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Indications / Contraindications
Indications
- Long-term IV access (>5 days) for antibiotics, chemotherapy, TPN, vesicant medications
- Poor peripheral venous access — failed peripheral IV attempts
- Frequent blood draws requiring central access
- Medications incompatible with peripheral infusion (osmolarity >900 mOsm/L, pH <5 or >9, vesicants)
- Bridge to tunneled catheter or port
Contraindications
- Absolute: Ipsilateral upper extremity DVT · AV fistula on ipsilateral arm (NEVER) · Ipsilateral mastectomy with axillary node dissection (lymphedema risk)
- Relative: Overlying infection at access site · Prior PICC same arm (choose opposite arm to reduce DVT risk) · Arm lymphedema · Severe bilateral arm pathology (consider femoral PICC)
- Note: If patient is a potential future dialysis patient — strongly consider tunneled catheter instead to preserve veins
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Pre-Procedure Checklist
Review imaging/history. Check prior PICC placements, DVT history, mastectomy, AV fistula, pacemaker/ICD leads (subclavian approach avoided with leads).
Labs (SIR Category 1 — low risk). Routine coagulation NOT required. PICC = Cat 1 per SIR (INR <3.0, PLT ≥20,000 sufficient; most anticoagulants do NOT need to be held).
US arm assessment. Identify patent, compressible target vein ≥3× catheter diameter. Map for DVT. Confirm absence of AV fistula.
Room setup. Fluoroscopy suite preferred for real-time tip positioning.
Consent. DVT (~5%), occlusion, CLABSI, malposition, phlebitis, catheter migration, artery/nerve injury (brachial).
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Relevant Anatomy
Vessel Hierarchy (best to avoid)
- Basilic vein — PREFERRED: Largest diameter, no major adjacent artery, medial aspect of upper arm, direct route to axillary → subclavian → SVC; mid-upper arm diameter typically 4–6 mm
- Brachial veins — Second choice: Paired veins adjacent to brachial artery (medial to lateral: brachial artery + median nerve); depth requires US guidance; risk of arterial puncture; use color Doppler to differentiate
- Cephalic vein — Third choice: Lateral upper arm, more superficial, but tortuous angle at deltopectoral groove ("cephalic arch") where it enters axillary vein at acute angle — causing resistance and malposition or failure to advance
▶ View brachial vein anatomy
Access Site & Tip Position
- Access site: Mid-upper arm (middle third) preferred — avoids kinking at antecubital fossa, reduces phlebitis, avoids axillary infection risk from armpit
- Target tip position: Lower 1/3 SVC / cavoatrial junction
- Right-sided PICC: Tip at level of tracheal bifurcation (carina) on CXR
- Left-sided PICC: Must be advanced 1–2 cm deeper than right-sided (longer path through innominate vein before descending to SVC)
Key Anatomic Relationships
- Brachial neurovascular bundle: brachial artery + paired brachial veins + median nerve — confirm vessel identity with color Doppler before access
- Cephalic arch: acute angulation as cephalic vein joins axillary vein at deltopectoral groove — most common cause of failure to advance or malposition via cephalic approach
- Left innominate vein crosses midline horizontally before joining right innominate to form SVC — left-sided PICCs must traverse this longer course
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Technique
Default RadCall approach · share your own below
Supplies
Ultrasound + sterile probe cover
ChloraPrep
Sterile drape + maximal barrier (gown, gloves, mask, cap)
1% lidocaine
PICC kit (21g introducer needle, 0.018" wire, dilator, peel-away sheath, PICC catheter)
0.035" Amplatz wire (if needed)
Tourniquet
Heparinized saline
StatLock or equivalent securement
Occlusive transparent dressing
Fluoroscopy C-arm
Steps
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Arm selection
Choose arm without prior PICC (select opposite), AV fistula, DVT, or ipsilateral mastectomy. Right arm preferred — shorter, straighter path to SVC. If bilateral pathology, consider left arm with expectation of deeper tip advancement.
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Room setup
Position patient supine with arm externally rotated and abducted 90°. This crucial step straightens the axillary vein and aids access to deep veins. Position US monitor and fluoroscopy C-arm for optimal visibility. Apply ECG leads for arrhythmia monitoring.
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Vessel assessment
Apply tourniquet above antecubital fossa. US short-axis view. Identify and map basilic, brachial, and cephalic veins in mid-upper arm. Confirm compressibility and absence of DVT. Apply color Doppler to differentiate vein from artery. Mark skin entry point at mid-upper arm. Target vessel diameter ≥3× catheter diameter (usually ≥4–6 mm for standard 4–5 Fr PICC).
