thrombosus with picc lines


Is it typical to develop a thrombus in the cephalic vein if you accessed the basilic for the picc line?   We had a pt recently discharged, we pulled picc line and 2 weeks later developed redness and edema.  Ultrasound showed thrombus in cephalic vein.


Also;  want is the treatment plan once you confirm a DVT?   



If the thrombus is occlusive, then the blood flow in that vessel is nil. The thrombus completely blocks off the blood flow, and is attached to the vessel wall and the PICC. By pulling on the line, that could possibly cause some part of the thrombus to unattach. Our experience is that anticoagualting for 2 days or so will not dissolve the thrombus, but prevents more from forming and in the long run, the thrombus should eventually dissolve. I have seen many cases of thrombus though, that never completely dissolve even with 3-6 months of Coumadin. We find patient's who have had subclavian thrombus related to PICC's or not, can often have a "nonpatent" vessel. This is narrowing, or stricture or blockage or residual thrombus (or whatever you want to call it ) in the vein and presents ongoing problems for this population. Part of our assessment for all PICC's is to evaluate any existing lines and the results of them.

In looking at cephalic veins, it is clearly a superficial vein, and if one were to scan patient's arms that don't have PICC's they would find that cephalic thrombus is actually pretty common. The median cubital vein is a common vessel to place IV's in the the antecub area and that connects with the cephalic vein, which does not have the flow in it that the basilic vein does.

Hope this helps!


Can you elaborate a bit more on the rationale for not pulling a line with an occlusive thrombus and starting anticoagulant. Versus, pulling the line if the clot is non-occlusive?

At our institution, we follow up with the results of the doppler study to determine two things.....exactly where the thrombus is and if it is occlusive or non-occlusive.  If the thrombus is occlusive, we administer Lovenox, heparin, etc for 1-2 days then remove the line.  If the thrombus is non-occlsuive and contained in the arm, we will pull the line if indicated. 

We used to leave the PICC in and anticoagulate.  In every one that we managed this way, the edema in the extremity dramatically decreased.  These were only for clots contained in the upper extremity and not for subclavian or central clots.  Hope this helps. 

Does anyone feel that you SHOULDN'T pull the catheter with the DVT alongside?  We had this happen three times in the last year and I am concerned about nursing liability to have the DVT travel into the heart and lungs as we pull the line because there is no longer an anchor for the clot.  One doc says "it is too small" to do any damage.  We have not made this into a specific policy as yet but will probably work on it soon.  Any thoughts on this?


Look at the AVA website for the 2006 Indianapolis AVA Conference.   There were several speakers who spoke on the topic of venous or catheter-related thrombosis.  Peter Bream is an interventional radiologist who gave a very good talk about catheter tip location and thrombosis.  One of the Italian doctors did an excellent overview of the literature about catheter-related thrombosis.   There is actually no consensus from the literature / studies about the best course of action when catheter-related venous thrombosis occurs.  It must be weighed on a case by case basis.   There are situations where the catheter may be left in place (due to limited access) and the patient may be treated with Lovenox, etc.  Pulling the catheter every time is not always the best course of action.

I agree that this is unlikely to be related to the basilic PICC. I have seen thrombi related to PIVs, especially when irritants are administered.

Cephalic vein is not considered a DVT. I have seen this before and I think it may be due to lines that may have been placed prior to your PICC in a peripheral vein or maybe just a traumatic situation in the arm.

The basilic vein is my of vein first choice. I never had a thrombus in the cephalic after pulling a PICC and I never heard about it. I had no DVT in the last 7 month and I place around 60 Piccs a month.

As soon as there is a confirmed DVT you have to pull the PICC and further treatment is up to the MD.