Forum topic

 When the INS Standards of Practice is silent on an issue, you can safely assume that there is no evidence upon which to make any recommendations. In my opinion, it would be an additional risk to attempt a PICC insertion in an arm where a previous thrombosis has been documented. The vein should be thoroughly assessed with US for compressability, which would give you some idea of the veins health. Vein thromboses do not remain as soft, maleable clots as what we typically think about. As thrombi age, smooth muscle cells migrate into them causing the thrombus to become a stenotic area in the vein. It is often difficult, or even impossible to cannulate these veins. Some will even require use of sharp surgical devices and techniques to open the lumen enough to be able to cannulate it. Then there is the question about why this thrombus developed in the first place. Was it due to another PICC or CVAD of some type? Was this related to catheter size, insertion technique, and/or patient hypercoaguable factors? What is the clinical condition of that extremity and the venous return? If a thrombus is located in the basilic vein, and you use the cephalic or bracial vein and another thrombus develops, what will this mean clinically for the patient? Then you have to assess the patient's factors, the infusion therapy characteristics, and length of therapy. What are the other choices for CVAD insertion? You must choose the most appropriate CVAD with the least risk and most benefit for the patient. In some patient's, it might be wise to attempt a PICC insertion in the presence of a past thrombotic event but it might not be best in other patients. It all comes down to a patient-specific risk vs benefit assessment. Then there is reent published evidence. I have not conducted a recent literature search on this issue, so can not tell you what is in the literature. But this is a critical step in your decision making process. Lynn

Evans, S., Sharp, J., Linford, L., Lloyd, J., Tripp, J. Jones, J., et al. (2010).  Risk of Symptomatic DVT Associated with Peripherally Inserted Central Catheters.  Chest, doi 10.1378/chest.10-0154 and  Jones, M., Lee, D., Segall, J., Landry, G., Liem, T., Mitchell, E. et. al. (2010) Characterizing resolution of catheter-associated upper extremity deep venous thrombosis.   The Society for Vascular Surgery, doi 10.1016/j.jvs.2009.07.124 are two among many articles that point to a previous DVT as an increased risk factor for another DVT.  The second article specifically addresses this issue "...A new catheter associated upper extremity DVT (CAUEDVTs) developed in association with the new catheter in 12 of the 14 (86%) subsequent catheter placements with all but one of these new CAUEDVTs developing in equal to or less than 10 days." 

Understandably 14 patients is a very small sample size but none the less the percentage is exceptionally high.

In my institution we have a long conversation with the provider prior to placing a line in a patient with a DVT anywhere, because of the risk.

Stuart Gordon, MSN, RN, CRNI, VA-BC

Keep in mind if the manufacturer has stated in the Instructions for Use (IFU) that the PICC is contraindicated in a location with previous thrombosis, you would then be placing the PICC "off-label." Also consider this....with one of the vessels presently thrombosed, using the other vessel in the extremity for PICC placement (and potential thrombosis) could result in serious consequences for the patient.

On a second thought, it's funny how physicians, clinicians etc. in general are asking for black/white hard core evidence (and sometimes common sense) for what is actually just good clinical practice. It's quite funny that patients who have existing complications (such as the presence of a thrombosis) are put into situations where their situation can actually be exacerbated. Maybe we should think what other types of VAD's would be prudent for a patient with an existing thrombus.

Thanks!