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Routine Peripherally Inserted Central Catheter Placement Resulting in Delayed Intravascular Foreign Body
Letters to the Editor
Routine Peripherally Inserted Central Catheter Placement Resulting in Delayed Intravascular Foreign Body From: Randall L. Siegel, MD, John L. Nosher, MD, and Leonard Bodner, MD Department of Radiology Robert Wood Johnson University Hospital 1 RWJ Place New Brunswick, NJ 08901 Editor: A 13-year-old female patient was admitted with bacterial pneumonia and parapneumonic effusion. The patient required a right chest tube and a peripherally inserted central catheter (PICC). Both procedures were performed in the computed tomography (CT) suite to preclude patient transport while under sedation. The chest tube placement was followed by placement of a 5-F double-lumen PICC (Arrow, Reading, PA). As is our routine, before placement of the PICC by the physician, the catheter was cut to 14.5 inches by the nurse based on measurements from the mid-humerus to the shoulder to the suprasternal notch. This was followed by insertion of the J-tipped wire through the PICC until the end of the wire was flush with the end of the PICC. After 1% lidocaine (Abbott Laboratories, North Chicago IL) was applied to anesthetize the skin, ultrasound guidance was used in the puncture of the left basilic vein. A 0.018-inch wire was introduced into the needle and the dilator and sheath were advanced over this wire into the vein. The dilator and wire were removed, and the PICC was advanced to the central venous system. A chest radiograph showed that the PICC was too long. The PICC was therefore removed from the sheath, the wire was pulled back, and the catheter was cut to a new length of 12.5 inches. After reinsertion of the PICC, a chest radiograph showed good position of the PICC (Fig 1). The wire and sheath were removed, the PICC was flushed with heparinized saline solution, and the catheter was sutured in place. Two days later, a chest radiograph was obtained to evaluate the patient’s pneumonia (Fig 2). There appeared to be a guide wire looped in the pulmonary artery. To exclude this being outside the patient, we wanted to repeat chest radiography after the dressing on the patient’s back was removed. Because of the pain involved in removing the dressing, the patient refused, but her parent agreed to a limited CT scan, which confirmed that the wire was in the pulmonary artery (Fig 3). After discussion with the pediatricians, it was determined that no other procedures had been performed on the patient after PICC placement, and therefore the foreign body was somehow related to the PICC. Based on the acute angles that the wire was taking, the assumption was that the foreign body was the outer wrap of the J-tipped wire, which would be floppy enough to make those turns. We believed that the inner part of the J-tipped
DOI: 10.1097/01.RVI.0000136035.86623.D3
Figure 1. Chest radiograph obtained immediately after PICC placement shows the tip in the lower SVC, the wire in the catheter, and no foreign body.
wire and the 0.018-inch puncture wire were not sufficiently floppy to make such turns. The following morning, the patient was brought to the angiography suite for foreign body retrieval and chest tube removal under sedation. The right common femoral vein was punctured, and, after placement of a 4-F sheath, the right pulmonary artery was catheterized with a Berenstein catheter (Boston Scientific, Watertown, MA) and a Glidewire (Boston Scientific). Exchange was made for a 10-mm Amplatz Goose Neck Snare (Microvena, White Bear Lake, MN), which was used to successfully snare the foreign body and remove it through the sheath. Inspection of the wire showed that it was in fact the outer wrap of the J-tipped wire, and measured 12.5 inches in length. The patient made an uneventful recovery and was discharged 3 days later. PICC placement has proved to be a safe procedure, with a recently reported complication event rate of two per 1,000 catheter-days. The most common complications are catheter dysfunction (eg, thrombosis, catheter related sheath, catheter malposition) and infection (1). Although guide wire fragment retrieval was reported as early as 1971 (2), and PICC fractures have been reported previously (3,4), our search of the literature did not yield any cases of a broken wire fragment resulting in a foreign body during PICC placement. Our goal was to try to ascertain what happened in this instance to be able to prevent future occurrences. The J-tipped guide wire is a 0.018-inch-diameter, 85-cmlong wire comprised of a 0.010-inch stainless-steel core wrapped by an outer spring made of 0.003-inch Tefloncoated stainless steel. The two wires are connected at both ends by a 2-mm ball weld with a weld strength of 15 N (3.5 lbs). The PICC is a 5-F dual-lumen polyurethane catheter with an extension line clamp proximal to each of the two hubs. The J-tipped wire is placed through the larger (18-
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Letters to the Editor
October 2004
JVIR
Figure 4. Photograph of PICC after the cut wire was pulled out with the tube clamp engaged. Note that the wire ends at the clamp (arrow). Figure 2. Chest radiograph obtained 1 day after PICC placement shows intravascular foreign body extending from the right pulmonary artery (black arrow) to the left pulmonary artery (white arrow).
