Declotting Methods for PICC lines

We have always used the 3-way stopcock method to declot PICC lines.  Recently we had an inservice by the Cathflo rep in which we were instructed in the single syringe method.  In reading the product information, the procedure says to "Instill the appripriate dose of CathfLo into the occluded catheter using a 10-12 cc syringe".  I am concerned about the word "instill" - if the line is clotted, you can't aspirate or flush, are you not running the risk of forcing the Cathflo into the line and rupturing the line?

If you kind of combine the two methods and use the single syringe, aspirate back suction, then release the suction, I don't believe that the Cathflo would be drawn in, like it would with the stopcock method.  Releasing the suction pressure only returns the syringe to the "pre-suction" state.

How are you performing the declotting procedure?  Thanks in advance!


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Yes, but you need to give me your contact information.

Wendy Erickson RN
Eau Claire WI

At our pediatric institution, only our IV team, Nutrition Support Nurse Clinicians and Hem/Onc RNs are trained to administer Cathflo for partial/drawback occlusions.  However, only the IV team and Nutrition Support can administer it in the event of a two-way occlusion.  Doses are dispensed from pharmacy from in a 10 ml syringe and it is always administered from that 10 ml syringe.  For partial occlusions, we instill it directly from the syringe.  For 2-way occlusions, we use the stopcock method with another empty 5 or 10 ml syringe.  We also will go "back and forth" - withdrawing and instilling the Cathflo - until it is tinged pink.  Whether a partial or 2-way occlusion, we allow to dwell for 1 hour before attempting to withdraw.  If unsuccessful, we will allow it to dwell for another hour (total of 120 minutes). If still unsuccessful, we may repeat the dose.  As for dose/volume,  patients < 10 kg receive 0.5mg diluted to 110% of the specific catheter volume. Patients > 10 kg receive a 1mg/ml preparation of 110% of the catheter volume (max dose of 2mg), or 2ml for PICCs/Broviacs and 3ml for SIPs if volumes are unknown.

Morgan Dunn, BSN RN CPON

Nutrition Support Service Nurse Clinician

Morgan L. Dunn, BSN RN CPON
Nurse Clinician
Nutrition Support Services
Nationwide Children's Hospital
Columbus, OH

We use the 10ml syringe


For those of you using the single syringe, negative pressure, technique to "instill" Cathflo, are you using a 10 mL or just the 3 mL syringe. After all of the teaching about using 10 mL syringes, I'd prefer to stick to this but want to make sure it's as effective. 

Many thanks,


Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

I've been placing PICCs and declotting them and other CVCs for over 20 years in a 200 bed acute care hospital with average of 30 to 50 lines daily to assist w/ maintainenance.  I've used both methods and I prefer the single syringe method as many of you do for the reason of simplicity - it rarely takes more than 10 minutes to get the dose in, however, on rare occasion I've taken up to 30 minutes. I've also not ruptured a catheter using the single syringe method.

Length of dwell time is always predicated on urgency of catheter usage; if there isn't urgency or risk of delayed meds, we prefer leaving for 2 to 4 hours, just because it often takes a single dose that long; if there's more urgency we'll check Q 30 minutes and repeat a second dose @ 60 minutes; on occasion we'll leave overnight since we don't have 24-Hr IV Team coverage. Nearly, always, the catheter will be fully functional following this treatment. Our facility allows staff RN's to instill tPA for withdrawal occlusion only; not for total occlusion - only IV Team nurses do this.

Regarding the FACTS: I've not used this system since it was revised from FAS. I was totally excited about the potential for preserving lines from unnecessary removal r/t to all the literature I read about the FAS Brushing procedure and study results. However, when we did employ the FAS system for over a year. It was expensive for us keeping all the different size brushes in stock and quite a challenge getting physician support for ordering the procedure and relying on the results. It was also time consuming locating the information about out-patients regarding catheter length and FR size because pt's wouldn't carry their ID cards with them and sometimes the writing on their catheters had worn off etc, etc. Like w/ anything if its not being ordered on more routine or frequent basis, the IV Team nurses would get insecure about performing the procedure because they hadn't done it for several weeks or (if they worked parttime) even months. Maybe FACTS is much more simplified than FAS, though, you can't get much simpler than instilling tPA for strictly occlusion issues. However, as I understand it, the brushing benefit of FACTS is even more directed toward routine brushing to decrease biofilm load and prevent CRBSI or when CRBSI occur to use in conjuction w/ repeated brushings and anti-biotic lock Rx, to "resterilize" an intraluminally colonized catheter. It is certainly a hopeful answer to unnecessary catheter removal, but I see it as needing to be presented to physicians to get them educated and excited about its efficacy. We certainly didn't have then nor now the time or energy to be their educators on this technology.


