• Users Online: 581
  • Print this page
  • Email this page

Year : 2010  |  Volume : 54  |  Issue : 3  |  Page : 272-274 Table of Contents     

How is that? Knotting of a peripherally inserted central venous catheter

Department of Cardiothoracic Surgery, CMC Hospital, Vellore, Tamil Nadu, India

Date of Web Publication10-Jul-2010

Correspondence Address:
Gnanamuthu Birla Roy
Department of Cardiothoracic Surgery, CMC Hospital, Vellore - 632 004, Tamil Nadu
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5049.65367

Rights and Permissions

How to cite this article:
Roy GB, Cheriyan AA, Rymbai ML. How is that? Knotting of a peripherally inserted central venous catheter. Indian J Anaesth 2010;54:272-4

How to cite this URL:
Roy GB, Cheriyan AA, Rymbai ML. How is that? Knotting of a peripherally inserted central venous catheter. Indian J Anaesth [serial online] 2010 [cited 2020 Dec 5];54:272-4. Available from: https://www.ijaweb.org/text.asp?2010/54/3/272/65367


An obese young man underwent a right posterolateral thoracotomy when the right basilic vein was cannulated in the conventional manner. A 14-G needle was used and a 75-cm 16-G peripherally inserted central venous catheter (PICC; Cavafix, B.Braun, Melsungen AG, Germany) was inserted. Some difficulty was encountered in accessing the vein, which was attributed to the patient's obesity. The catheter was advanced without resistance and was fixed at a distance of 40 cm, the measured distance between the sternal notch and the puncture site. This line was used intraoperatively. During surgery, the catheter was incidentally spotted in the superior venacava. The tip, however, was not visualised since it was inside the right atrium. In the postoperative period, the fluids were not flowing freely through the catheter. Efforts to improve it by flushing and manipulating the catheter were unsuccessful. Hence, it was decided to remove the same.

There was no resistance to the withdrawal till a distance of about 2.5 cm from the tip where it got impacted. Palpation just above the puncture site revealed a thickening in the catheter suggestive of a knot. With a venous tourniquet applied in the midarm to prevent a proximal migration of fragments in case of catheter fracture, steady traction was applied to the catheter to deliver it out. It revealed a well-formed knot about 2.0 cm from the tip [Figure 1]. Bleeding at the exit site was controlled with pressure. A retrospective scrutiny of the immediate postoperative chest X-ray showed a suspicious shadow in the catheter [Figure 2].

PICCs are routinely used to administer drugs and to monitor venous pressure. Common complications include phlebitis, thrombosis, malfunction, infections, bleeding, dislodgement and migration. Complications like cardiac arrhythmia and knotting are rarer. [1],[2]

It has been postulated that knotting of the PICC lines after a basilic vein cannulation can happen either at the puncture site or at the brachio-cephalic venous junction.

Two mechanisms are suggested for this at the puncture site. One is that the cannula would have counterpunctured the vein to create an exit port for the catheter. The second is that the cannula would have slipped out of the vein during the advancement of the catheter causing the formation an extravascular knot. [3]

Abduction of the arm to 45 to straighten the axillary vein to prevent knotting at the brachio-cephalic junction which is at a distance of about 13-14 cm from the insertion site at the cubital fossa has been stressed. [4]

The exact reason for knot formation in our patient is uncertain. It could have happened due to a counterpuncture at the time of the difficult cannulation. Such mechanisms have been implicated even when there is no resistance during cannulation or catheter advancement. [3]

We assert that knot formation should be suspected whenever flow through a PICC is compromised, after the commoner causes are ruled out, especially if there had been difficulty in cannulation, catheter advancement or stillet removal. This should be confirmed by fluoroscopy or a chest X-ray and decannulation planned immediately.

Aggressive attempts at decannulation should be avoided to minimize damage to the vein or catheter fracture. Whenever possible, the knot should be brought to an area of easy surgical access and removed by venotomy. Using introducers to unravel the knot, a technique suggested for the stiffer catheters, is inappropriate for PICC since the knots here are tighter and the chances of breakage are higher. [5] When a knot is stuck inside a major vessel or the heart, interventional radiological techniques or a major surgical procedure will be indicated. [6]

   References Top

1.Smith JR, Friedell ML, Cheatham ML, Martin SP, Cohen MJ, Horowitz JD. Peripherally inserted central catheters revisited. Am J Surg 1998;176:208-11.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Ikeda S, Shirley LD, Schweiss JF. Triple knotting of a central venous catheter. J Clin Anesth 1989;1:218-21.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Cherian VT, Venkatesan T, Adhikary SD. Knotting in peripherally inserted central catheters: More possible mechanisms. Can J Anaesth 2007;54:78-9.  Back to cited text no. 3  [PUBMED]    
4.Cherian V, Faheem M. Knotting of a peripherally inserted central catheter. Can J Anaesth 2004;51:1046-7.   Back to cited text no. 4  [PUBMED]    
5.Baldi J, Fishenfeld J, Benchimol A. Complete knotting of a catheter and a nonsurgical method of removal. Chest 1974;65:93-5.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Karanikas ID, Polychronidis A, Vrachatis A, Arvanitis DP, Simopoulos CE, Lazarides MK. Removal of knotted intravascular devices. Case report and review of the literature. Eur J Vasc Endovasc Surg 2002;23:189-94.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  


  [Figure 1], [Figure 2]

This article has been cited by
1 Transjugular retrieval of a knotted peripherally inserted central venous catheter (Epicutaneo-Cava catheter) in a neonate
Lindsay Zhou,Mathievathaniy Muthucumaru,Kenneth Tan,Kenneth Lau
BJR|case reports. 2016; : 20150327
[Pubmed] | [DOI]
2 A Comprehensive Review of Clinical Nurse Specialist-Led Peripherally Inserted Central Catheter Placement in Korea
Jeong Yun Park,Hyun Lim Kim
Journal of Infusion Nursing. 2015; 38(2): 122
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Article Figures

 Article Access Statistics
    PDF Downloaded326    
    Comments [Add]    
    Cited by others 2    

Recommend this journal