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Sterile prep
ChloraPrep prep to entire arm from deltoid to hand. Apply maximal sterile barrier (full gown + gloves + mask + cap + large sterile drape). Apply sterile US probe cover. Flush PICC catheter with heparinized saline.
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US-guided venipuncture
Reapply tourniquet. Use SHORT-AXIS US view — most reliable, avoids missing adjacent artery/nerve hidden in long-axis view. Advance 21g introducer needle at skin edge of probe. "Jabbing" technique — gently oscillate needle tip without advancing to visualize tip by subtle tissue movement. Confirm needle in vein lumen before advancing (vessel wall dimples then springs back). Aspirate dark venous blood to confirm. For deep brachial veins: hold catheter position firmly with one hand while other hand removes syringe to prevent dislodgement.
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Guidewire insertion
Thread 0.018" wire through needle under fluoroscopic visualization. TILT PATIENT'S HEAD toward insertion side to occlude ipsilateral jugular vein and prevent wire migration into neck (critical maneuver). Advance wire to IVC to confirm venous position — save a fluoroscopic image. Withdraw wire to the desired catheter tip position. Remove needle and note the wire length at the skin exit site — this is your catheter length.
▶ View wire in IVC
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Skin nick and peel-away sheath placement
Apply 1% lidocaine at insertion site if not already done. Make 2–3 mm skin nick at venipuncture site with #11 blade if skin is resistant. Insert dilator/introducer sheath over wire with firm, rotating motion. Remove dilator + wire, leaving peel-away sheath in place.
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PICC insertion
Cut PICC to measured length and thread through peel-away sheath. While sheath is peeling, keep catheter straight for smooth delivery. If retraction or resistance: re-insert wire for added stiffness. Peel sheath away symmetrically to prevent kinking.
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Fixation and dressing
Obtain final fluoroscopic image to confirm tip position at lower SVC / CAJ. Anchor with StatLock or equivalent. Apply occlusive transparent dressing. Ensure catheter hub is fixed — root of catheter prone to bending. Loop catheter proximal to insertion site, away from antecubital fossa.
▶ View final PICC position
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Troubleshooting
Problem
Cannot advance wire / resistance at shoulder
Cause: Cephalic arch angulation, subclavian kink, or tortuous axillary vein.
Fix: Have patient take deep breath; lower ipsilateral shoulder; try turning head to insertion side; withdraw to mid-subclavian and try different wire angle; if cephalic vein — switch to basilic.
Problem
Wire migrates into jugular vein (neck migration)
Cause: Common — wire follows path of least resistance into IJ.
Fix: Under fluoro, withdraw wire to subclavian; tilt patient's head toward insertion side (collapses ipsilateral IJ); re-advance. Can also compress ipsilateral IJ externally at neck.
Problem
Arrhythmia during wire passage
Cause: Wire tip in RA or RV.
Fix: Pull wire back 2–3 cm under fluoroscopy until arrhythmia stops; confirm tip in low SVC.
Problem
Tip in azygos vein
Cause: Wire/catheter angled posteriorly in SVC.
Fix: Withdraw to SVC, rotate catheter anteriorly, re-advance.
Problem
Arterial puncture (bright red pulsatile blood)
Cause: Brachial artery puncture — most common with brachial vein approach.
Fix: Remove needle immediately; hold firm pressure for minimum 5 minutes; do NOT advance wire if artery entered. Reassess with US after hemostasis.
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Complications
Immediate
- Arterial puncture (<2%) — brachial artery most common with brachial approach; direct pressure
- Nerve injury — median nerve adjacent to brachial veins; paresthesias during access → reposition
- Malposition (~10%) — jugular, axillary, azygos; detected on CXR; reposition over wire
- Air embolism (<1%) — keep catheter hubs capped; treat with left lateral decubitus + Trendelenburg
Delayed
- Catheter occlusion (~30%) — most common complication; tPA (alteplase 2mg/2mL) dwell for 2h to clear fibrin; pulsatile flushing after each use prevents
- DVT (~5%) — risk increased with: prior PICC same arm, small vessel, large catheter, cephalic vein, previous thrombosis; treat with anticoagulation ± catheter removal
- CLABSI (~2/1000 catheter-days) — maximal sterile barrier during insertion critical; hub-based infection most common source post-insertion
- Catheter migration/malposition — arm movement can shift tip; check CXR if concern; reposition under fluoro
- Phlebitis — usually superficial, not septic; warm compresses; consider catheter removal if persists
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Post-Procedure Care
Immediate (same day)
- Confirm catheter tip on fluoroscopy prior to use. Right-sided: cavoatrial junction. Left-sided: lower SVC / cavoatrial junction (1–2 cm deeper than right).
