The PICC That Does Not Come Out Liz Simcock Lead Clinical Nurse Specialist, Central Venous Access, University College London Hospitals NHS Foundation

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1 The PICC That Does Not Come Out Liz Simcock Lead Clinical Nurse Specialist, Central Venous Access, University College London Hospitals NHS Foundation Trust

2 Disclosure Employed by University College London Hospitals NHS Foundation Trust Angiodynamics satellite symposium

3 UCH Hospitals NHS Trust University College Hospital Macmillan Cancer Centre

4 Central Venous Access Team

5 One reason we use so many PICCs Removal of tunnelled & implanted CVCs requires surgical skills requires management of clotting risk of catheter embolism air embolism haematoma infection

6 Removing a PICC is easy.

7 Removing a PICC is easy.

8 unless it s not Video courtesy of Jack LeDonne

9 unless it s not Video courtesy of Jack LeDonne

10 Incidence of difficult removal Literature varies: Drewett % Wall % 8/829 PICCs in children (mostly silicone) Miall 2001 Quotes 1% - 12% 20% 8/40 PICCs in children (mostly polyurethane) cystic fibrosis Marx %

11 It s not just PICCs Haemodialysis lines (Field 2008) (Carillo 2009) Tunnelled CVC (Idowu 2016) Ports (Cerini 2017)

12 Why does it happen? Venospasm Thrombotic changes Entrapment Knotted PICC Foreign bodies

13 No. 1 cause of stuck PICC: Venospasm Stimulation of tunica media during removal (Wall 1995) Prevention: remove at a moderate rate (Wall 1995) do not apply pressure over vein (Wall 1995) Solution: wait and try again

14 Causes of stuck PICC: Thrombotic changes Many cases of thrombosis in PICCs without removal problems Hong 2011: In haemodialysis catheters association: Thrombosis Fibrosis Occlusion Stenosis

15 Forauer & Theoharis 2003 Excised veins & SVC in 6 patients who had died with centrally inserted CVC in situ After short-term catheter placement, focal areas of endothelial injury were seen in the vein wall adjacent to the catheter. Associated thrombus may or may not be present. Long-term catheters displayed vein wall thickening and bridges from the vein wall to the catheter. These observations represent a progressive reaction of the human vein wall to access devices.

16 Forauer & Theoharis 2003 Thickened vein walls Pedicle-like attachment Fibrin sheath

17 Miall 2001 PICC fractured while trying to be removed: The distal segment needed surgical removal and was found to be encased in a thrombus

18 PICC adherent to ventricular septum 17 month child Attempted to snare it with pigtail catheter via femoral vein Passed Terumo wire through pigtail catheter and snared, and pulled back to form a loop Tension applied at axillary end and PICC freed (Wong 2010)

19 Fibrin Sheath concentric layers of fibrin, collagen, and embedded inflammatory cells, often with a surface layer of endothelial cells, all of which surrounds the CVC in a circumferential manner. Hajjar 2015 Incidence 42% 100% (Field 2008) Fisher 2011: reviewed CT scans 147 patients Fibrin sheaths retained long after long-term CVC removal 13.6% (20/147) - nearly half calcified Venous occlusion and collaterals More prevalent in female

20 Knotted PICC Gnanamuthu 2010 (Gnanamuthu B R et al 2010)

21 How does that happen?

22 Transjugular retrieval neonate Zhou 2016 Retrieved via jugular sheath

23 Foreign bodies: Miall 2001 Cotton wool used to clean skin?

24 PICC stuck in Ventricular Assist Device Parikh et al 2011

25 So what should we do?

26 Confusion around best practice? Cystic Fibrosis chatroom 2017 They tried to pull it, it wouldn't come out, they wiggled it around and accidentally poked my heart (which does not feel good, for the record), and still couldn't get it, so they put me on high dose blood thinners for a week and then tried it again and it came out.

27 Technique 1: Just pull!

28 Just pull... Pain Venospasm Trauma to veins Infection risk (stretching in and out) PICC fracture: Distressing for patient Retained PICC: focus for infection / thrombosis May lodge in heart or pulmonary artery (Marx 1995) Can be removed via femoral veins (Wang 2015) Risks and costs of retrieval Secondary risks eg nerve damage (Mou 2016) Higher risk of fracture with silicon PICCs I much prefer the slow pull... I hated how my arm felt when they yanked it!!! YUK!!! Cystic Fibrosis chatroom 2017

29 Just pull I reached point where they stopped coming smoothly. They would be "stuck"... but all they ended up doing for me was to send me to Radiology. Once there they would just tug it out. It never went as far as surgery. And Radiology was always kinda baffled...which lead to them just pulling despite resistance Cystic Fibrosis chatroom 2017

30 Technique 2: Traction over time (Brown 1994) According to Sharpe 2011 this method foregoes ongoing visual monitoring of the catheter and breakage may go undetected Miall (2001) reports this technique leading to breakage of catheter.

