PICC for Sunday, September 29th, 2024
Contributed by
Cincinnati Childrens Hospital Medical Center
Neil Johnson MD.
History
Patient with established PICC placed via the right upper limb. PICC became difficult to flush and aspirate. Chest Radiograph shows PICC has appeared to change position in relation to the cardiac outline
Images (Click any image to enlarge)
Question
Based on the "Day 2" PICC contrast injection, what blood vessel is the PICC Tip now in?
Your answer
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Correct answer
Right Internal Mammary (Thoracic) vein
Discussion
With coughing / crying / deep breathing, PICC lines can "jump around". This one "jumped" into the right internal mammary (thoracic) vein.
The Internal Mammary Veins are bilateral veins draining the anterior chest wall posterior to the ribs and anterior to the lungs
Although uncommon, this is a well known abnormal position of the PICC Tip and should be recognized by your radiologists and the PICC repositioned or replaced.
A PICC tip in the right carotid artery might look similar and be easily confused with the internal mammary vein. Like the Carotid arteries, blood flow in the internal mammary veins is towards the head because the blood is draining the chest wall into the brachio-cephalic veins. Almost all other veins in the chest drain the other way.
Cincinnati Children's (CCHMC) poster for PICC Tip placement is included below and all CCHMC material is available at http://stopivharm.org.
Differential diagnosis
A PICC tip in the right carotid artery might look similar and can be easily confused with the internal mammary vein. The Azygous Vein is positioned in the angle between the trachea and the right main broncus. This vein is not in that position
Additional images
References
- https://www.elsevier.com/resources/anatomy/cardiovascular-system/veins/internal-thoracic-veins/19683
- https://www.perplexity.ai/search/internal-thoracic-vein-A4TStt.FTNGrg_8zsuSWbw
- http://stopivharm.org
- http://stopivharm.org/images/20201026_UpperLimbPicc.pdf