Stepwise dual-access endovascular retrieval of a fractured PICC embolized to the pulmonary arteries: A case report

Abstract

Peripherally inserted central catheters (PICCs) are commonly used for prolonged intravenous therapies, particularly in oncology patients requiring chemotherapy. Although generally safe, PICC-related complications such as catheter fracture and embolization are rare but potentially life-threatening conditions requiring urgent intervention. We report a rare case of PICC line fracture with embolization into the bilateral pulmonary arteries in a 57-year-old female undergoing chemotherapy for esophageal carcinoma at a private hospital in Dar es Salaam, Tanzania. The patient was asymptomatic, and chest computed tomography demonstrated a fractured PICC line looped within the right and left pulmonary arteries. Endovascular retrieval was initially attempted through a femoral venous approach using balloon-assisted mobilization and snare techniques; however, both strategies failed because the catheter lacked an accessible free end. Following A stepwise dual-access approach was subsequently performed using pigtail catheter-assisted repositioning of the fragment into the inferior vena cava followed by successful snare retrieval through the right internal jugular vein. The catheter was retrieved intact without procedural or cardiopulmonary complications. The patient was monitored for 24 hours postprocedure and subsequently discharged, with continued oncology admission for advanced metastatic disease unrelated to the PICC complication. This case demonstrates the feasibility of stepwise dual-access endovascular techniques for retrieval of complex embolized PICC fragments from the pulmonary circulation, particularly in resource-constrained settings.

Introduction

Peripherally inserted central catheters (PICCs) are a type of central venous catheter characterized by long, thin tubing typically measuring 40-60 cm in length and containing 1-3 lumens. They are introduced through veins of the upper arm, most commonly the basilic, brachial, or cephalic vein, and advanced until the catheter tip reaches the lower third of the superior vena cava near the cavoatrial junction [1]. PICCs are widely used for prolonged intravenous therapies, particularly chemotherapy, because they provide reliable long-term venous access and reduce the need for repeated venipuncture [2,3].

Despite their advantages, PICCs are associated with a range of complications. Minor issues such as phlebitis, sluggish blood withdrawal, resistance to flushing, and insertion site discomfort are usually self-limiting and require no specific intervention. In contrast, major complications including infection, thrombosis, and mechanical failure may necessitate urgent treatment or catheter removal [2,[4], [5], [6], [7], [8], [9]].

Among the mechanical complications, Catheter fracture and embolization are rare complications, occurring in less than 1% of cases, but they may result in serious consequences such as pulmonary embolism, cardiac arrhythmias, cardiac perforation, and sepsis, contributing to significant morbidity and mortality and necessitating prompt retrieval. Most catheter fractures are reported near the insertion site, particularly just distal to the cuff where the catheter caliber narrows, making it more susceptible to mechanical stress and breakage [10]. Fractured catheter fragments commonly embolize to the right heart or pulmonary arterial circulation and usually require urgent endovascular retrieval, as delayed removal may increase the risk of serious complications [11]. Retrieval of embolized catheter fragments may be technically challenging when the fragment does not present an accessible free end or is located in distal pulmonary arterial branches, which limits effective engagement with standard snare-based retrieval techniques [12].

This case highlights a rare occurrence of PICC fracture and migration into the pulmonary arteries in a patient undergoing chemotherapy for esophageal carcinoma at a private hospital in Dar es Salaam, Tanzania.

Case description

A 57-year-old female receiving platinum-based chemotherapy (cisplatin and 5-fluorouracil) for esophageal carcinoma presented for her sixth treatment cycle. A PICC placed in the right cephalic vein had been used uneventfully for the previous 5 cycles. Prior to the sixth session, the patient's daughter, a physician, noted the absence of the external portion of the PICC line. On examination, only the dressing remained in place, with no visible catheter at the insertion site. The patient was asymptomatic, with no cardiopulmonary manifestations.

A computed tomography scan confirmed the presence of the fractured PICC line, looped in the right and left pulmonary artery (Fig. 1).

Fig. 1.