- Secure catheter: StatLock anchored to skin. Transparent dressing changed q7d or when soiled. Date catheter
- Document: Insertion date, French size, number of lumens, tip position on CXR, arm and vein used, insertion length (at skin vs. from puncture site)
Ongoing Care
- Daily assessment: Inspect exit site, dressing integrity, line connections. Assess for erythema, swelling, tenderness, leakage
- Flushing protocol: Flush each lumen with 10 mL NS before/after use. After blood draws, TPN, or thick infusions: flush 20 mL NS. Positive pressure locking with 3–5 mL heparinized saline (10 units/mL) to prevent occlusion
- Dressing change: q7d or whenever wet/soiled/loose. Chlorhexidine swab for skin antisepsis. Allow to dry fully before applying new dressing
- Assess daily for need — remove PICC as soon as IV access no longer required
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Critical Pearls
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Basilic > Brachial > Cephalic: Basilic is largest, most direct, safest approach. Cephalic has "cephalic arch" angulation issue at deltopectoral groove — high rate of resistance and malposition.
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Mid-upper arm access, short-axis US: Avoids kinking at antecubital fossa, reduces phlebitis. Short-axis provides best visualization of adjacent artery and nerve — long-axis misses these.
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Turn head toward insertion side: Prevents wire migration into ipsilateral jugular vein. Simple, highly effective maneuver — do this before every wire advance into the central veins.
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Right-sided PICC: tip at carina on CXR: Left-sided requires 1–2 cm deeper to clear innominate vein angle and reach lower SVC / cavoatrial junction.
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Vein wall dimples — confirm true lumen entry: Even if vessel appears compressed on US, confirm free blood return before wire insertion. Vein wall may dimple without true lumen entry.
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CLABSI starts at the hub: Maximal sterile barrier at insertion + proper hub disinfection ("scrub the hub" × 15 sec) every access are the biggest risk modifiers for catheter-related bloodstream infection.
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Potential future dialysis patient — consider tunneled catheter instead: Any patient who may need dialysis should have arm veins preserved for potential AV fistula creation. A tunneled dialysis catheter via neck veins is preferred over PICC to preserve upper extremity vasculature.
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Pulsatile flush after EVERY use: Prevents fibrin sheath formation. "Push-pause" pulsatile technique creates turbulence inside the catheter lumen — most important single action for long-term patency.
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PICC Maintenance
Occlusion Management
- Inability to aspirate or infuse → confirm no kink/external compression first (CXR/arm inspection)
- tPA (alteplase) 2 mg/2 mL: Instill to fill lumen volume, dwell 30–60 min, aspirate; second dose if no return after first dwell
- Catheter pinch-off syndrome: Compression between clavicle and first rib (cephalic/subclavian approach); position-dependent symptoms; requires replacement if severe
- Fibrin sheath: Most common cause of late occlusion; consider exchange if tPA fails
DVT Management
- Symptomatic upper extremity DVT: Treat with anticoagulation (therapeutic LMWH or DOAC) × minimum 3 months
- If catheter still needed and functional: Can continue PICC with anticoagulation
- If catheter no longer needed: Remove after initiating anticoagulation — removing active DVT source is important
- Catheter-associated DVT without symptoms: anticoagulation recommended per SIR/ACR guidelines
CLABSI Management
- Fever + no other source in patient with PICC → blood cultures: draw from PICC AND peripherally
- Differential time to positivity (DTP) >2h favors catheter source
- Treat with appropriate antibiotics; remove PICC if: Staphylococcus aureus, fungal infection, or no clinical improvement at 72h
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- INS Standards for Infusion Therapy 2021
- ACR-SIR-SPR Practice Parameter for Central Venous Access
- Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) 2015
Primary References
- Chopra V et al. (MAGIC investigators). The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Ann Intern Med. 2015;163(6 Suppl):S1-40.
- Chopra V et al. Risk of venous thromboembolism associated with peripherally inserted central catheters. Ann Intern Med. 2013;159(3):142-150.
- Seckold T et al. A comparison of silicone and polyurethane PICC lines. J Vasc Access. 2015;16(3):167-177.