A 72-year-old woman presented with sudden onset shortness of breath at rest without associated symptoms. She had a history of hypothyroidism, atrial fibrillation, and multiple myeloma converting to acute lymphocytic lymphoma currently treated with vincristine. A month prior, she was hospitalized for initiation of chemotherapy with her hospital course complicated by a right-sided peripherally inserted central catheter (PICC)-related deep vein thrombosis (DVT). She was discharged with a left-sided double-lumen PICC.
On presentation, she appeared chronically ill with telemetry capturing paroxysms of new-onset atrial fibrillation. Computed tomography (CT) scan of her chest was performed to evaluate for pulmonary embolism and was negative. Troponin was less than 0.05 ng/dL. While manipulating her PICC, the patient heard a “whooshing” sound in her left ear. Chest radiograph performed to ascertain PICC position revealed that the tip had migrated to the left internal jugular vein (IJV). (Figure 1, Panel a) Upon further review of her CT, it became apparent that the PICC tip migration occurred after contrast injection. Her PICC was replaced with a single lumen power PICC and a chest radiograph confirmed appropriate placement. A repeat chest radiograph on hospital day 5 performed for persistent refractory dyspnea incidentally revealed the PICC tip had, once again, migrated to the left IJV. (Figure 1, Panel b) The PICC was adjusted with appropriate position confirmed by film. On hospital day 10, her PICC was flushed prior to routine phlebotomy where she again described a “whooshing” sound in her left ear. Another chest radiograph performed confirmed, once again, that the PICC tip had migrated back into the left IJV. The device was exchanged without complication and the tip location was confirmed to be appropriately placed in the cavoatrial junction.
Discussion:
Often overlooked by hospitalists, PICC-tip migration is a common complication, with an estimated frequency of 12-25%. Migration is important because PICCs that do not terminate at the cavoatrial junction are associated with greater rates of thrombosis. Migration is associated with high pressure infusions, intrathoracic pressure changes from vomiting and hiccup or spontaneously. Often migrations are discovered as an incidental finding on radiographic imaging. What is unusual about this case is that the patient heard turbulent flow in relation to migration, perhaps due to turbulence in the IJV radiating to the inner acoustic apparatus.
Conclusions:
PICC migration is a common complication and should be considered in any patient who reports hearing abnormal ipsilateral sounds when manipulating the device. However, not every patient will have this woman’s “PICCth sense” and providers must be vigilant. Confirming PICC tip location and developing institutional policies to require standard monitoring of the same are warranted.