Contrast-enhanced chest CT demonstrating a coiled peripherally inserted central catheter (PICC) fragment within the pulmonary arterial circulation. (A) Axial image showing intraluminal linear hyperdense catheter fragment (orange arrow) within the pulmonary artery. (B) Coronal reconstruction confirming catheter migration into the central pulmonary arteries. (C) 3D volume-rendered image demonstrating the course and intravascular location of the embolized PICC line (orange arrow).

The PICC line was composed of polyurethane with a diameter of 4 Fr. Informed consent was obtained, and the patient was taken to the catheterization laboratory for foreign body retrieval.

Endovascular retrieval technique

The procedure was performed under sterile conditions in a catheterization laboratory using local anesthesia at the right femoral access site with intravenous fentanyl (200 mcg in total) for analgesia. Systemic anticoagulation was administered with intravenous heparin prior to catheter manipulation. Right common femoral venous access was obtained and followed by the insertion of a 7F sheath.

Initial navigation of the right heart and pulmonary arterial system was performed using a multipurpose angiographic catheter over a double-length hydrophilic Terumo guidewire (Terumo Corporation, Japan). Following initial navigation, the hydrophilic wire was exchanged for a PTFE guidewire to provide improved support and stability for catheter manipulation. A 7F Judkins Right (JR 3.5) guiding catheter was then advanced over the PTFE wire. Pulmonary angiography was subsequently performed to delineate the pulmonary arterial anatomy and map the distribution and configuration of the embolized PICC fragment. Following angiographic assessment, selective wiring of the left pulmonary artery was achieved using a Run through NS guidewire.

First-line strategy: Balloon-assisted dislodgement

Initial retrieval efforts focused on balloon-assisted mobilization of the looped PICC fragment within the pulmonary artery. A 5 × 40 mm peripheral balloon was advanced into the pulmonary arterial system in an attempt to engage and dislodge the catheter loop; however, this was unsuccessful (Fig. 2A). The balloon size was selected according to the estimated diameter of the pulmonary artery branch and the floating intraluminal position of the PICC fragment. The retrieval strategy was based on the expectation that inflation of the balloon adjacent to the freely mobile catheter within the pulmonary artery could create sufficient contact between the catheter fragment and the vessel wall, thereby stabilizing the fragment and facilitating traction and mobilization. Subsequent wiring and manipulation of the right pulmonary artery also failed to achieve catheter mobilization. The Run through wire was therefore exchanged for a PTFE guidewire to improve support, after which the guide catheter was removed while maintaining wire position within the right pulmonary artery. A larger 10 × 40 mm peripheral balloon was then advanced directly over the PTFE wire into the right pulmonary artery and used in a further attempt to drag and centralize the PICC loop, but this strategy was also unsuccessful despite an hour of manipulation.

Fig. 2.

Endovascular retrieval of embolized PICC fragment. (A) Fluoroscopic image showing balloon inflation (blue arrow) in the pulmonary artery for catheter dislodgement. (B) Snare loop (green arrow) used to capture the PICC fragment (orange arrow). (C) Pigtail catheter (yellow arrow) assisting in engagement and retrieval of the catheter fragment.

Second-line strategy: Snare technique

Following failure of balloon-assisted retrieval, a 4F single loop Gooseneck snare system was deployed sequentially within the right and left pulmonary arteries (Fig. 2B). Multiple attempts to capture the embolized fragment were unsuccessful after an hour of manipulation.

The failure was attributed to the absence of an accessible free end of the catheter, which was looped within the distal pulmonary arterial branches.

Third-line strategy: Pigtail catheter-assisted repositioning

A 5F pigtail catheter was then advanced into the right pulmonary artery. Mechanical hooking of the PICC fragment was successfully achieved, allowing partial mobilization of the catheter. The fragment was subsequently retrieved from the pulmonary artery into the right ventricle and further into the inferior vena cava (IVC) (Fig. 2C).

However, complete retrieval via the femoral route was not feasible, as a segment of the catheter remained looped within the right ventricle, resulting in loss of coaxial alignment and inadequate traction for controlled extraction.

Procedural pivot: Access escalation strategy

Given persistent instability of femoral-based coaxial control and intraventricular looping of the catheter, a decision was made to escalate the access route. Right internal jugular vein (IJV) access was obtained, and a 6F sheath was placed to provide superior–inferior alignment with the right atrium and ventricle (Fig. 3A). The superior approach was selected because its closer proximity to the right ventricle provided improved support, maneuverability, and coaxial alignment for catheter manipulation and snare engagement.

