JVA

J Vasc Access 2016; 17 (6): e153-e155

DOI: 10.5301/jva.5000580

ISSN 1129-7298 CASE REPORT

Novel endovascular technique for removal of adherent

PICC
Julie Le1, Areg Grigorian2, Samuel Chen2, Isabella J. Kuo2, Roy M. Fujitani2, Nii-Kabu Kabutey2
1
Oakland University William Beaumont School of Medicine, Rochester, Michigan - USA
2
Division of Vascular and Endovascular Surgery, University of California Irvine, Irvine, California - USA

Abstract
Introduction: Peripherally inserted central catheters (PICCs) are a popular alternative to central venous lines.
PICCs can provide reliable long-term access for intravenous fluids, antibiotics and total parenteral nutrition. Mul-
tiple factors can contribute to difficult PICC removal including adherent fibrin and thrombus formation around
the catheter. We discuss a novel endovascular retrieval technique to remove tightly adherent PICCs.
Case presentation: A 42-year-old male with history of chronic pancreatitis requiring intravenous pain medica-
tions, presented with right upper extremity single lumen PICC that could not be removed by standard techniques.
The PICC line had been in place for approximately three years and was no longer functioning appropriately. Ultra-
sonography demonstrated thrombus alongside the length of the PICC.
Results: In order to remove the PICC we utilized a novel endovascular technique. A 0.018” mandril wire was
passed through the lumen of the PICC. Next, a puncture alongside the PICC was performed to place a 6 French
(Fr) sheath. A snare was then maneuvered through the sheath and used to capture the tip of the mandril wire.
The snare, mandril wire and PICC where withdrawn in unison, looping the PICC tip within the basilic vein. The tip
of the PICC was positioned near the antecubital fossa. A small incision was performed to capture the tip of the
PICC to remove the catheter.
Discussion: Tightly adherent PICCs can result after prolonged intraluminal dwell times. We describe a novel
endovascular technique that can be utilized for safe and successful removal of difficult embedded PICCs.
Keywords: Catheter, Endovascular, PICC, Removal

Introduction venous endothelium, thrombus and fibrin formation around

Peripherally inserted central venous catheters (PICCs)
have increasingly become utilized as an alternative to tra-
ditional central venous catheters in the hospital and outpa-
tient setting. PICCs can provide reliable long-term venous
access for intravenous fluids, medications and total paren-
teral nutrition. PICCs have relatively low risk of procedural
complications at the time of insertion and retrieval. A physi-
cian or trained registered nurse can typically perform PICC
removal by simple withdrawal at the bedside. Multiple fac-
tors that can contribute to difficult PICC removal include:
venous vasospasm, knotting, entanglement, adhesion to
Accepted: May 8, 2016
Published online: June 1, 2016
Corresponding author:
Nii-Kabu Kabutey, MD
University of California, Irvine Medical Center
Department of Surgery
Division of Vascular and Endovascular Surgery
333 City Blvd, West, Suite 1600
Orange, 92868 CA, USA
nkabutey@uci.edu
the catheter. We describe a hybrid technique for removal of
a long-standing PICC line complicated by extensive intralu-
minal thrombus and fibrinous attachments.
Case presentation
A 42-year-old-male with a history of chronic pain second-
ary to chronic pancreatitis presented to the vascular surgery
clinic after unsuccessful PICC removal attempts.
The right upper extremity single-lumen PICC was tightly
adherent, and caused considerable pain during attempted re-
traction of the catheter. Simple withdrawal techniques with
adjunctive strategies including warm compress, tourniquet
application, differing arm positioning did not help with re-
moval. Additionally, a small incision and exploration at the
insertion site with tension on the catheter did not assist in
removal of the PICC.
The patient’s PICC had been in place for approximately
three years and was no longer functioning appropriately.
There was no sign of entrance site infection. The patient
denied any recent fever or drainage from the insertion site.
Physical examination demonstrated edema of the right fore-
arm extending into the lateral neck with palpable right radi-
al and ulnar pulses with no focal sensory or motor deficits.

