Fluoroscopy-guided guidewire-assisted technique for difficult removal of a peripherally inserted central venous catheter (PICC) in children: a report of three cases and literature review

Introduction

Peripherally inserted central venous catheter (PICC) is a common alternative to central venous catheter. PICC can offer reliable long-term venous access for transfusion, chemotherapy, antimicrobial agents, and total parenteral nutrition, especially for cancer patients (1-3). In general, the removal of PICC at the conclusion of therapy is usually relatively easy without any complications. However, the removal can be challenging occasionally. The recommended noninvasive interventions, such as repositioning of the extremity, local hot compresses, vascular massage, and traction over time without pressure on the vascular wall, are well-known techniques (4). However, if the standard interventions fail to remove the catheter, there are no clear recommendations about what to do. Herein we describe three cases of fluoroscopy-guided guidewire-assisted removal of the firmly adherent PICC. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-119/rc).

Case presentation

We report three cases of difficult PICC removal in children with acute lymphoblastic leukemia (ALL). All cases were male, range 3–6 years, mean 5.00±1.73 years, catheter indwelling time 289–433 days, mean 367.33±72.83 days. All 3 cases underwent PICC intubation via the basilic vein approach and all catheters were 3.0 French (Fr), silicone, single-lumen PICCs (Bard Access Systems, Inc., Salt Lake City, UT, USA). Removal of the PICC at the end of the treatment course was difficult. The pullback of the catheter went smoothly for the first few centimeters, but then resistance was encountered. The catheter did not move backward at that point, although we applied strong continuous traction. Several noninvasive approaches to remove the catheter (e.g., repositioning of the extremity, application of hot compress, and vascular massage) were all with no success. Owing to fear for the catheter breakage due to stretching, the procedure was stopped. In order to remove the firmly adherent PICC safely, we used fluoroscopy-guided guidewire-assisted approach in hybrid operating room. After general anesthesia, the supine position was adopted and the upper extremity with PICC was abducted 90 degrees.

All procedures performed in this study were in accordance with the ethical standards of the institute and in line with the Helsinki Declaration (as revised in 2013). Written informed consents were obtained from the guardians of children for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Case 1

Case 1 was a 3-year-old boy, his catheter indwelling time was 433 days. Preoperative ultrasonography of upper extremity veins showed no abnormality. During the procedure, a 0.018-inch guidewire was advanced through the lumen of the PICC to right atrium. With the guidewire in place, the strength of manual traction on the catheter could be increased significantly. Under the guidance of fluoroscopy, the guidewire and the catheter were withdrawn in unison. No catheter fracture occurred throughout the process. The surgical procedure is shown in Figure 1.

Figure 1 The surgical procedure of case 1. (A) The location of catheter was determined under fluoroscopy (arrow: the tip of PICC). (B) A 0.018-inch guidewire was advanced through the lumen of the PICC to right atrium. (C) Under fluoroscopy, the guidewire and the catheter were withdrawn in unison. No catheter fracture occurred throughout the process. (D) After catheter removal, no residual catheter in the body confirmed by fluoroscopy. (E) The removed PICC. PICC, peripherally inserted central venous catheter.

Case 2

Case 2 was a 6-year-old boy, his catheter indwelling time was 380 days. Preoperative ultrasonography of upper extremity veins showed no abnormality. During the procedure, a 0.018-inch guidewire was advanced through the lumen of the PICC to inferior vena cava. The catheter fracture occurred when the guidewire and the catheter were withdrawn in unison. The broken end of PICC was located in the basilic vein under fluoroscopy. Due to the presence of the guidewire, the basilic vein was located easily on the body surface. Then two small incisions were performed to separate and remove the residual catheter. The surgical procedure is shown in Figure 2.

Figure 2 The surgical procedure of case 2. (A) The location of catheter was determined under fluoroscopy (arrow: the tip of PICC). (B) A 0.018-inch guidewire was advanced through the lumen of the PICC to inferior vena cava. (C) The catheter fracture occurred when the guidewire and the catheter were withdrawn in unison. The broken end of PICC (arrow) was located in the basilic vein under fluoroscopy. (D) Two small incisions were performed to separate and remove the residual catheter. (E) After catheter removal, no residual catheter in the body confirmed by fluoroscopy. (F) The removed PICC (arrow: the fracture point of PICC). PICC, peripherally inserted central venous catheter.

Case 3

Case 3 was also a 6-year-old boy, his catheter indwelling time was 289 days. Preoperative ultrasonography of upper extremity veins showed right axillary vein old thrombosis. Likewise, a 0.018-inch guidewire was advanced through the lumen of the PICC to right atrium. The catheter fracture occurred when the guidewire and the catheter were withdrawn in unison. The broken end of the PICC was located in the subclavian vein under fluoroscopy. Then, we punctured the right femoral vein to place a 6-Fr sheath. A snare was then passed through the sheath and used to capture the residual catheter under the guidance of the guidewire. The snare, guidewire, and residual catheter were withdrawn in unison from the femoral vein. The surgical procedure is shown in Figure 3.

