Do you recommend immediate catheter removal or anticoagulating for a certain amount of time before removing the tunneled dialysis catheter of a patient with an incidentally found, asymptomatic thrombus at the end of the catheter that does not interfere with hemodialysis?

I agree with Dr. @Dr. First Last. Since this tunneled dialysis catheter (TDC) is functioning well, there is no urgency to remove it. Infact, removal runs the risk of dislodging the thrombus causing pulmonary embolism. I would provide systemic anticoagulation with a vitamin K antagonist (coumadin) using the protocol described by Rossi et al., PMID 32410490. Maintain INR 2.5-3 for one month then reduce to INR 1.5-2 for 6 months. If available, lock the catheter with tPA once each week. The tPA will...

It depends on the size of the thrombus. In general, I prefer anticoagulation first, repeat ultrasound after 6 months and then decide whether to remove the catheter. Most of the time, I find there is significant decrease in size of the clot with anticoagulation alone.