Cite as: Mehra C, Dhar P. POCUS spotlight: peripherally inserted central catheter (PICC) insertion. ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra050126.009.

POCUS Spotlight

Introduction

The ability to obtain venous access is one of the most fundamental yet crucial components for a large number of diagnostic and therapeutic interventions.^1-4 Peripherally inserted central catheters (PICCs) are a subset of central venous catheters. They are 50 cm to 60 cm long single, double, or triple lumen catheters that are placed in a peripheral arm vein and terminate in the intrathoracic venous system. A properly placed PICC may facilitate a transition from a medical care facility to home for intermittent intravenous therapy.⁵ The failure rate of PICCs continues to be as high as 40%, leading to interruption of therapy.^6-10

Indications

PICCs are indicated in patients who require venous access for several weeks.¹¹ Common indications include patients with limited peripheral venous access, long-term intravenous medication administration, including total parenteral nutrition and blood product infusions, and frequent blood sampling.

Contraindications

Relative contraindications for PICCs include burns, trauma, skin infections, a history of venous thrombosis at the insertion site, active bacteremia, the presence of a hemodialysis fistula on the ipsilateral limb, small diameter of arm veins (smaller than 3 mm to 4 mm), and complete axillary lymph node dissection.¹²

Relevant Venous Anatomy

PICCs are placed through the basilic, brachial, cephalic, or medial cubital vein of the arm.¹³

The upper limb is drained by superficial and deep venous systems. The superficial venous system includes the cephalic, basilic, median cubital, and median antebrachial veins. The subclavian and axillary veins form the proximal group, while the brachial, radial, and ulnar veins form the distal group of the venous system. (Figure 1)

The basilic vein is preferred because of its superficial location and larger size. It has a comparatively straighter route to the superior vena cava (SVC) and provides a shallower angle for needle insertion.

The cephalic vein is smaller than the basilic vein. It offers a sharp-angle needle insertion and a tortuous course and carries a higher incidence of mechanical phlebitis.

The brachial vein is larger in size, runs a shorter course, and is located deeper than the basilic vein. There is a higher risk of inadvertent neurovascular injury because it runs alongside the brachial artery and the median nerve.

The median cubital vein joins the basilic vein and is prominent in the antecubital fossa. It carries a higher risk of mechanical phlebitis, owing to constant bending at the elbow crease.

Equipment

PICCs vary in length (50 cm to 60 cm), size (3, 4, or 5 French (Fr)), and the number of lumens (single to triple). Standard equipment while using the modified Seldinger technique includes:^4,14,15

1. High-frequency linear ultrasound transducer with sterile probe sheath cover
2. Sterile drapes
3. Tape measure
4. Heparinized saline flush
5. PICC insertion kit contents (Figure 2): PIC catheter, introducer needle, soft-tip guidewire, skin track dilator, catheter fixation device, and needle-free connector device

Appropriate Insertion Technique for PICC

PICC insertion involves a sequential approach that encompasses evaluation of a suitable vein, its cannulation, and confirmation of a safe PICC tip location.¹⁶

Pre-procedural evaluation and target vein selection

The venous anatomy is assessed at the antecubital fossa, bicipital-humeral groove, axilla, and the supraclavicular and infraclavicular fossae, as shown in Figures 1 and 3 and Video 1. Veins are selected in order of preference, starting with the basilic vein in the bicipital-humeral groove, followed by the brachial veins within the neurovascular bundle of the arm, and then the axillary vein. A stepwise approach is recommended for selecting a suitable vein using the rapid peripheral vein assessment (RaPeVA) protocol, as outlined in Table 1.^17-23

Choice of PICC size

Estimate the transverse diameter (or circumference of the vein) by applying minimum transducer compression. The ideal catheter-vein ratio is ≤ 1:3 (This leaves at least two-thirds of the vein diameter free for the flow surrounding the catheter.)³⁹ A cut-off point of 45% has been found to predict thrombosis.^24,40-43 (Figure 9). A 1 Fr catheter size corresponds to 0.33 mm. This implies that a 3 Fr catheter requires a vein diameter of at least 3 mm. Presumably, a larger PICC size can obstruct blood flow from superficial to deep veins via the perforators, leading to obstructed or sluggish flow. (Video 7)

Cutaneous Exit-site Location

Once an appropriate vein has been selected, the clinician should judiciously plan the exit site for the catheter (before proceeding with venipuncture). This involves division of the upper arm into three segments, which is the zone insertion method™ (ZIM).⁴⁴ (Figure 10 and Table 2)

Appropriate Aseptic Technique

PICC insertion requires adopting maximal barrier precautions. The use of a sterile cover for the transducer and the cable, especially when resting on the sterile field, is recommended.^22,23,45,46

Ultrasound-guided venipuncture

Ultrasound-guided venipuncture can be performed by visualizing the target vein in its short, long, or oblique axis, using either in-plane or out-of-plane needle insertion.^23,47-50 The modified Seldinger technique should be preferentially used for venipuncture.^51-54 (Figures 11, 12, and Video 8) Adjust the operating table, patient’s arm, and the ultrasound machine to best suit the ergonomics.

