BRIEF REPORT

Ultrasound-guided Tunneled Lower ExtremityPeripherally Inserted Central Catheter Placement in

Infants

Subramanian Subramanian, MD, David C. Moe, MD, and Jack N. Vo, MD

ABSTRACT

Tunneled lower extremity peripherally inserted central catheters (PICCs) are placed in infants under combined ultrasound andfluoroscopic guidance in the interventional radiology suite. In infants requiring a bedside procedure, image guidance is limited,often using portable radiographs during the procedure. This report demonstrates feasibility of placing tunneled lower extremityPICCs using ultrasound as the sole imaging modality for vascular access, intravascular length measurement, and finalconfirmation of catheter tip position in a case series of 15 critically ill infants. The technique negates the need for added imagingconfirmation methods that use ionizing radiation and can be performed at the bedside.

ABBREVIATIONS

ICU = intensive care unit, IVC = inferior vena cava, PICC = peripherally inserted central catheter, UVC = umbilical venous catheters

Peripherally inserted central catheters (PICCs) are usedin premature infants in the neonatal intensive care unit(ICU) and in other infants requiring stable long-term in-travenous access (1). These catheters can be placed by in-terventional radiologists from a tunneled approach intothe common femoral vein (2). Accurate placement of thecatheter tip in the inferior vena cava (IVC) 1–2 cm belowthe cavoatrial junction is desired to avoid potentialcomplications such as arrhythmias and infiltration intoadjacent tissues including pericardial and pleural spaces,which could lead to cardiac tamponade and death (1).Traditionally, when a PICC is inserted at the bedside,the location of the catheter tip is confirmed by a portableradiograph or portable fluoroscopy C-arm unit. Tar-geted neonatal echocardiography has been shown to bemore accurate than radiographs in locating the tip ofcatheters (3). Ultrasound has also been used to identifyumbilical venous catheter tip position (4). The purposeof this report is to describe a novel technique for place-ment of tunneled lower extremity PICCs in infants using

& SIR, 2013

J Vasc Interv Radiol 2013; 24:1910–1913

http://dx.doi.org/10.1016/j.jvir.2013.08.020

None of the authors have identified a conflict of interest.

From the Department of Pediatric Radiology, Children’s Hospital of Wiscon-sin, Medical College of Wisconsin, 9000 W Wisconsin Avenue, Milwaukee,WI 53226. Received June 1, 2013; final revision received August 21, 2013;accepted August 26, 2013. Address correspondence to S.S.; E-mail:drsubbusmc@yahoo.co.in

ultrasound as the sole imaging modality for vascularaccess, intravascular length measurement, and final con-firmation of catheter tip position.

MATERIALS AND METHODS

PatientsApproval from the institutional review board was ob-tained for the retrospective review of data for this report.Data from 15 consecutive critically ill infants who under-went tunneled lower extremity PICC insertion usingultrasound as the sole imaging modality for vascularaccess, intravascular length measurement, and final con-firmation of catheter tip position from October 2011 toMarch 2013 were retrospectively analyzed. Pertinent cli-nical data included gestational age, sex, weight at time ofcatheter insertion, prenatal history, reason for place-ment, access vessel, catheter type, technical success, andcomplication rate. The case details are summarized inthe Table. Median age at placement of the PICC was 11days (range, 1 day to 15 months), and median weightwas 3.36 kg (range, 1.01–8.27 kg). There were 10 malesand 5 females. All procedures were performed at the pat-ient’s bedside in the ICU except in a single case in whichthe procedure was done in the interventional radiologysuite. Informed consent was obtained from the parents.All patients were followed for 7 days to ensure adequatecatheter function and for potential complications ass-ociated with the catheter.

Table . Case Details

No. Age Sex Gestational Age

Weight at

Catheter Insertion Indication Access Vein

Catheter

Type Length Reason for PICC

1 1 day M 38 wk, 3 days 1.97 kg Hypoplastic left heart syndrome RCFV 3-F, SL 15 cm Long-term medication

administration

2 1 day M 39 wk 3.2 kg CDH RCFV 3-F, SL 16 cm TPN

3 1 day F 35 wk, 6 days 2.14 kg Segmental ileal volvulus LCFV 3-F, SL 16 cm TPN

4 15 mo M 37 wk 8.27 kg Laryngeal cleft RCFV 4-F, DL 25 cm Long-term venous access

5 11 days F 39 wk, 6 days 3.67 kg GBS sepsis RCFV 3-F, SL 16 cm Long-term antibiotics

6 3 mo M 34 wk 4.31 kg Osteogenesis imperfecta, respiratory failure RCFV 3-F, SL 16 cm TPN

7 5 days F 41 wk 3.7 kg Neonatal seizures RCFV 3-F, SL 17 cm Venous access

8 4 mo F 24 wk 4.71 kg Chronic lung disease RCFV 3-F, SL 17 cm Long-term venous access

9 3 mo M 26 wk 2.94 kg NEC RCFV 3-F, SL 17 cm TPN

10 12 days M 39 wk 3.36 kg ASD/VSD/arch hypoplasia RCFV 3-F, SL 16 cm Milrinone infusion

