PICC Placement

Procedure Guidelines

For Qualified Healthcare Professionals

   PICC: Peripherally Inserted Central Catheter                                   By Orhan Konez, MD, Vascular & Interventional Radiology

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PICCs: 1st photo shows a 5 Fr. Single Lumen PICC and the 2nd photo shows a Double Lumen PICC

 
Typical Procedure Table: These are the items needed for PICC. High-resolution (at least 5 MHz) ultrasound probe (with a sterile cover), micropuncture needle (20-21g needle), small wire (0.018 inch), peel-away sheath, PICC (peripherally inserted central catheter), small blade, skin preparation solution, suture (2.0) or butterfly for securing the catheter to the skin.  
Checking the arm veins with US: The patient is positioned on the procedure table and the arm is positioned (right or left depending on the interventionalistís desire and clinical setting) (e.g., If there is a breast cancer history on one side, the other arm is selected).   
  Ultrasound of the arm shows a vein. It is important not to compress the tissue much with the US probe; otherwise, the veins may disappear! Slight compression over the vessels help to distinguish the veins from arteries. With slight compression, the veins appear compressed and pulsation of the artery becomes more noticeable. Important to remember: if the vein is thrombosed, it becomes noncompressible! The second US image is with slight compression. 
Prepping the arm: Try to prep the arm all the way around. Place a tourniquet as high as possible. 

Which arm veins should be used ?

The larger the vein, the better; the basilic vein is the ideal vein. It is a good approach to attempt to obtain access as distally as possible, just above the elbow, in case you need multiple attempts 

Obtaining Access into the Vein: Ultrasound probe is positioned transverse, and the needle entry point just 1-2 cm distal to the US probe, angled slightly towards the probe. Some advocate using longitudinal positioning of the probe, but it makes it quite difficult to place the needle and the vein on the same plane. However (if ever needed), when the vein is entered, to confirm the needle position, longitudinal positioning of the probe can be used!
    Needle on US image: The needle tip is noticeable with a little back and forth motion of the needle. When the needle penetrates the upper wall of the vein, you usually feel ďpopĒ. When there is blood return, DO NOT HOLD THE NEEDLE. When the needle is held, this is the time it comes out of the vein (This is an unwritten rule in every needle procedure). Sometimes, the needle also penetrates the posterior wall of the vein, then there will be no blood return. If you suspect this has happened, pull the needle back slowly with some suction until you have a blood return.   
           

Blood return. If a tourniquet is used, blood return is commonly seen, but it may not be seen if no tourniquet is used. When you have blood return, do not hold the needle or hold it very lightly (during the wire placement etc.)   Placement of a small wire (0.018 inch). The wire should easily go into the vein; if there is resistance, do not push the wire. You can check under fluoro if the wire is being advanced in the vein or coiled around the tip of the needle. 
                    
The wire is seen in the central veins (Fluoroscopy): This confirms the patency of the subclavian vein. If the wire cannot be advanced, there is potentially subclavian vein stenosis or occlusion. Perform a limited venogram if needed.  Placement of the peel-away sheath. This goes over the wire. A small skin nick is needed to advance the peel-away sheath; otherwise it may be very difficult to advance this over the wire. 
Measurement of PICC length: X-ray shows the tip of the wire at the ideal location for PICC's tip.    The wire pulled back slightly (same distance as the hub of the peel-away and the skin entry site) and this point (clamped) on the wire used for the actual PICC length. There are several other methods described and used for measuring the PICC length, but this method is probably the easiest and most practical. 

 

Trimming the PICC: The wire and PICC are side by side; and trimming of the PICC (next photo)
Preparation of the PICC: A wire was placed into the PICC, the tip of the wire exiting the PICC slightly. This is needed to advance the PICC easily into the SVC.
Placing the PICC though the peel-away sheath: This combination (wire and trimmed PICC) is advanced through the peel-away sheath. 
Removal of the peel-away sheath: When the PICC is advanced all the way in, the peel-away sheath is removed. 

 

 

 

 

Final X-ray to confirm PICC position: The tip of the catheter is seen at the SVC/right atrial junction (arrow). This is the ideal location for PICCs. The other reason to obtain a radiograph is to rule out pneunothorax. 

 

 

 

 

 

 

Placing a dressing: Placement of a dressing and flushing the PICC with heparinized solution are the final steps of the procedure.

 

Disclaimer: This site is for qualified healthcare professionals only. Information accessed through this web page is presented in summary form in order to impart general information relating to  image guided placement of central catheters (Hickman, Port Catheter, PICC, Non-tunneled and similar catheters). Such information is not complete and may not include up to date information. This site should not be used as a formal teaching tool.  Dr. Orhan Konez makes no warranty as to the information's completeness, reliability or accuracy. 

 

 
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