Routine peripherally inserted central catheter placement resulting in delayed intravascular foreign body.

Editor: A 13-year-old female patient was admitted with bacterial pneumonia and parapneumonic effusion. The patient required a right chest tube and a peripherally inserted central catheter (PICC). Both procedures were performed in the computed tomography (CT) suite to preclude patient transport while under sedation. The chest tube placement was followed by placement of a 5-F double-lumen PICC (Arrow, Reading, PA). As is our routine, before placement of the PICC by the physician, the catheter was cut to 14.5 inches by the nurse based on measurements from the mid-humerus to the shoulder to the suprasternal notch. This was followed by insertion of the J-tipped wire through the PICC until the end of the wire was flush with the end of the PICC. After 1% lidocaine (Abbott Laboratories, North Chicago IL) was applied to anesthetize the skin, ultrasound guidance was used in the puncture of the left basilic vein. A 0.018-inch wire was introduced into the needle and the dilator and sheath were advanced over this wire into the vein. The dilator and wire were removed, and the PICC was advanced to the central venous system. A chest radiograph showed that the PICC was too long. The PICC was therefore removed from the sheath, the wire was pulled back, and the catheter was cut to a new length of 12.5 inches. After reinsertion of the PICC, a chest radiograph showed good position of the PICC (Fig 1). The wire and sheath were removed, the PICC was flushed with heparinized saline solution, and the catheter was sutured in place. Two days later, a chest radiograph was obtained to evaluate the patient’s pneumonia (Fig 2). There appeared to be a guide wire looped in the pulmonary artery. To exclude this being outside the patient, we wanted to repeat chest radiography after the dressing on the patient’s back was removed. Because of the pain involved in removing the dressing, the patient refused, but her parent agreed to a limited CT scan, which confirmed that the wire was in the pulmonary artery (Fig 3). After discussion with the pediatricians, it was determined that no other procedures had been performed on the patient after PICC placement, and therefore the foreign body was somehow related to the PICC. Based on the acute angles that the wire was taking, the assumption was that the foreign body was the outer wrap of the J-tipped wire, which would be floppy enough to make those turns. We believed that the inner part of the J-tipped wire and the 0.018-inch puncture wire were not sufficiently floppy to make such turns. The following morning, the patient was brought to the angiography suite for foreign body retrieval and chest tube removal under sedation. The right common femoral vein was punctured, and, after placement of a 4-F sheath, the right pulmonary artery was catheterized with a Berenstein catheter (Boston Scientific, Watertown, MA) and a Glidewire (Boston Scientific). Exchange was made for a 10-mm Amplatz Goose Neck Snare (Microvena, White Bear Lake, MN), which was used to successfully snare the foreign body and remove it through the sheath. Inspection of the wire showed that it was in fact the outer wrap of the J-tipped wire, and measured 12.5 inches in length. The patient made an uneventful recovery and was discharged 3 days later. PICC placement has proved to be a safe procedure, with a recently reported complication event rate of two per 1,000 catheter-days. The most common complications are catheter dysfunction (eg, thrombosis, catheter related sheath, catheter malposition) and infection (1). Although guide wire fragment retrieval was reported as early as 1971 (2), and PICC fractures have been reported previously (3,4), our search of the literature did not yield any cases of a broken wire fragment resulting in a foreign body during PICC placement. Our goal was to try to ascertain what happened in this instance to be able to prevent future occurrences. The J-tipped guide wire is a 0.018-inch-diameter, 85-cmlong wire comprised of a 0.010-inch stainless-steel core wrapped by an outer spring made of 0.003-inch Tefloncoated stainless steel. The two wires are connected at both ends by a 2-mm ball weld with a weld strength of 15 N (3.5 lbs). The PICC is a 5-F dual-lumen polyurethane catheter with an extension line clamp proximal to each of the two hubs. The J-tipped wire is placed through the larger (18DOI: 10.1097/01.RVI.0000136035.86623.D3 Figure 1. Chest radiograph obtained immediately after PICC placement shows the tip in the lower SVC, the wire in the catheter, and no foreign body. Letters to the Editor