Fig. 3.

Successful endovascular retrieval of the retained PICC fragment. (A) Snare catheter introduced via right internal jugular vein (IJV) access capturing the embolized PICC line. (B) Retrieved PICC line following complete extraction.

Final strategy: Internal jugular snaring and successful retrieval

Through the IJV approach, a 4F Gooseneck snare was used to successfully engage the remaining catheter fragment, which was entirely removed through the IJV access (Fig. 3B).

Total fluoroscopy time was 177.4 minutes, with a cumulative radiation dose of 2610 mGy and a total contrast volume of 100 mL. The overall procedure duration exceeded 5 hours. Following the procedure, the patient was monitored for 24 hours and discharged without complications.

Discussion

PICC line fracture and embolization is a rare yet potentially life-threatening complication. It was initially reported in 1995 by Linz DN in Japan [13]. Subsequently there have been multiple case reports been published describing this complications in multiple countries [[9], [10], [11], [12]]. To the authors’ knowledge, published reports describing endovascular retrieval of embolized fractured PICC fragments in sub-Saharan Africa remain limited.

There are multiple factors that can predispose a PICC line to fracture, including the type of material used. Most commercially available PICC lines are made from either silicone or Polyurethane. and several studies have compared silicone and polyurethane catheters in terms of fracture risk with contradicting findings. While most studies suggest that silicone is more prone to fractures [[14], [15], [16]], studies by Vandonia et al. [17] reported polyurethane had a higher fracture rate (7.8%) than silicone (1.4%) [17]. Silicone catheters are generally considered more susceptible to fracture due to their weaker mechanical strength and lower abrasion resistance. Despite having a thicker wall, silicone’s material properties make it more vulnerable to kinking and damage, particularly when inserted via the IJV, where increased movement and flexion occur [15]. In contrast, PU catheters are more durable and less likely to fracture under similar conditions [17]. However, the discrepancy in findings across studies suggests that other factors, such as catheter design, insertion technique, and patient-specific variables, may also play a role in fracture risk [15].

Other factors that contribute to PICC fatigue and fracture, include prolonged use, repeated dressing changes, and exposure to corrosive chemotherapeutic agents [3]. In our case, the exact mechanism of fracture could not be definitively established. However, the polyurethane PICC had been used over multiple chemotherapy cycles, and previously reported resistance during flushing may suggest progressive catheter fatigue or mechanical compromise. These findings support the concept that factors beyond catheter material alone may contribute to PICC fracture. This case underscores the importance of vigilant PICC care, regular catheter assessment, and early recognition of catheter dysfunction to help prevent complications.

Most patients remain asymptomatic, similar to our case. There have been reports of PICC embolization cases discovered incidentally years after migration. One such case involved a PICC fragment retrieved from the pulmonary artery 11 years after embolization following incidental detection. Another case involved a catheter found 14 years after embolization that was never extracted because the guidewire had become adherent to the vascular wall, making retrieval unfeasible [18,19]. Despite the potential for long-term asymptomatic cases, life-threatening complications can arise. When symptomatic, presentations may include arrhythmias, septic manifestations, and pulmonary symptoms such as cough, dyspnea, and pleuritic pain. Detached PICC fragments can migrate through the bloodstream and become lodged in the superior vena cava (15.4%), right atrium (27.6%), right ventricle (22%), or pulmonary arteries (35%) [4,7,9,20,21].

Migrated PICC fragments can be successfully retrieved percutaneously, with a success rate exceeding 90% and minimal complications. Various techniques, including balloon-assisted repositioning, snaring, and alternative venous access, are employed to manage complex cases [1,12,19,[22], [23], [24], [25], [26], [27], [28], [29], [30], [31]].

