Peripherally Inserted Central Catheters and Nontunneled Central Venous Catheters

Indications

There are three main indications for temporary CVC insertion: infusion therapy, exchange therapy, and hemodynamic monitoring. Although many CVCs can be used for phlebotomy, this use alone is rarely an indication for insertion unless in individuals with routine inpatient phlebotomy requirements and very difficult peripheral access.

PICCs are small-bore catheters placed through a peripheral arm or leg vein into the central veins. Midline catheters are shorter than PICCs and typically terminate in the axillary vein. Nontunneled CVCs are inserted more proximal to the central venous system in the internal jugular (IJ), subclavian, or femoral veins.

Indications for placement of a PICC or nontunneled CVC for infusion therapy include (1) rapid infusion of fluids or blood products to maintain hemodynamic stability, (2) infusion of vesicant solutions such as chemotherapeutic, cytotoxic, or inotropic medications or infusates with pH less than 5 or more than 9, more than 500–600 mOsm, more than 10% dextrose, or more than 5% amino acids, (3) total parenteral nutrition, (4) active infection that prevents placement of a more permanent device, and (5) coagulopathy that prevents placement of a more permanent device.

Indications for placement of a nontunneled CVC for exchange therapy (hemodialysis and apheresis) include (1) management of acute volume overload not responsive to other medical therapy, (2) management of severe acute electrolyte disorders, (3) management of acute hyperviscosity disorders, (4) short-term apheresis/hemodialysis treatment, (5) stem cell harvesting, (6) active infection that prevents placement of a more permanent device, and (7) coagulopathy that prevents placement of a more permanent device. Owing to small lumen size and low flow rates, current PICC technology does not permit exchange therapy or hemodialysis.

Indications for hemodynamic monitoring are usually encountered in patients in the intensive care unit. Nontunneled CVCs traditionally serve this function, but PICCs may be used with some limitation based on caliber. These catheters are most commonly inserted at the bedside in the intensive care unit setting.

Catheter choice should be made with expected length of treatment in mind. For short-term access (<2–4 weeks) for infusion, monitoring, or exchange therapy, a PICC or small-bore nontunneled CVC would be indicated. Some studies have reported PICCs functioning for longer than 1 year, and some anecdotal reports have noted functioning PICCs that have been present for longer than 2 years. However, such reports represent the exception rather than the rule.

For long-term access (>2–4 weeks) a tunneled catheter or implantable port may be indicated. A selection algorithm for choosing between PICCs, nontunneled CVCs, tunneled CVCs, and ports is provided in Fig. 83.1 .

PICCs have many advantages. They are safe and easy to place, prevent the need for frequent venipuncture, allow easy care and access for inpatients and outpatients, and are usually well tolerated by patients. Unlike tunneled catheters and ports that require conscious sedation, PICCs and nontunneled CVCs can be placed without sedation with little patient discomfort. They are also easy to remove or exchange in the event of malfunction or infection.

Bedside ultrasound-guided PICC placement by skilled nurses is the standard at many institutions, saving all but the most challenging of patients the time and cost of a trip to the interventional suite. At many institutions, only PICCs that cannot be advanced to the cavoatrial junction or the very difficult-to-access patients come to interventional radiology for placement under fluoroscopic guidance.

Nontunneled CVCs have similar properties to PICCs, with the advantage of accommodating large-bore catheters in the larger IJ, subclavian, and femoral veins. The major disadvantage of nontunneled CVCs is the high rate of catheter-related bloodstream infections. In fact, nontunneled CVCs account for most catheter-related bloodstream infections in the United States.

Indications for pediatric PICCs may include the need for venous access of 6 days or more or the need to administer vesicants or other infusates requiring dilution in the central venous system. Early PICC placement may spare patients numerous venipunctures. Selection criteria for catheter placement in pediatrics are otherwise similar to adults:

• It is important to choose the appropriate type of CVC for the intended use: infusion, exchange, or hemodynamic monitoring.

• PICCs and nontunneled CVCs are appropriate for access needs less than 2–4 weeks.

• Tunneled CVCs and ports are appropriate for access needs longer than 2–4 weeks.

Contraindications

There are very few strict contraindications to PICC and nontunneled CVC placement. These catheters can usually be placed safely regardless of existing coagulopathy or thrombocytopenia. Unlike with tunneled CVCs and ports, active infection or bacteremia does not contraindicate placement. Allergic reactions to contrast material and elevated serum creatinine are relative contraindications to placement under venographic guidance with iodinated contrast agents. However, ultrasound guidance or the use of alternative contrast agents such as carbon dioxide gas or gadolinium negates this contraindication. PICCs should not be placed on the same side as a previous mastectomy or axillary lymph node dissection, in a paretic extremity, or in the location of focal infection, burn, or radiation injury.

PICC placement may be precluded in patients in whom a suitable peripheral vein cannot be identified. Central venous thrombosis or occlusion also poses a relative contraindication. Occasionally a guidewire can be used to traverse the thrombosed vein, or access to the central veins can be achieved through collaterals, thus permitting central venous placement of the catheter tip. When this fails, PICCs may be positioned peripheral to the occluded central veins, thereby resulting in subclavian or axillary placement of the catheter tip. This position may be adequate provided that the fluids to be administered are not hyperosmolar or vesicant fluids. It has been shown that PICCs placed in a noncentral vein can provide reliable safe intravenous access for the administration of many medications for up to 2 weeks’ duration.

Placement of a PICC is contraindicated in any person undergoing hemodialysis or in whom hemodialysis is anticipated, including patients with renal transplants. PICCs are associated with a significant rate of peripheral venous thrombosis. To preserve peripheral veins for future hemodialysis access, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative advises against placement of PICCs in this patient population.

Equipment

Technique

Anatomy and Approach

The preferred location for PICC placement is in the nondominant arm. Placement above the antecubital fossa is preferred and may lower the risk of phlebitis. The order of preference is the basilic, brachial, cephalic, then median cubital vein. The preferred location for nontunneled CVC placement is the right IJ, left IJ, subclavian, then femoral vein. Anatomic reference is provided in Fig. 83.2 .

Basilic Vein

The basilic vein is the dominant superficial vein of the arm and merges with the axillary vein in the mid- to proximal arm. It is best found in the superficial fat of the medial aspect of the forearm. Approach from the medial part of the arm with the vein interposed between the ultrasound probe and the humerus allows control of the vessel. Proximity to the median antebrachial cutaneous nerve may require additional local anesthesia. Care should be taken to avoid the ulnar nerve located just medial to the vein.

Brachial Vein

The brachial vein is bounded proximally by the teres major muscle, where it continues as the axillary vein. The paired brachial veins parallel the brachial artery. There is increased risk of median nerve injury with brachial venipuncture, and ultrasound-guided placement is preferred to avoid injury to the medially located nerve.

Cephalic Vein

The cephalic vein drains through the clavipectoral fascia into the axillary vein at the shoulder. Approach from the lateral aspect of the arm with the vein interposed between the probe and the humerus allows control of the vessel. Navigation may be difficult in this sometimes tortuous vessel, which often has an acute angular insertion into the axillary vein. Arm abduction may aid passage of the guidewire or PICC through the clavipectoral fascia.

Median Cubital Vein

The median cubital vein drains the superficial forearm and hand and drains into the basilic and cephalic veins. It is often the most prominent vessel in the antecubital fossa and cannulation can sometimes be made without ultrasound. However, the vein may be occluded if there is a history of frequent cannulation. Numerous venous valves may also make cannulation difficult.

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