Figure 3. Two contiguous axial CT scans demonstrate the wire fragment in the pulmonary arteries (arrows).
gauge) lumen before passage of the PICC through the introducer sheath. For part of the outer spring to become separated from the inner core, the spring must be separated from the core in two places. The first place was probably at the tip of the wire. This likely occurred when the catheter was removed to have another 2 inches trimmed off the end. The J-tipped wire was probably not pulled back enough and the tip of it was cut off at the same time that the catheter was trimmed. The second break in the outer spring must have occurred at the extension line clamp, which was inadvertently left locked on the tubing as the J-tipped wire was pulled back. We recreated the proposed scenario on the benchtop by taking a PICC and cutting it to a length of 14.5 inches. We then passed the J-tipped wire until it was 1 inch from the tip. We then cut the PICC 2 inches shorter, locked the clamp, and pulled the wire out, which required normal to slightly in-
Figure 5. Close-up photograph of the two ends of the wire fragment show that both are irregular with no weld joint identified (arrows).
creased force. We repeated this four additional times. In four of five experiments, the outer wrap of the J-tipped wire broke right at the clamp (Fig 4). Visible inspection clearly showed the distal end of the wire to be different in appearance, being narrower and without the serrated appearance of the outer wrap. A low-pressure injection of saline solution through the catheter with the fragment inside (simulating the heparin flush after PICC placement) easily expelled the wire fragment from the PICC. In one case, the wire unwrapped. When we repeated the experiment five times with an intact J-tipped wire and the clamp locked, the wire would not pull out of the PICC unless tremendous force was used, and this experiment resulted in the wire coming out intact twice, the wire unwinding twice, and the wire breaking once. This would explain why the foreign body was not present on the final image after PICC placement (Fig 1), as the final flush was performed after the image was obtained.
Volume 15
Number 10
Letters to the Editor
•
1169
Our hypothesis is consistent with the measurements taken, namely that the length of the trimmed catheter was approximately the same length as the wire fragment, and that a ball weld was not seen at either end of the wire fragment (Fig 5). In conclusion, care must be taken to withdraw the Jtipped wire sufficiently out of a PICC before the length is trimmed, and the extension line clamp must be left open until the J-tipped wire has been removed. Also, visual inspection of the wire should be done to confirm that the wire was removed intact. Simultaneous failure to accomplish these three simple tasks may result in an intravascular foreign body. References 1. Moureau N, Poole S, Murdock MA, Gray SM, Semba CP. Central venous catheters in home infusion care: outcomes analysis in 50,470 patients. J Vasc Interv Radiol 2002; 13:1009 –1016. 2. Dotter CT, Rosch J, Bilbao MK. Transluminal extraction of catheter and guide fragments from the heart and great vessels: 29 collected cases. AJR Am J Roentgenol 1971; 111:467– 472. 3. Linz DN, Bisset GS, Warner BW. Fracture and embolization of a peripherally inserted central venous catheter. JPEN J Parenteral Enteral Nutr 1994; 18:79 – 80. 4. Chow LM, Friedman JN, Macarthur C, et al. Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J Pediatr 2003; 142:141–144.
Figure 1. Postdeployment SVC angiogram demonstrates the Bard Retrievable filter deployed below the left innominate vein/SVC junction and above the right atrium.
