Venous · IR Playbook

Peripherally Inserted Central Catheter Placement (PICC)

A peripherally inserted central catheter is introduced through an upper-arm vein and advanced until its tip lies in the lower superior vena cava or at the cavoatrial junction. It provides intermediate- to long-term central venous access while avoiding direct neck or chest venous puncture. Important complications are catheter-related thrombosis, infection and tip malposition.

Indications

• Prolonged intravenous antimicrobial therapy or other treatment generally expected to exceed 15 days
• Administration of vesicants, irritants, chemotherapy or parenteral nutrition requiring central delivery
• Repeated blood sampling or reliable venous access when peripheral access is inadequate

Relative contraindications

• Advanced chronic kidney disease requiring preservation of upper-extremity veins
• Ipsilateral mastectomy with lymph-node dissection, lymphoedema, pacemaker leads or central venous stenosis
• Uncorrected clinically significant coagulopathy

Equipment

• High-frequency linear ultrasound probe with sterile cover and sterile gel
• 21 G micropuncture needle
• 0.018-inch guidewire and peel-away introducer
• 4–6 Fr single- or multilumen PICC of appropriate length
• Local anaesthetic, syringes and saline flush
• Sutureless securement device and sterile transparent dressing

Procedure steps

1. Position the arm abducted and examine the upper-arm veins with ultrasound. Prefer a patent basilic vein because of its size and relatively straight course.
2. Perform hand hygiene, use maximal sterile barriers and prepare the skin with alcoholic chlorhexidine, allowing it to dry.
3. Infiltrate local anaesthetic and puncture the vein under real-time ultrasound guidance. Confirm intraluminal needle-tip position before advancing the 0.018-inch wire.
4. Make a small skin nick and advance the peel-away introducer over the wire. Remove the wire while preventing air entry and blood loss.
5. Measure and trim the catheter according to the device instructions. Advance it through the introducer to the lower SVC–cavoatrial junction under fluoroscopy or ECG-based tip navigation.
6. Confirm satisfactory central tip position, aspirate blood and flush every lumen. Record the external catheter length, apply a sutureless securement device and cover with a sterile dressing.

Complications

• Catheter-related upper-extremity venous thrombosis
• Catheter-related infection
• Tip malposition or catheter dysfunction
• Bleeding, arterial puncture or nerve irritation

Exam pearls

• Use real-time ultrasound for venous puncture and the smallest catheter with the fewest necessary lumens
• A PICC is defined by its central tip position, not merely by upper-arm insertion
• Preserve upper-extremity veins in patients with advanced chronic kidney disease
• Confirm tip location before infusion through a newly placed PICC

Viva questions

Which vein is preferred for PICC placement?

The basilic vein is usually preferred because it is relatively large and follows a straighter course toward the axillary vein.

Where should the PICC tip lie?

The desired tip position is the lower SVC or cavoatrial junction.

Why should PICCs be avoided in advanced chronic kidney disease?

PICC-associated thrombosis or stenosis may compromise upper-extremity veins required for future arteriovenous dialysis access.

Are prophylactic antibiotics routinely required?

No. Strict aseptic technique and maximal sterile barriers are required, but routine systemic antibiotic prophylaxis is not recommended.

References