I placed a PICC in a patient on 05/10/07, it was unremarkable. I cannulated the median cubital vein via micropuncture about 1.5-2" below the ac. The cxr was read by the radiologist as tip in SVC. This pt was subsequently transplanted on 06/19/07 and I was called the following day by the cardiologist to say that they saw the tip of the picc in the aorta. It was also confirmed by ct of the chest on 06/20/07. It was d/c'd and after I spoke with the cardiologist I went to see pt. The nurse said there was no bleeding from the site and the site was not even covered with a dsg. I could actually still see the vein I cannulated. It was such a routine placement, that I did not even recognize the guy. If there was any question about arterial placement I would have pulled the line or at the very least got a blood gas. The only thing I can think of is if at some point I went through the median cubital vein and into the brachiocephalic artey. The patient had 10 cxr between 05/10 and 06/20 with no mention of malposition. Any thoughts???