Retrieval of the Bard Recovery Filter from the Superior Vena Cava From: Dheeraj K. Rajan, MD, FRCPC, Kenneth W. Sniderman, MD, FRCPC, Barry B. Rubin, MD, PhD, FRCSC Divisions of Vascular and Interventional Radiology (D.K.R. and K.W.S.) and Vascular Surgery (B.B.R.) Toronto General Hospital University Health Network 585 University Avenue, NCSB 1C-553 Toronto, ON, Canada M5G 2N2 Editor: Filter placement in the superior vena cava (SVC) for prevention of pulmonary embolism from upper-extremity deep venous thrombosis remains controversial. Despite one large study (1) suggesting that placement of Greenfield permanent filters (Boston Scientific, Natick, MA) into the SVC is safe, the long-term safety of permanent filters has been questioned (2). This concern regarding the long-term safety of permanent filters has led to the development of retrievable filters, one of which can be retrieved safely with no time limit. Although the Bard Recovery filter (C.R. Bard, Tempe, AZ) has been placed safely in the inferior vena cava with only one documented migration (3), we present a case wherein this particular filter was successfully placed and retrieved from the SVC. A 20-year-old man presented with symptoms consistent with right upper-extremity effort thrombosis. Duplex ultrasound (US) examination confirmed subclavian vein thrombosis. He was admitted to the hospital and started on a regimen of intravenous heparin. The following day, the
DOI: 10.1097/01.RVI.0000134498.13735.81
patient developed pleuritic chest pain and shortness of breath. A contrast enhanced spiral computed tomographic examination of the chest confirmed the diagnosis of multiple segmental pulmonary arterial filling defects, consistent with pulmonary embolism. A duplex US examination of the lower extremities was normal. Despite adequate anticoagulation, the following day, the patient again developed pleuritic chest pain and became diaphoretic and tachycardic; electrocardiographic changes were consistent with recurrent pulmonary embolism. An echocardiogram demonstrated pulmonary hypertension. Concern for the patient not being able to tolerate a repeat pulmonary embolic event prompted consultation for placement of a filter. However, given the patient’s age and the consulting hematologist indicating that therapeutic anticoagulation could be obtained with other agents, consideration was given to the use of a retrievable filter. After informed consent was obtained, access to the SVC was obtained via the right internal jugular approach and an SVC angiogram was obtained to determine the junction of the left innominate vein and SVC as well as the level of origin of the right atrium. The venogram was obtained to also determine if the SVC was of sufficient length to accommodate the length of the filter. Subsequently, a Bard Recovery filter was deployed in the SVC (Fig 1). This filter is composed of nitinol wire with two levels of filtration that can accommodate a vessel size as large as 28 mm. The device is oriented for proper IVC filtration with deployment from a femoral approach. The internal jugular approach allowed for correct orientation of the filter with the apex of the filter pointing toward the right atrium with use of the femoral deployment device (currently the only device available). Serial chest radiographs were obtained to determine if filter migration was occurring. Six days later, it was believed that the patient’s clinical status
Routine Peripherally Inserted Central Catheter Placement Resulting in Delayed Intravascular Foreign Body From: Randall L. Siegel, MD, John L. Nosher, MD, and Leonard Bodner, MD Department of Radiology Robert Wood Johnson University Hospital 1 RWJ Place New Brunswick, NJ 08901 Editor: A 13-year-old female patient was admitted with bacterial pneumonia and parapneumonic effusion. The patient required a right chest tube and a peripherally inserted central catheter (PICC). Both procedures were performed in the computed tomography (CT) suite to preclude patient transport while under sedation. The chest tube placement was followed by placement of a 5-F double-lumen PICC (Arrow, Reading, PA). As is our routine, before placement of the PICC by the physician, the catheter was cut to 14.5 inches by the nurse based on measurements from the mid-humerus to the shoulder to the suprasternal notch. This was followed by insertion of the J-tipped wire through the PICC until the end of the wire was flush with the end of the PICC. After 1% lidocaine (Abbott Laboratories, North Chicago IL) was applied to anesthetize the skin, ultrasound guidance was used in the puncture of the left basilic vein. A 0.018-inch wire was introduced into the needle and the dilator and sheath were advanced over this wire into the vein. The dilator and wire were removed, and the PICC was advanced to the central venous system. A chest radiograph showed that the PICC was too long. The PICC was therefore removed from the sheath, the wire was pulled back, and the catheter was cut to a new length of 12.5 inches. After reinsertion of the PICC, a chest radiograph showed good position of the PICC (Fig 1). The wire and sheath were removed, the PICC was flushed with heparinized saline solution, and the catheter was sutured in place. Two days later, a chest radiograph was obtained to evaluate the patient’s pneumonia (Fig 2). There appeared to be a guide wire looped in the pulmonary artery. To exclude this being outside the patient, we wanted to repeat chest radiography after the dressing on the patient’s back was removed. Because of the pain involved in removing the dressing, the patient refused, but her parent agreed to a limited CT scan, which confirmed that the wire was in the pulmonary artery (Fig 3). After discussion with the pediatricians, it was determined that no other procedures had been performed on the patient after PICC placement, and therefore the foreign body was somehow related to the PICC. Based on the acute angles that the wire was taking, the assumption was that the foreign body was the outer wrap of the J-tipped wire, which would be floppy enough to make those turns. We believed that the inner part of the J-tipped
DOI: 10.1097/01.RVI.0000136035.86623.D3
Figure 1. Chest radiograph obtained immediately after PICC placement shows the tip in the lower SVC, the wire in the catheter, and no foreign body.
