Power Injectable Peripherally Inserted Central Venous Catheter Lines Frequently Flip After Power Injection of Contrast:

Peripherally inserted central catheter design and material for reducing catheter failure and complications

BACKGROUND

Peripherally inserted central catheters (PICCs) facilitate diagnostic and therapeutic interventions in health care. PICCs can fail due to infective and non-infective complications, which PICC materials and design may contribute to, leading to negative sequelae for patients and healthcare systems.

OBJECTIVES

To assess the effectiveness of PICC material and design in reducing catheter failure and complications.

SEARCH METHODS

The University of Queensland and Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the WHO ICTRP and ClinicalTrials.gov trials registers to 16 May 2023. We aimed to identify other potentially eligible trials or ancillary publications by searching the reference lists of retrieved included trials, as well as relevant systematic reviews, meta-analyses, and health technology assessment reports. We contacted experts in the field to ascertain additional relevant information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating PICC design and materials.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were venous thromboembolism (VTE), PICC-associated bloodstream infection (BSI), occlusion, and all-cause mortality. Secondary outcomes were catheter failure, PICC-related BSI, catheter breakage, PICC dwell time, and safety endpoints. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 12 RCTs involving approximately 2913 participants (one multi-arm study). All studies except one had a high risk of bias in one or more risk of bias domain. Integrated valve technology compared to no valve technology for peripherally inserted central catheter design Integrated valve technology may make little or no difference to VTE risk when compared with PICCs with no valve (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.19 to 2.63; I² = 0%; 3 studies; 437 participants; low certainty evidence). We are uncertain whether integrated valve technology reduces PICC-associated BSI risk, as the certainty of the evidence is very low (RR 0.20, 95% CI 0.01 to 4.00; I² = not applicable; 2 studies (no events in 1 study); 257 participants). Integrated valve technology may make little or no difference to occlusion risk when compared with PICCs with no valve (RR 0.86, 95% CI 0.53 to 1.38; I² = 0%; 5 studies; 900 participants; low certainty evidence). We are uncertain whether use of integrated valve technology reduces all-cause mortality risk, as the certainty of evidence is very low (RR 0.85, 95% CI 0.44 to 1.64; I² = 0%; 2 studies; 473 participants). Integrated valve technology may make little or no difference to catheter failure risk when compared with PICCs with no valve (RR 0.80, 95% CI 0.62 to 1.03; I² = 0%; 4 studies; 720 participants; low certainty evidence). We are uncertain whether integrated-valve technology reduces PICC-related BSI risk (RR 0.51, 95% CI 0.19 to 1.32; I² = not applicable; 2 studies (no events in 1 study); 542 participants) or catheter breakage, as the certainty of evidence is very low (RR 1.05, 95% CI 0.22 to 5.06; I² = 20%; 4 studies; 799 participants). Anti-thrombogenic surface modification compared to no anti-thrombogenic surface modification for peripherally inserted central catheter design We are uncertain whether use of anti-thrombogenic surface modified catheters reduces risk of VTE (RR 0.67, 95% CI 0.13 to 3.54; I² = 15%; 2 studies; 257 participants) or PICC-associated BSI, as the certainty of evidence is very low (RR 0.20, 95% CI 0.01 to 4.00; I² = not applicable; 2 studies (no events in 1 study); 257 participants). We are uncertain whether use of anti-thrombogenic surface modified catheters reduces occlusion (RR 0.69, 95% CI 0.04 to 11.22; I² = 70%; 2 studies; 257 participants) or all-cause mortality risk, as the certainty of evidence is very low (RR 0.49, 95% CI 0.05 to 5.26; I² = not applicable; 1 study; 111 participants). Use of anti-thrombogenic surface modified catheters may make little or no difference to risk of catheter failure (RR 0.76, 95% CI 0.37 to 1.54; I² = 46%; 2 studies; 257 participants; low certainty evidence). No PICC-related BSIs were reported in one study (111 participants). As such, we are uncertain whether use of anti-thrombogenic surface modified catheters reduces PICC-related BSI risk (RR not estimable; I² = not applicable; very low certainty evidence). We are uncertain whether use of anti-thrombogenic surface modified catheters reduces the risk of catheter breakage, as the certainty of evidence is very low (RR 0.15, 95% CI 0.01 to 2.79; I² = not applicable; 2 studies (no events in 1 study); 257 participants). Antimicrobial impregnation compared to non-antimicrobial impregnation for peripherally inserted central catheter design We are uncertain whether use of antimicrobial-impregnated catheters reduces VTE risk (RR 0.54, 95% CI 0.05 to 5.88; I² = not applicable; 1 study; 167 participants) or PICC-associated BSI risk, as the certainty of evidence is very low (RR 2.17, 95% CI 0.20 to 23.53; I² = not applicable; 1 study; 167 participants). Antimicrobial-impregnated catheters probably make little or no difference to occlusion risk (RR 1.00, 95% CI 0.57 to 1.74; I² = 0%; 2 studies; 1025 participants; moderate certainty evidence) or all-cause mortality (RR 1.12, 95% CI 0.71 to 1.75; I² = 0%; 2 studies; 1082 participants; moderate certainty evidence). Antimicrobial-impregnated catheters may make little or no difference to risk of catheter failure (RR 1.04, 95% CI 0.82 to 1.30; I² = not applicable; 1 study; 221 participants; low certainty evidence). Antimicrobial-impregnated catheters probably make little or no difference to PICC-related BSI risk (RR 1.05, 95% CI 0.71 to 1.55; I² = not applicable; 2 studies (no events in 1 study); 1082 participants; moderate certainty evidence). Antimicrobial-impregnated catheters may make little or no difference to risk of catheter breakage (RR 0.86, 95% CI 0.19 to 3.83; I² = not applicable; 1 study; 804 participants; low certainty evidence).

