Ultrasound-guided placement of peripherally inserted central venous catheters

Overview

The concept of achieving central venous access by cannulation of a peripheral arm vein is old, although only in the last decade has the peripherally inserted central catheter (PICC) emerged as a safe and cost-effective option. In the last century, PICCs were positioned by catheterization of visible or palpable superficial veins in the antecubital area (mostly the cephalic or the antecubital vein) or less often at the forearm or the upper part of the arm. Obviously, this “blind” cannulation could not provide any information about the actual diameter or trajectory of the vein. Hence, the rate of insertion failure, malpositioning, and catheter-related venous thrombosis was exceedingly high. Since the exit site of PICCs was usually located in the antecubital area, it was vulnerable to infections (because of extraluminal contamination) and local thrombophlebitis (because of catheter instability). Moreover, this exit site was rather uncomfortable for the patient and thus resulted in poor compliance with the device.

At the beginning of this century, the widespread use of ultrasound for guiding vascular access has dramatically changed the technique of insertion of PICCs. Currently, PICCs are inserted by ultrasound-guided puncture and cannulation of the deep upper arm veins (most often the basilic or brachial vein) via the modified Seldinger technique (venipuncture with a small-gauge needle, insertion of a thin guidewire through the needle, removal of the needle, insertion of a microintroducer-dilator over the guidewire, removal of the wire and dilator, insertion of the catheter through the introducer). This technique facilitates catheterization of large-bore veins of known diameter and trajectory while allowing positioning of the exit site in the upper part of the arm (halfway between the elbow and the axilla). As a final result, the rate of insertion failure is minimal, insertion-related complications are almost negligible, the exit site is handled easily by patients and nursing stuff (easy dressing and securement, good patient comfort), and the rate of late complications (infection, catheter-related venous thrombosis, dislocation) is low.

In other words, the 21st century ultrasound-guided PICC is a different venous access device than the 20th century PICC in terms of indications, insertion technique, expected rate of failure, and insertion-related complications, as well as the incidence of late complications.