Tightly adherent PICCs can result after prolonged intraluminal dwell times. We describe a novel endovascular technique that can be utilized for safe and successful removal of difficult embedded PICCs” Le et al (2016).
INTRODUCTION: Peripherally inserted central catheters (PICCs) are a popular alternative to central venous lines. PICCs can provide reliable long-term access for intravenous fluids, antibiotics and total parenteral nutrition. Multiple factors can contribute to difficult PICC removal including adherent fibrin and thrombus formation around the catheter. We discuss a novel endovascular retrieval technique to remove tightly adherent PICCs.
CASE PRESENTATION: A 42-year-old male with history of chronic pancreatitis requiring intravenous pain medications, presented with right upper extremity single lumen PICC that could not be removed by standard techniques. The PICC line had been in place for approximately three years and was no longer functioning appropriately. Ultrasonography demonstrated thrombus alongside the length of the PICC.
RESULTS: In order to remove the PICC we utilized a novel endovascular technique. A 0.018″ mandril wire was passed through the lumen of the PICC. Next, a puncture alongside the PICC was performed to place a 6 French (Fr) sheath. A snare was then maneuvered through the sheath and used to capture the tip of the mandril wire. The snare, mandril wire and PICC where withdrawn in unison, looping the PICC tip within the basilic vein. The tip of the PICC was positioned near the antecubital fossa. A small incision was performed to capture the tip of the PICC to remove the catheter.
DISCUSSION: Tightly adherent PICCs can result after prolonged intraluminal dwell times. We describe a novel endovascular technique that can be utilized for safe and successful removal of difficult embedded PICCs.
Peripherally-inserted central catheters (PICCs) are commonly used during hospitalization. Unfortunately, their use can be complicated by catheter-related thrombosis (CRT). Current guidelines recommend 3-6 months of anticoagulation for patients with CRT after catheter removal. This recommendation is based on extrapolation of data on lower extremity thrombosis, as data is lacking regarding the efficacy and safety of more specific management strategies. Many providers feel catheter removal alone is a reasonable treatment option, particularly for patients at risk for bleeding. We performed a retrospective analysis of hospitalized adult patients diagnosed with CRT at our center. We determined rates of progressive thrombosis and bleeding in cohorts of patients who underwent catheter removal vs those who had catheters removed and received anticoagulation. Among 83 total patients, 62 were treated with PICC removal alone, while 21 underwent PICC removal followed by therapeutic anticoagulation. Patients treated with PICC removal alone were more likely to have hematologic malignancy, receive chemotherapy, develop thrombocytopenia, and have brachial vein thrombosis. No patients in the PICC removal plus anticoagulation arm developed progressive thrombosis, while 6.4% of patients treated with catheter removal alone developed a secondary VTE event, including one PE, three DVTs, and five patients (8%) who developed progressive symptoms leading to initiation of anticoagulation. Major bleeding was significantly more common in the PICC removal + anticoagulation arm (28.5% vs. 4.8% p = 0.007). Catheter-removal alone results in significantly reduced major bleeding compared with catheter-removal plus anticoagulation. In select patients, catheter removal alone may be an option for CRT.
Keywords: Anticoagulation; Peripherally-inserted-central catheter; Thrombosis.
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Caring for your PICC line at home
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If you have just had a PICC line (Peripherally Inserted Central Catheter) put in your arm, there are some important things you need to know. This line is used for intravenous therapy such as medications, blood transfusions, extra fluids, or nutrition that you will need over an extended period of time.
The actual tube is about 24 inches long. It threads up your arm until it reaches the large vein above your heart. Your PICC may have one or two lines (also known as lumens); fluids will go into these lines. The PICC line generally stays in for about a month, but can be left in longer if needed and if you don’t get an infection. Regular checkups with your doctor are very important.
Your healthcare provider will give you specific instructions on how to care for your PICC line.
Here are some additional tips:
- Keep the dressing (or bandage) clean, dry, and secured to the skin. If it gets wet or torn, change it right away. Do not put lotions or ointments under the dressing.
- When you’re ready to change the dressing (or bandage) over your PICC line, make sure you do it in a clean, dry area away from drafts.
- Changing the dressing is a “sterile” process. Your nurse will explain how to handle the supplies without contaminating them.
- When showering, cover the dressing with a waterproof cover such as plastic wrap.
If you don’t care for your PICC line properly, you could develop complications such as occlusions (blockage), phlebitis (inflammation of a vein), thrombosis (blood clots), hemorrhage (bleeding), and infection.