Journal of the Korean Radiological Society 1995 ; 33(6) ‘ 861 - 864

Placement of Peripherally Inserted Central Catheters (PICC) : The Upper Arm Approach 1

In Wook Choo, M.D. , Sung Wook Choo, M.D. , Dong 11 Choi , M.D. ,

Jung Hwan Yoon, M.D. , Jae Woong Hwang, M.D. , James C. Andrews, M.D.2,

David M . Williams, M.D.3, Kyung J. Cho, M.D.3, Jae Hoon Li m , M.D.

Purpose: To evaluate a recently developed technique to place a medium-dur­ation(weeks to months) central venous access.

Materials and Methods : Within three-year period , 635 patients were referred to interventional radiology suite for placement of peripherally inserted central catheter( PICC). Contrast medium was injected into the peripheral intravenous line and a puncture was made into the opacified vein near the junction of the middle and upper thirds of the upper arm, eitherthe brachial or basilic vein under fluoroscopic guidance. A 5.5-French peel-away sheath was inserted into the vein and a 5-French silicone catheter was introduced with its distal tip to thejunction of the right atrium and superior vena cava.

Results: Catheter placement was successful in all patients unless there was a central venous obstruction . Catheters were maintained from 2 days to 5 months with a mean of 3 weeks. Complications included infection requiring removal of the PICC in 16 patients(2.5% }, acute thrombosis ofthesubclavian vein in 3(0.5%) . Occluded catheters i n 4 patients were easi Iy clea red with u roki nase i n pl ace .

Conclusion : The PICC system is an excellent option for medium-duration cen­tral venous access. Patients were able to carry on normal activit ies with the catheters in place.

Index Words: Catheters and catheterization , technology Veins , interventional procedure

Peripherally inserted central catheters(PICCs) have been in use initially in t t") e pediatric and neonatal patients(1 -3). These catheters locate to a cental vein to permit infusion of hypertonic and sclerotic antineo­plastic or antimicrobial agents. In larger children and adults , the need for long -term central venous access was achieved by large -bore central catheters placed in the jugular or subclavian veins , usually by surgeons. These large central catheters have a number of pro­blems, including catheter occlusion(4 , 5) , venous thr­ombosis , infection , pneumothorax , hemothorax , inad­vertent administration of agents into the pleural space, fracture and embolization into the heart and p비 monary circulation(6, 끼 ， difficult exchange or replacement , ex­pensive insertion , and difficult care. With proper atten-

'OepartmentolRadiology, Samsung Medi cal Center 20epartm entol Radiology , Mayo Clinic 30epartment ofRadiology , Un iversity 01 Michigan Hospitals Received Augu st1 4, 1995 ; Accepted November 24,1995 Address reprint requests to : Sung Wook Choo, M. 0., OepartmentolRadiology, Samsung Medical Center ï 50, Ilwon-Oong, Kangnam-ku, Seou11 35- 230Korea

Tel. 82-2- 341 0- 2518 Fax. 82- 2- 341 0-2559

tion to sterile technique and dr essing changes , these long fexible catheters could be left in situ for longer periods than conventional per ipheral IVs , and they did not damage the patient’s peripheral veins , since the drugs or alimentation fluids were delivered centrally in large veins in wh ich dilution quickly lowered the high osmolarity. The problem with bedside insertions was the low success rate, with wh ich the catheters could be threaded to the central circulation , particularly if the individuals who inserted the catheters were not ade­quately trained. It has become apparent that experts who were facile with catheters and worked in fluoro­scopic assistance far outperformed bedside insertions in terms of venipuncture success rate, speed , and com ­plication rate(8, 9) . The pu rpose of thi s study is to ev­aluate a recently developed rad iological tec hnique t。place a medium - duration PICC by upper arm app­roach.

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Journ al of the Korean Radiological Society 1995 ; 33(6) : 861 -864

PATIENTS and METHODS

Between April1991 and February 1994, 635 consecu­tive patients were referred to the angiointerventional suite at the University of Michigan Medical Center for placement of PICC. This group included 337 men and 298 women , ranged 12 -85 years old with a mean age of 51 years. The indications for PICC were antineo­plastic chemotherapy(227 cases) , long - term antibiotic infusion(312 cases) , total parenteral nutrition(37 ca­ses) , blood - products infusion(50 cases) , and long term IV administration of diuretics(9 cases) .