31 Technique 3: Be Patient WAIT 60 mins or longer (Marx 1995) WAIT overnight If fails; X-Ray / ultrasound to check for knotting (Zhou 2016) They were able to pull it 19 cm so a little more than half way. The same thing happened last time too. But about eight hours later they decided to try one last time and got it out. Cystic Fibrosis chatrooom 2017

32 Heat compress (eg Moureau 2002) Technique 4: Dilate the vein Wrist or hand massage (Marx 1995) GTN patch (Miall 2001) Gentle massage / milking of skin over the vein (Kim 1993) Warm or alcoholic beverage (Marx 1995) Systemic smooth muscle relaxants eg nifedipine (Marx 1995) If PICC gets stuck towards the end... Apply tourniquet above the end of PICC (Wall 1995)

33 Cystic Fibrosis chatroom 2006 I have had several PICC lines get stuck Usually hot packs up my arm and chest for about 1/2 hr before pulling it out helps dilate the veins enough for it to slip out

34 Arm exercise: pumping Change of position Address anxiety Techniques 5, 6, 7 and 8... Relaxation techniques (Miall 2001, Marx 1995) Ibuprofen TDS 24 hours (Miall 2001)? Cause & effect the IV nurses have taught me this trick where they tell you to open and close your hands (kind of like pumping up your veins before a blood draw). I m telling you it works everytime. Cystic Fibrosis chatroom 2006

35 Technique 9: Remove over a wire Video courtesy of Jack LeDonne

36 Technique 9: Remove over a wire Video courtesy of Jack LeDonne

37 How does that work? Idowu Elsevier Inc. All rights reserved.

38 Caution The amount of pull force that can be applied safely without causing vessel wall tear is not known. One should keep in mind that the amount of pull force that can be applied with a catheter with a wire thru the lumen is substantial and may exceed the strength of vascular integrity. Series of short repeated pull force may be more effective in loosening the stuck catheter rather than one extreme pulling force. Idawu 2016

39 Technique 9 tips: Removing over a wire Use a soft-tipped wire if possible Stylet in exceptional circumstances? (Sharpe 2011) Consider NOT cutting PICC? but how to avoid contaminating wire?

40 Surgical Techniques MD Junction they made a 1.5 inch incision very high on my upper arm. snipped the line and pulled it out backwards. They also made a small incision where the PICC was originally placed Unfortunately they were unable to repair the damage to the vein and so they tied it off. So I am now minus a PICC and part of a vein. MD Junction (online health support community) Vascular incision (Qian 2016): nerve damage Open thoracotomy (Carrillo 2009)

41 Interventional / Surgical Techniques Laser sheath extraction pacemaker leads: shown to be safe and effective (Camboni 2008) Carillo 2009: haemodialysis catheter Snare / wire techniques (Le 2016)

42 Endoluminal balloon dilation Cerini 2017 Previously described in stuck haemodialysis lines: Implantable port: 2.5mm balloon inflated to 6ATM No adverse events 2017 Elsevier Inc. All rights reserved.

43 TPA Infusion successful Brennan & Sheiman year-old male with stuck PICC in basilic vein thrombus surrounding PICC. infusion catheter was positioned within the pericatheter thrombus and TPA administered for 24hrs

44 Guidelines: INS 2016 Never forcibly remove a CVAD if resistance is encountered. Contact the LIP to discuss appropriate interventions for successful removal. Forcible removal can result in catheter fracture and embolization. Catheter pieces retained in the vein should be removed with endovascular techniques to reduce the risk of infection, thrombosis, and migration of the catheter piece INS Infusion Therapy Standards of Practice 2016

45 Guidelines: RCN 2016 If resistance is encountered when the catheter is being removed, the catheter should not be removed and the relevant HCP should be notified immediately and/or local policies followed Royal College of Nursing Standards for Infusion Therapy 4 th Edition RCN 2016

46 Association of Anaesthetists of Great Britain and Ireland 2016 Very long-term catheters may become attached to the wall of SVC/right atrium and cannot be removed by traction alone; cutting off and leaving in situ or surgical removal may be required. Devices can become knotted within veins. Seek advice from vascular surgery or interventional radiology if difficulties occur

47 Drewett 2000

48 Draft pathway outline for resistant PICC Step 1 Wait Heat Arm pumping GTN Massage Step 2 Wire Step 3 Xray Step 4 Interventional Radiology Tourniquet Relaxation

