The PICC Conundrum: Vein Preservation and Venous Access

Peripherally inserted central venous catheters (PICC lines) are being used with increasing frequency in the hospital and outpatient settings for patients who require venous access. Originally intended as a less invasive way to obtain long-term central venous access, PICC lines are now being used for a growing number of indications. Patients who require an extended course of antibiotics or other medications were often chosen to have a PICC line placed after treatment was begun with a peripheral intravenous (IV ) catheter. However, PICC lines are now often chosen as the first-line access option in patients with difficult venous access regardless of the duration of therapy required.

Hospitalized patients are older and more chronically ill than in the past. Many of these patients have poor peripheral veins caused by underlying disease, repeated phlebotomy, and IV catheters. Maintaining peripheral IV access can be challenging and time consuming for hospital staff. PICC lines obviate these frustrations and have therefore become staff’s preferred venous access device, often placed even when venous access may not truly be required for very much longer. Because of an increasing body of evidence that PICC lines interfere with future arteriovenous fistula placement for dialysis access, the rapid rise in the use of PICC lines has become of great concern.

PICC lines are single-lumen or dual-lumen catheters designed to be placed in a peripheral vein with the tip advanced into a central vein—typically the subclavian vein, brachiocephalic vein, or superior vena cava. They can be placed in the cephalic, median cubital, or basilic veins of the upper arm.

Ultrasound is commonly used to facilitate accurate placement, especially in the more deeply located basilic vein. PICC lines provide convenient, long-term venous access with low rates of failure from thrombosis or infection. They last longer and require less maintenance than peripheral IV catheters. And because they are placed in larger veins at the elbow or above, they can usually be successfully placed even in the most challenging patient. Hospital nursing staff can be trained to place the lines, and this often allows PICC placement to be readily available day or night. These advantages of PICC lines have led to a dramatic rise in their use, especially in the hospital setting.

Unfortunately, this increasing use of PICC lines has come with a cost for patients with chronic kidney disease who go on to require dialysis. PICC lines are associated with a 23–57 percent incidence of thrombosis of the vein in which they are inserted (1). Additionally, 7.5 percent of patients experience central venous abnormalities after the use of PICC lines (2). Loss of peripheral and central venous patency may preclude the successful placement of arteriovenous fistula access when that is necessary. This is a grave concern for these patients, in whom arteriovenous access options have a profound impact on morbidity and mortality during dialysis.

But the problem with prior venous access devices limiting future dialysis access options is not unique to PICC lines. Repeated venipuncture, peripheral IV catheters, and central venous catheters are associated with phlebitis, venous sclerosis, stenosis, and thrombosis. Central venous catheters cause endothelial denudation, smooth muscle proliferation, and pericatheter thrombus even with relatively short-term use (3,4). Not all central venous access sites are the same. Various studies have shown that central venous catheters placed in the subclavian vein are associated with a 13–42 percent incidence of venous stenosis or occlusion, whereas internal jugular catheters are associated with only a 0.3–3 percent incidence (57). Tunneled small-diameter catheters placed in the internal or external jugular veins may be associated with an even lower risk of catheter-related central venous complications and do not cause direct damage to peripheral veins (8).

So what are we to do to preserve the veins of patients with chronic kidney disease who may progress to a need for dialysis? PICC lines certainly have a high risk of interfering with future arteriovenous fistula placement by causing stenosis and thrombosis of both peripheral and central veins. But peripheral IV catheters and central venous catheters also carry significant risk. Several organizations have established guidelines and position statements that can be helpful in considering this issue. The Fistula First Coalition (9), the National Kidney Foundation (10), and the American Society of Diagnostic and Interventional Nephrology (11) all have provided useful direction. The Renal Network Inc. (NW 4, 9, 10) has developed a tool kit to aid in implementing a vein preservation strategy (12).

Based on these sources, several recommendations can be made. First, the actual need for venous access should be assessed carefully in all patients. Reducing the frequency of venipuncture and choosing oral medication therapy when possible can significantly reduce venous injury. When venous access is required, patients who are at risk for requiring dialysis in the future should be identified. This requires a review of their history and prior laboratory values. Patients with stage 3–5 chronic kidney disease, patients currently receiving dialysis, and patients with functioning kidney transplants should be identified before venous access is obtained. Venous access in these patients should occur with the following priority:The dorsal veins of the hand are the preferred location for phlebotomy and peripheral venous access; the internal jugular veins are the preferred location for central venous access; the external jugular veins are an acceptable alternative for venous access; the subclavian veins should not be used for central venous access; placement of a PICC should be avoided; and tunneled small-bore catheters in the internal or external jugular location should be used as an alternative to PICC lines and nontunneled internal jugular central venous catheters.
 

For these recommendations to be implemented, processes will have to be established within the hospital to ensure that estimated GFR is determined and medical history is obtained in every patient being considered for central venous access, including a PICC line. In most instances, when the patient is at risk for future kidney failure, PICC lines should not be used. Protocols should be in place to guide decisions regarding the appropriate venous access when the patient fits one of the above categories at risk for requiring future dialysis. Finally, physicians must be available with expertise to guide these decisions and place the tunneled small-bore catheters. Careful attention to venous access decisions should be effective in reducing venous catheter–associated complications and in preserving the veins of patients at risk for needing dialysis in the future so that successful arteriovenous fistulae can be constructed.

Notes

[1] Timothy Pflederer, MD, is associated with the Renal Intervention Center in Morton, IL, and is a member of the ASN Interventional Nephrology Advisory Group.

References

1.Allen AW, et al. Venous thrombosis associated with placement of peripherally inserted central catheters. J Vasc Interv Radiol 2000; 11:1309–1314.

2.Gonzalves CF, et al. Incidence of central venous stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol 2003; 26:123–127.

3.Forauer AR, Theoharis C. Histologic changes in the human vein wall adjacent to indwelling central venous catheters. J Vasc Interv Radiol 2003; 14:1163–1168.

4.Ducatman BS, McMichan JC, Edwards WD. Catheter-induced lesions of the right side of the heart: A one-year prospective study of 141 autopsies. JAMA 1985; 253:791–795.

5.Hernandez D, et al. Subclavian vascular access stenosis in dialysis patients: Natural history and risk factors. J Am Soc Nephrol 1998; 9:1507–1510.

6.Trerotola SO, et al. Tunneled infusion catheters: Increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology 2000; 217:89–93.

7.Bambauer R, et al. Complications and side effects associated with large bore catheters in the subclavian and internal jugular veins. Artif Organs 1994; 18:318–321.

8.Sasadeusz KJ, et al. Tunneled jugular small-bore catheters as an alternative to peripherally inserted central catheters for intermediate-term venous access in patients with hemodialysis and chronic renal insufficiency. Radiology 1999; 213:303–306.

9.Fistula First Breakthrough Initiative (FFBI) national coalition. Breakthrough initiative coalition position paper: Recommendations for the use of PICC lines. July 2008. www.fistulafirst.org.

10.National Kidney Foundation KDOQI Guidelines 2006. www.kidney.org.

11.Hoggard J, et al. Guidelines for venous access in patients with chronic kidney disease: A position statement from the American Society of Diagnostic and Interventional Nephrology Clinical Practice Committee and the Association for Vascular Access. Semin Dial 2008; 21:186–191.

12.PICC line toolkit. The Renal Network, Inc. Vascular access advisory panel. www.therenalnetwork.org.


February 2012 (Vol. 4, Number 2)