Prior to the procedure , each patient permitted writ­ten , informed consent , as approved by the clinicians The patient’ s nondominant arm was used whenever possible. Patients were positioned with the arm ab­ducted and externally rotated , and the axilla and upper arm were prepared and sterily draped.

PICC insertion technique uses a fluoroscopic - ve­nographic approach. Initially , a srnall needle is inser­ted in a vein on the thumb , wrist , hand , or other periph­eral location. Contrast medium(20 -50 ml) is then in­jected until suitable veins at midhumerallevel against an upper arm torniquet are filled . The basilic vein is preferred because it is larger and follows a more direct course to the axillary and subclavian veins and su­perior vena cava , although the cephalic vein is suitable in most patients. Entry above the antecubital fossa is preferred because the veins are larger more proxi ­mally(toward the heart) and have generally been sp­ared the ravages of repeated phlebotomy since they are deep at this location and rarely can be palpated. An additional advantage of this entry location is that the catheter is not subjected to repeated bending across the antecubital fossa with arm motion. After induction of local anesthesia with 2% lidocaine, the chosen entry

Fig . 1. 5-F single lumen PICC. Catheter wings(arrows) are to be sutured for fi xation and large hub is des igned for easy handl ing A 5.5.F peel -away sheath (long arrow)

vein is punctured under direct continuous vision with a 21 gauge needle by confirming blood aspiration. With a minipuncture system , a 0.018 - inch wire is passed into the vein . Subsequently , a 5 - F dilator sheath is ad­vanced over the wire to maintain venous access.

The PICC system was a single or duallumen 5-F sili­cone catheter(Cook Inc. , Bloom ington , In) with a larger hub end and pinch clamp(Fig. 1) to let the patient and his safeguard to get easy handling. The required len­gth of catheter was determined by advanc ing a gui­dewire through the dilator to the junction of the su­perior vena cava and the r ight atrium , and the catheter was cut to the length traversed by the wire. Next , a O. 035 - inch guide wire was advanced under fluoroscopy into the distal infer ior vena cava. A 5.5 -F peel -away sheath(Cook Inc. , Bloom ington , In) was advanced into the vein , and a 5 -F silicone catheter was subsequently advanced over the wire with its tip in the superior vena cavalright atrial junction in such a way that the tip kicks with each card iac cycle(Fig. 2). After the catheter was placed into the position , the sheath was removed , and the wings at the catheter hub sutured in place with two 4 - 0 prol ine stitches.

Following radiographic imaging of the catheter , all channels of the PICC were irrigated with heparinized saline and finally flushed with a heparin lock solution contain ing 100 U/mL of heparin. Infusion caps were placed on each port hub and pressure was held on the puncture site until hemostasis was obtained. The PICC was secured the skin by means of an occlusive dress­ing which was changed every 5 to 7 days. Care was taken to flush the catheter with heparin solution after each use.

RESULTS

A total of 635 PICC devices was used in the 635 PICC

Fig ‘ 2. A 5-F silicone catheter is subsequ ently pl aced via righ t basili c vein with its tip in the superior vena cava/ri ght atrial junc. tion(arrow) in such a way th at the ti p ki cks with each cardi ac cyc le

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In Wook Choo, et al: Placement of Peripherally Inserted Central Catheters

patients. Successful initial insertions were achieved in 635 of 635(100%) consecutive patients excluding 17 patients with central venous obstruction on digital sub­traction venogram

Catheters were indwelling from 2 days to 5 months, with a mean duration of 3 weeks. The catheters were used for antineoplastic drug infusion , administration of antibiotics , total parenteral nuitrition , administration of diuretics , and trasfusion of blood products.

Overall complications after the procedures occured in 23 patients(3.6%). Complications requiring removal of the catheter occured in 19 patients(3%). Sixteen catheters(2.5%) were removed because of infection. In fourteen cases , frank infection was present around the insertion site , and in the other two, blood cultures con­tained gram - positive Staphylococcus epidermidis of the skin flora , and the catheter was thought to be the source through the insertion site(1 이. Symptomatic ac­ute subclavian vein thrombosis occured in three pa­tients. Arm swelling responded to removal of the ca­theters and systemic anticoagulation with an admi­nistration of 2500 Units of Heparin. In four patients , the catheters became occluded after blood drawing , but were easily cleared with 5000 Units of Urokinase.

