case_images: PMC6180852_01
case_images: Digital subtraction angiogram performed during peripherally inserted central venous catheter insertion demonstrates a filling defect in the left brachiocephalic vein (black arrow), representing a thrombus. A left internal jugular vein central line is in situ (white arrow).
case_images: bjrcr.20150315.g001.jpg
case_images: PMC6180852_01_bjrcr.20150315.g001.jpg
case_images: fig1
case_images: A digital subtraction angiogram was performed that demonstrated thrombus in the left brachiocephalic vein (Figure 1).
case_images: Fluoroscopic spot image obtained during PICC insertion shows the tip of the PICC (P) in the distal superior vena cava. The white arrows denote the dilated azygos vein. CL, left internal jugular vein central line; PICC, peripherally inserted central venous catheter.
case_images: bjrcr.20150315.g002.jpg
case_images: PMC6180852_01_bjrcr.20150315.g002.jpg
case_images: fig2
case_images: Bloomington, IN) double-lumen polyurethane PICC was then inserted over the guidewire with its tip sited in the distal SVC (Figure 2). Blood was readily aspirated from the PICC and the line was flushed and secured.
case_images: Frontal chest radiograph 9 days after peripherally inserted central venous catheter insertion shows a small right-sided pleural effusion (black arrow) and a curve in the distal catheter tip (white arrows). The heart is normally oriented but the gastric bubble is under the right hemidiaphragm, consistent with situs ambiguus.
case_images: bjrcr.20150315.g003.jpg
case_images: PMC6180852_01_bjrcr.20150315.g003.jpg
case_images: fig3
case_images: A chest radiograph was performed (Figure 3) that showed a small right-sided pleural effusion.
case_images: Frontal chest radiograph 10 days after PICC insertion shows large bilateral pleural effusions with atelectasis. The PICC tip remains curved (white arrows). PICC. peripherally inserted central venous catheter.
case_images: bjrcr.20150315.g004.jpg
case_images: PMC6180852_01_bjrcr.20150315.g004.jpg
case_images: fig4
case_images: A repeat chest radiograph was obtained that showed large bilateral pleural effusions (Figure 4).
case_images: (a) Axial slice from the CTPA shows large bilateral pleural effusions (EF) and pneumomediastinum (white arrows). A nasogastric tube (NG) is sited within the oesophagus, which is displaced anteriorly together with the trachea by a large mediastinal effusion. The PICC tip (P) is adjacent to locules of mediastinal gas. The azygos is not clearly seen on this image, as it is isodense to the surrounding effusion. (b) Coronal three-dimensional maximum intensity projection reconstruction of the CTPA shows the PICC displaced outside the superior vena cava. CTPA, CT pulmonary angiogram; PICC, peripherally inserted central venous catheter.
case_images: bjrcr.20150315.g005.jpg
case_images: PMC6180852_01_bjrcr.20150315.g005.jpg
case_images: fig5
case_images: The CTPA was negative for a PE but did demonstrate large bilateral pleural effusions, a moderate-sized pericardial effusion, a mediastinal effusion and pneumomediastinum (Figure 5a,b).
case_images: (a) Oblique axial slice from the CT scan obtained after drainage of the effusions shows that the PICC tip (white arrow) has perforated the wall of the azygos (A). The azygos is dilated and has a similar diameter to the SVC (S). (b) Coronal three-dimensional reconstruction also demonstrating perforation of the azygos (A) by the PICC (white arrow). There is variant drainage of the azygos into the right lateral wall of the SVC (S). This creates a favourable angle for migration of a left-sided PICC into the azygos. BC, left brachiocephalic vein; PICC, peripherally inserted central venous catheter; RA, right atrium; SC. left subclavian vein; SVC, superior vena cava.
case_images: bjrcr.20150315.g006.jpg
case_images: PMC6180852_01_bjrcr.20150315.g006.jpg
case_images: fig6
case_images: A repeat CT scan showed that the PICC was not actually coiled within the SVC, but had migrated to the azygos and caused a perforation (Figure 6a,b).