The Perimetric Protuberance-Periosteal Chondroma

Abstract

Total parenteral nutrition (TPN) is a life-saving therapy for patients who are not able to utilize the gastrointestinal tract. There are several different types of central venous catheters (CVC) used to deliver TPN. To safely deliver hyperosmotic TPN solutions, CVC tip position should be in the in lower superior vena cava (SVC) or at the junction of SVC and right atrium (RA). New techniques such as intravascular electrocardiogram (ECG) are being used for tip confirmation to help facilitate expedient use of PICC lines replacing the need for chest x-ray (CXR) confirmation. We present a case of a TPN patient who had a PICC line placed, and ECG confirmed tip as being in the SVC. The patient developed chest pain with flushing of the PICC prompting surgical service to obtain a CXR. The CXR suggested the line was in the either in mammary vein or aorta and recommended replacement. Interventional radiology flushed a small amount of contrast through the PICC and fluoroscopy confirmed the PICC tip was in the left internal mammary vein with reflux of contrast in the left innominate vein. The left innominate vein was occluded due to thrombosis and vasospasm. The patient required increased level of care (PCU) for 2 days, but was eventually discharged with home total parenteral nutrition and has done well. We conclude that care should be taken when using ECG confirmation for PICC tip placement and we feel that patients requiring hyperosmotic TPN should still require CXR confirmation to ensure tip appropriate tip location