PICC rupture as a clinical presentation of  pinch-off syndrome

Vertakova Krakovska B, Kunderlik M

INTRODUCTION

Peripherally inserted central catheters (PICC) are very common catheters used in oncological patients to deliver chemotherapy and other medications.  We report a rare, but potentially critical complication - catheter rupture as a result of the pinch-off syndrome (POS).  POS is defined as a compression of the catheter in the space anterior to the first rib and posterior to the clavicle.  The compression is rated on a scale of 0 to 3 (Grade 0 - a regular catheter course without luminal narrowing; grade 1-an an altered catheter course without luminal narrowing; grade 2- luminal narrowing; and grade 3 exhibits catheter fracture). Early detection of POS requires only catheter removal, while no intervention may result in life-threatening complications caused by catheter fragmentation.

 CASE-PRESENTATION

56- year old female with duplex carcinoma (breast and ovarian cancer), requiring intravenous chemotherapy had her single lumen 4F PICC placed via the left vena basilica in July 2018, ECG navigation (picture 1) as well as chest X-ray (picture 2) showed catheter position in cavo-atrial junction, no complications were described.  The PICC line was used for intravenous chemotherapy application for 18 months, with no complications. Later on, in January 2020 (18 months later), the patient experienced a catheter occlusion. When attempting to flush the catheter (not successful), the patient experienced sharp pain under her left clavicular bone. A catheter rupture has been suspected.   Chest X-ray and fluoroscopy with intravenous contrast was performed (picture 3 and 4). The suspected PICC rupture was confirmed. The catheter was successfully removed under fluoroscopy control without complications. Examination of the catheter showed a big rupture (7mm), the integrity has been maintained (picture 5). The patient recovered without any complications.

DISCUSSION AND CONCLUSION

The pinch-off syndrome can present with pain or swelling of the shoulder, but patients can also be asymptomatic and the syndrome can be accidentally identified on a chest X-ray. In our clinical case, the pain mentioned by the patient and X-ray led us to the rare diagnosis of POS. The potentially dangerous situation was resolved successfully. We implanted 1512 PICC catheters during a 6 year period (2015-2020).  Only one catheter rupture was diagnosed (0.066%).  It is very important to control the catheter before every chemotherapy administration. It is mandatory to check free aspiration of venous blood and smooth administration of rinsing to avoid the potentially life-threatening situation (paravazation of cytostatics). Early detection of POS requires only catheter replacement, but no intervention may result in life-threatening complications caused by catheter fragmentation. Catheter fragmentation is a condition when pieces of the catheter may break off to cause ventricular tachycardia, vessel embolization, and cardiac perforation.