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Sally Walker
PICC removal in presence of occlusive thrombus

We have an older gentleman who has had a 5 fr dual lumen PICC (right basilic vein) for just over a month (he is almost 2 months post open heart surgery with post-op infection)--antibiotics, other meds. For about the past week and a half, his right arm has been more edematous than his left and we asked for US to assess. US was finally done yesterday and shows complete occlusion of right basilic and axillary veins, with partial occlusion of subclavian vein. We have been unable to remove the PICC--it will not budge. Tried heat with no change; this man is already on low dose heparin (INR at 1.2 fairly consistently over the post-op period). The physician has asked that the PICC be removed in Angio--I suspect that will not happen soon.

Any suggestions as to other things I  might try to get this PICC out at the patient's bedside? 

As always, I appreciate all the contributions.


If the patient has an

If the patient has an occlusive thrombosis in the extremity extending to the axillary and subclavian vein, it sounds as though he needs anticoagulated, not low dosed.  Is there any reason he is not on full dosing heparin or lovenox? 

I know of nothing published on what to do in these cases.  Lynn, do you?  In my previous practice, we worked with the attending physician and anticoagulated the patient for a few days and then removed the line.  The anticoagulation continued for up to 6 months.  We did not have any negative consequences from this, but that is not to say that it won't happen.

Also something to think about--NOT treating this patient from this serious complication is something that must be weighed against the potential complications from treating him.  Loss of the subcalvian vein, pulmonary embolus and post thrombotic syndrome are 3 possible outcomes of upper extremity deep vein thrombosis.

In looking at the reason a thrombosis may have occurred, I would like to throw out there a couple of thoughts I have.  I did a presentation on this very thing at AVA this year!  You have not mentioned his underlying risk factors for thrombosis, but he is obivously post-operative, is elderly, has an inflammatory process occurring (antibiotics) and a dual lumen was placed.  You did not state the design of the catheter, tapered or not. Also not mentioned--was the PICC placed on the same side a the central line that he had for his surgery and was it in the left or right arm? (Each of the things I mentioned can be risk factors for thrombosis.)  Nevertheless, these factors may have played a role in the DVT developoment.  Assessment of the patient and the vessel is critical to optimum outcomes from catheter placement.

Good luck!  I'd like to know the outcomes of your actions!


Cheryl Kelley RN BSN, VA-BC

I need to clarify, loss of
I need to clarify, loss of the future use of the subclavian vein is what I should have said.

Cheryl Kelley RN BSN, VA-BC

Sally Walker
Cheryl, I am sorry I was

Cheryl, I am sorry I was unable to attend AVA this year, would have appreciated your presentation. I will respond to your questions, and first must let you all know that I was successful in getting the PICC removed from this gentleman. I am very new at this, so also sought the advice of a more experienced nurse here. After more heat to his right arm/shoulder and one little sub-lingual ativan (for him, not me!!), I settled in for as long as I needed to gently, but firmly get the PICC removed. It did take only a couple of minutes to feel it release, then come out cleanly--no evidence of clot material, and in spending a bit of time in his room after, no immediate ill-effects on his part.

This gentleman is about 2 months post open-heart surgery, with a wound infection. He has been quite ill and relatively immobile until about 2 weeks ago, when efforts to mobilize him intensified. The PICC was a 5 fr, dual lumen, reverse taper, groshong, and was in the right basilic vein, the same side as the CVC placed in OR. His INR is being maintained at about 1.2, so the surgeons are confident he is adequately anticoagulated.

He will have on-going need for central venous access as he is readied for further surgery for a Zenker's diverticulum--his poor peripheral venous status, surprisingly, has not changed!!

Thank you all again for your thougtful contributions to the discussion.


rivka livni
Once I could not remove an

Once I could not remove an imbeded catheter. It was very difficult, IR came up to bedside to walk me through it.

I set up as if for an exchange over a wire, inserted the guidewire into the catheter. Then pulled the dilator out of the peel away and insert the dilator over the wire and into the catheter to dilate it and the vein, then the catheter came out, though, not easily. Although the patient did not feel anything, it was very difficult to do. it took about 20 minutes of a sterile procedure, and I will never do it again. Unlike your case our patient did not have an infection and no thrombus, and by the way, he has had a few PICC after that without any problems.

Unless someone else knows something I don't, I suggest you send him to IR for removal. If that thrombus is infeted, you may not want to mess around with it. IR should prioritize this to do fairly soon.

Good Luck.

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