Critical Care: Fellow Case Report Poster - Critical Care III |

An Uncommon Complication of a Common Procedure FREE TO VIEW

Simon Yau, MD; Dharani Narendra, MD
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Baylor College of Medicine, Sugar Land, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):251A. doi:10.1016/j.chest.2016.08.264
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SESSION TITLE: Fellow Case Report Poster - Critical Care III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Common complications of peripherally inserted central venous catheter (PICC) insertion are thrombosis, bleeding, and mal positioning. We present a unique complication of PICC insertion

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.

DISCUSSION: There are several possible mechanisms to explain knotting of a PICC. First, counter puncture of the vessel can allow for formation of an extravascular knot. Second, angulation at the brachiocephalic junction favors coiling of a catheter. Third, the prior central venous line likely increased the risk of coiling. The removal of coiled catheters often requires surgical intervention. Progressive serial dilation with larger sheaths is a newer technique that allows for a less invasive means of removing coiled catheters.

CONCLUSIONS: Clinicians should be cognizant of the possibility of coiling the tip of a PICC when resistance is met, especially if there are preexisting catheters.

Reference #1: Cherian, V, et al. Knotting of a peripherally inserted central catheter. Canadian Journal of Anesthesia 2004; 51:10: 1046-1047.

DISCLOSURE: The following authors have nothing to disclose: Simon Yau, Dharani Narendra

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