Case report: Severe consequence of unnecessary retention of a TIVAD, phlegmasia cerulea dolens—A case for better stewardship

Totally implanted venous access devices (TIVADs) have been used for decades in cancer management. Traditionally placed in the chest wall, they can also be inserted in the upper arm using peripherally inserted central catheter methodologies (PICC-Ports), which are recognized as a safe and comfortable alternative. However, as with all vascular access devices, their safety profile depends on appropriate management, including timely removal. We report a case of Phlegmasia Cerulea Dolens (PCD)-critical venous ischemia-occurring a year after treatment completion due to a retained device. A 59-year-old breast cancer patient presented with arm edema ipsilateral to a PICC-Port, 1 year after chemotherapy had ended. Despite an initial "normal" duplex ultrasound (DUS), her condition worsened into full-blown PCD with cyanosis and loss of pulses. CT angiography revealed massive thrombosis, and standard anticoagulation failed, necessitating interventional radiology for subclavian stenting. While TIVADs are established as a safe method of chemotherapy administration, their safety remains contingent upon adherence to insertion protocols, timely removal, and knowledge of international guidelines. Leaving an inactive device for 12 months post-treatment represents a significant risk. Furthermore, a false-negative initial ultrasound led to a critical diagnostic delay, underscoring that strong clinical suspicion should sometimes override early negative imaging to prevent progression from deep vein thrombosis to PCD. Ultimately, "lost to follow-up" patients with retained TIVADs and non-compliance with international guidelines represent a major iatrogenic risk in cancer management.