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  Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 57  |  Issue : 3  |  Page : 340-342
 

PICC fracture and embolization into pulmonary artery - a rare but potentially life-threatening complication: A case report


1 Department of Pediatric Haemato-Oncology, B J Wadia Hospital for Children, Mumbai, Maharashtra, India
2 Department of Pediatric Cardiology, B J Wadia Hospital for Children, Mumbai, Maharashtra, India

Date of Submission23-Dec-2018
Date of Decision25-Mar-2019
Date of Acceptance26-Mar-2019
Date of Web Publication05-Aug-2020

Correspondence Address:
V P Krishnan
Department of Pediatric Haemato-Oncology, B J Wadia Hospital for Children, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_834_18

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 » Abstract 


Peripherally inserted central catheter (PICCs) are popular means of long-term intravenous access in oncology patients. Fracture and embolization are rare but potentially serious complications. Here we present an unusual fracture of the PICC line in a 9-year-old boy with Ewing's sarcoma with embolization to the right ventricle (RV) and right pulmonary artery (RPA) which was retrieved percutaneously by trans-catheter snare assisted retrieval. Adequate care and precautions like handling by trained nursing staff/parental education must be undertaken to prevent such complications.


Keywords: Embolization, fracture, Peripherally inserted central catheter, pulmonary artery


How to cite this article:
Krishnan V P, Jain S, Mishra J, Mudaliar S. PICC fracture and embolization into pulmonary artery - a rare but potentially life-threatening complication: A case report. Indian J Cancer 2020;57:340-2

How to cite this URL:
Krishnan V P, Jain S, Mishra J, Mudaliar S. PICC fracture and embolization into pulmonary artery - a rare but potentially life-threatening complication: A case report. Indian J Cancer [serial online] 2020 [cited 2020 Sep 20];57:340-2. Available from: http://www.indianjcancer.com/text.asp?2020/57/3/340/291418




Peripherally inserted central catheter or PICCs are catheters inserted into the superior vena cava from peripheral veins such as basilic vein, cephalic vein or median cubital vein. They are mainly used for situations needing long-term venous access like in children receiving chemotherapy. PICCs are associated with complications such as breakage/leakage, phlebitis, catheter-related infections, thrombosis and migration. Fracture and migration are rare but potentially serious complications which can be associated with arrhythmias, pulmonary embolism, cardiac perforation and cardiac tamponade.[1] Here we present an unusual fracture of the PICC line with embolization to the right ventricle (RV) and right pulmonary artery (RPA).


 » Case Report Top


A 9-year-old boy diagnosed with left femur Ewing's sarcoma had a PICC (Bard Groshong® NXT ClearVue® PICC 4.0 Fr single lumen) inserted via the right median cubital vein before chemotherapy. Position of the catheter was confirmed with chest radiograph. The child received six cycles of chemotherapy preoperatively and seven cycles postoperatively via the PICC line with the PICC line in situ for a period of 255 days. For his radiotherapy, the child was referred to another hospital. During the course of radiotherapy, it was found that the PICC line had occlusion. Hence, an attempt was made at that centre for removal, which resulted in fracture of the PICC and incomplete removal. The child was referred back to our hospital. On referral, the child was asymptomatic. Chest radiographs and echocardiogram done showed embolization of the PICC fragment in the RV and RPA [Figure 1]. The patient was taken to the cardiac catheterisation laboratory for percutaneous retrieval. A 6 Fr short introducer sheath was placed in the right femoral vein by modified Seldinger technique. On fluoroscopy, the line was noted to be hanging in the RV with both the free ends wedged in the RPA [Figure 2]. It would have been technically challenging to hold one of the free ends of the line in the RPA. Hence, a pigtail catheter was passed through the loop hanging in the RV and pulled back to unloop the line [Figure 3] and [Figure 4]. The loop was pulled out of the RV and down into the inferior vena cava. One of the free ends, which were now lying in the right atrium, was held with the help of a Goose neck snare and pulled out en masse of the sheath placed in the right femoral vein. Post-procedure was uneventful [Figure 5]; hence, the patient was discharged after observation for 1 day.
Figure 1: Pre - procedure chest radiograph

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Figure 2: Fluroscopy in anteroposterior plane demonstrating the PICC line hanging in the right ventricle straddling the main pulmonary artery with both free ends wedged deep in the right pulmonary artery

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Figure 3: The PICC line being entangled by a pigtail catheter to pull it down and unloop the free ends

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Figure 4: The free end of the PICC line being held with the help of a snare to pull it out of the femoral venous sheath

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Figure 5: Post-procedure chest radiograph

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 » Discussion Top


PICCs are a popular choice for children needing long-term intravenous access like in chemotherapy. Catheter fracture is a less common complication and mainly occurs near the entrance site during removal.[2] Chow et al.[3] indicated that catheter fatigue is associated with the breakage of the PICC. They found that the average time of PICC fracture from insertion to discovery was 93 days. Factors which may lead to catheter fatigue are long duration of PICC in situ, chemotherauptic agents, weekly dressings, blockages and so on.[2] In our patient, the PICC fracture occurred after 255 days as compared with 10 months and 328 days as reported by Fang et al.[1] and Hu et al.[4], respectively, but longer than the average time of 93 days as reported by Chow et al.[3] In our patient, the fracture PICC was retrieved percutaneously by trans-catheter snare-assisted retrieval similar to the previous reports.[1],[4] In our patient, the initial attempted removal of the PICC was done in another center. This emphasises the importance of specially trained nursing staff to handle PICCs.[4]


 » Conclusion Top


PICC fracture and embolization, though a rare complication, can be potentially life-threatening situation with multitude of complications. It can be removed by either trans-catheter retrieval or open cardiac surgery. The latter can cause considerable morbidity. Hence, adequate care and precautions such as handling by trained nursing staff/parental education must be undertaken to prevent such complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Fang F, Zhang H, Yang W. An unusual Peripherally inserted central catheter (PICC) fracturedin Vivo with embolization happened in a child: A case report. Case Reports Clin Med 2015;4:10-3.  Back to cited text no. 1
    
2.
Kossoff EH, Poirier MP. Peripherally inserted central venous catheter fracture and embolization to the lung. Pediatr Emerg Care 1998;14:403-5.  Back to cited text no. 2
    
3.
Chow LM, Friedman JN, Macarthur C, Restrepo R, Temple M, Chait PG, et al. Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J Pediatr 2003;142:141-4.  Back to cited text no. 3
    
4.
Hu M, Ma ZC, Zhang J, Hu F, Liang XY, Dai XC, et al. A peripherally inserted central vein catheter fractured and slid into the right pulmonary artery: A case report. Chin Nurs Res 2015;2:86-8.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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