Off Label Picc as a Femoral Catheter in an Almost Noncannulated Patient

ABSTRACT

Introduction: 39-year-old patient presented with rapid progressive metastatic (lung, bone) sarcoma. He was in a life-threatening situation on peritoneal dialysis, with cardiomyopathy and ongoing infectious endocarditis. He had multiple cannulations with the introduction of dialysis catheters (jugular, axillary, femoral veins), AV fistulas on both shoulders for hemodialysis followed by calcification of these fistulas and he had tumour thrombosis of the right femoral vein. He should receive chemotherapy, but unfortunately, he tested positive for COVID-19. He developed massive bilateral covid related pneumonia. Subsequently, he fell down and broke his right arm (traumatic humerus fracture with dislocation). Method(s) According to the guidelines from GAVACELT, in covid patients, PICC is recommended as a safe and simple central venous access (CVA). This patient needed a safe CVA, because of intravenous application of antibiotics to treat the endocarditis. We were not able to use the upper part of the body to insert the line. In addition, the patient underwent kidney transplantation followed by graft explantation, because of rejection. We did not exactly know, how was the condition of the renal vessels. There was a possibility that venous stenosis would be present in the postoperative area. We decided to use the PICC 'off label', to insert from the left femoral vein, the one and only possible vein to insert a line in this patient. Result(s) We used ultrasound to guide the cannulation. Through the left femoral vein, we successfully inserted a 4Fr one-lumen tunnelled PICC line without complications. We checked the distal end of the PICC also by X-ray, to ensure the right tip position. Discussion and conclusion: We managed to cannulate this complicated patient to ensure safe CVA, despite all obstacles. We conclude, that there is no non-cannulate patient. The physician must select the correct procedure and the most suitable vein to insert the catheter.