wire and the 0.018-inch puncture wire were not sufficiently floppy to make such turns. The following morning, the patient was brought to the angiography suite for foreign body retrieval and chest tube removal under sedation. The right common femoral vein was punctured, and, after placement of a 4-F sheath, the right pulmonary artery was catheterized with a Berenstein catheter (Boston Scientific, Watertown, MA) and a Glidewire (Boston Scientific). Exchange was made for a 10-mm Amplatz Goose Neck Snare (Microvena, White Bear Lake, MN), which was used to successfully snare the foreign body and remove it through the sheath. Inspection of the wire showed that it was in fact the outer wrap of the J-tipped wire, and measured 12.5 inches in length. The patient made an uneventful recovery and was discharged 3 days later. PICC placement has proved to be a safe procedure, with a recently reported complication event rate of two per 1,000 catheter-days. The most common complications are catheter dysfunction (eg, thrombosis, catheter related sheath, catheter malposition) and infection (1). Although guide wire fragment retrieval was reported as early as 1971 (2), and PICC fractures have been reported previously (3,4), our search of the literature did not yield any cases of a broken wire fragment resulting in a foreign body during PICC placement. Our goal was to try to ascertain what happened in this instance to be able to prevent future occurrences. The J-tipped guide wire is a 0.018-inch-diameter, 85-cmlong wire comprised of a 0.010-inch stainless-steel core wrapped by an outer spring made of 0.003-inch Tefloncoated stainless steel. The two wires are connected at both ends by a 2-mm ball weld with a weld strength of 15 N (3.5 lbs). The PICC is a 5-F dual-lumen polyurethane catheter with an extension line clamp proximal to each of the two hubs. The J-tipped wire is placed through the larger (18-
1167
1168
•
Letters to the Editor
October 2004
JVIR
Figure 4. Photograph of PICC after the cut wire was pulled out with the tube clamp engaged. Note that the wire ends at the clamp (arrow). Figure 2. Chest radiograph obtained 1 day after PICC placement shows intravascular foreign body extending from the right pulmonary artery (black arrow) to the left pulmonary artery (white arrow).
Figure 3. Two contiguous axial CT scans demonstrate the wire fragment in the pulmonary arteries (arrows).
gauge) lumen before passage of the PICC through the introducer sheath. For part of the outer spring to become separated from the inner core, the spring must be separated from the core in two places. The first place was probably at the tip of the wire. This likely occurred when the catheter was removed to have another 2 inches trimmed off the end. The J-tipped wire was probably not pulled back enough and the tip of it was cut off at the same time that the catheter was trimmed. The second break in the outer spring must have occurred at the extension line clamp, which was inadvertently left locked on the tubing as the J-tipped wire was pulled back. We recreated the proposed scenario on the benchtop by taking a PICC and cutting it to a length of 14.5 inches. We then passed the J-tipped wire until it was 1 inch from the tip. We then cut the PICC 2 inches shorter, locked the clamp, and pulled the wire out, which required normal to slightly in-
Figure 5. Close-up photograph of the two ends of the wire fragment show that both are irregular with no weld joint identified (arrows).
creased force. We repeated this four additional times. In four of five experiments, the outer wrap of the J-tipped wire broke right at the clamp (Fig 4). Visible inspection clearly showed the distal end of the wire to be different in appearance, being narrower and without the serrated appearance of the outer wrap. A low-pressure injection of saline solution through the catheter with the fragment inside (simulating the heparin flush after PICC placement) easily expelled the wire fragment from the PICC. In one case, the wire unwrapped. When we repeated the experiment five times with an intact J-tipped wire and the clamp locked, the wire would not pull out of the PICC unless tremendous force was used, and this experiment resulted in the wire coming out intact twice, the wire unwinding twice, and the wire breaking once. This would explain why the foreign body was not present on the final image after PICC placement (Fig 1), as the final flush was performed after the image was obtained.
