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Less Is More
November 2014

Does My Patient Still Need This Central Venous Catheter?A Teachable Moment

Author Affiliations
  • 1Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
JAMA Intern Med. 2014;174(11):1725-1726. doi:10.1001/jamainternmed.2014.4208

A woman in her 30s was transferred to our institution after 3 weeks of progressively worsening dyspnea and swelling in her face and upper extremities bilaterally. Her medical history included chronic pancreatitis and malignant melanoma in situ of the left lower leg. She had an implanted port accessing her left subclavian vein placed several years prior owing to poor peripheral venous access. This port was used intermittently for blood draws and infusion of intravenous fluids and medications when she had flairs of her chronic pancreatitis. She initially presented to her local emergency department where a contrast-enhanced chest computed tomographic scan showed a nonocclusive thrombus in the left brachiocephalic vein surrounding the central venous catheter (CVC). On arrival to our institution, she was hemodynamically stable. Findings from her physical examination showed facial plethora, distended neck veins, and edema in the upper extremities bilaterally. A venogram revealed an obstruction at the confluence of the right and left innominate veins. Site-directed thrombolysis with alteplase was performed, and the CVC and the port were removed on the following day after a repeated venogram showed improvement in the stenosis. Her symptoms greatly improved after the procedure, and she was discharged while receiving warfarin with outpatient follow-up.

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