AUTHORS' CONCLUSIONS

There is limited high-quality RCT evidence available to inform clinician decision-making for PICC materials and design. Limitations of the current evidence include small sample sizes, infrequent events, and risk of bias. There may be little to no difference in the risk of VTE, PICC-associated BSI, occlusion, or mortality across PICC materials and designs. Further rigorous RCTs are needed to reduce uncertainty.

Peripherally inserted central catheter malposition into the azygos vein: A case series report and review of the literature

BACKGROUND

Peripherally inserted central catheters (PICCs) are frequently utilized for extended intravenous treatments. However, complications such as incorrect placement into the azygos vein can result in significant health issues. A thorough understanding of these aspects is crucial to enhance the safety and effectiveness of PICC procedures, thereby improving patient care outcomes.

METHODS

The research was conducted on a cohort of 12 patients who experienced PICC malposition into the azygos vein. Systematically reviewed information on classification, imaging manifestations, potential influencing factors, and methods for identification, prevention, and management.

RESULTS

The analysis uncovered two PICC malposition classifications within the azygos vein, each with unique imaging characteristics. It also pinpointed several factors influencing malposition, offering valuable insight into potential risks. Moreover, it established effective detection methods, underscoring the significance of imaging techniques. Additionally, it outlined strategies for preventing and managing PICC malposition in the azygos vein, enhancing overall comprehension of the issue.

CONCLUSIONS

The findings emphasize the importance of taking a proactive stance to avoid malposition and stress the necessity of prompt and precise intervention when malposition does happen, thereby enhancing the safety and effectiveness of PICC processes.

Practical use of the central venous access port for contrast-enhanced CT: comparison with peripheral intravenous access regarding enhancement and safety

AIM

To evaluate the efficacy of using the central venous (CV) port compared with peripheral intravenous access for contrast-material injection for contrast enhancement during the portal venous phase.

MATERIALS AND METHODS

Patients were divided into three groups: CV delay, CV routine, and peripheral access (PA) groups. Patients in the CV delay group underwent injection in the arm-down position with an additional delay, while those in the CV routine and PA groups underwent injections with the routine injection protocol for portal venous phase imaging. Contrast enhancement was evaluated by measuring the mean radiodensity (Hounsfield units) values for the aortic arch, abdominal aorta, inferior vena cava, portal vein, and spleen. The peak injection pressure was recorded and compared among the three groups.