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Fig. 1 - Snare alongside embedded peripherally inserted central
catheter (PICC) used to capture mandril wire that was inserted
through the PICC.
Ultrasonography revealed occlusive thrombus involving the
right basilic, axillary, subclavian, and brachiocephalic veins
with extension into the right internal jugular vein.
The patient was started on a heparin drip and taken to the
hybrid operating room for removal of the 6 Fr single lumen
PICC after consent had been obtained. The external portion
of the PICC was sterilized with chlorohexidine and not imme-
diately transected to allow for the catheter to remain in situ
in case it could not be successfully retrieved. Ultrasound guid-
ance was used to cannulate the right basilic vein adjacent to
the PICC. A 0.035” glide-wire was manipulated alongside the
length of the PICC line to the level of the right atrium. Next,
a 6 Fr sheath was placed over the wire. An EN Snare® (Merit
Medical, South Jordan, Utah, USA) was passed over the wire.
Multiple attempts were made to capture the tip of the PICC
line within the EN Snare® device without success. The tip of
the catheter was most likely adherent to the vessel wall. In
order to capture the PICC a 0.018” mandril wire was placed
into the lumen of the catheter and advanced just past the
level of the tip. The EN Snare® was then able to capture the
mandril wire (Fig. 1). Once this was achieved, the EN Snare®,
mandril wire, and PICC line were all retracted back towards
the sheath within the right basilic vein (Fig. 2). The tip of the
Novel endovascular technique for removal of adherent PICC
Fig. 2 - Peripherally inserted central catheter looped within basilic
vein after the mandril wire was snared at the cavo-atrial junction.
Fig. 3 - Section of peripherally inserted central catheter with adher-
ent fibrin sheath encased along the length of the catheter.
PICC line was kinked by the EN Snare® and would not enter
the 6 Fr sheath and the EN Snare® device was slipping off the
tip of the mandril wire as it was being drawn into the sheath.
At this point a small longitudinal incision was performed to
encompass both the PICC and 6 Fr sheath insertion sites. Dis-
section of the skin incision site was carried down to the level
of the vein. As the sheath was withdrawn from the vein, the
PICC tip also came out of the vein at the level of the inci-
sion and was grabbed with forceps and the entire PICC was
removed in one piece. It was only at this time the exterior
segment of the PICC hub and wing were transected to allow
complete removal of the entire catheter. The remainder of
the catheter was removed with gentle retraction. There was
a fibrin sheath encased around multiple portions of the PICC
(Fig. 3). Manual compression was performed for hemostasis
and the patient was discharged home the same day on oral
anticoagulation for treatment of the deep venous thrombus.
Discussion
The vast majority of PICCs can be removed by simple
withdrawal at the bedside or in the clinic. Adhesions to
venous endothelium resulting from infection, endothelial
thrombus, fibrin formation, and venospasm can all contrib-
ute to difficult PICC removal (1). Complications of the PICC
removal can include PICC fracture and fragment emboliza-
tion. These complications can be catastrophic due to the risk
© 2016 Wichtig Publishing
Le et al
of potential cardiac or pulmonary emboli (2). We describe
an endovascular technique that can be employed to safely
remove densely adherent PICCs. We hypothesize that the
PICC line was likely adherent to an enveloping fibrin sheath
along a majority of its length. Snaring the tip of the mandril
wire and pulling it out with the PICC towards its origin, likely
allowed for the disruption of dense adhesions along the ve-
nous endothelium.
In the pediatric population, PICCs are often used for hy-
peralimentation and medication administration, and can be
met with resistance during removal mainly due to the small
size of the upper extremity veins and intense venospasm
(1). This occurs when the tunica media layer is stimulated
during catheter removal and manifests as a palpable cord.
This resistance to PICC removal can be treated with heat
application to the upper extremity. If this is unsuccessful,
catheter removal is delayed by 12-24 hours to allow the ve-
nospasm to subside (2).
In the adult population there are a number of factors that
can lead to difficult PICC removal including infection, endo-
thelial thrombus, fibrin formation. Prolonged intravascular
PICC dwell times can lead to thrombosis in the deep or su-
perficial veins (3). This is the leading cause of morbidity in
patients with PICCs, with a symptomatic incidence of roughly
3%-8% (4-6). Thrombus, fibrin adhesion, development of
calcification and infection may all lead to dense intraluminal
catheter adherence. Kabra et al recently reported a difficult
PICC line removal leading to a complication of brachial vein
stripping due to the vein being tightly adherent to the PICC
throughout its entire length (7).
Accepted adjuncts to assist in difficult catheter re-
moval include gentle massaging of the upper arm, warm
compresses over the course of the catheter for vein dis-
tension, tension on the catheter, and tourniquet applica-
tion (6). However, once these options fail, invasive surgical
management is often required. Desai and colleagues (8)
recently described an endovascular technique designed to
release central venous catheters entrapped at the superior
vena cava cardiopulmonary bypass cannulation site. Resis-
tance to central venous catheter removal can occur at a su-
ture fixation point caused by closing purse string sutures
at the cardiopulmonary bypass cannulation site. Through
and through wire access utilizing a reverse curve catheter
around the suture fixation site allowed for downward trac-
tion to release the suture tension and allow for catheter
removal (8). This method may be adapted to be potentially
© 2016 Wichtig Publishing
e155
employed when there is a single identifiable point of PICC
fixation to the venous endothelium.
The endovascular technique described in this report is
likely more suitable for catheters with multiple points of
adherence. Placement of a mandril wire through the PICC
catheter to allow for snaring distal to the tip demonstrates
a novel approach for PICC removal employing an endo-
vascular technique that may be used when conservative
options fail.
Disclosures
Financial support: No grants or funding have been received for this
study.
Conflict of interest: None of the authors has financial interest
related to this study to disclose.
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