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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 134-135

Placement of tunneled peripherally inserted central catheter for long-term chemotherapy in femoral vein in a patient with major vessel thrombosis of upper extremity


Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

Date of Submission22-May-2019
Date of Decision20-Oct-2019
Date of Acceptance22-Nov-2019
Date of Web Publication27-Oct-2021

Correspondence Address:
Abhijit S Nair
Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_56_19

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  Abstract 


Peripherally inserted central catheter (PICC) placement can be extremely challenging and difficult in certain situations. In this case report, we have described PICC placement in right femoral vein in a patient who had thrombosis of arm veins and great veins in neck. We have described a unique way of tunneling the catheter in lower abdominal wall so as to use it for long term and avoid infections which is common with groin lines.

Keywords: Chemotherapy, femoral vein, peripherally inserted central catheter


How to cite this article:
Prasad Mantha SS, Sai Kaushik P H, Nair AS, Rayani BK. Placement of tunneled peripherally inserted central catheter for long-term chemotherapy in femoral vein in a patient with major vessel thrombosis of upper extremity. CHRISMED J Health Res 2021;8:134-5

How to cite this URL:
Prasad Mantha SS, Sai Kaushik P H, Nair AS, Rayani BK. Placement of tunneled peripherally inserted central catheter for long-term chemotherapy in femoral vein in a patient with major vessel thrombosis of upper extremity. CHRISMED J Health Res [serial online] 2021 [cited 2021 Dec 2];8:134-5. Available from: https://www.cjhr.org/text.asp?2021/8/2/134/329449




  Introduction Top


A peripherally inserted central catheter (PICC) is placed for various indications such as intravenous chemotherapy, parenteral nutrition, and antibiotics. In patients with malignancies, the placement of PICC can pose unique problems which make the procedure technically difficult and challenging. This further adds to discomfort to the patient, as well. In this case report, we describe PICC placement in the right femoral vein in a patient who had thrombosis of arm veins and great veins in the neck. We describe a unique way of tunneling the catheter in the lower abdominal wall so as to use it for long term and avoid infections, which are common with groin lines.


  Case Report Top


A 36-year-old male diagnosed with primary mediastinal B-cell lymphoma was referred for the placement of PICC for chemotherapy. On reviewing his case records, we encountered a computed tomography (CT) scan which showed an anterior mediastinal mass, for which he received three chemotherapy cycles with a central line. There was a documented difficulty while insertion of central line possibly due to mediastinal mass. Recent positron emission tomography scan showed significant decrease in size and metabolic activity of anterior mediastinal mass with a nonfluorodeoxyglucose avid filling defect in the left internal jugular and left brachiocephalic vein – likely to be thrombus [Figure 1]a. The thrombus was also seen in the CT chest coronal section [Figure 1]b. Therefore, we opted for a right-sided PICC placement. Right basilic vein showed the presence of thrombus on ultrasonography (US). Therefore we decided decided for right brachial vein cannulation under asepsis with US guidance. Unfortunately, we failed to cannulate it as the vein caliber was small for puncture and subsequent cannulation. The right cephalic vein was very small in caliber and is usually not preferred for the PICC placement as the course in the arm is unusually tortuous. Thereafter, we decided to cannulate right femoral vein, with tunneling of the catheter toward inferior part of right abdomen.
Figure 1: (a) Positron emission tomography-computed tomography image showing thrombus in the left internal jugular vein and left brachiocephalic vein (shown with yellow arrow), (b) computed tomography scan showing thrombus in the left internal jugular vein and left brachiocephalic vein (highlighted with blue), (c) yellow arrow: chemoport tunneler, right arrow: peripherally inserted central catheter entry through right femoral vein, (d) red arrow: peripherally inserted central catheter shown in an X-ray erect abdomen

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Under aseptic conditions, inferolateral aspect of the abdomen and lateral part of the right thigh were infiltrated with 1% lidocaine and a small incision was made on the lateral part of thigh. Thereafter, a chemoport tunneler was passed cranially 3–4 cm above the inguinal crease. Then, the PICC was attached was attached and brought out in the thigh using the tunneler [Figure 1]c.

Right femoral vein was punctured under US-guidance and a guidewire was inserted in the vein followed by 1 cm incision at the guidewire site. The PICC was then passed using tunneler toward the incision. After passing a sheath, guidewire was removed after confirming clear venous blood from the sheath. Thereafter the PICC was passed into the sheath. The sheath was torn off once the catheter was adequately inside the vein. Final position of catheter was checked fluoroscopically [Figure 1]d.


  Discussion Top


PICC lines are considered a safe and reliable way of long-term central venous access for chemotherapy in patients with malignancy and in patients who require long-term venous access for antibiotics and parenteral nutrition.[1] The basilic, brachial, and cephalic veins are used for PICC insertion based on caliber and compressibility of the veins confirmed by the preprocedural US.[2] Previous venipuncture and cannulations at the level of antecubital fossa can make PICC insertions at the above-mentioned veins technically difficult. In the presence of superior vena cava (SVC) syndromes and mediastinal masses, guidewire insertion and subsequent threading of PICC can be quite difficult.[3]

Femoral vein cannulation is another option for PICC placement, but there are high chances of bloodstream infections.[4] To avoid this, we decided to tunnel the catheter so that the chances of infection are less. Wan et al. have described PICC placement at midthigh level in 221 patients with SVC syndrome which they found it feasible and safe.[5] The authors compared complications such as exudation, skin allergy, catheter-related infection and occlusion, venous thrombosis, phlebitis, and catheter malposition in patients with femoral PICC to an upper limb PICC. They found that the incidence of complications were same. We were not aware neither we thought about midthigh PICC placement when we performed this procedure. In this patient, PICC was in situ for 6 weeks after which it was removed as chemotherapy cycles were over. No groin or puncture site infection was noted until PICC was removed.

To conclude, PICC inserted via a femoral vein is a safe and reliable alternative technique in patients in whom upper limb access is difficult.

Informed consent was obtained from patient for using images and sharing clinical information for medical education. Patient was assured anonymity and that personal details will not be disclosed whatsoever.

Acknowledgments

We are thankful to Dr. Krishna Kishore Kotthapalli, Fellow in Onco-Anaesthesia, and Dr. Poornachand Anne, Consultant Anesthesiologist, in the Department of Anaesthesiology at Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, for helping us during the procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cotogni P, Pittiruti M. Focus on peripherally inserted central catheters in critically ill patients. World J Crit Care Med 2014;3:80-94.  Back to cited text no. 1
    
2.
Gonzalez R, Cassaro S. Percutaneous central catheter. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459338/. [Last accessed on 2019 Mar 21; Last updated on 2019 Feb 11].  Back to cited text no. 2
    
3.
Parás-Bravo P, Paz-Zulueta M, Sarabia-Lavin R, Jose Amo-Setién F, Herrero-Montes M, Olavarría-Beivíde E, et al. Complications of peripherally inserted central venous catheters: A retrospective cohort study. PLoS One 2016;11:e0162479.  Back to cited text no. 3
    
4.
Castro D, Martin Lee LA. Femoral vein central venous access. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459255/. [Last accessed on 2019 Mar 22; Last updated on 2019 Feb 25].  Back to cited text no. 4
    
5.
Wan Y, Chu Y, Qiu Y, Chen Q, Zhou W, Song Q. The feasibility and safety of PICCs accessed via the superficial femoral vein in patients with superior vena cava syndrome. J Vasc Access 2018;19:34-9.  Back to cited text no. 5
    


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