Nerve Damage Secondary to Removal of Fractured PICC Fragment

Introduction

Peripherally inserted central catheter (PICC) has been widely used in clinical practice, especially for patients needing periodic chemotherapy for tumors, long-term parenteral nutrition, and intravenous injection (1). Despite all its merits, PICC is associated with several catheter-related complications. Among them, catheter fracture is a rare one, with an estimated incidence rate of 0.69% in our hospital. It may happen during catheter insertion, high-pressure flushing, and removal (2, 3). The incidence of catheter fracture in the UK ranges from 0.2% to 9.7%, which is consistent with our data (4).

Generally, PICC fractures are removed using the radiographic method (5) or vascular incision. A radiographic method is used mainly when the catheter fracture retracts into the body and migrates to the superior vena cava or atrium without vein thrombus, while vascular incisions are applicable under the conditions of a breakage located in the upper limb vein or appeared vein thrombosis or adherence to the blood wall. The interventional method has been widely reported with no post-operative complication noted in all of these cases. There has been no report of the vascular incision and the possible complications.

On March 20^th, 2014, catheter fractures occurred during extraction of a PICC from a cancer patient in our department. The ultrasound results of the patient in this report showed the PICC remnant located in her left brachial vein and there was no venous thrombus. The fracture could be removed by either of the methods (radiographic method or vascular incision) according to the invasive technology department. The patient requested removal by vascular incision and signed the informed consent. We successfully performed vascular incision to remove the fracture, after which a nerve injury unfortunately occurred. The treatment process is presented below and the related literature is reviewed.

Case Presentation

A 67-year-old woman was hospitalized for the eighth cycle of chemotherapy after surgical resection of moderately differentiated adenocarcinoma of sigmoid. A single-lumen 18-guage (4-Fr) silicon PICC (Bard Groshong, USA) was successfully placed in the left brachial vein under ultrasound guidance on October 21, 2013. The inserted portion of PICC was 36 cm in length, while 6 cm was left outside. The procedure was uneventful without catheter occlusion. Five months later, the patient finished the eighth cycle XELOX regime. A nurse performed the procedure according to institutional protocol, explained the indication and helped the patient to relax. Unfortunately, the catheter fracture occurred during extraction and a residue of 33 cm was deposited in the body (Figs. 1, 2). Vascular incision was performed to remove the fracture from the left brachial vein by the vascular surgery department. After the operation, the patient was transferred to the floor and received a thrombosis prophylaxis. On the following day, the patient complained of a mild pain at the surgical site with a numerical rating scale (NRS) score of 2. Physical examination showed no oozing bleeding from the incision, swollen but moveable limb, and touchable arteriopalmus. Slight elevation of the affected limb was initiated along with prescribed bed rest. On day 2 after surgery, the patient left hospital without discharge order that afternoon and did not return until the day 4. The pain worsened, with a NRS score of 5. The upper limb was obviously swollen with subcutaneous dotty ecchymosis and lump at the incision site. On the fifth morning after surgery, the swelling aggravated and numbness, paresthesia, and reduced activities of the left upper limb were noted. After vascular surgical consultation, anticoagulation treatment was discontinued and 1 g/day oral diosmin was started. Vascular ultrasound color Doppler examination showed a hematoma in the low echo area of subcutaneous layer of the left arm (Fig. 3).

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Fig. 1

X-ray chest with fracture catheter.

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Fig. 2

Intravenous ultrasound with fracture catheter.

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Fig. 3

Vascular ultrasound color Doppler with a hematoma.

On day 6 after surgery, the second emergent operation was performed to clear the hematoma and suture the brachial vein. One day after that, the patient complained of dull pain and minor swelling. Diosmin treatment was continued while the uptake of low molecular weight heparin was suspended. The electromyography showed that the conduction volatility and velocity of median nerve of her left limb was reduced and the action of sensory nerve was slow. The results also indicted a possible neurogenic injury of short abductor muscle of the left thumb. After discussion with physicians from the vascular surgery, neurology and rehabilitation departments, pregabalin was added at a dose of 75 mg to relieve the pain with symptom improvement. Corresponding support therapies were carried out. In order to retrieve the function of the median nerve, a combination therapy of mecobalamin tablets, vitamin B12, and electro-acupuncture was needed. The patient was discharged and followed up regularly. Currently, the patient has improved perceptibly after 2 months of combination therapy.

Discussion

Conclusion

Nurses must be highly cautious about the risks of catheter fracture, know the possible causes and take effective measures to prevent their occurrence and development. The conclusions are: (i) use power injectable polyurethane PICCs; (ii) before PICC removal, rule out PICC-related thrombosis; (iii) if there is some difficulty on removal, stop and use ultrasound to understand where the obstacle is thrombosed or the rolling of a fibroblast sleeve; (iv) if the PICC needs to be freed surgically, please let an experienced vascular surgeon do this.