DISCUSSION

With the introduction of PICC devices primarily in pediatric literatures(1 -3) , relatively little is written about these devices in radiological literature(8, 9) Although the PICCs were initially inserted at bedside, it rapidly became that such insertions were only suc­cessful with large adequate peripheral veins. Patients, who need temporary or long term central venous ac­cess , often do not have visible peripheral veins , and this fact limits the easy placement of PICC device at bedside. It has become apparent that experts who were facile with catheters and worked in fluoroscopic assist­ance far outperformed bedside insertions in te- rms of venipuncture success rate , speed , and complication rate(4-9).

Advantages in interventional radiology technologies are to locate and target undamaged veins and advance the catheter into the central circulation with safety. The basilic vein is preferred because it is larger and follows a more direct course to the axillary and subclavian veins and superior vena cava , although the cephalic vein is suitable in most patients. When the initial at­tempt to cannulate the adequate vein is unsuccessful such as inadvertent entry into the brachial artery or ex­travasation of contrast medium at fluoroscopy , the minipuncture system can result in minimal damage and prevent the serious compl ication with final suc­cess , but this has not occured in this study. The fl­uoroscopic -venographic guidance ofthe PICC through the collateral veins and into central circulation is an ­other advantage when major veins are segmentally

occluded about the elbow, shoulder , or subclavian area that is impossible at bedside or by surgeons(8). Advantage of entry above the antecubital fossa is that the catheter is not subjected to repeated trauma across the antecubital fossa with arm motion(9).

The PICCs are intended for and well t이 erated by the patients who require venous access for up to 3-5 months, and their dwell time is optimal to complete therapy with a single device. Service interval of the PICCs can be maximized by careful attention to site care , heparin flushing after each use, and restricting blood sampling through small lumen. In patients re­quiring blood draws, the largest channel is used and meticulous flushing of the channel after the draw is critical for the longer service interval. Blood sampling was avoided as possible because PICCs through which blood was drawn had not longer service interval than those through which blood drawing was not achieved (8).

The catheter occlusion after the blood drawing has occured in four patients in our series , and cleared with 5000 units of urokinase successfully. When the PICCs fail because of dislodgement, breakage, leakage, or occlusion , they can be easily be exchanged over a guide wire or through a peel -away sheath. Exchang­eability into the same vein is a fascinating advantage of the PICCs over other devices such as Hickman , Bro­viac right atrial catheter , and subcutaneous infusion ports(8 , 9, 11). Fortunately , failures other than occ­lusion have notoccured in our series.

The overall complication rate of the PICCs {23 of 635 (3.6%)} in our series compares favorably with that of other devices(3.5-8.9%) (8 , 9) and , surgical or bed­side approaches. PICC complications of infection(n= 16) and venous thrombosis(n=3) in our series are minor when compared with those of surgical approach such as pneumothorax , hemothorax , breakage with embolization of fragments to p비monary circulation , and injection port occlusion(4 -18). The PICCs are less expensive than other devices, with lowered morbidity , mortal ity, and fee of the surgery.

In conclusion , the PICC system by radiological inser­tion is an excellent option for medium - duration central venous access. Patients were able to carry on normal activities with the catheters in place without difficulty.

REFERENCES

1. Bottino J, McCredie KB , Groschel 0, Lawson M. Long-term intra­venous therapy with peripherall y inserted Silastic central ve­nous catheters. Cancer 1979 ; 43: 1937 -1943

2. Dolcourt JL , Bose CL. Percutaneous insertion 01 Silastic ca­theters in newborn inlants. Pediatrics 1982 ; 70: 480-486

3. Durand M, Ramanathan R, Martinelli B, Tolentino M. Prospective evaluation 01 percutaneous central venous Silastic catheters in newborn inlants with birth weights 01 510 to 3, 920 grams. Pedi­

atrics 1986 ; 78: 245-250

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Journal of the Korean Radiological Society 1995 ; 33(6) ; 861-864

4. Hinkle DH, Zandt-Stastny DA, Goodman LR , et al. Pinch-oll syn- 127-137

drome: a complication 01 implantable subclavian venous access 12. Lameris JS, Post PJM , Zonderland HM , Gerritsen PG , Kapp-

devices. Radiology 1990 ; 177: 353-356 ers-Klunne MC , Schutte HE. Percutaneous placement 01 Hic-

