PICC migration and perforation of internal jugular vein after neck dissection

Abstract

Peripherally inserted central catheters (PICCs) were introduced as an alternative to centrally inserted central catheters (CICCs) inserted into the jugular vein to provide central venous access. In head and neck reconstructive surgery, PICCs are preferred over CICCs because they do not obstruct surgical access, such as during neck dissection. Additionally, PICCs offer a safer option than peripheral access for the infusion of vesicants, irritants, hyperosmolar solutions, antibiotics, prolonged parenteral nutrition, and chemotherapy agents. We present a case of perforation of the internal jugular vein caused by PICC migration in the early postoperative days following neck dissection and free flap reconstruction. During surgical exploration, a large cervical hematoma was evacuated. Bleeding was traced to multiple lacerations of the internal jugular vein, the largest measuring 15 mm. The venous anastomosis of the radial forearm free flap was intact. The internal jugular vein was temporarily clamped, repaired with sutures, and the PICC was removed intraoperatively. Despite the lacerations being caudal to the anastomosis, the free flap was preserved, and the patient was discharged without further complications. An increase in thoracic pressure, such as that resulting from a forceful cough or vomiting, can lead to the displacement of PICC lines. In patients who have undergone neck dissection, episodes of vomiting or severe coughing should be carefully monitored for the risk of PICC tip migration. This migration could cause simultaneous laceration of the vessel wall, leading to potentially life-threatening hematomas. Monitoring the tip position of PICCs in this type of patient could be performed at the bedside at least weekly during scheduled dressing changes and/or sutureless system changes. In this way, secondary malpositions of the tip could be identified early and potentially life-threatening complications such as those in this report could be avoided.