I recently had to refer a patient for a PICC placement by Interventional Radiology who has SVC syndrome (the SVC is occluded below the level of the azygous). The radiologist placed the PICC tip into the azygous vein. After two weeks, we now are having trouble with blood return and have had to Cathflo it twice in one week. I know this tip placement will be problematic and expect issues. Why would a radiologist choose this placement? Should a PICC have even been placed at all? This patient also has abdominal distension and lower leg edema, with warmth, redness and pain. He also has facial swelling and lower hand and arm edema bilaterally. I suggested to the family that they seek a vascular surgeon. The patient has had three failed (occluded) ports in the upper torso and now has a failed port in his right groin. Any words of wisdom for this case? His wife is frustrated, the patient is miserable and their PCP keeps blowing him off.
Wow, sounds like a vascular access diasaster! Does the abd distention and lower extremity edema indicate that there is also a problem in the IVC? If so, that might be part of the IR's rationale for using the azygous vein. But this can easily produce back pain and neuro problems from retrograde infusions because the azygous drains the spinal column. But the azygous still flows into the SVC so it does not make sense that this would be the tip location. With SVC problems, the tip location is usually placed in the IVC. If that is also a problem, then it looks like tip location inside the right atrium would be next. In other words, the tip would be placed so that infusion occurs below the thrombus problems rather than above them. There are ways to get to the IVC other than femoral such as transhepatic or translumbar, but it is usually IR who would choose these approaches. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks for the response, Lynn. This guy's SVC is occluded below the azygous, so RA placement isn't possible (the rad tried). He also had a venogram from the right femoral vein and they couldn't reach the SVC from that approach either. I also suspect IVC occlusion as well. I think it's time for a vascular surgeon, which the PCP's office tells me they are working on. In light of this, any tips on how to keep this azygous-placed (ugh!) PICC functional? Would it be wise to continue to frequently use Cathflo? How frequently can you use Cathflo? PIV's are virtually impossible in this guy, other than to butterfly his hands for labs, and even that is difficult, given the edema. He also has a GI malasorption disorder and runs low potassiums all the time and comes in weekly for a couple of K riders, so good access is a necessity. I've just got to keep this PICC limping along until he can get something better.
The blood flow from the azygous must go through the SVC so I do not understand why this site was chosen. The azygous vein joins the SVC on its posterior side at the level of the 2nd intercostal space. What is the actual insertion site? All blood and fluid flow from the azygous vein must flow through the SVC. If both SVC and IVC are occluded, how is any blood flow moving through his heart? Some venous pathway must be open if only partially. The extremity edema is caused by this severe alteration in venous blood return. So any tip location would have similar issues. I suspect the lack of blood return with the current PICC is because of the SVC obstruction. The thrombus in the SVC could be propagating to this azygous tip location, but any other tip location such as innominate or axillosubclavian vein could produce the same outcome. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861