Indications
- Long-term IV access anticipated to exceed 5 days
- Antibiotics (prolonged courses — osteomyelitis, endocarditis)
- Chemotherapy or other vesicant medications requiring central venous access
- Total parenteral nutrition (TPN)
- Poor peripheral venous access
- Frequent blood draws for monitoring
Contraindications
| Type | Contraindication |
|---|
| Absolute | Ipsilateral upper extremity DVT (current); AV fistula or AV graft on ipsilateral arm; ipsilateral mastectomy with axillary lymph node dissection; prior radiation to ipsilateral axilla/subclavian |
| Relative | Coagulopathy (SIR Category 1 — INR <3.0, PLT ≥20K; no hold required); bacteremia (consider tunneled catheter); planned hemodialysis (preserve arm veins); allergy to catheter materials |
Never place a PICC in the same arm as an AV fistula or AV graft. In patients anticipated to require dialysis, discuss with the clinical team — tunneled catheter placement preserves upper extremity vasculature for fistula creation.
Relevant Anatomy
Vein Hierarchy
| Vein | Preference | Advantages | Disadvantages |
|---|
| Basilic | First choice | Largest caliber; most direct course to axillary/subclavian vein; medial upper arm | Deeper than cephalic; medial location |
| Brachial | Second choice | Acceptable caliber; accessible | Adjacent to brachial artery and median nerve — use Doppler; paired veins common |
| Cephalic | Last resort | Superficial, easy access | Cephalic arch creates acute angle at junction with axillary vein — high rate of resistance and tip malposition |
Tip Position
- Target: lower one-third of the SVC at the cavoatrial junction (CAJ)
- Right-sided PICC on CXR: tip at or just below the carina
- Left-sided PICC: requires 1–2 cm deeper advancement than right-sided to reach equivalent position at CAJ due to longer course
- Avoid right atrium (arrhythmia risk) and subclavian/brachiocephalic vein (thrombosis risk, inadequate hemodilution)
Key Relationships
- Mid-upper arm access preferred — avoids antecubital kinking with elbow flexion
- Brachial neurovascular bundle: brachial artery and median nerve run with the brachial veins — confirm vein compressibility and arterial pulsation on Doppler before puncture
- Cephalic arch: acute angulation at the deltopectoral groove — reserve for use only when other veins are unavailable
Pre-Procedure Checklist
History Review
- Prior PICC lines (same arm — increased DVT risk)
- History of upper extremity DVT
- Prior mastectomy or axillary lymph node dissection
- AV fistula or graft
- Cardiac pacemaker leads (may limit wire advancement)
- Anticipated need for hemodialysis
Labs
SIR Category 1: INR <3.0, platelets ≥20,000. Anticoagulants do not need to be held.
Ultrasound Arm Assessment
- Confirm vein is patent and compressible (no DVT)
- Confirm no AV fistula in the arm
- Assess vessel diameter — target vessel should be at least 3× catheter diameter to minimize DVT risk
Consent Discussion Points
- DVT: ~5% (higher with prior PICC, cephalic vein, or larger catheter)
- Catheter occlusion (~30% — most common delayed complication)
- CLABSI (~2 per 1,000 catheter-days)
- Malposition (~10%)
- Phlebitis
- Arterial or nerve injury
Equipment Overview
- Ultrasound with sterile probe cover and gel
- PICC kit: introducer needle, guidewire, dilator, peel-away sheath, catheter
- Fluoroscopy unit for tip confirmation
- Maximal sterile barrier: full sterile gown, sterile gloves, mask, cap, large sterile field drape
- Catheter securement device
- Occlusive transparent dressing
- Local anesthetic
Procedure Overview
- Arm selection and patient positioning: supine, arm abducted and externally rotated
- Ultrasound vein mapping: short-axis assessment of basilic, brachial, and cephalic veins; confirm patency, diameter, and absence of DVT
- Measure external catheter length from insertion site to target tip position
- Apply maximal sterile barrier; prep and drape the arm
- Ultrasound-guided venipuncture: short-axis needle visualization into vein lumen
- Advance wire under fluoroscopic guidance; turn patient's head toward the insertion side to prevent jugular migration
- Skin nick; advance peel-away sheath over wire
- Insert catheter to measured length; remove peel-away sheath
- Fluoroscopic tip confirmation at the cavoatrial junction
- Apply securement device and occlusive transparent dressing
Complications
| Complication | Rate | Recognition & Management |
|---|
| Arterial puncture |
<2% |
Brachial artery most common. Recognized by pulsatile bright red blood. Remove needle and apply direct pressure for ≥10 min. Never advance wire into artery. |
| Nerve injury |
Uncommon |
Median nerve runs adjacent to brachial veins. Paresthesias or pain during needle advancement → stop and reposition. Persistent deficits are exceedingly rare. |
| Malposition |
~10% |
Tip in jugular vein, azygos vein, or contralateral brachiocephalic. Detected on fluoroscopy or post-procedure CXR. Reposition over wire under fluoroscopic guidance. |
| Air embolism |
<1% |
During sheath exchange. Prevent by keeping patient supine and covering hub during exchanges. Treat with left lateral decubitus Trendelenburg position and supplemental O₂. |
| Catheter occlusion |
~30% (most common delayed) |
Fibrin sheath or thrombus. Treat with alteplase dwell per institutional protocol. Prevent with pulsatile flushing technique after every use. |
| DVT |
~5% |
Risk factors: prior PICC same arm, cephalic vein, large catheter relative to vessel. Presents as arm swelling and pain. Diagnose with upper extremity duplex US. Anticoagulation per DVT protocol; remove PICC when clinically feasible. |
| CLABSI |
~2/1,000 catheter-days |
Fever with no other source. Blood cultures from PICC and peripheral vein. Remove if S. aureus, fungal, or no clinical improvement at 72 h. Treat with appropriate antibiotics. |
| Catheter migration |
Variable |
Tip moves from optimal position. Detected on CXR. Reposition or replace as needed. |
Post-Procedure Care
- Apply catheter securement device to prevent dislodgement
- Flush with pulsatile technique after every use; heparin lock per institutional protocol
- Dressing change every 7 days or when soiled/non-occlusive
- Daily assessment for insertion site infection, phlebitis, and arm swelling (DVT)
- Remove catheter as soon as no longer clinically needed — risk of DVT and CLABSI increases with dwell time
Catheter Maintenance Overview
- Occlusion: alteplase dwell per protocol to clear fibrin or thrombus
- DVT: anticoagulation per DVT protocol; remove PICC when safe; consult hematology for recurrent events
- CLABSI: blood cultures from PICC and peripheral site simultaneously; remove catheter for S. aureus bacteremia, fungemia, or failure to improve at 72 h; treat with organism-directed antibiotics
When to Escalate
- Pulsatile bright red blood during venipuncture: arterial puncture — remove needle, hold pressure; do not attempt PICC placement in that arm
- Arrhythmia during wire advancement: withdraw wire; fluoroscopic guidance for repositioning
- New arm swelling or pain post-placement: upper extremity duplex US to evaluate for DVT
- Fever with no other identifiable source: CLABSI workup with paired blood cultures; infectious disease consultation for S. aureus or fungal bacteremia