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Canadian Journal of Anesthesia 51:1046-1047 (2004)
© Canadian Anesthesiologists' Society, 2004

Correspondence

Knotting of a peripherally inserted central catheter

Vinanti Cherian, FFARCSI and Mohammad Faheem, FFARCSI DEAA

Mullingar, Ireland

To the Editor:

Peripherally inserted central venous catheterization (PICC) is a technique used both in the ward setting and in the intensive care unit. Cost and safety considerations favour the use of PICCs as an alternative to other vascular access devices.1 Knotting of catheters is a well-recognized complication of both central and peripheral venous catheterization.2,3 We wish to highlight such a case and discuss the appropriate management.

A 65-yr-old male with a past history of chronic obstructive pulmonary disease and hypertension required a PICC line for amiodarone infusion.

Under aseptic conditions, a 16-gauge (G) PICC line (Intramedicut -2, Sherwood Medical, Tullamore, Ireland) was inserted via the right cephalic vein in the antecubital fossa. During insertion resistance was felt at 13 cm. Therefore, instead of advancing the line, an attempt was made to withdraw it. However there was resistance to withdrawal also. Several attempts were made to advance the line. Each time resistance was felt at the same point, and the line could not be withdrawn smoothly. At this stage we suspected that the line had kinked inside the vein and a guide wire from a 16-G central line (Multicath, Vygon, European Union) was used in an attempt to straighten the catheter. This technique, using fluoroscopy, has been used to unravel intracardiac catheter knots.4 However it proved unsuccessful in our case. Hence the procedure was abandoned. The right internal jugular vein was then cannulated with no complications.

The percutaneously inserted catheter was subsequently retrieved under local anesthesia using a 0.5-cm skin incision. There was a double knot in the catheter 7 cm from the tip (FigureGo).



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  		FIGURE A tight double knot at 7 cm from the tip of a peripherally inserted central venous catheterization line.

 
This case highlights the fact that knot formation is possible in PICCs and that there should be a high index of suspicion if resistance is felt at the time of catheter advancement. Repeated attempts can lead to loop formation, resulting in a knot. It is interesting to note that resistance was observed in the previous two cases at approximately 14 cm2,3 and at 13 cm in our case. This distance of 13 to 14 cm correlates with the brachio-cephalic junction which appears to have been the point of obstruction.

We suggest that special attention be paid to proper positioning of the arm at the time of catheter advancement. This entails abducting the arm 45° from the trunk5 thus straightening the course of the axillary vein. If there is resistance felt consistently at the same level it would be prudent to abandon the procedure early.

References

1 Ng PK, Ault MJ, Maldonado LS. Peripherally inserted central catheters in the intensive care unit. J Intensive Care Med 1996; 11: 49–54.

2 Khan ZH, Tabatabhai SA. Complication of catheter knotting after right cephalic vein cannulation. Anesth Analg 1996; 82: 215–6.

3 Ikeda S, Shirley LD, Schweiss JF. Triple knotting of a central venous catheter. J Clin Anesth 1989; 1: 218–21.[Medline]

4 McMichan JC, Michel L. Knotting of central venous catheters: nonsurgical correction. Chest 1978; 74: 572–3.[Abstract/Free Full Text]

5 Nickalls RW. A new percutaneous infraclavicular approach to the axillary vein. Anaesthesia 1987; 42: 151–4.[Medline]




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Home page
 Canadian J. AnesthesiaHome page
V. T. Cherian, T. Venkatesan, and S. D. Adhikary
Knotting in peripherally inserted central catheters: more possible mechanisms
Can J Anesth, January 1, 2007; 54(1): 78 - 79.
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Knotting PICC
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