Unsuccessful Peripherally Inserted Central Catheter Placement

Abstract

Editor: Complications associated with peripherally inserted central catheters (PICCs) include phlebitis, venous thrombosis, catheter-related blood infections, exit site infections, occlusions, and catheter malfunction (1,2). When PICCs are compared directly with central venous catheters, not only are they associated with higher rates of phlebitis, but their use can result in more difficult insertion attempts (2). Herein we present a case of a failed PICC insertion. A 49-year-old man with a history of scleroderma complicated by intestinal dysfunction and malabsorption that required chronic total parenteral nutrition was hospitalized for acute abdominal pain secondary to a ruptured pancreatic pseudocyst. He underwent surgical management of the pseudocyst; however, his postoperative course was complicated by recurrent hemorrhage and repeat abdominal exploration. The patient continued to receive total parenteral nutrition via a double-lumen PICC inserted into the superior vena cava originating from the left basilic vein. A prolonged hospital course was marked by multiple infectious complications, which necessitated removal of the old PICC, followed by reinsertion of a new one into the left basilic vein. Incorrect placement of the new PICC was suspected as a result of the inability to easily flush the catheter and completely visualize the catheter on an upright chest radiograph. Attempts to withdraw the malpositioned PICC were unsuccessful with gentle traction. Under fluoroscopy, no radiopaque dye could be injected intraluminally, nor could a guide wire be threaded through the length of the catheter. Surgical exploration at the insertion site revealed an extensive extraluminal knot in the PICC line limiting its removal (Figure). The knot is believed to have occurred as a result of multiple attempts at advancing and withdrawing the PICC against the resistance of its initial extraluminal placement. Despite the relatively high rates of minor complications associated with the use of PICCs, they can be placed safely by a wide variety of health care professionals and are therefore a valuable tool for vascular access in many types of patients (3,4). The difficult removal of PICCs is an uncommon complication and is typically associated with the presence of phlebitis, thrombus, or perivascular fibrin deposition. Conservative approaches to removal include gentle traction, relaxation exercises, or administration of smooth muscle relaxants. Aggressive attempts at removal should be avoided to minimize damage to the vein, possible catheter fracture, and/or subsequent embolization of catheter fragments (5). When conservative measures prove unsuccessful, surgical cutdown should be used for safe catheter removal.