11 4 mo, 4 days M 24 wk 2.85 kg Chronic lung disease RCFV 3-F, SL 14 cm TPN

12 11 days M 38 wk 4.84 kg Arrhythmia, tricuspid atresia/VSD/ASD RCFV 3-F, SL 17 cm Vasoactive infusion

13 8 days M 33 wk 1.93 kg Truncus arteriosus, Edwards type II, interrupted

aortic arch

LCFV 3-F, SL 16 cm Vascular access for

inotropic support

14 3 days M 40 wk, 1 day 3.525 kg Left CDH RCFV 3-F, SL 16 cm Vascular access

15 1 mo, 22 days F 26 wk, 1 day 1.01 kg NEC RCFV 1.9-F, SL 10 cm Vascular access

ASD ¼ atrial septal defect, CDH ¼ congenital diaphragmatic hernia, DL ¼ double lumen, GBS ¼ group B streptococcus, LCFV ¼ left common femoral vein, NEC ¼ necrotizing

enterocolitis, RCFV ¼ right common femoral vein, SL ¼ single lumen, TPN ¼ total parenteral nutrition, VSD ¼ ventricular septal defect.

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Figure 1. Photograph (a) and ultrasound scan using a liver

window (b) of the upper abdomen. A 21-gauge micropuncture

needle was advanced into the common femoral vein under

ultrasound guidance from the tunneled medial thigh approach.

An 0.018-inch wire was threaded to the lower cavoatrial junction

using the liver as a window to visualize the wire tip.

Figure 2. Ultrasound scan of the upper abdomen using a liver

window to ensure appropriate position of the catheter tip below

the cavoatrial junction. (Available in color online at www.jvir.org.)

Subramanian et al ’ JVIR1912 ’ Ultrasound-guided PICC Placement in Infants

TechniqueSedation was provided by the ICU or anesthesiology team.A wide sterile preparation was performed from the knee tothe upper abdomen. A tunneled path from the medial thighjust above the knee was formed using a 7-cm, 21-gaugemicropuncture needle (EchoTip percutaneous entry needle;Cook, Inc, Bloomington, Indiana). The common femoralvein was accessed using real-time ultrasound guidance(LOGIQ E9 L8 18-MHz high-frequency transducer; GEHealthcare [Milwaukee, Wisconsin] or SLA/13-6 MHzhigh-frequency transducer; SonoSite, Inc [Bothell, Wash-ington]). A graduated 0.018-inch wire (Bard Access Sys-tems, Inc, Salt Lake City, Utah) was advanced underultrasound guidance to the lower cavoatrial junction usingthe liver as an imaging window to permit visualization andto confirm wire position (Fig 1a, b). The lower cavoatrialjunction is the point at which the IVC diameter begins toincrease at the level of the diaphragm. The hepatic veinscan be visualized at their confluence with the intrahepaticIVC at the level of the cavoatrial junction, which can serveas an additional anatomic landmark.

The access needle was exchanged over the wire for apeel-away sheath, and intravascular distance was meas-ured using the graduated wire. Through the peel-awaysheath, a PICC (Bard Access Systems, Inc) cut to ameasured intravascular length 1–2 cm below the cavoa-trial junction was advanced to its final position over thewire. Ultrasound was used to confirm the final position ofthe catheter tip (Fig 2). Technical success was defined asthe ability to advance the wire and catheter and confirmthe final catheter tip position in the IVC 1–2 cm below thecavoatrial junction with ultrasound as the sole imagingmethod along with a functional catheter capable ofaspiration and forward flushing.

RESULTS

The reason for PICC insertion was total parenteralnutrition administration in five patients, long-term med-ication administration in eight patients, long-term anti-biotic administration in one patient, and venous accessin one patient. Right common femoral vein access wasused in 13 patients, and left common femoral vein accesswas used in 2 patients. A 3-F single-lumen power PICC,the default catheter for this procedure at our institution,was used in 13 patients, a 1.9-F single-lumen PICC wasused in 1 infant because of low weight (1.01 kg) withassociated small size of the common femoral vein, and a4-F double-lumen power PICC was used in 1 patientbecause of the requirement for simultaneous infusion ofincompatible medications. The technical success rate forplacement of the tunneled PICC was 100%.Complications were assessed using the Society of

Interventional Radiology (SIR) classification system formajor and minor adverse outcomes (5). There were noimmediate complications, such as inadvertent arterial

Volume 24 ’ Number 12 ’ December ’ 2013 1913

puncture, venotomy hematoma, or arrhythmia from guidewire manipulation. At 7 days’ follow-up, two patients haddied of comorbid disease unrelated to catheter insertion. Apremature infant 1 month, 23 days of age died ofnecrotizing enterocolitis 1 day after PICC placement,and a 12-day-old premature infant died of cardiac failurein the setting of complex congenital heart disease 4 daysafter PICC placement. The remaining 13 patients hadfunctional PICCs free of infection or other complications.Radiographs were obtained in 14 patients 1–61 days aftercatheter insertion for unrelated indications. One patientwith right-sided congenital diaphragmatic hernia showedan aberrant course of the PICC on an abdominal radio-graph obtained 1 day after catheter insertion with sub-sequent ultrasound showing catheter migration into theright hepatic vein. All remaining PICCs were shown to bein satisfactory position.

