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Canadian Journal of Anesthesia 54:78-79 (2007)
© Canadian Anesthesiologists' Society, 2007

Correspondence

Knotting in peripherally inserted central catheters: more possible mechanisms

Verghese T. Cherian, MD FFARCSI, Thiruvenkatarajan Venkatesan, MD DNB and Sanjib Das Adhikary, MD

Christian Medical College Hospital, Vellore, India, E-mail: vtcherian{at}cmcvellore.ac.in

To the Editor:

While the knotting of peripherally inserted central venous catheters (PICCs) is a well described complication1,2 the factors contributing to its occurrence have not been fully explored. We present a patient who experienced knotting of a PICC line, the clinical details of which suggest mechanisms for this complication which have not been described previously.

A 56-yr-old female weighing 60 kg with a low grade glioma in the left frontal region was scheduled for an elective craniotomy and mass excision for which she required PICC line insertion. Under aseptic conditions, with the right arm abducted, the basilic vein was cannulated with a 14-G needle and cannula and a 75- cm long 16-G PICC (Cavafix, B.Braun, Melsungen AG, Germany) was inserted through the cannula. Although the cannula could not be completely inserted into the vein, the tip was sited well inside the lumen as evidenced by free flow of blood. As no resistance was encountered during insertion of the catheter, the catheter was therefore fixed at a distance of 40 cm, the distance measured from the sternal notch to the point of insertion. However, attempts to remove the stylet were unsuccessful and it was not possible to pull back the entire assembly, including the catheter. The course of the vein was radiologically screened under an image intensifier. The tip of the catheter was located in the upper arm and a knot could be visualized just above the elbow near the entry point of the skin (FigureGo). The catheter was retrieved using a small skin incision under local anesthesia. There were multiple loops in the catheter approximately 9 cm from the tip. The knot was lying outside the vein.


Figure 1
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  		FIGURE x-ray of the right arm showing the knot at the lower end of the humerus and the tip of the catheter at the level of upper arm. Arrow indicates a metal pointer placed on the skin to locate the knot.

 
Previous reports quoting this complication identified that resistance was felt after inserting the catheter about 13 to 14 cm.2,3 This distance correlates with the brachio-cephalic junction which appeared to be the point of obstruction. It is evident from our report that even without apparent resistance while inserting these catheters, knotting is still a possibility for two possible reasons. The first possible mechanism is that the needle of the cannula could have punctured the vein and provided a port of exit for the catheter. A second possible mechanism is that once the catheter had been advanced through the cannula over a certain distance, the cannula could have slipped out of the vein, leading to extravascular knotting as the catheter was further advanced. However, it has been suggested by some authors that the tip of the cannula should be withdrawn outside the lumen of the vein and sited subcutaneously to avoid the rare complication of air embolism.4 It has also been suggested that this method will protect the catheter from kinking. The circumstances of this case challenge that assumption, and suggest that it may be preferable to leave the cannula inside the vein during catheter insertion.

Knotting of a PICC is a potential complication which one must consider whenever there is difficulty in advancing the catheter, or when there is difficulty in removing the stylet. When this complication is suspected, the course of the catheter should be confirmed radiologically, and the catheter removed surgically, as excessive traction on the catheter could lead to further complications.

Footnotes

Accepted for publication October 5, 2006.

References

1 Khan ZH, Tabatabai SA. Complication of catheter knotting after right cephalic vein cannulation. Anesth Analg 1996; 82: 215–6.[Medline]

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

3 Cherian V, Faheem M. Knotting of a peripherally inserted central catheter (Letter). Can J Anesth 2004; 51: 1046–7.[Free Full Text]

4 Shang NG. Choosing the equipment. In: Latto IP, Shang Ng W, Jones PL, Jenkins BJ (Eds). Percutaneous Central Venous and Arterial Catheterisation. London: WB Saunders; 2000: 13–31.





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