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A 48-year-old man diagnosed with left gingivobuccal sulcus carcinoma was started on chemotherapy for which a peripherally inserted central catheter (PICC) was placed via the right antecubital vein. The position of the catheter tip in the superior vena cava was confirmed on a chest radiograph.
After 3 weeks of PICC line insertion, the patient reported back to the oncology outpatient department with no external component of the PICC line visible in the right antecubital fossa. Chest radiograph depicted the PICC line coiled within the right and left pulmonary arteries with the free ends in the right descending pulmonary artery and the left upper lobe pulmonary artery, respectively (figure 1A). It was postulated that the PICC detached from its external connector and the entire catheter migrated in one piece to the pulmonary arteries. The patient was otherwise asymptomatic with normal laboratory parameters.
Percutaneous retrieval of the PICC line with use of a loop snare via the right common femoral venous approach was planned; however, since both ends were within the branches of the pulmonary arteries, it was difficult to place the loop snare at the ends of the catheter to grasp it. To overcome this difficulty, a 6 Fr pigtail catheter-guidewire assembly was introduced through the contralateral femoral vein in the left pulmonary artery. As the guidewire within the pigtail catheter was withdrawn, the distal loop of the pigtail catheter grasped the PICC which was then pulled back into the main pulmonary artery (figure 1B). The loop snare was then used to grasp one of the free ends of the catheter, and the entire assembly was withdrawn under fluoroscopic guidance (figures 1C and 2A). Postpercutaneous retrieval fluoroscopy revealed no retained fragments within the chest (figure 2B).
PICC lines are frequently used in patients undergoing chemotherapy to provide central venous access. Catheter fracture and migration is a rare, but serious complication, with pulmonary artery been reported as the most frequent site of embolisation.1 The migrated fragments can result in thromboembolism, infection, arrhythmias and even death. Distal lodgement within the pulmonary artery branches, as seen in this case, can also result in thrombosis and subsequent pulmonary infarction. Percutaneous retrieval techniques are frequently employed to retrieve the embolised fragments, with use of loop snares being most common. However, cases where none of the ends are available for snaring (eg, with the distal ends lodged in the vessel wall or within the pulmonary artery branches), use of flexible biopsy forceps or Dormia baskets has been reported.2 However, a simple innovation using a pigtail catheter can bring the free end of the embolised catheter to an accessible location where it can be snared easily and retrieved subsequently; thus, providing a novel and viable alternative approach in such tricky scenarios.
Peripherally inserted central catheter fracture and migration is a rare, but serious complication, with pulmonary artery being the most frequent site of embolisation.
The embolised fragment can result in thromboembolism, infection, arrhythmias and even death; hence, percutaneous retrieval techniques are frequently employed to retrieve the fragments.
Cases unsuitable for use of loop snares, due to the ends of the catheter fragment being in inaccessible locations, can be made amenable by using a pigtail catheter to pull back the fragment to an accessible location, as described in this case.
Contributors NNP, KPG and SK have participated sufficiently in the conception of the idea, development of the intellectual content, design, writing and final approval of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.