Bedside removal of a knotted peripherally inserted central catheter using a Seldinger guidewire: Case report

Introduction

Peripherally inserted central catheters (PICC) have become a cornerstone of modern healthcare, providing reliable long-term intravenous access for a wide range of therapies, including chemotherapy, long-term antibiotic administration, and parenteral nutrition. Their popularity stems from several advantages over traditional central venous catheters, such as lower infection rates, ease of insertion at the bedside, and reduced risk of pneumothorax. Despite these benefits, PICC insertion is not without complications. These can range from relatively minor issues like phlebitis and catheter occlusion to more serious events such as deep vein thrombosis, catheter-related bloodstream infections, and, rarely, catheter fracture or knotting. PICC knotting, while uncommon, represents a potentially serious complication that can lead to significant morbidity.^1–3 The exact incidence of PICC knotting is unclear due to underreporting and variations in reporting practices, but estimates suggest it occurs in less than 1% of insertions; reports of PICC knotting during insertion are relatively rare. ⁴ Several factors may predispose patients to PICC knotting, including anatomical variations in the venous system, catheter characteristics (e.g. length, material), insertion technique, and excessive patient movement. A knotted PICC can obstruct the catheter lumen, preventing effective infusion or aspiration of fluids. Furthermore, attempts to remove a knotted PICC can lead to catheter fracture, embolization, or vascular perforation, potentially resulting in life-threatening complications. Various techniques have been described for removing knotted PICCs, including surgical intervention, thrombolytic therapy, and guidewire-assisted techniques. ⁵ Managing a knotted PICC presents a unique challenge for healthcare professionals; the choice of technique depends on several factors, including the location and complexity of the knot, the patient’s clinical condition, and the expertise of the healthcare team. This case report describes the successful removal of a knotted PICC using the Seldinger technique, a minimally invasive approach that utilizes a guidewire to provide support and rigidity during catheter extraction. This technique offers a potentially safe and effective alternative to more invasive procedures, and its dissemination can contribute to improved patient safety and outcomes. This report aims to highlight the importance of prompt recognition and effective management of knotted PICCs and to contribute to the growing body of literature on this rare but important complication.

Case description

Management

Given the clear suspicion of a mechanical complication, and to avoid the risk of catheter rupture, the guidewire was carefully reinserted into the catheter lumen. The guidewire provided essential internal support, allowing controlled rotational traction to be applied. This decisive maneuver ultimately facilitated the successful removal of the PICC. Inspection revealed a single loose knot approximately 2 cm from the distal tip, with no further signs of damage (Figures 1 and 2).

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Figure 1.

Close-up of the single knot on the PICC (black arrow), approximately 2 cm from the tip.

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Figure 2.

Overview: knot (black arrow) and distal segment beyond the knot (red arrow).

No post-explant imaging was performed given intact retrieval, absence of symptoms, and normal site assessment.

Conclusions

Knotting of peripherally inserted central catheters is uncommon but clinically relevant because forceful traction during removal can precipitate fracture and embolization. When unexpected resistance is encountered, escalation without first restoring internal support is unsafe. In this case, reintroducing a 0.018-inch guidewire restored column strength and allowed controlled, gentle rotational traction, enabling intact explant without fluoroscopic snare retrieval or surgical cut-down. This aligns with a pragmatic stepwise pathway: stop traction, assess mechanical causes, restore support, and proceed cautiously while preparing an escalation plan if resistance persists.

In the presence of removal resistance, infusion therapy standards recommend suspending traction and reassessing rather than forcing extraction; recent clinical series likewise associate aggressive maneuvers with higher risk of catheter fracture. ⁶ The physiologic rationale for the wire-assisted maneuver is the increase in axial rigidity of the system; fluoroscopy-guided “wire-assisted” techniques report similar benefits when bedside attempts fail. ⁷ If the guidewire does not resolve the problem, or there is suspicion of a tight knot, adherence, or partial fracture, endovascular retrieval with a snare remains the accepted salvage strategy.^8,9 However, such interventional radiology techniques are resource-intensive and may not be readily available in all clinical settings, underscoring the importance of less invasive alternatives when feasible. ¹⁰ It is important to note that interventional radiology services were not accessible at the hospital where this complication occurred. Consequently, the successful implementation of the Seldinger technique with guidewire assistance for PICC removal in this case underscores its potential as a valuable first-line intervention in facilities with limited access to specialized interventional radiology capabilities.

Two practical points emerge. First, adjuncts for tip confirmation and behavior during advancement (e.g. intracavitary ECG patterns that do not show the expected P-wave augmentation) can be early clues to looping or malposition. Second, meticulous documentation of the resistance encountered, the measures taken to mitigate fracture risk, and the final catheter integrity is essential for patient safety and quality assurance. Limitations of this report include its single-case nature and the inability to compare guidewire-assisted extraction with alternative strategies; nevertheless, the maneuver is simple, reproducible, and immediately applicable at the bedside when no signs of catheter adherence, vascular injury, or partial fracture are present. When a PICC meets unexpected removal resistance, avoid forceful traction. Reintroduction of an appropriately sized guidewire to restore internal support can permit safe extraction of a knotted catheter and may obviate invasive retrieval. Clear escalation pathways, team training, and careful documentation should be standard to minimize risk in these rare but consequential events.