DISCUSSION

Conventional techniques for PICC and central venouscatheter placement in the interventional radiology suiteinclude using ultrasound for initial venous access fol-lowed by the use of fluoroscopic guidance for real-timewire and catheter advancement. A subset of unstable andcritically ill infants may not be appropriate candidates totransport from the ICU for vascular access procedures.As a result, alternative bedside methods are attempted.Bedside procedures present unique challenges secon-

dary to limited workspace, suboptimal access to thepatient, lack of easy access to additional equipment,and lack of added (fluoroscopic) image guidance androutine that the interventional radiology suite provides.Traditionally, bedside catheter insertions have required astatic portable radiograph obtained during or after theinsertion procedure to aid in identifying the position ofthe wire or catheter; this can be cumbersome and time-consuming. Additionally, multiple studies have demon-strated that a radiograph may not be accurate ordefinitive in localizing the catheter tip after PICC place-ment (3). Finally, there is a 10-fold increased incidenceof complications if a PICC is placed within a cardiacchamber or in a noncentral location in children (6).Targeted neonatal echocardiography has been shown

to be more reliable than radiographs for identification ofthe catheter tip position of upper extremity PICCs. In amore recent study by Jain et al (3), there was only 59%concordance between targeted echocardiography and chestradiography; this may be due to difficulty in accuratelyidentifying the position of the superior vena cava–right atrialjunction on the radiographs. The sensitivity of radiographyin determining malposition was 64%, and specificity was55%. Targeted neonatal echocardiography also helped toavoid a second radiograph in 41% of patients.Ultrasound also has been shown to be helpful in

identifying the tip position of umbilical venous catheters

(UVCs). Simanovsky et al (4) suggested that ultrasoundmay replace radiographs for identification of UVCposition. Greenberg et al (7) demonstrated that real-time ultrasound at the bedside can determine theposition of the UVC, and repositioning can be per-formed during the initial insertion procedure. Tauzinet al (8) showed that echocardiography of PICC tipsafter placement allows more accurate assessment ofintravascular position in infants with low birth weight.The present report demonstrates that the liver can

serve as an excellent imaging window to the IVC fordetermination of guide wire and PICC location ininfants. This report also introduces the use of ultrasoundfor identification of the guide wire tip to determineintravascular length during the procedure. This man-euver improves on the use of ultrasound simply todetermine catheter tip location after placement (2,3,7,8).In this report, all lower extremity tunneled PICCs

were successfully placed and positioned entirely underultrasound guidance using the liver as an imagingwindow to confirm the catheter position in the IVCbelow the cavoatrial junction. This use of ultrasoundeliminated the need for additional imaging methods thatwould otherwise require an ionizing radiation exposureto the infant. A potential limitation to this technique isthe lack of imaging guidance for wire manipulationbetween the common femoral vein access and theintrahepatic IVC.In conclusion, placement of a tunneled lower extremity

PICC using ultrasound as the sole imaging modality forvascular access, intravascular length measurement, andfinal confirmation of catheter tip position is a technicallyfeasible and a desirable option for infants, particularlywhen the procedure is performed at the bedside.

REFERENCES

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2. Lungren M, Pabon-Ramos WM. Single incision technique for placingtunneled central venous catheters in infants. J Vasc Interv Radiol 2013; 24:755–756.

3. Jain A, McNamara PJ, Ng E, El-Khuffash A. The use of targeted neonatalechocardiography to confirm placement of peripherally inserted centralcatheters in neonates. Am J Perinatol 2012; 29:101–106.

4. Simanovsky N, Ofek-Shlomai N, Rozovsky K, Ergaz-Shaltiel Z, Hiller N, Bar-Oz B. Umbilical venous catheter position: evaluation by ultrasound. EurRadiol 2011; 21:1882–1886.

5. Sacks D, McClenny TE, Cardella JF, Lewis CA. Society of InterventionalRadiology clinical practice guidelines. J Vasc Interv Radiol 2003; 14:S199–S202.

6. Racadio JM, Doellman DA, Johnson ND, Bean JA, Jacobs BR. Pediatricperipherally inserted central catheters: complication rates related tocatheter tip location. Pediatrics 2001; 107:E28.

7. Greenberg M, Movahed H, Peterson B, Bejar R. Placement of umbilicalvenous catheters with use of bedside real time ultrasonography. J Pediatr1995; 126:633–635.

8. Tauzin L, Sigur N, Joubert C, Parra J, Hassid S, Moulies ME. Echocar-diography allows more accurate placement of peripherally insertedcentral catheters in low birthweight infants. Acta Paediatr 2013; 102:703–706.