Clinicians in Action is a spotlight series highlighting some of the interesting cases that Vascular Wellness clinicians have treated. These cases generally involve challenging situations or intriguing patient history and may involve more than one Vascular Wellness clinician as our clinicians have the ability to consult each other, including the on-call clinician whose serves as a clinical escalation path, via real-time HIPPA compliant communication. The diversity of these situations is why we believe that our clinicians, as a group, are the most experienced and best trained and supported vascular access providers and why our clients trust us to provide superior care to our mutual patients.
The Clinical Case
This case took place in a hospital and the patient happened to be the best friend of the clinician’s father, which added some interesting dynamics. The Vascular Wellness clinician placed a Peripherally Inserted Central Catheter (PICC) in the patient’s upper left arm as the patient had surgery on his right arm and was contraindicated for a PICC placement on that side. The clinician verified placement of the PICC and departed. Sometime over the next few weeks, the PICC line started functioning intermittently on blood return and became difficult to flush. The Vascular Wellness clinician was called back and after assessing the patient and PICC line, was able to restore the patency of the PICC. About 30 minutes later, the patient’s wife contacted the clinician stating that the line was no longer functioning, and she returned to the hospital to re-examine the situation.
Diagnosis and Treatment
The Vascular Wellness clinician ordered a chest X-ray (see image) to check on current PICC line placement and positioning. She reviewed a side-by-side comparison of the first chest x-ray that confirmed the PICC placement and the current chest x-ray. She first verified and confirmed that the PICC line correctly ended in the Superior Vena Cava (SVC) but did not stop there. Using her experience and training, she kept looking and saw that the PICC was in a “v” position and out of alignment, a diagnosis called Pinch-Off Syndrome.
She reported her findings to the patient’s nurse and managing physician. Although the managing physician had never heard of Pinch-Off Syndrome, she did some research, discussed with other physicians and all of them concluded that the Vascular Wellness clinician was correct. At this point, incorporating the detailed recommendation from the Vascular Wellness clinician, the managing physician developed a new treatment plan that included removal of the PICC and placement of an Internal Jugular (IJ) line. The clinician was able to relay this difficult information to her father’s friend, who was very nervous at this point, and she placed the new line with a successful outcome. After the line was placed, the patient said, “I wouldn’t let anyone but you do this to me.” As vascular access experts who focus on vascular access daily, Vascular Wellness clinicians often provide additional and valuable clinical input to supplement a patient treatment plan similar to this situation.
After the IJ was successfully placed, the Vascular Wellness clinician reflected on the situation. She believes that because the patient was unable to use his right arm due to the surgery, he overcompensated with his left arm that contained the PICC. This overcompensation and activity caused the PICC to kink along the brachial cephalic vein leading to the SVC.
What is Pinch-Off Syndrome?
Pinch-Off Syndrome is a rare syndrome but not without significant potential consequences. If the catheter gets completely pinched off, it could eventually break and dislodge in the body. This floating emboli (i.e., an object being carried in the blood stream) in the body can travel to the heart, the lung, or the brain causing either a heart attack, a pulmonary embolism, or a stroke. In short, Pinch-Off Syndrome can result in significant injury and death.