Fluoroscopic PICC Line Placement

Anatomy and Physiology

The right basilic vein’s size and proximity to the skin make it the attempted vein of choice for PICC placement. [5] The basilic vein is usually accessed between the axilla and the antecubital fossa. Originating from the dorsal venous network of the hand, the basilic vein travels on the medial aspect of the upper extremity. After combining with the brachial vein, the axillary vein is formed, which becomes the subclavian vein at the border of the first rib and continues centrally to become the brachiocephalic (innominate) vein. [6] The right and left innominate veins to combine at the superior vena cava. A right basilic venotomy location provides the least tortuous path toward the superior vena cava. It is thought that this vein also has the least number of valves and provides a more optimal access angle. [3] 

If the basilic vein is not accessible or occluded, an attempt at accessing the right brachial vein may be attempted. [3] There is a higher risk of inadvertent arterial puncture with this venous access location with the brachial artery nearby. Alternatively, the cephalic vein may be used for access. If the venous system of the right upper extremity is not accessible due to superficial infection, trauma, or obstruction, a left-sided approach may be attempted.

Indications

Because of their low rates of infection, peripherally inserted central catheters are indicated in patients that require IV therapy for lengths of time that range from weeks to months. [7]

Specific indications for fluoroscopic PICC line placement include:

• Intravenous infusion of irritant medications (chemotherapy) [7]
• Total parental nutrition (TPN) [8][7]
• Long term administration of medications (antibiotics) [7]
• Monitoring of interventions (central venous pressure and repeat blood sampling) [9]
• Patients with poor peripheral access (reducing the number of needle punctures to the skin)
• Multiple blood transfusions [10]
• Aberrant central venous anatomy

Contraindications

There are no absolute contraindications to central venous catheter placement as they are used in emergent situations in the most critical of patients. However, there are relative contraindications to fluoroscopic PICC placement. These contraindications include:

• Skin infections
• Trauma or burns to the upper extremities [11][3]
• Active bacteremia [12]
• Patient agitation
• Procedure refusal by the patient

Additionally, fluoroscopic procedures are contraindicated in pregnant patients unless the procedure is medically necessary for patient well-being. PICC placement can be performed using ultrasound without the use of fluoroscopy in these patients.

Equipment

Most hospitals have kits that contain standard equipment for central venous access. Items needed for the procedure include:

• Sterile draping material
• Ultrasound and probe with sterile probe cover
• Ultrasound gel
• Sterile gown, gloves, and cap
• Chlorhexidine solution
• 20cc normal saline flush
• Suture material
• Dressing
• Local anesthetic (1% lidocaine)
• Catheter
• Introducer needle
• Guidewire
• Dilator
• Blade
• Leaded glasses and apron for radiation protection

Preparation

Discuss the procedural risks and benefits with the patient. Connect the patient to a cardiac monitor to detect arrhythmias that may occur as a result of wire access into the right atrium. Place the patient in a supine position with the arm abducted and externally rotated. Use ultrasound to identify and select the appropriate vessel for access. With the measuring tape, measure the distance from the antecubital fossa to the midclavicular line and turn the tape measure to reach the third intercostal space at the right border of the sternum. This will be the approximate measurement of the catheter. Prep the area with an antiseptic solution. Appropriately drape the patient with sterile draping material. Place the sterile cover over the ultrasound probe. Ensure supplies are arranged in a sterile and organized fashion for easy access. Ensure items are in the center of the sterile field. Flush all catheter lumens with normal saline and clamp them shut. Sedation may be given for the procedure.

Technique or Treatment

Directly visualize the access vein with ultrasound and anesthetize the skin and subcutaneous tissue over the area of the vein with 1% lidocaine. Using the access needle, puncture the vein while directly visualizing the needle tip. Ultrasound will confirm the correct positioning of the needle within the vein, as will blood return from the needle. An axial view of the vessel with the ultrasound will allow visualization of the needle tip. Advance guidewire through the needle and check wire purchase with fluoroscopy to ensure positioning in at minimum the subclavian vein. Remove the needle while keeping the wire in place. Using the scalpel, make a small nick in the skin to widen the needle tract to allow more room for the introducer. Thread the introducer and dilator over the wire, through the skin, and into the vein. Trim the catheter to the previously measured length using the scalpel provided in the PICC kit. Remove the wire and dilator while leaving the introducer in place. Place a finger over the opening of the introducer to avoid air aspiration during removal. Slowly insert the entire length of PICC with obturator into the introducer sheath and visualize with fluoroscopy correct positioning at the cavoatrial junction. Snap open and pull the two wings of the sheath apart and alternate advancing catheter between pulls slightly. Aspirate and flush each lumen checking for blood return. Remove the obturator and place caps on the PICC lumens. Secure the catheter to the skin using a locking device and cover it with dressings.

