At our hospital, PICC (peripherally inserted central catheters) are frequently used, with approximately two hundred cases of catheter insertion each year. Recently, there has been an increasing number of reports regarding complications associated with PICC, including infection, catheter-related thrombosis, fibroblastic sleeve formation, and phlebitis. Studies have shown that fibroblastic sleeve formation is common across all types of central venous access devices [8, 9]. The fibroblastic sleeve is a membrane that wraps around the surface of the catheter and adheres tightly to the vessel wall, which can prevent the catheter from being removed, even when the catheter is pulled out [10]. In the case of PICC, the fibroblastic sleeve can form around the outer surface of the catheter and tightly adhere to the vessel wall.

Some studies suggest that color Doppler ultrasound imaging may show thickening of the catheter wall as a characteristic feature of fibroblastic sleeve formation. However, ultrasound has certain limitations, especially in patients with thicker fat layers, where the view may not be optimal. According to Passaro et al. [11], while color Doppler ultrasound can help identify changes in the catheter wall, its diagnostic efficacy is often limited by factors like body habitus. Currently, although fibroblastic sleeve is often confirmed after the catheter is removed, indirect signs—such as catheter malfunction, resistance during traction, and imaging abnormalities—may support the suspicion of sleeve formation. Imaging modalities like vascular ultrasound and contrast venography can be helpful, although they are not definitive. Therefore, clinical experience plays a crucial role in diagnosing this condition. When a fibroblastic sleeve is suspected, it is important to avoid forceful removal, which may lead to catheter fracture, and to explore other management options.

Pharmacological therapy is commonly used to treat fibroblastic sleeve formation, with drugs such as urokinase, streptokinase, and tissue plasminogen activator (tPA) being frequently used. Among these, tPA has been shown to be particularly effective in recanalizing occluded catheters, as demonstrated by studies from Altaf F et al. [12]. In the present study, tPA was used for five patients, but its effect was limited. This may be due to the confined space between the outer and inner walls of the PICC catheter, which limits the ability of the thrombolytic agent to penetrate and dissolve the fibroblastic sleeve.

Wang Jianxin’s study [8] suggests that applying local vascular pressure can help detach the fibroblastic sleeve from the catheter’s outer wall, allowing the drug to reach the space between the fibroblastic sleeve and the vessel wall. By applying a tourniquet 2–3 cm above the remaining catheter tip (11–15 cm above the puncture site), local vascular pressure can be increased, which may help expand the venous lumen and facilitate the dissolution of the fibroblastic sleeve. When a fibroblastic sleeve forms tightly around the catheter, thrombolytic drugs cannot easily enter the space between the vessel wall and the catheter. Thus, the effect of drug treatment is diminished.

The first patient underwent three days of thrombolysis without a tourniquet, which may explain the limited effectiveness, as the thrombolytic drug could not penetrate the fibroblastic sleeve to reach the vessel wall. In contrast, the remaining four patients received thrombolytic therapy combined with the use of a tourniquet, which increased the pressure and expanded the space between the catheter and the vessel wall, thereby improving the drug’s effectiveness.

When catheter removal is difficult and the catheter exhibits significant resistance, the formation of a fibroblastic sleeve should be strongly suspected. To address this, it is recommended to attempt expanding the local venous lumen to facilitate the removal of the “thickened” catheter wrapped in the fibroblastic sleeve. Fibroblastic sleeve formation typically begins at the site where the catheter tip contacts the vessel wall, and over time, it extends toward the heart. It has been shown that the catheter tip can move in response to heartbeats and body movements, and friction may cause local endothelial damage, activating mural thrombosis [13, 14]. This process likely contributes to fibroblastic sleeve formation around the catheter.

In the five cases reported here, the fibroblastic sleeve measured five to seven cm in length. A tourniquet was applied at the axillary and acromion points, approximately 11–15 cm above the puncture site. This placement was chosen based on the catheter’s remaining length, confirmed by either direct measurement or routine maintenance records. By applying pressure at the correct site, venous filling was improved, which facilitated the removal of the catheter without causing damage. It is important to avoid using excessive force during removal, as this could cause catheter breakage. The tourniquet should only be removed once the catheter is successfully and safely removed.

However, this conservative approach has limitations. It may not be effective in all cases, especially when severe adhesion or catheter fracture is suspected. In such situations, invasive methods such as interventional radiology-guided removal or surgical exploration may be necessary. Future studies should compare conservative and invasive strategies to guide optimal management.

While this method has some limitations, it provides valuable guidance for clinical practice. It emphasizes the importance of well-trained nursing teams and the optimization of clinical protocols to better address such complications, enhance patient safety, and improve care quality.