Figure 3 The surgical procedure of case 3. (A) The location of catheter was determined under fluoroscopy (arrow: the tip of PICC). (B) A 0.018-inch guidewire was advanced through the lumen of the PICC to right atrium. (C) The catheter fracture occurred when the guidewire and the catheter were withdrawn in unison. The broken end of PICC (arrow) was located in the subclavian vein under fluoroscopy. (D) A snare was used to capture the tip of the residual catheter under the guidance of the guidewire. (E) The snare, guidewire and residual catheter were withdrawn in unison. (F) The removed PICC (arrow: the fracture point of PICC). PICC, peripherally inserted central venous catheter.

Discussion

PICC is increasingly utilized in pediatrics and has become an important intravenous infusion tool. It has many advantages, including easy insertion, short operation time, few complications (5,6), reliable intravenous access, and high satisfaction (7). However, it also induces complications, including catheter-related thrombosis, catheter-related infection, catheter dysfunction (migration, obstruction, and fracture), accidental removal, and others (8). In most cases, the PICC can be removed easily. Difficult PICC removal is a rare complication, with rates varying from 0.34% to 8.40% (9-11). Currently, there are only scattered reports of problems related to PICC removal. Reported hypothetical causes for difficult PICC removal are vascular vasospasm, knotting, entanglement, adhesion to vascular endothelium, thrombus, fibroblastic sleeve, or pinch-off syndrome (12,13).

When extubation encounters resistance, the procedure should be stopped immediately, and the reasons should be evaluated. Ultrasonography is very useful to identify reasons for difficult PICC removal because it can explore hemodynamic changes, identify vascular stenosis, and the presence or absence of occlusion (14). Ultrasonography can also identify the location and size of thrombus, as well as monitor the thrombosis after extubation and thrombus therapy. Zhan et al. reported that once the children encountered difficult PICC removal, an ultrasonography should be performed for screening so as to determine whether there was an adherent PICC (15). In our cases, ultrasonography of case 1 and case 2 showed no abnormality. Difficult removal may be due to adhesion of the catheter to the venous endothelium. However, the reason for difficult removal in case 3 was thrombus around the catheter which was confirmed by ultrasonography.

In general, the noninvasive methods used for difficult PICC removal included reposition of the extremity, warm and moist compresses, vessel massage, and traction over time (4,12). A systematic review reported that sustained firm continuous or intermittent traction over several hours was successful in 44.4% of cases (16). However, the disadvantage of traction is that the strength is operator-dependent and too much traction can induce catheter fracture and fragment embolization (17). They can also be catastrophic due to the potential risk of cardiac or pulmonary embolism (18). The invasive approaches included open surgery and endovascular techniques. Due to large trauma and high risk, open surgery is used as a final alternative. Meanwhile, the surgical removal has certain blindness, the catheter tip may still remain in the body and lays the hidden trouble for a series of serious complications (infections, vegetations, cardiac arrhythmias, etc.) in the future. Miall et al. reported that among eight patients with pancreatic cystic fibrosis who encountered difficult PICC removal, two underwent successful surgical removal (19). Compared to open surgery, endovascular techniques have the characteristics of less trauma, low risk, and quick recovery, and can be used as the first choice for difficult PICC removal. Le et al. reported a novel endovascular technique for the firmly adherent PICC removal (12). A 0.018-inch mandril wire was advanced through the lumen of the PICC. Next, a puncture alongside the catheter was performed to place a 6-Fr sheath. A snare was then passed through the sheath and used to capture the mandril wire tip. The snare, mandril wire, and catheter were withdrawn in unison, looping the catheter tip within the basilic vein. The catheter tip was positioned near the antecubital fossa. A small incision was performed to capture the catheter tip to remove the PICC (12). Zhang et al. reported their endovascular experience about removal of the firmly adherent PICC (20). During the procedure, femoral vein was punctured, whole orbita through Guidewire that was from the distal end of PICC to femoral vein was established, adhesion of PICC was separated gradually using 6 Fr multipurpose A catheter or long sheath, and then removed (20).

The PICC catheter for children has strong flexibility, brittle texture, and poor folding resistance. When extubation encounters resistance, it is easy to break the catheter in the body. In our cases, we used fluoroscopy-guided guidewire-assisted approach for difficult PICC removal. Inserting a guidewire can increase the catheter support force significantly and the catheter can be successfully removed in some cases (case 1). The whole extubation process must be carried out under fluoroscopy which gave us a direct visualization of the catheter. When catheter fracture occurs, we can find and determine the location of fracture at the first time. If the broken end of the catheter is in the superficial vein of the upper extremity, we can make a small incision to separate and remove the residual catheter (case 2). The presence of the guidewire makes it easier to locate the superficial veins. If the broken end of the catheter is located in the axillary vein or the subclavian vein or even the superior vena cava, a snare will be used to capture the residual catheter (case 3). For this situation, retaining the guidewire is also very important. The presence of the guidewire reduces the risk of potential cardiac or pulmonary emboli of the residual catheter and makes it easier to capture the residual catheter under the guidance of the guidewire.

