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Sally Walker
central line options for chemo

I attempted to place a PICC in woman who had a right mastectomy with axillary dissection (and subsequent right arm edema); tried left basilic, cephalic veins and could not advance either beyond about 35 cm. After nearly an hour of working with this woman, I arranged with one of the radiologists to get her to the angio suite, with PICC (wire still in place) and sheath in cephalic vein, to see if he could finish the insertion. He tried for nearly an hour, again both cephalic and basilic veins, concluding with an angiogram that she had an occlusion at the right brachiocephalic vein. 3 years ago, she had had an inplanted central access device--unclear about the specifics, but she recalls that the first one "did not work at all" and the second one developed a clot, was removed. On xray, at the time of insertion of what I believe to be the first IVAD, the tip of the catheter is in the area of the mid superior vena cava. Two days later, the xray shows the tip in the area of the junction of the SVC-right brachiocephalic vein. My question--and pardon the lengthy intro--is, of course, regarding her options. She has metastatic disease, and was scheduled to start 5 weeks of chemo. Her peripheral options are close to nil. Would anyone consider a right internal jugular vein PICC for that length of time? 

 I greatly appreciate, in advance, your contributions to this forum generally, and my question specifically.

Sally Walker, RN, CRNI

(and relatively new PICC nurse) 

I would try to investigate
I would try to investigate what happened to the other implanted ports because either her stories don't make sense or the care was mismanaged.  What does "did not work at all" mean?  Problems with accessing?  flushing? blood return?  Second one developed a clot. in the line?  in the blood vessel?  did they try cath flo?  An implanted port still seems to be the best option if it is placed properly and managed properly.
Gwen Irwin
I wouldn't place a PICC

I wouldn't place a PICC there.  Of course, inserting in the RIJ isn't in our scope of practice at our facility. 

I would probably discuss with the MD and ask for access via RIJ and place port.  In cases like this, our radiologists and surgeons are using power ports and accessing via the IJ.

Gwen Irwin

Austin, Texas

Sally Walker
I will just clarify my

I will just clarify my initial message--at the time of the attempted PICC insertion, it was found, in radiology that the occlusion existed in her left brachiocephalic, not right. Since no attempt has yet been made to access on the right side, patency has not been assessed.


Thank you all again for your thoughtful contributions to the conversation.

Sally Walker, RN, CRNI

Victoria, BC

A right IJ would not be out

A right IJ would not be out of the question. If in your scope of practice.  I have routinely done R and L IJ insertions (not at the same time) on patients with bilateral mastectomy. Where was the current IVAD right or left. If nonfunctional I would recommend removal or revision.

Jeffery Fizer RN, BSN

Sally Walker
In response to the last

In response to the last question, posed by fizerjk: her IVAD was on the left. At the time of insertion (in May, 2005), the tip was placed in the SVC. Just over a month later, the tip was located at the junction of the  left innominate vein and SVC. The IVAD was assessed in radiology, using fluoroscopy, for patency when there had been difficulty reported in attempting to withdraw blood when accessing the device--IR found it to be functioning.

Since we were, in our current attempts, unsuccessful at placing the PICC (on the left), the patient was to return to her oncologist to re-think a strategy. I have not spoken with the physician, but will make that call Monday to see if they have a new plan for access.



Gwen Irwin
I would still ask for a RIJ

I would still ask for a RIJ approach for an implanted port.

Gwen Irwin

Austin, Texas

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