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Discontinuing PICC's & CVC's in presence of DVT?

Our IV Team, (acute hospital setting), is called to discontinue PICC or CVC's's when there is a known thrombus in the arm or upper vasculature.  Concern has been raised if this is appropriate or should these catheters be removed by physicians.   It seems reasonable for us to remove them if we meet no resistance during the process.  Is there a time when we shouldn't remove them such as visible collateral circulation in upper chest/neck area or confirmed thrombus in subclavian?  Dependent on clot size?  Please share your input and/or current practices.


I am not aware of any

I am not aware of any published guidelines for this issue. It is important to remember that we remove asymptomatic CVCs all the time that have silent catheter-related thromboses. In fact the vast majority are clinically silent. So you still need to have the assessment skills and knowledge, and removal skills regardless of whether there is a diagnosed thrombosis or not. Lynn 


Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

I posed this same question

I posed this same question to a clin. spec. for the company that provides our PICC lines and it got passed around the clin. spec. arena and came back to me like this:

There is no evidence-based data on this that I know of, and I have looked and asked just about everyone I know. The most definitive opinion I've heard came from Boaz Markowitz MD who spoke at a general session and many breakouts at AVA this year. He said he has done the same questioning, and found no specific data... but finally asked a colleague who is the editor of the journal Chest. Chest has an annual symposium on DVT, and publishes a special issue discussing current trends. He said that this colleague recommends pulling the line immediately if the clot IS NOT totally occlusive on ultrasound, but treating with Lovenox for 48 hours before pulling the line if the clot IS totally occlusive.
Again, there's no study to support this, but in the absence of data, Dr. Markowitz recommended deferring to the opinion of the most enlightened and educated expert in study of DVTs and their treatment.
Halle Utter
This topic came up today in

This topic came up today in a discussion with a colleague.  She was told by a younger physician that it is acceptable to use the indwelling thrombosed line for infusion of heparin, and that this is a better treatment than pulling the PICC on the affected side and replacing it with another PICC on the opposite unaffected side, because "the damage is already done".  I have always wondered personally if pulling these lines dislodges the thrombus causing a pulmonary embolism, but maybe it's not significant enough to cause a symptomatic response.  Lynn's point is well taken, since we know there is a large volume of clinically silent catheter-related thromboses. I have never seen symptoms of a PE when I pulled a PICC, with known clot or not, but have certainly wondered about it.  Are there any circumstances under which pulling the line is not clinically indicated?  Anyone else ever heard what this young physician told my colleague?  There was one case I recall where a patient has a large thrombus along the line extending into the SVC and they treated the patient with a slow drip of TPA for a while before removing the line, but I never saw the outcome.  We sure could use some more studies/information in this area!


Halle Utter, RN, BSN

Intravenous Care, INC 

Hallene E Utter, RN, BSN Intravenous Care, INC

Ditto for us on the info

Ditto for us on the info posted thus far.  We used to refuse to pull a line with a known thrombus, and had the MDs do it.  It bothered me that we had such a firm stance and no data, little literature.  Now, our team decided we'll remove the line after discussing with MD (the extent of occlusion, pt. history, etc.), and ask that the physician be in house/available in case of embolus.  We've yet to have an embolic episode occur (that we were aware of).

Plus....most of the residents know very little about PICCs and we do a much better job handling them, so we'd just as soon be the ones removing them (and the MDs agree!).

I've also suggested in some cases that the line be used for lysis, but usually they want them removed immediately. 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

I am so glad that this

I am so glad that this subject has been raised again!  The information already posted has been very valuable.  The question I would like to pose to the experts on the forum is......once a patient has a documented history of DVT in the upper extremitiy or chest area whether it was due to a PICC line or another type of CVC is there a standard in regards to the placement of a new PICC line or another type of a CVC in this type of patient at any point?  If there are no contraindications to placing a new PICC or CVC does anyone know if there are standards or guidelines to follow in regards to how soon this may take place and if the catheter should be placed in the opposite side if not contraindicated for some other reason.....and if the opposite can not be soon can a PICC or CVC be placed on the side of thrombosis once it is has been resolved with antiocoag therapy?  Is there any information in regards to this same question with patients who have a history of SVC Syndrome? 

Thanks in advance to anyone who can help me to find the correct standard of practice once and for all!  


Daphne Broadhurst
Our facility participated in

Our facility participated in a pilot trial studying the outcomes of leaving a CVAD insitu in the presence of a thrombosis. The published study conclusion: "Treatment of UEDVTs secondary to central catheters in cancer patients with standard dalteparin/warfarin can allow the central line to remain in situ with little risk of line failure or recurrence/extension of the DVT."

KOVACS, M. J. ; KAHN, S. R. ; RODGER, M. et al. Journal of Thrombosis & Haemostasis. 5(8):1650-1653, August 2007.


Daphne Broadhurst
Ottawa ON

Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

Diane Mitchell RN BSN MA,

Diane Mitchell RN BSN MA, Manager IVT & Infusion Center, SSM St. Mary's Health Center, St. Louis

This is all very good information- thank you all for your ongoing input!

Diane Mitchell RN

I am looking for any

I am looking for any information on what the standard is for most facilities with regard to the PICC nurse pulling a line associated with thrombus formation....I did see the one entry form Mari Cordis, stating that the nursing staff pull the lines....we also asked the physicians to pull the lines associated with documented clot formation, but as Mari stated, we are rethinking this...does anyone have any literature or have any experience with this?  What is the general consensus of most PICC teams...I look forward to obtaining any advice or information.  I am doing a lit search on the incidence in pulmonary embolism with thrombus due to picc line placement but have not had much success.  Once again, any information would be helpful.


The majority of catheter

The majority of catheter related thrombosis is clinically silent - you have no signs and symptoms to tell you there is a problem. So in my opinion, it does not matter who pulls the line but they need to know the risk and be ready to handle the consequences. For your literature search use "upper extremity deep vein thrombosis" to produce better results. There are numerous articles out there and most link the cause to the presence of all types of CVCs. Lynn 


Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Something to think about
Something to think about when removing PICC's that have a known DVT:  At my facility, we had open and frequent dialogue with the doppler techs in the vascular lab.  They knew that if we had a patient with a DVT and a PICC, that we wanted to know the origination of the clot, the terminal location of it and it is was a "complete occlusion" or not.  If the clot was adhered to the catheter AND the vessel walll completely, we would anticoagualate for 2 days with standard heparin infusion and then pull it.  Not saying it is right or wrong, but it worked for us.  The PICC team was also the ones who pulled it as we had the experience to know what felt OK and what didn't.

Cheryl Kelley RN BSN, VA-BC

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