Conclusions

Difficult PICC removal can result after prolonged dwell times. When conventional noninvasive interventions are unsuccessful, fluoroscopy-guided guidewire-assisted technique is a safe and effective method for the removal of adherent PICC.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-119/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-119/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-119/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institute and in line with the Helsinki Declaration (as revised in 2013). Written informed consents were obtained from the guardians of children for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Evans RS, Sharp JH, Linford LH, et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest 2010;138:803-10. [Crossref] [PubMed]
2. Sriskandarajah P, Webb K, Chisholm D, et al. Retrospective cohort analysis comparing the incidence of deep vein thromboses between peripherally-inserted and long-term skin tunneled venous catheters in hemato-oncology patients. Thromb J 2015;13:21. [Crossref] [PubMed]
3. Li J, Fan YY, Xin MZ, et al. A randomised, controlled trial comparing the long-term effects of peripherally inserted central catheter placement in chemotherapy patients using B-mode ultrasound with modified Seldinger technique versus blind puncture. Eur J Oncol Nurs 2014;18:94-103. [Crossref] [PubMed]
4. He L, Ye Q, Huang L, et al. Using phlebotomy to remove a difficult peripherally inserted central catheter insertion and removal in very low birth weight infants: case report of a rare complication. AME Case Rep 2024;8:51. [Crossref] [PubMed]
5. Cotogni P, Barbero C, Garrino C, et al. Peripherally inserted central catheters in non-hospitalized cancer patients: 5-year results of a prospective study. Support Care Cancer 2015;23:403-9. [Crossref] [PubMed]
6. Ong B, Gibbs H, Catchpole I, et al. Peripherally inserted central catheters and upper extremity deep vein thrombosis. Australas Radiol 2006;50:451-4. [Crossref] [PubMed]
7. Liem TK, Yanit KE, Moseley SE, et al. Peripherally inserted central catheter usage patterns and associated symptomatic upper extremity venous thrombosis. J Vasc Surg 2012;55:761-7. [Crossref] [PubMed]
8. Duwadi S, Zhao Q, Budal BS. Peripherally inserted central catheters in critically ill patients - complications and its prevention: A review. Int J Nurs Sci 2019;6:99-105. [Crossref] [PubMed]
9. Long BX. Analysis and nursing of related factors of PICC extubation difficulty in patients with cancer. Jilin Medical Journal 2010;31:3291-2.
10. Wall JL, Kierstead VL. Peripherally inserted central catheters: resistance to removal: a rare complication. J Intraven Nurs 1995;18:251-4. [PubMed]
11. Krein SL, Saint S, Trautner BW, et al. Patient-reported complications related to peripherally inserted central catheters: a multicentre prospective cohort study. BMJ Qual Saf 2019;28:574-81. [Crossref] [PubMed]
12. Le J, Grigorian A, Chen S, et al. Novel endovascular technique for removal of adherent PICC. J Vasc Access 2016;17:e153-5.
13. Vlasenko SV, Agarkov MV, Khilchuk AA, et al. Endovascular management of the peripherally inserted central venous catheter iatrogenic pinch-off syndrome: A case report. Radiol Case Rep 2019;14:381-4. [Crossref] [PubMed]
14. Zhao LS, Wang SM, Zhao L, et al. Effect of Ultrasonography on PICC Extubation Process. Chinese Journal of Ultrasound in Medicine 2016;32:1140-2.
15. Zhan S, Xue XY. Nursing report on the difficulty of PICC extubation in a child with acute lymphoblastic leukemia. Electronic Journal of Practical Clinical Nursing Science 2018;3:167, 171.
16. Serrano M, García-Alix A, López JC, et al. Retained central venous lines in the newborn: report of one case and systematic review of the literature. Neonatal Netw 2007;26:105-10. [Crossref] [PubMed]
17. Jones SA, Giacomantonio M. A complication associated with central line removal in the pediatric population: retained fixed catheter fragments. J Pediatr Surg 2003;38:594-6. [Crossref] [PubMed]
18. Chemaly RF, de Parres JB, Rehm SJ, et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis 2002;34:1179-83. [Crossref] [PubMed]
19. Miall LS, Das A, Brownlee KG, et al. Peripherally inserted central catheters in children with cystic fibrosis. Eight cases of difficult removal. J Infus Nurs 2001;24:297-300. [Crossref] [PubMed]
20. Zhang X, Qing YZ, Ba HJ, et al. The intervention technique for removal of adherent peripherally inserted central catheter. Chinese Journal of Vascular Surgery 2017;9:56-8. (Electronic Version).