed. Results None of the four NFCs was able to avoid the BV into the catheter. Positive NFC showed a lower BV as compared to the other three NFCs when tested with PICC: 0.83 [0.76–0.95] mm ³ versus 1.14 [0.95–1.53] mm ³ of Q-SYTE, versus 1.27 [1.02–1.59] mm ³ of Neutron, versus 1.24 [0.95–1.84] mm ³ of Bionector, whereas no differences were observed when tested with Midline. No differences were observed between different clamping sequences when used with neutral and anti-reflux NFCs. Conclusion This study examined the performance of various NFC technologies with PICC and Midline. While no device eliminates BV, positive displacement NFCs showed lower flow reflux compared to the others when used with PICC. No difference between clamping sequences was observed for neutral and anti-reflux NFCs.

Arterial old-long-segment thrombus is a difficult-to-handle complication in brachio-cephalic fistula, leading to totally chronic occlusion, fistula dysfunction, and potential upper limb ischemia. This case study presented the successful clinical experience of using Fogarty adherent clot catheter to remove an old-long-segment thrombus (15 cm) in the brachial artery, which was guided by ultrasound. The procedure resulted in long-term patency of the arteriovenous fistula with no early or delayed complications. This study highlighted the effectiveness, safety, and practicality of this procedure, offering the advantages of brachial artery revascularization to prevent further ischemic complications, preserve valuable vascular access, and maintain full functionality, minimal trauma, and reduced radiation exposure.

Background The placement of central venous catheter in the cervico-thoracic region (CICC) is often required in patients needing access to the bloodstream for medication administration or rapid volume replacement. However, the exit site of the catheter in the neck poses a high risk of infection, is uncomfortable for the patient, and is difficult for healthcare providers to manage. For centrally inserted central catheters (CICCs) designed for short-term use, tunneling to distance the exit site from the venipuncture site is not typically performed. Aim The purpose of this article is to present a tunneling technique that allows the repositioning of the catheter exit site to the infraclavicular fossa using only the materials included in standard CICC kits. Methods At the Vascular Access Unit of ASST Spedali Civili in Brescia, we developed a rapid tunneling technique for short-term CICCs that requires no additional materials beyond those in standard kits. This technique was applied to 250 patients requiring short-term central venous access, relocating the catheter exit site from the neck to the infraclavicular region. Results In all 250 cases, the technique successfully relocated the catheter exit site to the infraclavicular region, providing a location that patients found more comfortable and that was easier for healthcare staff to manage. Conclusions The proposed technique offers a valid alternative for the placement of short-term CICCs, even in critical or resource-limited settings where conventional tunneling equipment is unavailable. With proper precautions, this method can be implemented by any physician involved in device placement. Further investigation is needed to determine whether this procedure reduces catheter-related bloodstream infections (CRBSIs), though the technique’s design suggests this may be a potential benefit.

Background In the creation of arteriovenous fistulas (AVF) for hemodialysis, regional brachial plexus block (BPB) has a sympatholytic effect, increasing blood flow and diameters in the vessels. Methods A prospective, randomized, clinical-surgical pilot study was carried out, comprising 40 patients, randomly allocated into two groups (BPB or local anesthesia—LA). The diameter (veins and arteries), and the flow, peak systolic velocity (PSV), pulsatility index (PI), and pulsatility index ratio (PIR) of the arteries were evaluated before and after anesthesia. Flow was measured in the AVF at the end of the procedure and 30 days after. To analyze pain perception, the visual analog scale (VAS) was applied during anesthesia (T1), during surgery (T2), and at discharge (T3). All analyses were performed using R v. 4.3.1. A p -value <0.05 was considered statistically significant. Results Comparing BPB with LA, in the pre- and post-anesthesia periods, there was an increase in the diameters of the cephalic and basilic veins ( p < 0.001) and the ulnar artery ( p < 0.001). There was a significant increase in the PSV of the radial and brachial ( p < 0.001) and ulnar ( p = 0.0017) arteries. There was an increase in flow in the radial, ulnar, and brachial arteries ( p < 0.001). There was a significant decrease in the PI for the radial ( p = 0.0022), ulnar and brachial ( p < 0.001) arteries. The BPB group had a significant change in the PIR of the arteries ( p < 0.001). Regarding pain perception, the BPB group presented a decrease at T2 ( p < 0.001). Conclusions For this study, in the group that received BPB, there was an increase in the diameters of the arteries and veins as well as the flow and PSV of the arteries, and decreasing the PI, the PIR, and in the perception of intraoperative pain.

