Where is a Peripherally Inserted Central Catheter (PICC) line usually placed?

PICC Line Placement Location

PICC lines are typically placed in the upper arm, specifically in the basilic vein, brachial vein, or cephalic vein, with the basilic vein being the preferred access site due to its larger size and superficial location. 1

Anatomical Considerations for PICC Placement

Preferred Veins for Access

• Basilic vein: First choice due to:
  • Larger diameter
  • More superficial location
  • Lower incidence of complications 1
• Brachial vein: Second choice, but carries higher risk of:
  • Brachial artery injury
  • Median nerve damage 1
• Cephalic vein: Less preferred due to:
  • Smaller size
  • Higher thrombosis rate (57% vs 14% for basilic vein) 2
  • Greater risk of catheter kinking as it overlies the biceps muscle 1

Insertion Technique

• Ultrasound-guided insertion is strongly recommended for all PICC placements 1
• Placement in the midarm (rather than antecubital fossa) is associated with:
  • Better nursing care
  • Lower risk of infection
  • Lower risk of thrombosis 1

Catheter Tip Position

The tip of the PICC line should be positioned in:

• Lower third of the superior vena cava
• Atrio-caval junction
• Upper portion of the right atrium 1

This positioning is critical to minimize the risk of:

• Mechanical complications
• Thrombotic complications
• Catheter malfunction 1

Tip position should be verified during or immediately after the procedure using:

• Intraoperative fluoroscopy, or
• Post-operative chest X-ray 1

Advantages of PICC Lines

• Lower risk of insertion complications compared to central venous catheters
• Exit site in midarm keeps the catheter away from endotracheal, oral, and nasal secretions
• Suitable for both inpatient and outpatient use
• Can be used for medium-term access (up to 3 months) 1

Common Complications to Monitor

1. Venous thrombosis:

   • Overall thrombosis rate: 23-38% 2
   • Highest in cephalic vein (57%)
   • Lowest in brachial vein (10%) 2

2. Catheter tip movement:

   • Silicone PICCs move less than polyurethane PICCs
   • PICCs in cephalic vein show less tip movement than those in basilic or brachial veins 3

3. Rare but serious complications:

   • Arteriovenous fistula formation 4
   • Catheter malposition
   • Infection

Best Practices for PICC Placement

• Use maximal barrier precautions during insertion
• Apply 2% chlorhexidine in 70% isopropyl alcohol as skin antiseptic
• Allow antiseptic to fully dry before insertion
• Use sterile, transparent, semi-permeable polyurethane dressing
• Change dressing every 7 days or sooner if compromised 1

Key Pitfalls to Avoid

• Avoid blind insertion techniques - always use ultrasound guidance
• Avoid antecubital fossa placement - midarm placement is superior
• Don't skip verification of tip position - malposition can lead to serious complications
• Don't place PICCs in patients with end-stage renal disease who may need future hemodialysis access, due to high risk of venous thrombosis 2

By following these guidelines, PICC lines can be safely and effectively placed to provide reliable medium-term venous access with minimal complications.