Is it acceptable to remove the peripherally inserted central catheter (PICC) when a proximal brachial vein deep vein thrombosis (DVT) is suspected?

PICC Line Removal in Suspected Proximal Brachial Vein DVT

Do not routinely remove a functional PICC line when proximal brachial vein DVT is suspected or confirmed, unless specific clinical criteria are met. 1

Decision Algorithm for PICC Removal with DVT

Remove the PICC if ANY of these conditions exist:

• The PICC is no longer clinically necessary for the patient's care 1, 2
• The PICC is only being used for phlebotomy and adequate peripheral veins are available 1, 2
• Symptoms of venous occlusion persist (arm pain, swelling) despite ≥72 hours of therapeutic anticoagulation 1, 2
• Confirmed line-related bloodstream infection with objective bacteremia evidence 1, 2

Do NOT remove the PICC if ANY of these conditions exist:

• Irritant or vesicant infusions remain necessary for treatment 1, 2
• Poor peripheral venous access exists and the patient requires frequent phlebotomy (would necessitate another PICC placement) 1, 2
• Less than 72 hours of therapeutic anticoagulation has been provided, even if minimal symptom improvement 1, 2

Uncertain situations (clinical judgment required):

• Patient cannot receive systemic anticoagulation but the PICC remains clinically necessary 1
• Line-related infection is suspected but not yet confirmed 1, 2

Management When PICC Remains In Situ

Initiate therapeutic anticoagulation for at least 3 months when treating PICC-related DVT, regardless of whether the catheter is removed 1, 3. This represents the standard of care and shorter durations are inappropriate. 1

Anticoagulation specifics:

• Target INR of 2-3 if using warfarin 1
• Prefer low-molecular-weight heparin over warfarin in patients with active cancer 1
• Anticoagulation without catheter removal is the treatment of choice for catheter-related thrombosis when the catheter must remain functional 4, 3

Critical Clinical Context

The evidence strongly supports that mandatory functioning catheters can remain in place with anticoagulant treatment 4. A 2019 retrospective study found that catheter removal alone (without anticoagulation) resulted in 6.4% secondary VTE events including pulmonary embolism, though this approach had significantly lower major bleeding rates (4.8% vs 28.5%) 5. However, guideline-based care prioritizes the combination of catheter retention (when clinically necessary) plus therapeutic anticoagulation. 1

Special circumstances requiring urgent intervention:

Immediate referral to interventional radiology is appropriate when symptoms of venous occlusion are associated with phlegmasia cerulea dolens (swollen, enlarged, painful, purplish discoloration of the affected limb) 1

Common Pitfalls to Avoid

• Never remove a functional PICC prematurely (before 72 hours of anticoagulation) if vesicant infusions are ongoing 1, 2
• Never use catheter removal as definitive therapy in the absence of contraindications to anticoagulation—this is rated as inappropriate 1
• Do not place a new PICC within 30 days of PICC-related DVT due to high recurrent thrombosis risk 1, 2
• Anticoagulation is not a contraindication to PICC removal when removal criteria are met; standard hemostasis with firm pressure ≥5 minutes is sufficient 2

Removal Technique When Indicated

If removal criteria are met, follow these steps:

• Position patient supine with exit site below heart level to minimize air embolism risk 2
• Use chlorhexidine-alcohol for skin antisepsis 2
• Apply gentle, steady traction; never use excessive force 2
• Apply firm digital pressure for at least 5 minutes after removal 2
• Inspect the catheter to confirm it is intact and complete 2
• If resistance is encountered, consult interventional radiology or vascular surgery—never forcefully pull 2