Navigation of PICC Guidewire Through the Vessel and Confirmation of an Acceptable Guidewire Tip Location Using Ultrasound

The guidewire advancement should be tracked along its course, starting from the venipuncture site and across the vessels in the supra/ infraclavicular fossae. The guidewire and catheter tip location should also be confirmed at the cavo-atrial junction prior to the conclusion of the PICC placement procedure. The ECHOTIP protocol provides valuable input for guidewire tracking when ultrasound is used as a navigational tool.^{17,18,20,55-58}

Ultrasound-assisted intraprocedural guidewire-tip navigation: Ultrasound tracks the guidewire course through the axillary, subclavian, and brachiocephalic veins to its termination in the SVC.^22,59 A 7-12 MHz linear transducer is used to visualize the guidewire inside the lumen of the cannulated vein and up to the axillary and subclavian veins in the infra or supraclavicular fossae. (Figures 12, 13 and Video 9) A linear transducer placed over the supraclavicular fossa helps to trace the guidewire within the subclavian and brachiocephalic trunk.^60,61 The ultrasound appearance of the guidewire transit from the subclavian vein to the brachiocephalic trunk gives the appearance of “sparkling guidewire” and has been termed as “sparkling guidewire sign” by the authors. (Figure 12 and Video 10)

Ultrasound-assisted intraprocedural guidewire-tip localization: The use of various intraprocedural methods for catheter tip localization at the cavo-atrial junction is recommended by current guidelines.^{22,23,58,62-64} A phased array echo probe is used for confirming tip location using apical four-chamber or subcostal views.

Direct method: It involves direct visualization of the tip of the catheter at the junction between the SVC and right atrium (RA) or between the RA and the IVC (for PICC inserted through the femoral route). In practical usage, the catheter tip is initially visualized within the RA cavity and withdrawn slightly to rest at the SVC-RA junction.^60,61,65-70

Indirect method: “Bubble test” is the rapid injection of 5-10 ml of agitated normal saline through the catheter. The appearance of a cloud of microbubbles in the RA in less than 2 seconds confirms the tip placement in the proximity of RA.^52,71-78 (Video 11) A delay in the appearance of microbubbles of more than 2 seconds correlates with an incorrect tip placement.⁷⁰ As the PICCs are longer and narrower than a proximally inserted central venous catheter (CVC), a cut-off limit of 2 seconds is higher than that suggested for CVC (1 second).⁷⁹

Other methods for intra-procedural tip confirmation include intracavitary electrocardiogram, fluoroscopy and the use of pre-insertion anthropometric algorithms.^22,23,80-82 Post-procedure catheter manipulation is not supported by current guidelines.^22,23,83

Measures to Secure PICC Exit-site:

A secure dressing and catheter stabilization approach helps minimize micro-motion and reduces the risk of vein thrombosis and PICC fracture.^{22,23,45,46,84,85} Strategies for protecting the exit site include subcutaneous tunneling of the proximal portion of the catheter, using cyanoacrylate adhesive to seal both the catheter exit and venipuncture sites,^86-90 and catheter design modifications, such as a reverse-tapered diameter to prevent backflow of infused fluid.⁹¹

Rationale for Tunneling

Subcutaneous tunneling of a PIC catheter allows for relocation of the exit site away from the skin puncture site. This is especially helpful in patients with complex vascular access, cognitive dysfunction, and a need for long-term parenteral nutrition.^92-100 (Figure 14) For example, for a PICC inserted in the yellow zone, an exit site can be chosen in the green zone by tunneling the bare portion of the catheter (Rapid Assessment of Vascular Exit Site and Tunneling Options [RAVESTO] Protocol).^23,101 Tunneling can be performed using a dedicated tunneling device or a peripheral intravenous cannula.^{92-100,102,103}

PICC Fixation and Dressing Specifications

Cover the exit site with a semi-permeable, transparent membrane dressing, preferably with a moisture vapor transfer rate of 1,500 g/m²/day or more.^6,104 Fixation may be done with a sutureless, securement device that secures winged catheters, such as PICCs.^12,105-109 (Figure 11). The extra portion of PICC staying outside the exit site should be curled back to protect the catheter from being accidentally pulled or kinked at the elbow crease. This portion should be covered by a separate dressing or device.

Ultrasound Guidance to Avoid Malposition of PICC

Malposition of a PICC involves unintentional placement into the ipsilateral internal jugular vein or the contralateral subclavian vein or curling back within the ipsilateral subclavian vein and tracking toward the axillary vein, where it may coil in the axilla.⁶⁵ Reported rates of PICC malposition range from 35%-65%.¹¹⁰

Malposition can be avoided by carefully following the guidewire and catheter passage through the veins using sonographic guidance as described earlier.

