Are You Still Getting Called Regarding Peripherally Inserted Central Catheters?

Peripherally inserted central catheters (PICC) are increasingly used in modern clinical practice, especially among critically ill patients (1). The main attraction to the use of PICCs in clinical practice is likely driven by their perceived safety, low procedural complication rate, ability to facilitate care transition, low cost, and ease of insertion (2, 3).

PICCs are used for several indications, including extended antibiotic therapy, difficult venous access, total parenteral nutrition, chemotherapy, and occasionally central venous monitoring. They are usually single-lumen or dual-lumen catheters that are inserted under ultrasound guidance by a nurse-led team. Above-the-elbow basilic, brachial, or cephalic veins are commonly used for PICC insertion, with the catheter tip being in the central venous system (superior vena cava, subclavian vein, or brachiocephalic vein). Because more than 50% of critically ill patients require venous access, the use of PICCs is seen as a marker for a high burden of morbidity.

Patients with chronic kidney disease (CKD) and those using dialysis have a high burden of comorbidities related to a cluster of risk factors, both traditional (such as diabetes, hypertension, peripheral arterial disease, and heart failure) and nontraditional (abnormal mineral metabolism, left ventricular hypertrophy, and anemia). This profile of comorbidities places CKD patients at a higher risk for hospitalization, which usually requires venous access and intravenous therapies (4), leading to a high exposure to PICCs.

It is well acknowledged that PICC placement is associated with significant morbidity and mortality. In a comprehensive review and meta-analysis of approximately 30,000 patients, PICCs were associated with an increased risk of deep vein thrombosis and residual central venous stenosis (5). Furthermore, PICCs are associated with three times the risk of all-cause thromboembolism (4). Moreover, other complications of these catheters include thrombophlebitis and catheter-associated bacteremia with subsequent sepsis, endocarditis, and osteomyelitis (6).

The PICC-related complications have deleterious effects on vein quality and are associated with a lower frequency of functional arteriovenous (AV) fistulas in the CKD population (2). In a case control study, El Ters et al. (2) compared the PICC exposure in 120 patients receiving dialysis through a dialysis tunneled catheter or an AV graft with the exposure to 162 patients receiving dialysis through an AV fistula. They found that the frequency of previous PICC exposure was higher among AV fistula patients (44% vs. 20%), and this exposure was associated with fewer functioning AV fistulas (p < 0.001).

By contrast, in a dialysis population, McGill et al. (7) used the US Renal Data System to anlayze 34,000 patients who started dialysis by central venous catheter and found that 12.6% of them had previously used PICCs. Furthermore, PICCs placed before or after dialysis initiation were independently associated with a low likelihood of transition to AV fistula or graft. The presence of these catheters within the vein lumen for prolonged times is associated with repetitive trauma and subsequent thrombosis and stenosis (8).

Accordingly, the American Society of Nephrology, as part of the American Board of Internal Medicine’s “Choosing Wisely” campaign, recommended consulting nephrologists before inserting PICCs in patients with CKD stage 3 to 5 (9). Moreover, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines for vascular access recommended preservation of the forearm and upper arm veins, which are suitable for fistula creation, in patients with CKD stage 4 or 5. These veins should not be used for venipuncture or the placement of PICCs (5).

Now, with all these practice guidelines in place that discourage the use of PICCs in the CKD population, why are we still getting called or consulted regarding PICCs? With the increased risk of vein depletion of the upper extremity caused by healthcare-related venipuncture, how are we, as nephrologists, performing as the gatekeeprs of the venous real estate for our CKD patients?

The honest answer is that despite the available guidelines and the known disastrous effects of PICCs, a substantial number of dialysis patients continue to receive PICCs under the watch of their nephrologists (3).

Whereas some programs have already developed institutional protocols in which PICC insertion orders in patients with CKD stage 3 to 5 trigger the need for a nephrology consultation, most community hospitals lack such processes and protocols. Furthermore, despite these efforts and guidelines to avoid PICCs in patients with advanced CKD, 33.1% of short-term PICCs (dwell time <5 days) were seen in patients with GFR <60 mL/min (10).

All in all, the expanding use of PICCs is associated with vascular injury and subsequent venous thrombosis and stenosis. Morover, even with the current guidelines from different societies, there is a tendency to choose the PICC mostly for convenience and for a short dwelling time. In view of this reality, we are far from winning the battle for preserving the patient’s venous real estate. To overcome the PICC tide, more coordinated collaborative efforts are required among different disciplines and specialties, mainly interventionists, nephrologists, hospitalists, and oncologists. In addition, PICCs should be inserted for valid indications, not out of convenience. Finally, more efforts by the stakeholders, mainly nephrologists, at the grassroots level are needed. One such effort is to advocate the use of small-bore (4-Fr or 5-Fr) rather than the current (6-Fr) central venous catheters as good alternatives to the current use of PICCs in patients with advanced CKD.