Highlights

  • Recurrent central venous access can lead to central venous occlusions.

  • Collateral flow can be used adventitiously for PICC tip placement.

  • Sharp recanalization can be used to reconstitute patency of an occluded SVC.

Abstract

Purpose: To present a unique case in which intravenous medications were administered intermittently through a peripherally inserted central catheter (PICC) line over 2 years in the presence of an occluded superior vena cava (SVC) due to impressive collateral development. However, SVC recanalization was ultimately needed to allow for long-term future access needs.

Case Description: This is a 25-year-old female with cystic fibrosis with known chronic occlusion of the SVC requiring multiple ports and PICC lines to maintain venous access. Despite conservative measures, it eventually became impossible to pass the occlusion via guidewire to properly place a PICC line. Sharp recanalization of the SVC occlusion with port placement was scheduled and successfully performed. The SVC was stented due to severe residual stenosis following recanalization and balloon angioplasty.

Results: Imaging revealed a significantly enlarged hemiazygos vein and numerous prominent collaterals throughout the mediastinum and chest wall, resulting in the majority of chest venous drainage entering the inferior vena cava. After recanalization, her SVC and port remained patent and functional.

Conclusions: For patients with SVC occlusion requiring venous access, a PICC line with the tip placed near the confluence of the brachiocephalic veins may serve as a temporary method for venous access in the presence of extensive collateral flow. However, for long-term access, sharp recanalization of the occlusion should be considered to restore normal laminar blood flow patterns and allow for optimum central venous catheter tip placement at the cavoatrial junction.

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