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I would like some advice and assistance with a case I am currently managing (ie - got dumped in my lap).

The patient is a 23 year old female with severe migraine disease, for which she takes a whole host of medications. Once or twice a year she receives a 3-5 day course of daily infusion therapy (goes in at 0730, receives a cocktail of IV meds until about 1500, goes home, comes back the next day for more of the same). On two occasions this has not been sufficient to manage her headache and she has to be admitted for several days of continuous IV therapy.

On her recent admission 3 weeks ago she had a 5Fr DL PICC placed a right mid-upper arm brachial vein puncture. After 5 days she developed pain in the proximal upper arm with minimal swelling of the right arm compared to the left.

Ultrasound showed a segment (6-10cm) of brachial vein with occlusive thrombus surrounding the PICC. The basilic and cephalic veins were patent. There was no clot in the axillary or subclavian veins.

The PICC was removed and she was started on Lovenox and Coumadin, stopping the Lovenox when the INR went above 2.

All pain and swelling resolved within a few days. I have been unable to get the patient in for a repeat ultrasound, but am fairly confident that the clot has resolved.

This young lady has no clinical or family history to suggest that she might have a coagulopathy.

Questions:

1 - Should the PICC have been removed as it was?

2 - Should anticoagulation have been started in the first place?

3 - I do plan to get a repeat ultrasound to verify that the clot has resolved. Assuming that there is NO CLOT at ultrasound, is there any reason to continue coumadin therapy? If so, for how long?

3a - If there IS clot present, should coumadin be continued? If so, for how long?