Only the IV nurses instill the activase..they were trying to inservice the floor nurses but we thought this may cause possible problems...most of them won't change a central line dressing or place a we felt it was not a safe idea.

Do nurses in your facility install the cathflo, or is it only done by the PICC team?  Does this fall under the nursing umbrella for medication administration, or is a seperate competency required?  Any imput would be helpful.  Thanks!

We frequently use activase to declot lines....about a hr. dwell time...also we have had success with the "plunger" method of flushing the lines...unfortunately the dual lumen arrow PICCs we tried were very small and did not last..I believe they were a 22g.  for both lumens..very tiny and they occluded easily.

what do you do if it is a double lumen catheter? do you declot both lumens?


The reason Genentech says to "instill Cathflo" is because of legal reasons and the way the original clinical studies were set up.  It is confusing because the studies were designed to address only lack of blood return, but not complete intraluminal occlusions.  When I teach declotting techniques, I emphasize that there are 2 different types of thrombotic catheter occlusions that are addressed by Cathflo:  1.  intraluminal occlusion, which is what most nurses think of as a catheter occlusion.  2.  Lack of blood return or sluggish flow which is usually due to fibrin or thrombus OUTSIDE the catheter tip.  I teach to use a single syringe, attach it directly to the hub of the catheter, and pull gently back to "instill" the Cathflo---in other words it will mix with the saline in the catheter and get up to the clot interface deep in the catheter lumen and begin to delot.  You need to pull back on the syringe (GENTLY) repeatedly to help the Cathflo move up the catheter lumen as it is declotting.  The 3-way stopcock method also gets the Cathflo up to the clot interface, but from that point onward it is declotting passively.   If the occlusion is lack of blood return but you can infuse, then you want to gently and slowly instill the entire 2 mls.  the Cathflo needs to attach to all that fibrin or thrombus at the catheter tip.  Wait at least 30 minutes before checking for blood return.

Nadine Nakazawa, RN

PICC Nurse, Stanford Hospital

President-elect AVA 

Nadine Nakazawa, RN, BS, OCN, CRNI, VA-BC

There is another alternative to declotting PICCs. Its a product called Fibrin Analysis Catheter Testing System (FACTS).  It comes in a complete kit with an endoluminal brush which can be administered by a nurse or doctor.  The kits are all size specific since catheters come in various french sizes and lengths.

 The FACTS's primary use is to culture all CVCs/PICCs/Dialysis Catheters for sepsis WITHOUT having to remove the line from the patient.  Studies show results are 96% accurate with the FACTS method. Furthermore, results are determined by the lab within 60 minutes

 A secondary feature of the FACTS product is its ability to restore catheter patency.  The Endoluminal Brush has been widely used to restore patency and has an efficiency equal to or better than t-PA in thrombosed catheters. It has also been used in combination with thrombolytic drugs. However, the main advantage of the Brush is that it will remove all debris, regardless of its nature, and, that it physically removes, rather than dissolves, the debris and its colonizing micro-organisms. Researchers have shown that a single brushing, followed by the withdrawal of 10 ml of blood through the line, reduces the bacterial count between 70 and 90%.

 In addition, you don't have to wait for hours for results like with tPA.  The results with the FACTS are pretty immediate.

 If you would like additional information regarding the FACTS product, please email me - with your contact information.


I also use the single syringe method and it is a 1 ml syringe at that.  Our tPA is prepared by our pharmacy and is only a .5mg. dose (.5ml).  The key is not to force it but gently pump the plunger to attempt to work the tPA into the line.  We use some very small PICCs (1.9 Fr.) and it will take a while to open those up.  I have seen them open after two days (with just one initial instillation).  I've found that if more tPA is needed the chances of it opening are not very high.

Is there a difference in method required when declotting a groshong picc vs another type of Picc?  we have in the past only used negative pressure with a three way stopcock for a groshong picc.

Hi All, I'm a new nurse manager in A Critical access Hospital and new with the declotting sytem (Cathflo).  We use the 3 way stopcock. Can you share your policy with me?  Please help! Thanks, Renee

Renee Farmer

I have a policy and would be glad to share if still needed.