Safe use of PICCs (Instructions for Caregivers and End Users)

The risk of infection increases with every interruption to the closed system.^111,112 A “closed system” should be maintained at the open end of the catheter by the use of a sterile, self-sealing, swabable, needle-free access connector.^6,111 Use “push-pause technique” or “positive pressure finish” to flush and lock the catheters. Flush and lock the catheter with heparinized saline (10 units/ml) after each use. (Video 12) The use of smaller-volume syringes to flush a blocked catheter can generate higher internal pressure and increase the risk of catheter rupture.¹¹³ A total break can result in possible catheter embolus.

Overview of the Technique of PICC Insertion

The following are the steps for the sterile, modified Seldinger technique:

1. Informed and written consent from the patient.
2. Make a note of the patient’s ipsilateral arm circumference at 10 cm from the elbow crease. This can help the clinician to compare arm swelling later as a possible complication of PICC.
3. Adjust the operating table, patient’s arm. and the ultrasound machine to best suit the ergonomics.
4. Conduct pre-procedure ultrasound scan for assessment of a suitable vein for cannulation (RaPeVa Protocol).
5. Assess the vein-to-catheter ratio for the desired catheter size.
6. Mark the course of the chosen vein with a skin marking pen. This helps to track the guidewire and catheter from the insertion point to the ipsilateral subclavian vein.
7. Expose, clean, and drape the ipsilateral arm, supra-clavicular and infra-clavicular regions, neck, and suprasternal notch. This helps to scan these regions for guidewire navigation without compromising the sterility of the ultrasound transducer during PICC insertion.
8. Use maximum barrier precautions during the insertion procedure.
9. Use the Dawson’s ZIM^TM protocol to select the venipuncture and exit site.
10. Raise the skin weal with local anesthetic.
11. In a step-wise manner, access the vein with a venipuncture needle and thread the guidewire through the puncture needle.
12. Use the ECHOTIP protocol for intraprocedural navigation of guidewire and the final tip location at SVC-RA junction.
13. Dilate the skin track using the dilator and peel-away introducer set. Peel and remove the peel away introducer while keeping the dilator in place. Railroad the catheter over the guidewire, or remove the guidewire and introduce the styletted catheter per the manufacturer’s instructions.
14. Use the RAVESTO protocol for assessment of PICC exit-site and securement strategies.
15. Flush the catheter with heparinized saline solution.

Complications Related to PICC

Factors potentiating the risk of complications include arterial or nerve injury, suboptimal catheter tip location, exit site in red or yellow zone, along with poor fixation methods, and lack of asepsis.^{4,16,22,23,40,45,46,64,114-12}

Commonly encountered complications include thrombophlebitis and catheter dislodgement, defined as a change in the catheter’s position of more than 2 cm from its original location without affecting function. This can potentially lead to vessel wall perforation and extravasation.^4,6 Other complications include catheter-related infection,^11,124-133 catheter-related thrombosis, and catheter blockage.¹³⁴

Additional Useful Tips

A single useful tip for the assessment of patency of both the superficial and deep venous system simultaneously, using the principles described previously, has been named by the authors as “axillo-cephalic-deep inspiration-valsalva assessment technique (ACIVA technique).” A linear ultrasound transducer is placed in the supraclavicular fossa, and the drainage of the cephalic vein into the axillary and subclavian veins is assessed. These veins collapse completely with the coaptation of their anterior and posterior walls with deep inspiration and expand with the Valsalva maneuver. (Video 13)

Importance of examining cephalic vein confluence with the axillary vein:

This confluence is an area of increased turbulence. Often, a valve is found in the cephalic vein just prior to its junction with the axillary vein. Gentle cranio-caudal tilt of the linear ultrasound transducer, while visualizing the distal subclavian vein at both supra and infraclavicular regions, aligns the cephalic vein with the subclavian vein. (Figure 15 and Video 14)

“Peripheral Venous Swirl Test”: In patients with challenging venous access, eg, contractures over the shoulder or elbow, the clinician can flush 5 ml of agitated saline through the IV cannula or the venipuncture needle (proximal to the elbow) and observe the swirl within the subclavian or brachiocephalic trunk (termed as Peripheral Venous Swirl Test by the authors). This is followed by PICC insertion, using the modified Seldinger technique.¹³⁵ (Video 15)

Conclusion

The use of strategies outlined in this article allows the clinician to confidently use ultrasound for preliminary venous assessment, real-time venipuncture, guidewire tip navigation, and guidewire and catheter tip location, as well as for the evaluation of some late non-infective complications.

Further, the use of needle-free injectable ports, sutureless securement techniques, maximum barrier precautions, the appropriate choice of exit site, and tunneling the distal portion of the PICC increases the safety profile and the cost-effectiveness of the procedure.^{4,25,31,32,50,62,63,73,125-132}

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