5. Aitken DR , Minton JP. The “pinch-off sign": a warning 01 impend- kmann catheters. comparison 01 sonographically guided and

ing problems with permanent subclavian catheters. Am J Surg blind techniques. AJR 1990 ; 155 : 1 097-1099

1984 ; 148 : 633-636 13. Kirkemo A, Johnston MR. Percutaneous subclavian vein place-

6. Propp DA, Cline 0 , Hennenlent BP. Catheter embolism. J Emerg mentoltheHickman catheter. Surgery 1982 ; 91 : 349-351

Med1988 ; 6: 17-21 14. Dick L, Mauro MA, Jaques PF, Buckingham P. Radiologic inser-

7. Richardson JD, Grover FL, Trinkle JK. Intravenous catheter tion 01 Hickman catheters in HIV-positive patients: infectious

emboli : experience with 20 cases and collective review. Am J complications. JVasc Interv Radio/1991 ; 2 :327-329

Surg1974;128 :722-727 15. Robertson LJ , Mauro MA , Jaques PF. Radiologic placement 이

8. Cardella JF , Fox PS, Lawler JB. Interventional radiologic place- Hickman catheters. Radiology 1989 ; 170: 1007-1009

ment 01 peripherally inserted central catheters. J Vasc Interv 16. Lund GB, Li eberman RP, Haire WD , Martin VA, Kessinger A, Radio/1993 ; 4: 653-660 Armitage JD. Translumbar inlerior vena cava catheters lor

9. Andrews JC , Marx MC, Williams DM , Sproat 1, Walker-Andrews long-term venous access. Radiology 1990 ; 174 : 31-35 SC. The upper arm approach lor placement 01 peripherally 17. Cassidy FP, ZajkoAB, Bron KM , Re川y JJ, Peitzman AB , Steed

inserted central catheters lor protracted venous access. AJR DL. Noninlectious complications 01 long-term central venous

1992 ;158:427-429 catheters:radiologic evaluation and management. AJR 1987 ;

10. Takasuki JK , 0 ’Connell TX. Prevention 01 complications in per- 149 : 671-675

manent central venous catheters. Surg Gynecol Obstet 1988 ; 18. Hull JE, Hunter CS, Luiken G. The Groshong catheter: initial ex-

167 ‘ 6-11 perience and early results 01 imaging-guided placement. Radi-

11. Mauro MA, Jaques PF. Radiologic placement 01 long-term cen- ology 1992 ; 185 : 803-807

tral venous catheters: a review. J Vasc Interv Radio/1993 ; 4

대 한 밤 사 선 의 학 회 지 1995 ; 33( 6) : 861-864

말초정맥을 통한 중심정맥도관 삽입 :상완접근술1

1 삼성의료원 방사선과

2마요클리닉 방사선과

3 口|수|간대학병원 방사선과

주인욱 · 주성욱 · 최동일 · 윤정환 · 황재웅 · 제임스 앤드류즈2 데이비드 윌리암즈3 . 조경저13 . 임재훈

목 적.이 연구는 근래 새로이 소개된 상완말초정맥을통한중심정맥 도관 응엠술을 평가하기 위함이다.

대상 및 방법 :3년동안 635명의 환자에 대해 이 시술을시행하였다.조영제를사용하여 상완부위 정맥을가시화하고，투시

하에 전공을 시행하였다. 정맥에 5.5 프렌치 탈피초를 읍업한 후， 5 프렌치 도판을 끝부분이 상대정맥과 우심방이 만나는 부

우|어| 우|치시켰다.

결 과:모든 환자에서 성공적으로 시술되었고， 기간은 2일에서 5개월로 평균 기간은 3주일이었다. 도관 삽입후 도관제거

가 필요하였던 합병증은 16예의 감염 (2.5%) ， 쇄골하 정맥의 급성 혈전즘 3예 (0.5%) 였다. 도관 폐쇄는 유로키나제 직접 투

여로재개통되었다.

결 론:상완부위 밀초정맥을통한중심 도관 삽입술은수주에서 수개월간의 기간을요하는중심정맥 확보술로가장좋은

방법이었고， 환자들은 불편없이 도관을 옴에 지니고 정상 생활을 영위할 수 있었다.

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