I recently had a patient who weighed over 600 pounds in which I placed a picc line. When I scanned her vessel, I could see it clearly, but then it quickly dropped off the screen. I knew that she would have some tortuous vessels, but I have encountered these patients many times and have been successful in placing their catheters into the SVC. I measured my catheter and trimmed at 47 (insertion was mid-way up the right arm). Catheter seemed to thread without difficulty and flushed easily and gave great blood return. CXR showed tip in axillary, confused, I ordered a humerus X-Ray to see the path the catheter had taken. The entire 47cm catheter was in a serpiginous vessel in her upper arm. Due to the large size of this patient, no one was willing to place a central line either subclavian or IJ; (she required surgery to remove her submental fat just to trach her). The doctor chose to leave this picc line in place as it is her only access for now. It has been 5 days and it still flushes great, a little sluggish on blood return, but after tPA - did fine. I have recommended that they do not do blood draws through this line and do circumferential measurements of her extremity as I understand the high tendency for this vessel to not only thrombose, but even infiltrate. I have strongly encouraged the physicians to inquire with surgery about the possibility of placing a tunneled catheter, but her weight prevents her from having it done in IR. We do bariatric surgeries here and I am hoping that the surgery department posesses a table that can accomodate her weight and do fluoro as well, maybe then they could place a tunnelled catheter. Would you have left your picc line (or midline technically) in place or insist on it's removal and leave them scrambling for access for this patient.