RESULTS

No complications related to power injection were observed during 119 contrast-material injections performed using the CV port device. The CV delay group showed significantly lower radiodensity values than the PA group (165.7 ± 20.1 versus 181 ± 19 HU [p<0.01] for the portal vein); however, no significant differences in mean radiodensity values were observed between the CV routine and PA groups (p>0.05). The median peak injection pressure was 73.5, 67, and 47 psi in the CV delay, CV routine, and PA groups, respectively (p<0.01).

CONCLUSION

The CV port can be used for safe contrast-material injection while maintaining contrast enhancement on portal venous phase comparable to that achieved with peripheral intravenous access.

Femorally inserted central catheter, migration and catheter damage during contrast media injection: A case report

Femorally inserted Central Catheters are increasingly used also for medium and long-term catheterization as an alternative to Centrally and Peripherally inserted Central Catheters. If certified as "power injectable," they may be used for contrast media injection during radiological examinations. It is important to consider the risk that, as with other types of catheters, the injection of contrast media could cause migration or damage to the device. The case of a Femoral catheter migration in hepatic vein, during CT scan, is described.

Self-correction of a migrated power-injectable peripherally inserted central catheter following contrast-enhanced computed tomography

The use of power-injectable peripherally inserted central catheter (PIPICC) is a common practice, but displacement of these lines following injection of contrast media has been reported in 15.4% of cases. This report presents imaging evidence of displacement and self-correction of a PIPICC line following contrast-enhanced computed tomography.

Misplacement of piccs following power-injected CT contrast media

Peripherally inserted central catheters (PICCs) may be used to administer contrast injection during CT (computed tomography) scans to improve diagnostic accuracy. This is usually done with the use of a power injector. Research has shown that misplacement of catheters following contrast injection can occur. The aim of this review was to analyse appropriately positioned pre-scan PICCs that malposition following injection of contrast media during a CT scan, evaluate whether tip location or right or left insertion plays a part in the displacement of PICCs after CT, and to ensure those involved are aware of the risks and the safety checks required following such procedures. A quantitative method was used, gathering information from the team's insertion database to review 2045 records of contrast-injectable PICCs between 1 January 2015 and 30 April 2020. Analysis of the data indicated that 1% of appropriately sited PICCs malposition following contrast CT injection and that the catheter is able to self-correct back to its original position at an average interval of 24-72 hours without any other intervention. Further research is needed to explore other factors that could influence the rate of self-correction and complications of prolonged catheter malposition.

Practical administration of intravenous contrast media in children: screening, prophylaxis, administration and treatment of adverse reactions

Administration of intravenous contrast media to children is a routine practice at many clinical imaging centers, that can involve special considerations. In this paper, we provide practical information to facilitate optimal performance and oversight of this task. We provide targeted screening questions that can help to identify high-risk pediatric patients for both iodine-based and gadolinium-based intravenous contrast media administration. These include children at risk for allergic-like reactions, thyroid dysfunction, contrast-induced nephropathy, and nephrogenic systemic fibrosis. We make recommendations for addressing "yes" responses to screening questions using risk stratification schema that are specific to children. We also present criteria for selecting children for premedication prior to intravenous contrast administration, and suggest pediatric regimens. Additionally, we discuss practical nuances of intravenous contrast media administration to children and provide a quick-reference table of appropriate treatments with pediatric dosages for adverse contrast reactions.

Randomized Clinical Trial Evaluating Complications and Complication-Related Removal of Arm-Situated Power-Injectable and Non-Power-Injectable Totally Implanted Venous Access Devices among Cancer Patients

PURPOSE

To evaluate the hypothesis that power-injectable (PI) totally implanted venous access devices (TIVADs) situated in the arm are associated with more frequent complications and complication-related removal than non-power-injectable (NPI) arm TIVADs among adult cancer patients.

MATERIALS AND METHODS

In this single-center trial, 211 adult chemotherapy patients were randomized to receive either a PI or a NPI arm TIVAD. Follow-up involved a standardized telephone interview 1 week after insertion, followed by a chest X-ray, arm X-ray, and Doppler ultrasound at 3 months and 12 months. Online complication reporting was also provided by patients and care providers for a minimum of 1 year. The primary end point was removal for port-related complications; the secondary end point was the occurrence of any port-related complication.