49 Thanks for listening! Your thoughts please!

50 References Association of Anaesthetists of Great Britain and Ireland Safe Vascular Access May 2016 Brennan I.M., Sheiman R. 24-Hour pericatheter TPA infusion to aid removal of adherent peripherally inserted central venous catheter. CardioVascular and Interventional Radiology. Conference: Cardiovascular and Interventional Radiological Society of Europe, CIRSE Munich Germany. Conference Publication: (var.pagings). 34 (SUPPL. 3) (pp 545), September Brown, J Peripherally inserted central catheters: insertion, care, use and maintenance San Antonio, Texask GESCO International Inc 1994 Camboni D et al Explantation of implantable defibrillator leads using open heart surgery or percutaneous techniques. Ann Thorac Surg 85: Carillo R et al A Novel Technique for Tethered Dialysis Catheter Removal Using the Laser Sheath Seminars in Dialysis Vol 22, No 6 (November December) 2009 pp Cerini P et al Endoluminal Dilation Technique to Remove Stuck Port-A-Cath: A Case Report Ann Vasc Surg Aug;43:317 Drewett, S, Central venous catheter removal: procedures and rationale British Journal of Nursing, 2000, Vol 9, No 22 Field M; Pugh J; Asquith J; Davies S; Pherwani AD A stuck hemodialysis central venous catheter. Journal of Vascular Access. 9(4):301-3, 2008 Oct-Dec. Fisher, J et al Retained Fibrin Sheaths After Long-Term Indwelling Central Venous Catheter Removal: A Common CT Finding with Associated Complications STR Abstracts J Thorac Imaging Volume 26, Number 2, May 2011 Forauer, A. R & Theoharis, C Histologic Changes in the Human Vein Wall Adjacent to Indwelling Central Venous Catheters J Vasc Interv Radiol 2003; 14: Gnanamuthu B R et al How is that? Knotting of a peripherally inserted central venous catheter Indian J Anaesth May-Jun; 54(3): Hajjar, K.A 2015 Central venous catheter thrombosis and the fibrin sleeve: unraveling the mystery European Journal of Haematology 98 ( ) Hong JH 2011 A breakthrough technique for the removal of a hemodialysis catheter stuck in the central vein: endoluminal ballon dilatation in the central vein: endoluminal balloon diatation of the stuck catheter Journal of Vascular Access 2011: 12:381-4 Idowu, O et al 2016 Mechanics of a Stuck Central Venous Catheter Removal Journal ofpediatric Surgery 51(2016) INS Infusion Therapy Standards of Practice Journal of Infusion Nursing: Supplement to January/February 2016 Volume 39, Number 1S Kim, E et al Adhesion of percutaneously inserted silastic central venous lines to the vein wall associated with Malassezia furfur infeftion JPEN 1993: 17: Le, J., Grigorian, A., Chen, S., Kuo, I.J., Fujitani, R.M. and Kabutey, N.K. (2016) Novel endovascular technique for removal of adherent PICC. The Journal of Vascular Access. 17(6):e153-e155, 2016 Nov

51 References Marx, M The Management of the Difficult Peripherally Inserted Central Catheter Line Removal Journal of Intravenous Nursing, Vol 18 No 5, September / October 1995 Miall, L et al Peripherally Inserted Central Catheters in Children With Cystic Fibrosis Journal of Infusion Nursing Vol. 24, No. 5, September/October 2001 Mou QQ; Wang YX; Xu QH; Liu X; Li YJ. Nerve damage secondary to removal of fractured PICC fragment. Journal of Vascular Access. 17(4):e79-81, 2016 Jul 12 Moureau, N How to remove a PICC with ease Nursing. 32(5):30, May [I.V. ROUNDS] Parikh, M, Wong, M, Farrimond, J An unknown complication of peripherally inserted central venous catheter in a patient with ventricular assist device Annals of Cardiac Anaesthesia 2011 Volume 14 Issue 2 Page Qian et al Nerve Damage Secondary to Removal of Fractured PICC Fragment Journal of Vascular Access July 2016 Volume: 17 issue: 4, page(s): RCN Standards for Infusion Therapy 4 th Edition RCN 2016 Sharpe, EL & Roig, JC A novel technique for difficult removal of a neonatal peripherally inserted central catheter (PICC) Journal of Perinatology (2012) 32, 70 7 Wall JL, Kierstead VL. Peripherally inserted central catheters: resistance to removal: a rare complication J Intraven Nurs Sep-Oct;18(5): Wang, Q et al Percutaneous retrieval of PICC fractures via the femoral vein in six cancer patients. J Vasc Access Jan-Feb;16(1):47-51 Wong K et al Transcatheter removal of peripherally inserted central catheter adherent to the ventricular septum" Proceedings of Singapore Healthcare Volume 19 Number Zhou L, Muthucumaru M, Tan K, Lau K. Transjugular retrieval of a knotted peripherally inserted central venous catheter (Epicutaneo-Cava catheter) in a neonate. BJR Case Rep 2016; 2: