CASE REPORT
Upper extremity deep vein thrombosis: a complication of an indwelling peripherally inserted central venous catheter Peter J. Carr & James C. R. Rippey Emergency Medicine, Faculty of Medicine, Dentistry and Health Sciences, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Nedlands, Western Australia 6009, Australia
Correspondence Peter J. Carr, Emergency Medicine, Faculty of Medicine, Dentistry and Health Sciences, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, M516, 2nd Floor, R Block, QEII Medical Centre, Nedlands, Western Australia 6009, Australia. Tel: +61893464356; Fax: +61893461665; E-mail: peter.carr@uwa. edu.au [email protected]
Key Clinical Message We report a case of peripherally inserted central venous catheter (PICC)associated deep vein thrombosis (DVT). Ultrasound images and video of subclavian thrombus are presented. PICC line-associated DVT, particularly in cancer patients is not uncommon. Point-of-care Emergency Department ultrasound can readily diagnose this complication and device removal is not always necessary.
Funding Information This report is funded by The University of Western Australia, Emergency Medicine department. Received: 9 February 2014; Revised: 25 September 2014; Accepted: 25 October 2014 Clinical Case Reports 2015; 3(3): 170–174 doi: 10.1002/ccr3.187
Introduction The use of the peripherally inserted central venous catheters (PICC) for intravenous nutrition [1] and intravenous therapy developed a new era for vascular access science. Since the PICC’s debut in the 1970s its popularity has increased exponentially. This is attributed primarily to perceived safety, ease of insertion, and increased dwell time when compared to other central venous access devices [2]. PICCs are, however, not without complication, and the relatively high rate of PICC-associated thrombus is recognized [3, 4].
Case History A 40-year-old male with a diagnosis of metastatic cholangiocarcinoma (malignancy of the bile ducts) presented to a busy metropolitan ED. He had been receiving intravenous chemotherapy for several weeks, through a 5Fr dou170
ble lumen power injectable PICC inserted into his right basilic vein. He presented with right arm swelling, discomfort, and discoloration (Fig. 1). Bedside ultrasound in the emergency department rapidly confirmed our clinical suspicion, and displayed an acute, completely occlusive PICC-associated thrombus, involving the basilic, axillary, and subclavian veins (Fig. 2–5). There was no internal jugular or brachiocephalic vein involvement.
Outcome The patient was commenced on therapeutic anticoagulation (subcutaneous enoxaparin twice daily). The PICC was not removed as the patient required intravenous therapy. His symptoms settled entirely within 5 days. We had the opportunity to review the patient 6 weeks postdiagnosis of his PICC-associated deep vein thrombosis (DVT)
ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
P. J. Carr & J. C. R. Rippey
Upper extremity deep vein thrombosis
and repeated the ultrasound examination. This demonstrated complete resolution of the basilic, axillary, and subclavian thrombus, and confirmed patency of these previously occluded vessels (Fig. 6–7).
Discussion The vascular access device choice selected for treatment of metastatic cholangicarcinoma was a 5Fr power injectable PICC. This was to facilitate administration of palliative chemotherapy and potential intravenous medication and to avoid the trauma of repeated venipuncture for blood sampling. The risk factors for intravascular thrombus formation in this case include all of Virchow’s triad – endothelial injury, hemodynamic flow changes, particularly stasis and hypercoagulability [5]. This patient had local vessel trauma from the PICC insertion procedure, the PICC line itself alters flow dynamics within the vessel and for this reason the smallest catheter size is suggested [6]. Furthermore, the PICC may act as a nidus for thrombus formation. Finally, malignancy frequently creates a hypercoagulable state.
Conclusion Figure 1. Right sided PICC and associated plethoric swollen arm suggesting upper limb deep venous thrombosis.
Our case graphically demonstrates the utility of bedside ultrasound in the diagnosis of PICC-associated thrombus.
Figure 2. This image shows the position of the PICC and where thrombus was demonstrated with ultrasound, throughout the basilic, axillary and subclavian veins.
ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
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Upper extremity deep vein thrombosis
P. J. Carr & J. C. R. Rippey
Figure 3. Dual images (original left; legend right). This image shows the occlusive subclavian vein thrombus (dark red) ending as it meets the right internal jugular vein to form the right brachiocephalic vein (blue).
Figure 4. Dual images (original left; legend right). A transverse view of the axillary vein with PICC in place, surrounded by echogenic thrombus that is distending the vein (dark red). The axillary artery (red) and cephalic vein (blue) are also seen.
Figure 5. Dual images (original left; legend right). A longitudinal view of the axillary vein containing the PICC. The line is surrounded by echogenic thrombus (red). [Correction added on 3 February 2015, after first online publication: Figures 5 and 6 captions were interchanged]
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ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
P. J. Carr & J. C. R. Rippey
Upper extremity deep vein thrombosis
Figure 6. Dual images (original left; legend right). A transverse view of the axillary vein with PICC in place (dark red). The vein is no longer distended, and the blood flowing freely around the PICC is anechoic. The axillary artery (red) and cephalic vein (blue) are again seen, the cephalic vein is no longer distended. [Correction added on 3 February 2015, after first online publication: Figures 5 and 6 captions were interchanged]
Figure 7. Dual images (original left; legend right). A longitudinal view of the axillary vein containing the PICC. Resolution of the thrombus has occurred with blood now flowing freely around the PICC (blue).
Once the diagnosis is made, the PICC does not need to be removed, and resolution of thrombus with therapeutic anticoagulation is usual [7]. Therefore, repeated venipuncture and vascular access procedures are minimized maintaining vessel health and integrity as well as reducing a cost for the healthcare provider. Chopra and colleagues recently published a systematic review and meta-analysis on risk of venous thromboembolism associated with PICCs. They found increased DVT rate with PICCs in comparison to central venous catheters. It identified patients with a critical illness or malignancy to have the highest risk for catheter associated DVT [4]. Consideration of the risks, benefits and patient preference should take precedent before deciding on a PICC.
Conflict of Interest None declared. References 1. Hoshal, V. L. 1975. Total intravenous nutrition with peripherally inserted silicone elastomer central venous catheters. Arch. Surg. 110:644–646.
ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
2. Walshe, L. J., S. F. Malak, J. Eagan, and K. A. Sepkowitz. 2002. Complication rates among cancer patients with peripherally inserted central catheters. J. Clin. Oncol. 20:3276–3281. 3. Gallieni, M., M. Pittiruti, and R. Biffi. 2008. Vascular access in oncology patients. CA Cancer J. Clin. 58:323– 346. 4. Chopra, V., S. Anand, A. Hickner, M. Buist, M. A. Rogers, S. Saint, et al. 2013. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet 382: 311–325. 5. Bagot, C. N., and R. Arya. 2008. Virchow and his triad: a question of attribution. Br. J. Haematol. 143:180–190. 6. Nifong, T. P., and T. J. McDevitt. 2011. The effect of catheter to vein ratio on blood flow rates in a simulated model of peripherally inserted central venous catheters. Chest 140:48–53. 7. Berube, C., and J. L. Zehnder. Catheter-related upper extremity venous thrombosis. In: UpToDate, Post, T. W. (Ed), UpToDate, Waltham, MA. Available at http://www. uptodate.com/contents/catheter-related-upper-extremityvenous-thrombosis?source=search_result&search=picc+ associated+dvt&selectedTitle=1~150 (Accessed on May 14, 2014).
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Upper extremity deep vein thrombosis
Supporting Information Additional Supporting Information may be found in the online version of this article:
174
P. J. Carr & J. C. R. Rippey
Video S1. The case is briefly discussed and the ultrasound features of PICC associated venous thrombus are demonstrated with ultrasound video loops.
ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
Upper extremity deep vein thrombosis: a complication of an indwelling peripherally inserted central venous catheter Peter J. Carr & James C. R. Rippey Emergency Medicine, Faculty of Medicine, Dentistry and Health Sciences, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Nedlands, Western Australia 6009, Australia
Correspondence Peter J. Carr, Emergency Medicine, Faculty of Medicine, Dentistry and Health Sciences, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, M516, 2nd Floor, R Block, QEII Medical Centre, Nedlands, Western Australia 6009, Australia. Tel: +61893464356; Fax: +61893461665; E-mail: peter.carr@uwa. edu.au [email protected]
Key Clinical Message We report a case of peripherally inserted central venous catheter (PICC)associated deep vein thrombosis (DVT). Ultrasound images and video of subclavian thrombus are presented. PICC line-associated DVT, particularly in cancer patients is not uncommon. Point-of-care Emergency Department ultrasound can readily diagnose this complication and device removal is not always necessary.
Funding Information This report is funded by The University of Western Australia, Emergency Medicine department. Received: 9 February 2014; Revised: 25 September 2014; Accepted: 25 October 2014 Clinical Case Reports 2015; 3(3): 170–174 doi: 10.1002/ccr3.187
Introduction The use of the peripherally inserted central venous catheters (PICC) for intravenous nutrition [1] and intravenous therapy developed a new era for vascular access science. Since the PICC’s debut in the 1970s its popularity has increased exponentially. This is attributed primarily to perceived safety, ease of insertion, and increased dwell time when compared to other central venous access devices [2]. PICCs are, however, not without complication, and the relatively high rate of PICC-associated thrombus is recognized [3, 4].
Case History A 40-year-old male with a diagnosis of metastatic cholangiocarcinoma (malignancy of the bile ducts) presented to a busy metropolitan ED. He had been receiving intravenous chemotherapy for several weeks, through a 5Fr dou170
ble lumen power injectable PICC inserted into his right basilic vein. He presented with right arm swelling, discomfort, and discoloration (Fig. 1). Bedside ultrasound in the emergency department rapidly confirmed our clinical suspicion, and displayed an acute, completely occlusive PICC-associated thrombus, involving the basilic, axillary, and subclavian veins (Fig. 2–5). There was no internal jugular or brachiocephalic vein involvement.
Outcome The patient was commenced on therapeutic anticoagulation (subcutaneous enoxaparin twice daily). The PICC was not removed as the patient required intravenous therapy. His symptoms settled entirely within 5 days. We had the opportunity to review the patient 6 weeks postdiagnosis of his PICC-associated deep vein thrombosis (DVT)
ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
P. J. Carr & J. C. R. Rippey
Upper extremity deep vein thrombosis
and repeated the ultrasound examination. This demonstrated complete resolution of the basilic, axillary, and subclavian thrombus, and confirmed patency of these previously occluded vessels (Fig. 6–7).
Discussion The vascular access device choice selected for treatment of metastatic cholangicarcinoma was a 5Fr power injectable PICC. This was to facilitate administration of palliative chemotherapy and potential intravenous medication and to avoid the trauma of repeated venipuncture for blood sampling. The risk factors for intravascular thrombus formation in this case include all of Virchow’s triad – endothelial injury, hemodynamic flow changes, particularly stasis and hypercoagulability [5]. This patient had local vessel trauma from the PICC insertion procedure, the PICC line itself alters flow dynamics within the vessel and for this reason the smallest catheter size is suggested [6]. Furthermore, the PICC may act as a nidus for thrombus formation. Finally, malignancy frequently creates a hypercoagulable state.
Conclusion Figure 1. Right sided PICC and associated plethoric swollen arm suggesting upper limb deep venous thrombosis.
Our case graphically demonstrates the utility of bedside ultrasound in the diagnosis of PICC-associated thrombus.
