25/11/2021: The second PICC procedure
The second PICC procedure was performed on 25 November 2021. The procedure was the same as the first one, but the venous access site was in the left brachial vein. The length for the catheter tip was 24cm, measured from the patient’s left elbow to the SVC. The venous access at the peripheral left brachial vein and the cannulation step advancing to the SVC went smoothly until the inserted catheter reached 21cm in length. When the catheter tip went further forward to 24cm in length, flushing the catheter encountered resistance and demonstrated no blood return. The PICC nurses decided to pull the catheter back to 21cm in length and asked for the verification of the catheter tip location using X-ray. The catheter tip location was confirmed in the left para mediastinal border. Figure 2 displays the catheter tip location in the second PICC.
The unexpected position of the catheter tip surprised the PICC nurses and was then explained by a cath-lab interventionist and a cardiac surgeon, who performed diagnostic catheterization and the palliative surgeries for this patient. The catheter tip was acceptably placed in the distal to the persistent left superior vena cava, only 0.5cm above the left superior cavopulmonary anastomosis. Figure 3 shows the patient’s PLSVC taken by diagnostic catheterization prior to the Fontan procedure on 10 November 2021.