RESULTS

Forty-two complications occurred (19.9% of patients), precipitating the removal of 6 PI ports and 7 standard ports. Time-to-removal did not differ between TIVAD types (hazard ratio 0.75, 95% confidence interval [CI] 0.25-2.24; P = .61). Complications were related to thrombosis, infection, or mechanical issues, with no statistical difference between groups for overall occurrence (23.1% vs 17.0%, odds ratio 1.47, 95% CI 0.74-2.92; P = .27); however, by type of complication, thrombosis occurred more frequently among PI TIVAD patients (15.2% vs 6.1%, odds ratio 2.79, 95% CI 1.04-7.44; P = .03).

CONCLUSIONS

There was no difference in port-related complication occurrence or complication-related removal when using the arm PI port compared with the NPI port among cancer patients.

Displacement of a power-injectable PICC following computed tomography pulmonary angiogram

Displacement of peripherally inserted central catheter (PICC) lines during contrast-enhanced computed tomography examinations is an underappreciated phenomenon. We report a case of iatrogenic PICC line displacement following the power injection of contrast during a computed tomography pulmonary angiogram. During the study, the PICC line was shown to move on 2 occasions, resulting in 2 nondiagnostic studies. We review the available literature on the topic and suggest possible strategies to avoid this phenomenon. Radiologists should be aware of PICC line migration, and it should become common practice to review the catheter tip position after computed tomography examinations.

Tip Migration Post-Contrast Pressure Injection Through Pressure-Injectable Peripherally Inserted Central Catheters Causing Vascular Injury: A Report of 3 Cases

Pressure-injectable peripherally inserted central catheters are now widely used for contrast pressure injections for CT scans. While they are generally regarded as safe, they are not free from complication. In this case review, we present three cases of PICC tips migrating post-CT contrast pressure injection including into the pleural cavity and subsequent complications, to raise awareness of this complication not previously encountered in our institution. Level of Evidence Level 4, Case Series.

Systematic review of the safety and efficacy of contrast injection via venous catheters for contrast-enhanced computed tomography

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In ICU patients, contrast injection via central venous catheters is a safe alternative to peripheral injection.

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Implementing a safety protocol before power injection via central venous catheters is advisable.

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The quality of scans varies and remains not sufficiently investigated in scans with higher flow rates.

Objective

To examine the safety and efficacy of contrast injection through a central venous catheter (CVC) for contrast-enhanced computed tomography (CECT).

Methods

A systematic literature search was performed using PubMed. Studies were deemed eligible if they reported on the use of CVCs for contrast administration. Selected articles were assessed for their relevance and risk of bias. Articles with low relevance and high risk of bias or both were excluded. Data from included articles was extracted.

Results

Seven studies reported on the use of CVCs for contrast administration. Catheter rupture did not occur in any study. The incidence of dislocation ranged from 2.2-15.4%. Quality of scans was described in three studies, with less contrast enhancement of pulmonary arteries and the thoracic aorta in two studies, and average or above average quality in one study. Four other studies used higher flowrates, but did not report quality of scans.

Conclusion

Contrast injection via CVCs can be performed safely for CECT when using a strict protocol. Quality of scans depended on multiple factors like flow rate, indication of the scan, and cardiac output of the patient. In each patient, an individual evaluation whether to use the CVC as access for contrast media should be made, while bolus tracking may be mandatory in most cases.

Contributing factors for a late spontaneous peripherally inserted central catheter migration: a case report and review of literature

PURPOSE

Peripherally inserted central catheters (PICCs) are associated with some adverse events, the most frequent are thrombosis, tip catheter malposition and spontaneous late migration. However, the cause of spontaneous late migration in most cases remains unknown. We carried out this study to add data to the literature on PICCs late spontaneous migration.

METHODS

We conducted a systematic review of all manuscripts describing PICC spontaneous late migration in adult populations and we also described two cases of late PICCs migration.

RESULTS

We identified five studies for a total of 58 cases of PICC late migration. In our two cases, patients' activity is an important contributing factor for late spontaneous PICC migration.

CONCLUSIONS

To avoid late catheter misplacement, initial malposition should be immediately identified and promptly corrected and a detailed patients training should be carried out.