Post Procedure Care

The dressing and venotomy site should be inspected to check for bleeding and erythema. Dressings should be changed at a minimum once per week. After each use, the PICC should be flushed with normal saline.

Complications

PICCs are generally inserted safely, but complications may arise relating to device insertion, functionality, or post-procedure infection. The most common complications tend to be vascular in nature. [13] Vascular complications such as accidental arterial puncture, bleeding, vasospasm, and pseudoaneurysm formation have been reported in the literature following PICC insertion. [14][15]

In addition to arterial injury, peripheral nerves and brachial nerve plexuses present in the upper extremity may be damaged. [14] Although accessed peripherally, the central termination of the catheter has been reported to rarely cause pneumothorax, air embolism, and thoracic duct injury due to incorrect terminal positioning. [14][13] Proper ultrasound training and fluoroscopic guidance to ensure proper catheter position can lower the chance of these complications.

Mechanical catheter occlusions can occur by either intraluminal or extraluminal causes. Intraluminal obstruction most commonly occurs from coagulated blood or products of infusion that have precipitated. Extraluminal obstruction usually results from fibrin sheath formation, thrombus at the tip, or incorrect catheter positioning. [14] This may pose issues for patients that require regular use of their PICC. With advances in catheter design and product material usage, occlusions rates have dropped drastically. [16]

Catheter-related infections are a fairly common occurrence. A study by Nasia et al. concluded that the PICC-associated bloodstream infection rate was 2.4% or 2 to 5 per 1000 catheter days. [17] This rate was similar in another study on ICU patients comparing central venous catheters with PICCs. PICCs were associated with an infection rate of 2.2 per 1000 catheter days versus 6 per 1000 catheter days for central venous catheters. [18] These rates were significantly higher than patients with a PICC receiving outpatient care at 0.4 per 1000 catheter days. [17] When comparing PICC and tunneled central venous catheters for TPN administration, PICC was associated with a significantly lower rate of CRBSI. [19]

Clinical Significance

Fluoroscopic PICC line placement is becoming more commonly used in clinical practice. The use of fluoroscopic guidance eliminates the need for a post-procedure check X-ray. Real-time fluoroscopic guidance allows the practitioner to confidently place the PICC and ensure that they have inserted the catheter into the correct vessel, ensure the line does not have any kinks or coils and that the tip terminates in the correct anatomical location.

PICC usage has increased significantly since the advent of central venous access. However, they do have advantages over other types of catheters for central venous access, some of which include:

• Ability to use in an outpatient setting [20]
• Lower risk of infection in inpatient settings
• Ability to remain in for months at a time for long term treatments and diagnostics [21]

Fluoroscopically guided PICC placement is not without caveats. Not every facility has the ability to perform fluoroscopically guided procedures. Patients may be unable to travel to the radiology department to have the procedure done, such as in the ICU. Ultrasound guidance without fluoroscopy would have to be performed at the bedside in these patients. In addition, pregnant patients would be better suited to performing the procedure without fluoroscopic guidance to avoid unnecessary excess radiation to the fetus. Fluoroscopic guidance can aid in cases of PICC placement in difficult patients with tortuous anatomy. Improving healthcare professional's knowledge and exposure to this technique will ultimately improve patient outcomes and reduce the risk of infection, hemorrhage, and vascular injury.

Enhancing Healthcare Team Outcomes

Fluoroscopic PICC placement involves coordinated care with several healthcare professionals. The medical team responsible for looking after the patient must consider the indications, weigh the risks and benefits and make an informed decision regarding PICC line placement and whether the patient would benefit from fluoroscopic guidance for the procedure. Radiologists perform the fluoroscopic PICC placement or supervise as a trained physician assistant performs the procedure. Following the line placement, the aftercare is provided primarily by the nursing staff.

As previously described, careful monitoring and maintenance of these lines are paramount in preventing procedural complications. If one should arise, effective communication of the entire multidisciplinary team will aid in treating the complication and preventing occurrences in the future. In addition, many health care facilities also have teams of infectious disease staff to monitor the number and root cause of catheter-associated bloodstream infections. This data aids in the institutional protocol changes to provide a safer service for patients in need of care.

This research was supported (in whole or part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. However, the views expressed in this publication represent those of the author and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.