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guidance well before 2006. Nowadays, ultrasound guidance is a standard technique for puncturing the vein. PICC line insertion has become a routine Interventional Radiological procedure. The Interventional Radiology team check the patient’s history, indication for the line, coagulation profile, they plan the insertion site, and choice of catheter.

ITEMS REQUIRED  PICC line set that contains the catheter, puncture needle, peel-away sheath, guide wire, injection caps, and fixation device  Fluoroscopy x-ray machine  Ultrasound machine with linear transducer for puncturing the vein.

PROCEDURE  The patient is positioned in the supine position on the angiography table with upper extremity (that chosen for PICC insertion) placed in supine position  Ultrasound is used to check a suitable vein (basalic vein is preferred because of the size and the straight direction toward the SVC)  A tourniquet is placed in the upper arm to distend the target vein  Local anesthetic (lignocaine 1%) is infiltrated into the skin and subcutaneous tissue at the insertion site  The vein is punctured under ultrasound guidance  After confirming the tip of the needle is within the vein or visualization of back flow of blood, the guide-wire is advanced through the needle, the wire should go smoothly with no resistance  The guide wire is screened with x-ray and the tip is positioned in the distal SVC  A small skin incision is made and the peel away sheath is inserted over the guide-wire  The guide wire is used to measure the required catheter length and then removed  The catheter is trimmed to the required length, and inserted through the peel-away sheath. Peel-away sheath is peeled out  The position of the catheter tip in the SVC is confirmed with fluoroscopy  The catheter is fixed with fixator and ready to be used  If there is resistance in advancing the catheter into the vein you may need to inject contrast through the catheter to check for stenosis or abnormal anatomy.

DISCUSSION There are two types of PICC lines based on the locking mechanism that is used to maintain positive pressure inside the catheter, inner valve and clamped PICC. A retrospective study of 12,500 PICC lines comparing lines with proximal valves and those with clamps showed occlusion or infection was 2.24 times lower when using lines with proximal valve. This study supports that PICC line with proximal inner valve significantly reduce blockage, infection and rupture, which can occur secondary to blockage.

 DVT and infection are complications that could occur with PICC lines

Power injectable PICC lines can save

cost by using one line for all types of indications; they can also be used with automatic injectors. In a pilot study of 300 patients comparing three different PICC designs, 100 patients used power PICC, 100 patients with inner valve PICC, and 100 patients with Polyurethane PICCs with an antimicrobial coating, Di Giacomo conclude that power PICC line provide better durability and lower complication rates, this would result in better patient management, cost saving, decreased patient mortality from complications and better usage of nursing and medical staff. DVT and infection are complications that

could occur with PICC lines. These could increase patients’ length of stay (LOS). According to Masoorli irritation of Tunica Intima during insertion is a possible reason for venous thrombosis, moreover, poor

insertion technique could cause infection in the PICC line. Using guide-wires with a floppy tip will reduce the incidence of venous thrombosis caused by irritation of the Tunica Intima. Infection related complications could be reduced by adopting infection control, local hospital guidelines and policies. Polyurethane and silicone are the most common materials for PICC lines. Silicone provides flexibility that could reduce damage to the vein, however, reduce the flow rate, Polyurethane is stiff and has higher flow rate. Silicone increases risk of infection because of likelihood of Staphylococcus aureus contamination with this type of PICC lines. Medical technology evolution will help reducing PICC lines associated venous thrombosis and infections. Symptoms related to thrombosis can

be improved by low dose anticoagulant therapy. Prophylactic anticoagulant to prevent PICC associated DVT is ineffective, as shown in the retrospective study of 896 patients and 1296 PICC lines. PICC line insertion service can

be provided by the IV team, nurses, technologists, physicians assistants or by Interventional Radiologists. Involvement of the IV team, nurses, technologists and physicians assistants to place PICC lines has economic advantages, this can lead up to 90% cost saving and will allow Interventional Radiologists to perform complex cases and improve staff utilization. ■


 REFERENCES References available on request (

Imaging & Diagnostics Issue 4 2011 29

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