I like using a 3 way stopcock with a 10cc syringe attached to the back luer. I aspirate the line about 10 times and expel it's contents and lock the vacuum. Then I attach a 3cc syringe with 1cc of cathflo to the top luer position and release the cathflo into the line. The 3cc syringe is then pulled back and allowed to re-instill several times until the cathflo becomes pink in color. It's then left to instill 2 hours, unless I have time to check it in 30 minutes.The stopcock allows less alcohol scrubbing inbetween attaching and detaching syringes. I also have a theory that the stopcock does not allow a loss of vacuum like a end cap valve. 


[quote=Julie Mijatovich]

Does anyone have a procedure written for catheter occlusions and or declotting cvads.


Julie Mijatovich

Fort Wayne, in


Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.

Does anyone have a procedure written for catheter occlusions and or declotting cvads.


Julie Mijatovich

Fort Wayne, in

I totally agree, Patty.  That's why I was questioning the word "instill" in the Cathflo instructions.  Thanks, everyone, for your responses!  I have what I need!

Wendy Erickson RN
Eau Claire WI

As long as you never force the Cathflo into the catheter you wont rupture the line. You are doing a gentle push pull technique that mixes the Cathflo into the line and "dissolving the clot" along the way. Rupturing the line comes with forcing  which should never be done so as long as you follow basic principles of working with any catheter or any technique, there is no danger of rupturing the catheter.

I've used the stopcock and single syringe method.  I prefer the single syringe.  You don't need any special equipment (i.e stopcock) and it's just as easy - less "bulky" so to say.  I attach the syringe with the cathflo directly to the hub of the line, removing the cap.  Pulling back creates the negative pressure that pulls any serum around the clot back, then releasing draws the cathflo (possibly mixed with some of the serum) back into the line.  It may take a while, but eventually you work the cathflo down around the clot and it dissolves, and Presto, blood return! It's rare it doesn't work, usually only unsuccessful if the cause of the occlusion in NOT clot, but a precipitate.   

Hallene E Utter, RN, BSN Intravenous Care, INC

I have spent as long as thirty minutes "working" the Cath Flo into an occluded lumen. At the point I was ready to give up, the lumen opened. Nancy Rose RN IV Team VA Medical Center Wilmington, DE (800) 461-8262 ext 4830

Nancy Rose 

I've used both methods. Either way you are causing a negative pressure in the catheter that gently absorbs the cathflo as described above. Sometimes this may take me 15-20 minutes at the bedside to slowly play with it and gently allowing the cathflo to be absorbed into the catheter.  Pull up a chair and have a chat while you attempt to instill.  For safety reasons, if I cannot get it all in, I do not leave the syringe attached.  I'll come back in an hour or 2 and see if what had been instilled had been effective.  Need to calculate the 2ml volume in syringe to see if any was absorbed at all. 

Do people spend more time than this attempting to instill?  When do you call it quits?

Prior to using the cathflo, I change cap and sometimes this was all that was needed.  Then we confirm placement prior to cathflo

I've seen a couple of hospitals that uses three-way stopcock period. It doesn't matter what type of occlusion it is. The one you're describing is complete occlusion. The concept is creating negative pressure in the syringe when you pull to the 8 mL mark. Notice how the Cathflo stays at the bottom of the syringe. Then you really don't the release the plunger but gently assist it going back. That will push the Alteplase further into the catheter when you do the plunger several times. If you are certain that it is a thrombotic occlusion you're treating, then the single syringe works just as well as the stopcock method. In other hospitals, they would do both. I actually prefer the single syringe technique myself. I've had great success with it. It also is a question of who gets to declot the lines because if you're thinking of educating your staff to something new, it's got to be extensive education or reeducation. Finally, why change the procedure that already works for your facility? Was the rep recommending that you do it with 1 syringe?

We are exchanging whatever solution is left in the catheter with Cathflo.  It is not pushed in to instill it.  Aspirating collaspes the catheter drawing some of the solution out into the syringe with the Cathflo in it and then gradually releasing (not letting snap back) there by the catheter now has some cathflo in it.  This is done a number of times and the concentration of Cathflo in the catheter gradually strengthens.

But do you actually "instill" the Cathflo?  Do you push it in?  Are you concerned about possible rupture of the line?

Wendy Erickson RN
Eau Claire WI

I have use both methods.  My staff likes to use the stopcock method.  I now prefer the single syringe method and it works well, very well, with less supplies.