Removing the PICC line where there is a DVT?

[CPLibra, ADN, BSN, RN]

Hello, everyone!

I had a patient who had a PICC line on the left upper arm. The impression of the US of the venous showed that the left upper arm had a DVT that was partially occlusive. They also did a US on the right arm, but impression showed negative for DVT of the right arm. The cardiologist consult had asked the previous nurse to remove the PICC line from the left upper arm once there is a line established in a different location. The nurse endorsed it to me to find another IV site on the right arm (as opposed to just getting a PICC line inserted on the right arm). Granted, patient is AOX1, combative, and a hard stick, in which that would make sense why this patient had a PICC line in the first place anyways. Nonetheless, I got an IV site on the right wrist-forearm area that was patent and flushes well.

When it was time to remove the PICC line on the left arm where the DVT was at, I questioned whether it was safe to be removing the PICC line due to the increased risk of dislodging that partially occlusive clot. The vascular consult was not reachable, so I was unable to get the vascular consult's orders. However, the cardiologist consult gave orders to the previous nurse that it was okay to do so (but I was unable to find that order anywhere on the computer). At the end of the shift, I had decided to not remove the PICC line and to endorse to the on-coming nurse to try to reach out again to the vascular consult regarding orders to leave the PICC line in, to try to implement medical interventions to either dissolve or thin out that clot, and then get a repeat US venous for the status of the clot. The on-coming nurse had stated that it was best to leave the PICC line in to prevent dislodging that clot and would clarify orders with the vascular consult rather than the cardiologist.

My question is: Would the removal of the PICC line where the DVT is at increase the risk for dislodging the clot and possibly increasing the chances of PE? Have you had an order or a situation in which you had to remove the PICC line at the same location as to where the DVT is? Is it safe to remove the PICC line in the same location of where the DVT is at?

[zoidberg, BSN, RN]

Depends on where the clot is, (i.e. which vein and relation to line).Do you have a vascular access team (picc team)? They can provide guidance. If not maybe IR. There is risk for a PE even with the line staying in. You can anticoagulate and then reassess for clot presence but not sure how much evidence there is for that course. Any picc that remains in place for a good while will have some thrombus formation. These are not ultrasounded, and are removed without knowledge of the thrombus, and no adverse events happen. So it could be removed likely without issue. Sorry if it’s not a straight forward answer. Hope it helps.

[zoidberg, BSN, RN]

admin: This might get more replies if moved to the infusion nursing section.

[IVRUS, BSN, RN]

As long as you have a PICC that ONLY has involvement with a Thrombus, then research shows that it is important to savage it and lyse the clot with a 4-6 hr infusion. But, if it is thrombosed and infected, it must be removed.

[inthecosmos, BSN, MSN, RN, APRN]

On 6/9/2019 at 5:21 PM, IVRUS said:

As long as you have a PICC that ONLY has involvement with a Thrombus, then research shows that it is important to savage it and lyse the clot with a 4-6 hr infusion. But, if it is thrombosed and infected, it must be removed.

Thank you for this valuable info!