Peripherally Inserted Central Catheter

Overview

A peripherally inserted central catheter (PICC) is a long venous catheter inserted via a peripheral arm vein (typically the basilic or brachial vein) and advanced so the tip sits in the lower third of the superior vena cava (SVC) at the cavoatrial junction. PICCs are used for medium- to long-term intravenous access (weeks to months) and are placed under ultrasound and fluoroscopic guidance in the IR suite.

PICCs are one of the most commonly requested IR procedures in the NHS. They are safe, reliable, and can be placed as a day-case procedure with minimal sedation requirements.

Indications

• Prolonged intravenous antibiotic therapy (e.g., endocarditis, osteomyelitis — typically >7 days)
• Parenteral nutrition (TPN)
• Chemotherapy (power-injectable PICC required for contrast-enhanced CT staging)
• Repeated venous blood sampling in patients with difficult peripheral access
• Long-term IV access where a tunnelled line is not appropriate
• Home IV therapy (OPAT services)

Contraindications

Absolute

• Infection or cellulitis at the proposed insertion site
• Known complete occlusion of the central veins on the side of insertion (e.g., SVC obstruction)
• Ipsilateral upper limb DVT involving the target vein

Relative

• Severe coagulopathy (INR >1.5 or platelets <50 × 10⁹/L) — correct before proceeding
• Ipsilateral AV fistula or planned fistula — avoid that arm
• Previous axillary or subclavian vein stenosis (e.g., from prior lines or pacemakers)
• Ipsilateral mastectomy with axillary clearance — relative; discuss with team
• Small-calibre veins (<3 mm basilic) — consider alternative access
• Anticipated need for access >6 months (consider tunnelled line or port instead)

Pre-Procedure

Consent

Obtain written informed consent. Discuss the following risks (rates per BSIR/CIRSE standards):

Complication	Approximate Rate
Failure to place	1–5%
Line-related infection	2–5% over line lifetime
Line-related thrombosis (symptomatic)	2–4%
Bleeding / haematoma at insertion site	1–2%
Malposition requiring repositioning	2–5%
Pneumothorax	<0.1% (very rare with arm insertion)
Air embolism	Very rare
Cardiac arrhythmia (during guidewire insertion)	Rare, usually transient

Bloods

• FBC — platelets >50 × 10⁹/L
• Coagulation screen — INR <1.5
• U&Es — baseline renal function (especially if contrast may be used)
• Group & Save — not routinely required

Imaging

• Review any prior cross-sectional imaging for central venous patency
• If history of previous central lines or venous issues, consider CT venogram or Doppler US of the central veins

Preparation

• Confirm the request and indication — check for any AV fistula, previous lines, or mastectomy
• Patient fasted — not usually required (local anaesthetic procedure)
• Anticoagulants: withhold warfarin (INR <1.5), hold DOACs for 24–48 hours per local protocol, hold prophylactic LMWH for 12 hours
• Cannula for IV access not routinely needed unless sedation planned
• Position: supine, arm abducted to 45–90° on an arm board

Equipment

• PICC line: Bard PowerPICC Solo² (4Fr single lumen or 5Fr dual lumen) or equivalent. Power-injectable PICCs preferred for oncology patients requiring contrast CT
• Ultrasound: High-frequency linear probe (e.g., 10–15 MHz) with sterile probe cover
• Micropuncture set: 21G micropuncture needle, 0.018″ guidewire, coaxial 4–5Fr introducer
• Guidewire: 0.035″ hydrophilic guidewire (e.g., Terumo Glidewire) for navigation if needed
• Peel-away sheath: Usually included in the PICC kit
• Sterile drape pack, chlorhexidine 2% in 70% alcohol skin prep
• Local anaesthetic: 1% lidocaine, 5–10 mL
• Dressing: Transparent semi-permeable dressing (e.g., Tegaderm or IV3000), StatLock or similar securement device
• Fluoroscopy: C-arm for tip positioning confirmation
• Saline flush: 10 mL 0.9% NaCl syringes, heparinised saline (10 units/mL) for locking lumens

Technique

Step 1: Vein Selection and Mapping

• Apply a tourniquet to the upper arm
• Using the linear US probe, assess the veins of the upper arm in the following order of preference: basilic vein (preferred — larger, straighter course), then brachial vein, then cephalic vein (least preferred — tortuous course, sharp angle at deltopectoral groove)
• Measure vein diameter — aim for at least 3–4 mm to accommodate the PICC (catheter should occupy no more than 45% of the vein diameter to reduce thrombosis risk)
• Assess compressibility to exclude DVT
• Ideal puncture site: mid to upper arm, above the antecubital fossa (reduces infection and kinking)
• Measure the insertion length: from puncture site, along the vein course, over the shoulder, to the third right costal cartilage (approximate cavoatrial junction). Alternatively, measure to the sternoclavicular joint and add 2–3 cm

Step 2: Preparation and Access

• Position the patient supine with the arm abducted on an arm board. Ensure the C-arm can cover from the insertion site to the heart
• Full aseptic technique: surgical hand wash, sterile gown and gloves, full draping of the arm
• Prep the skin with 2% chlorhexidine in 70% alcohol — allow to dry for at least 30 seconds
• Infiltrate local anaesthetic (1% lidocaine) at the planned puncture site, creating a superficial skin bleb then deeper infiltration around the vein
• Using real-time US guidance (short-axis or long-axis approach), puncture the basilic vein with the 21G micropuncture needle. Confirm venous blood return
• Advance the 0.018″ micro-guidewire through the needle under fluoroscopic guidance

