Keywords
peripherally inserted central catheter - localization - computed tomography - complications
- intervention
Introduction
Nowadays peripherally inserted central catheter (PICC) is widely used in medical treatment
for long-term intravenous (IV) administration of medication (e.g. chemotherapy) or
parenteral nutrition. It is placed in a peripheral vein (usually basilic vein, cephalic
vein, or median cubital vein) and travels along the brachial vein, axillary vein,
and subclavian vein until it reaches the superior vena cava (SVC).[1] PICC is a good choice for prolonged venous access. The accurate incidence rate of
PICC fracture is unknown due to a lack of long-term, large-scale, and prospective
studies. However, PICC fracture is potentially life-threatening and may result in
serious outcomes. Retrieval of the fractured PICC fragment can now be accomplished
with radiographical assistance using percutaneous techniques which have a high success
rate of more than 90%, with few complications.[2]
Case Report
In a 50-year-old female diagnosed with adenocarcinoma rectum with a PICC seen traversing
through left axillary, left brachiocephalic into the SVC visualized in a 3-month–old
neonate's X-ray ([Fig. 1]).
Fig. 1 Three months old chest X-ray showing the PICC line in position (yellow arrows showing
PICC location). PICC, peripherally inserted central catheter.
Fig. 2 HRCT axial view showed the broken PICC line into the right atrium and right ventricle
(yellow arrow). HRCT, high-resolution computed tomography; PICC, peripherally inserted
central catheter.
Follow-up admission of patient revealed a missing PICC line which the patient was
unaware of and the nursing staff confirmed that removal of PICC line has not been
done by them. Evaluation for missing PICC line was advised by imaging and computed
tomography (CT) thorax was advised.
The CT findings showed linear hyperdensity forming coils in the right atrium, inferior
vena cava (IVC), and extending to right ventricle and further into the pulmonary arteries
consistent with PICC line. The proximal end was lying in the right atrium and distal
end coiled up in the main and right pulmonary artery ([Fig. 3]) and into the left pulmonary artery ([Fig. 4]) confirmed that PICC line was located within the heart.
Fig. 3 HRCT reformatted sagittal section showing broken PICC line into the right ventricle
and extending into the main pulmonary trunk (yellow arrow). HRCT, high-resolution
computed tomography PICC, peripherally inserted central catheter.
Fig. 4 HRCT axial cuts demonstrating presence of the coiled PICC line in the left pulmonary
artery (yellow arrow). HRCT, high-resolution computed tomography; PICC, peripherally
inserted central catheter.
The retrieval of the migrated PICC was performed immediately after detection on imaging.
Under local anesthesia, using an ultrasound-guided percutaneous right femoral venous
approach, a 9-F catheter sheath and snare taken, positioned in right atrium (RA),
and the free end in RA is grasped in snare and pulled out through the sheath ([Fig. 5]). Whole of the broken segment of PICC retrieved.
Fig. 5 Retrieved PICC line. PICC, peripherally inserted central catheter.
Discussion
Use of central and peripheral access devices is an integral part of modern oncology
care for long-term infusion chemotherapy. In addition, PICC may be used for total
parenteral nutrition, administration of antibiotics, and rehydration therapy. With
proper maintenance, they can remain in situ up to 1 year. Optimal usage of PICC requires
periodic (weekly) dressings and flushing. Majority of the complications can be avoided
by proper maintenance. Common complications include phlebitis, vein thrombosis with
embolization, and catheter occlusion. Catheter damage can occur with any PICC, sometimes
due to defective products but more often from improper care.[3] Migrated PICC may cause an increased incidence of thrombosis. Migration of a catheter
has been reported as a delayed complication of PICC insertion.[4] Catheters can migrate at an estimated rate of 0 to 3.1% within 1.5 years.[5]
The migrated PICC of our patient was located in the right atrium, ventricle, and extending
up to the pulmonary arteries; it was a consequence of migration that shifted the segment
of the catheter into the heart. Regular chest radiography is the common choice to
ensure the safety of the inserted PICC. If it was found broken or missing on chest
X-ray, a CT scan should be performed to find out the exact position of the migrated
PICC. The retrieval of the migrated PICC was performed immediately after detection
on imaging in our case study.
Conclusion
Regular check X-ray should be taken for patients with PICC line to ensure the correct
positioning of the catheter into the SVC. Any displacement/malpositioning can cause
lethal complications, for example, vein thrombosis or embolization.
