FIBRIN SHEATH
MANAGEMENT
Dr. Eyhab Elobeid
IR Fellow
Fibrin sheaths are a complex of fibrin, collagen,
and thrombus around a foreign body, which over
the course of several weeks organizes into a fibrin
sheath.
 They are reported to occur in 50 to 100% of
patients with central venous catheters.

In the first 24 hours, a newly placed catheter
activates the coagulation cascade thrombus and
fibrin adhere to it.
 As the catheter continuously rubs against the
vein wall, endothelial cells are denuded from the
vein wall exposing smooth muscles cells and
fibroblasts below.
 This inflammatory process results in thrombus
development, intimal hyperplasia, and smooth
muscle cell migration onto the adjacent catheter.

Originating where the catheter enters the vein,
cellular migration progresses distally along the
catheter toward its tip.
 After several weeks, thrombus and fibrin are
gone and a well-organized sheath composed
primarily of collagen, fibroblasts, epithelial cells,
and smooth muscle cells encompass the catheter.


It has been reported that 50% of catheter
malfunctions are the result of a collagen sheath.
FIBRIN FORMATION
MANAGEMENT
1.
2.
3.
4.
Thrombolytic infusion (eg, recombinant tissue
plasminogen activator over 1-3 hours)
Mechanical disruption (with a guide wire
and/or balloon)
Fibrin sheath stripping (with a snare via
transfemoral venous access)
Over-the-wire catheter exchange
THROMBOLYTIC INFUSION
Fill catheter with small dose thrombolytic agent
(e.g., tPA 1-2 mg, urokinase 5000 U).
Check catheter function after 30-60 minutes.
 If no change, repeat dose of thrombolytic agent.
Check catheter function after 30-60 minutes.

If no change, obtain contrast study of catheter:
 For extensive fibrin sheath, infuse thrombolytic
agent
for 4-8 hours (e.g., tPA 1 mg/hr, urokinase 50,000
U/hr).

MECHANICAL DISRUPTION (WITH A GUIDE WIRE
AND/OR BALLOON)
FIBRIN SHEATH STRIPPING
In Group 1 (no sheath, normal vein) only 1/20 (5%)
developed subsequent central venous stenosis.
 In Group 2 (fibrin sheath, normal vein) 9.3% developed
central venous lesions.
 All patients 100% in Group 3 (fibrin sheath, vein
stenosis) developed central venous disease on followup.

THANK YOU