Figure 2. This image shows the position of the PICC and where thrombus was demonstrated with ultrasound, throughout the basilic, axillary and subclavian veins.
ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
171
Upper extremity deep vein thrombosis
P. J. Carr & J. C. R. Rippey
Figure 3. Dual images (original left; legend right). This image shows the occlusive subclavian vein thrombus (dark red) ending as it meets the right internal jugular vein to form the right brachiocephalic vein (blue).
Figure 4. Dual images (original left; legend right). A transverse view of the axillary vein with PICC in place, surrounded by echogenic thrombus that is distending the vein (dark red). The axillary artery (red) and cephalic vein (blue) are also seen.
Figure 5. Dual images (original left; legend right). A longitudinal view of the axillary vein containing the PICC. The line is surrounded by echogenic thrombus (red). [Correction added on 3 February 2015, after first online publication: Figures 5 and 6 captions were interchanged]
172
ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
P. J. Carr & J. C. R. Rippey
Upper extremity deep vein thrombosis
Figure 6. Dual images (original left; legend right). A transverse view of the axillary vein with PICC in place (dark red). The vein is no longer distended, and the blood flowing freely around the PICC is anechoic. The axillary artery (red) and cephalic vein (blue) are again seen, the cephalic vein is no longer distended. [Correction added on 3 February 2015, after first online publication: Figures 5 and 6 captions were interchanged]
Figure 7. Dual images (original left; legend right). A longitudinal view of the axillary vein containing the PICC. Resolution of the thrombus has occurred with blood now flowing freely around the PICC (blue).
Once the diagnosis is made, the PICC does not need to be removed, and resolution of thrombus with therapeutic anticoagulation is usual [7]. Therefore, repeated venipuncture and vascular access procedures are minimized maintaining vessel health and integrity as well as reducing a cost for the healthcare provider. Chopra and colleagues recently published a systematic review and meta-analysis on risk of venous thromboembolism associated with PICCs. They found increased DVT rate with PICCs in comparison to central venous catheters. It identified patients with a critical illness or malignancy to have the highest risk for catheter associated DVT [4]. Consideration of the risks, benefits and patient preference should take precedent before deciding on a PICC.
Conflict of Interest None declared. References 1. Hoshal, V. L. 1975. Total intravenous nutrition with peripherally inserted silicone elastomer central venous catheters. Arch. Surg. 110:644–646.
ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
2. Walshe, L. J., S. F. Malak, J. Eagan, and K. A. Sepkowitz. 2002. Complication rates among cancer patients with peripherally inserted central catheters. J. Clin. Oncol. 20:3276–3281. 3. Gallieni, M., M. Pittiruti, and R. Biffi. 2008. Vascular access in oncology patients. CA Cancer J. Clin. 58:323– 346. 4. Chopra, V., S. Anand, A. Hickner, M. Buist, M. A. Rogers, S. Saint, et al. 2013. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet 382: 311–325. 5. Bagot, C. N., and R. Arya. 2008. Virchow and his triad: a question of attribution. Br. J. Haematol. 143:180–190. 6. Nifong, T. P., and T. J. McDevitt. 2011. The effect of catheter to vein ratio on blood flow rates in a simulated model of peripherally inserted central venous catheters. Chest 140:48–53. 7. Berube, C., and J. L. Zehnder. Catheter-related upper extremity venous thrombosis. In: UpToDate, Post, T. W. (Ed), UpToDate, Waltham, MA. Available at http://www. uptodate.com/contents/catheter-related-upper-extremityvenous-thrombosis?source=search_result&search=picc+ associated+dvt&selectedTitle=1~150 (Accessed on May 14, 2014).
173
Upper extremity deep vein thrombosis
Supporting Information Additional Supporting Information may be found in the online version of this article:
174
P. J. Carr & J. C. R. Rippey
Video S1. The case is briefly discussed and the ultrasound features of PICC associated venous thrombus are demonstrated with ultrasound video loops.
ª 2015 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