Volume 15
Number 10
Letters to the Editor
•
1169
Our hypothesis is consistent with the measurements taken, namely that the length of the trimmed catheter was approximately the same length as the wire fragment, and that a ball weld was not seen at either end of the wire fragment (Fig 5). In conclusion, care must be taken to withdraw the Jtipped wire sufficiently out of a PICC before the length is trimmed, and the extension line clamp must be left open until the J-tipped wire has been removed. Also, visual inspection of the wire should be done to confirm that the wire was removed intact. Simultaneous failure to accomplish these three simple tasks may result in an intravascular foreign body. References 1. Moureau N, Poole S, Murdock MA, Gray SM, Semba CP. Central venous catheters in home infusion care: outcomes analysis in 50,470 patients. J Vasc Interv Radiol 2002; 13:1009 –1016. 2. Dotter CT, Rosch J, Bilbao MK. Transluminal extraction of catheter and guide fragments from the heart and great vessels: 29 collected cases. AJR Am J Roentgenol 1971; 111:467– 472. 3. Linz DN, Bisset GS, Warner BW. Fracture and embolization of a peripherally inserted central venous catheter. JPEN J Parenteral Enteral Nutr 1994; 18:79 – 80. 4. Chow LM, Friedman JN, Macarthur C, et al. Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J Pediatr 2003; 142:141–144.
Figure 1. Postdeployment SVC angiogram demonstrates the Bard Retrievable filter deployed below the left innominate vein/SVC junction and above the right atrium.
Retrieval of the Bard Recovery Filter from the Superior Vena Cava From: Dheeraj K. Rajan, MD, FRCPC, Kenneth W. Sniderman, MD, FRCPC, Barry B. Rubin, MD, PhD, FRCSC Divisions of Vascular and Interventional Radiology (D.K.R. and K.W.S.) and Vascular Surgery (B.B.R.) Toronto General Hospital University Health Network 585 University Avenue, NCSB 1C-553 Toronto, ON, Canada M5G 2N2 Editor: Filter placement in the superior vena cava (SVC) for prevention of pulmonary embolism from upper-extremity deep venous thrombosis remains controversial. Despite one large study (1) suggesting that placement of Greenfield permanent filters (Boston Scientific, Natick, MA) into the SVC is safe, the long-term safety of permanent filters has been questioned (2). This concern regarding the long-term safety of permanent filters has led to the development of retrievable filters, one of which can be retrieved safely with no time limit. Although the Bard Recovery filter (C.R. Bard, Tempe, AZ) has been placed safely in the inferior vena cava with only one documented migration (3), we present a case wherein this particular filter was successfully placed and retrieved from the SVC. A 20-year-old man presented with symptoms consistent with right upper-extremity effort thrombosis. Duplex ultrasound (US) examination confirmed subclavian vein thrombosis. He was admitted to the hospital and started on a regimen of intravenous heparin. The following day, the
DOI: 10.1097/01.RVI.0000134498.13735.81
patient developed pleuritic chest pain and shortness of breath. A contrast enhanced spiral computed tomographic examination of the chest confirmed the diagnosis of multiple segmental pulmonary arterial filling defects, consistent with pulmonary embolism. A duplex US examination of the lower extremities was normal. Despite adequate anticoagulation, the following day, the patient again developed pleuritic chest pain and became diaphoretic and tachycardic; electrocardiographic changes were consistent with recurrent pulmonary embolism. An echocardiogram demonstrated pulmonary hypertension. Concern for the patient not being able to tolerate a repeat pulmonary embolic event prompted consultation for placement of a filter. However, given the patient’s age and the consulting hematologist indicating that therapeutic anticoagulation could be obtained with other agents, consideration was given to the use of a retrievable filter. After informed consent was obtained, access to the SVC was obtained via the right internal jugular approach and an SVC angiogram was obtained to determine the junction of the left innominate vein and SVC as well as the level of origin of the right atrium. The venogram was obtained to also determine if the SVC was of sufficient length to accommodate the length of the filter. Subsequently, a Bard Recovery filter was deployed in the SVC (Fig 1). This filter is composed of nitinol wire with two levels of filtration that can accommodate a vessel size as large as 28 mm. The device is oriented for proper IVC filtration with deployment from a femoral approach. The internal jugular approach allowed for correct orientation of the filter with the apex of the filter pointing toward the right atrium with use of the femoral deployment device (currently the only device available). Serial chest radiographs were obtained to determine if filter migration was occurring. Six days later, it was believed that the patient’s clinical status