A peripherally inserted central catheter (PICC) line refers to a type of central line that is used for long-term vascular access in patients with chronic kidney disease (CKD). However, the American Board of Internal Medicine’s (ABIM) Choosing Wisely campaign recommends that the PICC line placement be avoided for long-term vascular access in patients with CKD stages 3 to 5. This is to help preserve arm veins for an eventual arteriovenous graft or fistula placement for hemodialysis.
What Are the Alternatives to PICC Line Placement?
There are several alternatives to PICC line placement for long-term vascular access among patients with chronic kidney disease or those who may need hemodialysis. Some of the most commonly used alternatives include:
Arteriovenous Fistula (AV Fistula)
This is a surgically created connection between an artery and a vein in the arm. It has the lowest risk of infection and the longest lifespan, making it the preferred method of vascular access for hemodialysis.
Arteriovenous Graft (AV Graft)
Is similar to an AV fistula, but a synthetic graft is used to connect an artery and a vein, instead of a surgical connection.
Internal Jugular Central Line
This is a catheter that is inserted into the internal jugular vein in the neck. This is preferred to PICC line placement as it helps preserve the arm for an eventual AV fistula placement in patients with CKD Stages 3 to 5.
Subclavian Central Line
Involves the insertion of a catheter into the subclavian vein near the clavicle. It isn’t commonly used as there is a higher risk of vein stenosis associated with this method.
Peritoneal Dialysis Catheter: In this method, a catheter is inserted into the peritoneal cavity during peritoneal dialysis. It is a less commonly used alternative to hemodialysis.
The alternative method you choose depends on the individual patient’s anatomy and health status.
Avoiding the Subclavian
Avoiding the subclavian vein for hemodialysis catheter placement is an important consideration in the placement of long-term vascular access catheters for patients who may need hemodialysis.
This is because using the subclavian vein can increase the risk of vein stenosis compared to internal jugular veins.
Vein stenosis involves the narrowing or constriction of the vein which can lead to decreased blood flow and difficulty accessing the vein for hemodialysis. This can impact the overall effectiveness of the treatment.
Optimal Site for Hemodialysis Catheter Placement
The optimal site for hemodialysis (HD) catheter placement is often considered to be the right internal jugular vein (RIJ). This is because the RIJ is larger and more accessible than the left internal jugular vein (LIJ). It also has a lower risk of catheter malfunction and catheter-related bloodstream infections (CRBSI).
The second best option in case the RIJ is unavailable is the LIJ. However, this increases the risk of catheter malfunction and CRBSI. This is because the LIJ is smaller and closer to the heart compared to the RIJ while increasing the risk of infections.
Avoiding Femoral HD Catheter Placement in Obese Patients
It is important to avoid femoral HD catheter placement in obese patients to ensure the success of the hemodialysis treatment. This is because obesity can impact the placement and performance of the catheter, increasing the risk of catheter colonization and CRBSI.
Excess fat and tissue around the groin in obese patients can make it difficult to access the femoral brain. This also increases the risk of complications and may lead to infections.
It is thus recommended that the use of femoral HD catheter placement be avoided among patients with a body mass index (BMI) of over 30. Instead, the HD catheter placement can be performed on the RIJ or LIJ.
Catheter Length and Placement
The catheter length and its placement site are extremely important factors to consider during hemodialysis treatment as they can affect the safety and performance of the HD catheter. This is because it affects the flow rate of the dialysis solution, and can lead to complications such as catheter malfunction and other catheter-related bloodstream infections.
The tip of the catheter should be placed at the cavo-atrial junction or in the proximal right atrium to ensure optimal flow rates. This placement also allows for the efficient exchange of dialysis solutions and helps to minimize the risk of complications.
The hemodialysis catheter length used for most adults is 15 to 16 cm for right internal jugular (RIJ) HD catheters, 20 cm for left internal jugular (LIJ) HD catheters, and 20 to 30 cm for femoral HD catheters. The length of the catheter is determined by the size of the vein and the specific needs of the patient. Larger catheters are associated with an increased risk of complications, so choosing the right size is therefore very important.
Risks and Complications of PICC Line Placement
PICC line placement, like any other medical procedure, comes with certain risks and complications. Some of the most common complications associated with PICC line placement include:
Infection
The risk of infection increases with the duration of the PICC line placement. This can lead to serious infections such as sepsis which can be life-threatening if not treated promptly.
Thrombosis
The formation of blood clots around the PICC line is a common complication and can cause serious problems such as embolisms or strokes.
Catheter migration
The PICC line can move from its original position, causing discomfort, pain, and even damage to surrounding tissues.
Infiltration or extravasation
Infiltration occurs when the catheter punctures the vein wall and enters surrounding tissue which can cause swelling, pain, and tissue damage. Extravasation occurs when the catheter punctures the vein wall and fluid enters the surrounding tissue.
Conclusion
PICC line placement is a commonly used procedure for long-term vascular access in patients with chronic kidney disease. While it has many advantages, including ease of insertion and reduced risk of infection compared to other forms of central lines, it also comes with certain risks and complications. Proper insertion techniques, regular monitoring, and prompt identification and treatment of any problems that arise can minimize these risks and improve patient outcomes.
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References
Kallo, S. Wish, J. Nephrologists Versus Peripherally Inserted Central Catheters: Are the PICCs Winning? Clin J Am Soc Nephrol. 2016 ;11(8): 1333–1334
Ahsan Sohail, M.Vachharajani,T. Anvari,E. Central Venous Catheters for Hemodialysis—the Myth and the Evidence. Kidney Int Rep. 2021; 6(12): 2958–2968
Hernandez Garcilazo, N. Vachharajani,T. Peripherally inserted central catheter in patients with chronic kidney disease. Cleveland Clinic Journal of Medicine August 2021, 88 (8) 431-433