Bedside removal of a knotted peripherally inserted central catheter using a Seldinger guidewire: Case report

Abstract

Peripherally inserted central catheters (PICCs) rarely develop true knots, but when they do, forceful removal can precipitate catheter fracture and embolization. Bedside strategies that restore internal support before extraction may prevent escalation to invasive retrieval. An older adult female requiring prolonged intravenous antibiotics underwent ultrasound-guided right basilic PICC insertion (4 Fr, single lumen, polyurethane, power-injectable) using a standard Seldinger technique. After advancement through a peel-away sheath, flushing and aspiration were unsuccessful and intracavitary ECG did not show the expected P-wave augmentation. Gentle traction met immediate resistance. A 0.018-inch nitinol, straight-tip guidewire was reintroduced into the catheter to restore column strength; with controlled, gentle rotational traction the PICC was removed intact. Inspection showed a single loose knot approximately 2 cm proximal to the distal tip. A new PICC was placed contralaterally during the same session. No complications occurred and the patient was discharged without device-related sequelae. This case illustrates a pragmatic bedside maneuver for difficult PICC removal: pause traction, consider mechanical causes such as looping or knotting, reintroduce a guidewire to increase axial rigidity, and attempt controlled extraction while preparing an escalation plan. The approach may obviate fluoroscopic snare retrieval or surgical cut-down when there is no evidence of adherence, vascular injury, or partial fracture. When unexpected resistance is encountered during PICC removal, avoid forceful traction. Guidewire reintroduction can permit safe extraction of a knotted catheter and should be part of a stepwise troubleshooting algorithm.