Two major innovations—ultrasound guidance and catheter tunneling—have transformed central venous catheterization, significantly reducing early and late complications. Ultrasound enables accurate vein selection based on anatomical and functional criteria, facilitates safer venipuncture, and broadens access to previously avoided veins (e.g. brachiocephalic, axillary). It also allows real-time guidance for wire direction, tip navigation, and the immediate diagnosis of complications. Tunneling, once exclusive to cuffed catheters, is now increasingly used for non-cuffed devices to optimize the exit site independently of the venipuncture site. This strategy reduces infection, thrombosis, and dislodgment risks by relocating exit from high-risk zones (e.g. groin, neck) to cleaner, more secure areas. Despite widespread adoption of these innovations, current guidelines often confuse puncture and exit sites, leading to outdated recommendations. For example, guidelines labeling femoral or jugular access as high-risk often fail to differentiate between venipuncture and exit locations. Ultrasound-guided femoral puncture with tunneling can yield low-thrombosis, low-infection configurations, especially with mid-thigh or abdominal exit sites. Similarly, supraclavicular puncture of the internal jugular vein with tunneling avoids the traditional high-neck exit and its associated complications. Recommendations promoting subclavian access are also problematic, as safe ultrasound access is often only feasible via supraclavicular routes, not by traditional blind infraclavicular approaches. The field must shift from old anatomical dogma to ultrasound-based, tunneled approaches tailored to each patients need. Clear distinction between venipuncture and exit sites is essential for modern, evidence- based vascular access practices.

Background Ultrasound-guided dynamic needle tip positioning (DNTP) and acoustic shadowing technologies demonstrate superior efficacy to palpation in improving radial artery catheterization success rates. This study aimed to evaluate the benefits of combining DNTP with acoustic shadowing technology for patients undergoing radial artery catheterization. Method In this randomized controlled study conducted at a single center, 152 patients requiring radial artery catheterization during anesthesia were enrolled. Participants were randomly assigned to either the ultrasound-guided acoustic shadowing combined with dynamic needle tip positioning (AS-DNTP) group or the DNTP group (1:1). All procedures were performed by experienced operators. The primary outcome was the number of needle tip retractions and directional corrections, while the secondary outcomes included the first-pass success rate, total number of attempts, ultrasound localization time, overall operating time, length of the intra-arterial catheter, needle tip position score, and overall complications. Results The AS-DNTP group demonstrated fewer total needle tip retractions and directional corrections (2.22 ± 1.06 vs 2.84 ± 1.18, p = 0.001), and a higher first-pass success rate (96.10%, 74/77 cases) compared to the DNTP group (86.67%, 65/75 cases), with an absolute difference of 9.44% (95% confidence interval (CI): 0.31%–19.28%; p = 0.038). Additionally, the AS-DNTP group had a lower overall number of attempts (1.04 ± 0.195 vs 1.13 ± 0.342, p = 0.038) and a shorter ultrasound localization time (6.78 ± 2.28 s vs 7.57 ± 2.55 s, p = 0.045). Conclusion AS-DNTP technology holds the potential to reduce the need for needle tip retractions and directional corrections during radial artery catheterization while increasing the first-pass success rate and decreasing the ultrasound localization time.

Point-of-care ultrasound-guided (POCUS) venous and arterial access involves accurately guiding a needle from the skin surface through subcutaneous tissue to the target vessel. The success of this procedure relies heavily on the operator’s ability to locate and direct the needle tip, which can lead to multiple puncture attempts and iatrogenic complications. A literature review revealed a lack of comprehensive protocols addressing the sonographic details necessary for effective needle identification and vessel cannulation. This paper presents a systematic approach, the “3 Stations of the Needle” protocol, which includes: (1) identifying the needle after initial skin puncture within the subcutaneous tissue; (2) navigating the needle to the vessel’s outer wall; and (3) advancing the needle tip into the vessel lumen. This protocol offers a practical educational method for an ultrasound mastery learning program, enhancing needle identification, guidance, safety, and procedural success in venous and arterial cannulation.

Introduction According to current guidelines Totally Implantable Venous Access Devices (TIVADs) require regular maintenance (i.e. flushing with 0.9% Sodium Chloride solution) when not in use. Existing evidence suggests that extending flushing intervals up to 12 weeks does not compromise catheter function, but longer intervals or omitting flushes require more research. Methods To facilitate a future randomized controlled trial (RCT), various methods were evaluated for assessing functional (CINAS classification, vacutainer filling time (VFT)), microbial (tip culture, swabs), radiological (linogram), and macroscopic (visual inspection) changes in TIVADs after a 12-weekly maintenance regimen. TIVADs from 70 patients were assessed upon TIVAD removal. Results Concerns over the perceived invasiveness of the linogram resulted in only 36% of eligible patients eventually consenting to participate in the trial. Eighty-six percent had normal TIVAD function, with an average VFT of 23 s/10 mL (SD 5 s/10 mL). Linograms were aberrant in 15% of patients, but the majority of anomalies did not correlate with visible thrombus on inspection or functional issues. No positive microbial cultures were found. Conclusions The primary end point of any future research on TIVAD maintenance should primarily be focused on the functionality of the TIVAD. The CINAS classification effectively standardizes reporting of TIVAD functionality. Although VFT offers a precise measurement of aspiration function, optimal target values remain unclear and clinical relevance might be limited in a functional TIVAD. The added value of a linogram seems to be negligible. An RCT trial comparing 12-weekly TIVAD maintenance versus no maintenance would be invaluable for both patients and health care providers. Clinical Trials register (NCT03948958).