In our case, initial attempts involved inflating a peripheral balloon in both pulmonary arteries to reposition the PICC line. This approach was successfully utilized in previous study by Lee et al. [28] to remove catheter fragments from superior vena cava. However, limitations exist, particularly when the balloon size is not optimal if too large, it may not pass through the fragment, and if too small, it may fail to secure the catheter adequately [23,31]. In our case, the method failed because of a mismatch between the relatively large diameter of the pulmonary artery branch and the smaller caliber of the catheter fragment, resulting in inadequate apposition of the balloon against the catheter surface. In addition, the smooth, low-friction surface of the PICC material likely contributed to slippage, preventing effective engagement and traction by the balloon.

Following the unsuccessful balloon retrieval, a loop snare was utilized. The gooseneck loop snare remains the most widely used device for endovascular retrieval of intravascular foreign bodies [19,22,25,26,29,30]. Yen et al. [26] reported successful retrieval of embolized PICC fragments in 13 patients using a goose-neck snare, particularly when the catheter’s free end was accessible in the pulmonary trunk [26]. Similarly, Teragawa et al. [25] reported a successful endovascular technique using a snare with a suture to retrieve a migrated broken PICC in the pulmonary artery of a chemotherapy patient [25]. While this technique offers better control over catheter movement, it presents potential risks, including vascular injury and challenges related to selecting an appropriate suture type and thickness [22]. However, when the catheter fragment is lodged in the pulmonary artery, the loop snare becomes less effective because the free end is not easily accessible, and maneuvering the loop in such a confined space is challenging [12]. In our case, the snare approach failed due to inability to engage and secure the fragmented PICC within the pulmonary artery, secondary to the absence of a freely accessible catheter end and its unfavorable intraluminal position.

A 5F pigtail catheter was then inserted into the right pulmonary artery, successfully hooking and partially retrieving the PICC line, dragging it through the right ventricle into the IVC. However, a portion of the catheter remained looped in the right ventricle, complicating extraction via the femoral sheath. To overcome this, right IJV access was established, and a snare catheter was successfully deployed to retrieve the remaining PICC line. Previous reports have described stepwise and dual-access endovascular retrieval strategies for fractured PICC fragments embolized to the pulmonary arteries. Papa et al. [32] reported simultaneous dual-access retrieval using pigtail and snare catheters introduced through double transfemoral venous access [32]. Teragawa et al. [25] described sequential retrieval attempts through both jugular and femoral venous access because the catheter fragment was impacted within the pulmonary artery wall [25]. Similarly, Peng et al. [27] reported dual-access retrieval of fractured PICC fragments from the pulmonary circulation using combined pigtail and snare catheter techniques [27].

In resource-constrained settings, including sub-Saharan Africa, limited access to advanced imaging and specialized endovascular equipment, as well as variable availability of trained interventional teams, may influence the timing and complexity of managing catheter-related complications. This underscores the importance of adaptable, stepwise endovascular approaches using available resources.

To prevent catheter migration and embolization, Michael Rosenberg, an interventional radiologist in the United States, invented the SecurAcath device a subcutaneous securement system placed beside the indwelling catheter to minimize movement and migration [[33], [34], [35], [36]].

To minimize complications, healthcare providers must adhere to evidence-based protocols for PICC line placement and maintenance, prioritize regular assessments, and promptly replace aging catheters. Furthermore, education and training programs should equip clinicians to recognize and address catheter-related emergencies effectively, particularly in settings with limited resources.

Conclusion

PICC line fracture and embolization to the pulmonary artery is a rare but potentially fatal complication requiring immediate and effective intervention. This case underscores the importance of catheter care, timely diagnosis, and the integration of multidisciplinary expertise, especially among Cardiovascular surgeons, interventional cardiologists, radiologists, critical care teams and cardiovascular Technicians.

The successful retrieval underscores the value of advanced percutaneous techniques and adaptability in managing complex vascular complications. This report emphasizes the necessity of continuous education, robust training, and feasibility of advanced minimally invasive retrieval techniques in resource-constrained settings.

Author contributions

All authors contributed to the conception, drafting, critical revision, and final approval of the manuscript and agree to be accountable for all aspects of the work.

Ethical approval

Institutional review board approval was not required for this type of study.

Data availability

The data supporting the findings of this case report are available from the corresponding author upon reasonable request, subject to institutional regulations.

Patient consent

Written informed consent was obtained from the patient for the publication of this case report and any accompanying images.