CASE PRESENTATION: A 51-year-old woman underwent roux-en-y gastric bypass with subsequent pancreatectomy for Nesidioblastosis. One month later she presented with abdominal pain and was found to have pneumoperitoneum. Emergent exploratory laparotomy revealed perforation at jejunostomy site requiring surgical intervention. She had a prolonged course with an open abdomen. A prior left subclavian line had been previously placed, but given the prolonged need for TPN, PICC placement was attempted. Using ultrasound, a guidewire was placed and visualized in the left basilic vein. With the exception of mild initial resistance, a catheter was advanced smoothly to 40 cm. However, there was no blood return, and flushing the ports was met with resistance. Chest radiograph revealed no PICC in the chest. Furthermore, attempt at withdrawing the catheter was met with resistance after withdrawal to 30 cm. Patient was taken to interventional radiology where under fluoroscopy, the PICC line was found to be knotted in the upper arm. A guidewire was inserted through the PICC, but attempts to reduce the knot failed (Image 1). Next, progressively larger introducer sheaths (up to 10 French) were advanced over the catheter to create a tract. Finally, the tract was sufficiently large and the knotted PICC was removed in its entirety (Image 2). Patient tolerated procedure well with no vascular compromise.