Step 3: Sheath Placement

• Make a small nick in the skin at the puncture site with a No. 11 blade
• Advance the coaxial micropuncture dilator/sheath over the wire
• Remove the dilator and 0.018″ wire, leaving the sheath
• If using a peel-away sheath system, upsize over a 0.035″ wire if required by the PICC kit instructions

Step 4: PICC Insertion

• Trim the PICC to the pre-measured length (if using a trimmable catheter — trim from the distal end per manufacturer instructions)
• Flush all lumens with saline
• Advance the PICC through the peel-away sheath to the pre-measured length
• As the catheter tip reaches the subclavian/brachiocephalic region, turn the patient's head towards the ipsilateral side to occlude the internal jugular vein and prevent inadvertent jugular cannulation
• Peel away the sheath in two halves while holding the PICC in position

Step 5: Tip Confirmation

• Fluoroscopic check: the tip should sit at the cavoatrial junction (lower SVC), approximately at the level of the carina or just below
• If the tip is too high (in the brachiocephalic vein or SVC above the carina), advance further
• If the tip has gone into the IJ, withdraw and re-advance with the head turned
• If the tip is in the contralateral brachiocephalic, use a hydrophilic wire to redirect
• Aspirate and flush all lumens to confirm function

Step 6: Securing and Dressing

• Clean the insertion site and surrounding skin
• Apply a StatLock or equivalent securement device — avoids sutures and reduces infection
• Apply a transparent semi-permeable dressing (Tegaderm)
• Lock all lumens with heparinised saline (or saline if heparin-free protocol) per local policy
• Document the PICC length at skin (external length) for future reference

Post-Procedure Care

• Chest X-ray: Not routinely needed if tip position confirmed fluoroscopically. If no fluoroscopy used, obtain a CXR to confirm tip position before use
• Line can be used immediately after tip confirmation
• Dressing changes: First change at 24 hours, then weekly or if soiled/loose. Use aseptic non-touch technique (ANTT)
• Flushing: Flush each lumen with 10 mL 0.9% NaCl before and after use, and at least weekly if not in regular use. Use pulsatile flush technique
• Observation: Check insertion site daily for signs of infection, phlebitis, or dislodgement
• Activity: Advise patients to avoid heavy lifting or vigorous arm movements for 24 hours. Keep dressing dry
• Documentation: Record line type, number of lumens, vein used, insertion length, external length at skin, tip position, and any complications
• Removal: Gentle steady traction — do not force. If resistance felt, obtain imaging to exclude fibrin sheath or venous adhesion. PICC lines do not require theatre for removal

Complications

Early

Complication	Management
Malposition	Reposition under fluoroscopy. If in the IJ, withdraw and re-advance with head turned. If in contralateral brachiocephalic, use wire-assisted repositioning
Arterial puncture	Rare with US guidance. Remove needle, apply direct pressure for 10 minutes. Very low risk of significant bleeding from brachial artery puncture with micropuncture needle
Haematoma	Apply pressure. Usually self-limiting. Large haematomas may require US assessment
Arrhythmia	Usually caused by guidewire in the right atrium — withdraw wire/catheter slightly. Typically self-resolving
Air embolism	Rare. Position patient head-down and left lateral (Durant's manoeuvre). Supportive care. Aspirate air if possible via the catheter

Late

Complication	Management
Line-related bloodstream infection (CRBSI)	Blood cultures (peripheral and from line). If confirmed CRBSI, line removal usually required. Consider antibiotic lock therapy if line salvage attempted. Involve microbiology
Venous thrombosis	US Doppler to confirm. Anticoagulation with LMWH or DOAC. Line can often remain in situ if still functioning and required. Remove line when no longer needed
Catheter occlusion	Attempt flushing with 0.9% NaCl using a 10 mL syringe (do not use smaller syringes — excessive pressure risk). If blocked, use urokinase (5,000–25,000 units in 2 mL, dwell 30–60 minutes) or alteplase 2 mg per lumen
Catheter fracture / embolisation	If catheter fragment embolises, refer for IR snare retrieval. Do not flush a fractured catheter
Fibrin sheath	Presents as ability to flush but inability to aspirate. Linogram to confirm. Options include fibrinolytic therapy, catheter exchange over a wire through the sheath, or line removal
Tip migration	Check external length at skin. If migrated, reposition or replace. CXR to confirm
Phlebitis / mechanical irritation	Common in the first few days. Warm compresses, consider upsizing vein or downsizing catheter if recurrent

Key Tips

• Always use the basilic vein first — it is larger, straighter, and has a lower malposition rate than the cephalic vein
• Catheter-to-vein ratio matters: keep the catheter occupying <45% of the vein diameter to minimise thrombosis risk. A 4Fr PICC in a 4 mm basilic vein is acceptable; a 5Fr dual-lumen in a 3 mm vein is not
• Turn the head towards the ipsilateral shoulder as the tip passes the subclavian/IJ junction — this simple manoeuvre significantly reduces IJ malposition
• Measure twice, cut once: accurate pre-measurement avoids the need for repositioning. Err slightly long rather than short — a tip in the upper right atrium can be pulled back, but a short PICC in the SVC may need replacing
• Avoid the antecubital fossa: insert at or above the mid-arm to reduce kinking and infection risk
• Power-injectable PICCs: always use for oncology patients who will need contrast-enhanced CT scans. Check the maximum flow rate and PSI rating
• StatLock over sutures: sutureless securement reduces infection rates and is recommended by NICE and Epic guidelines
• Document everything: line type, French size, number of lumens, vein used, arm laterality, insertion length, external length at skin, tip position on fluoro. This saves time when troubleshooting later
• PICC vs Midline: if treatment duration is <7 days and peripheral drugs only, consider a midline catheter instead — lower thrombosis risk and does not require tip confirmation