Where should the tip of a Peripherally Inserted Central Catheter (PICC) line be positioned?

Optimal Positioning of PICC Line Tips

The tip of a Peripherally Inserted Central Catheter (PICC) line should be positioned in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium to minimize complications. 1

Anatomical Considerations for PICC Tip Placement

Upper Body PICC Lines (Internal Jugular/Subclavian Approach)

• Optimal position: Lower third of the superior vena cava (SVC), at the atrio-caval junction, or upper portion of the right atrium 1
• Radiographic landmark: The tip should be at the level of the right atrial-superior vena cava junction 1
• Avoiding complications:
  • Position outside the pericardial sac to prevent pericardial effusion/tamponade 1
  • The carina serves as a reliable landmark - the tip should be positioned near this level 2, 3
  • For adults, placement approximately 4 cm below the carina will result in placement near the cavoatrial junction 3

Lower Body PICC Lines (Femoral Approach)

• Optimal position: Above the renal veins (first lumbar vertebra) 1
• Rationale: Reduces risk of thrombotic complications while ensuring adequate central placement

Evidence-Based Positioning Guidelines

Adult Patients

• Placing the catheter tip peripherally to the atrio-caval junction significantly increases risk of:
  • Venous thrombosis (p<0.001) 4
  • Internal catheter repositioning (p<0.001) 4
• Right-sided access is preferred over left-sided to reduce thrombosis risk 1

Pediatric Patients

• Small infants (47-57 cm body length): Tip should be at least 0.5 cm above the carina 1
• Larger infants (58-108 cm body length): Tip should be at least 1.0 cm above the carina 1
• Rationale: In newborns, the pericardial reflection is located from 4 mm above to 5 mm below the carina 1

Verification of Proper Placement

• Initial verification: Ultrasound confirmation during placement allows for immediate use without waiting for radiographic confirmation 5
• Final confirmation: Post-procedure chest X-ray remains the gold standard, especially for:
  • Left-sided approaches
  • Patients with anatomical variants
  • When complications are suspected 5
• Arm position: Critical during radiographs as movement can cause catheter migration 6

Important Considerations and Pitfalls

• Catheter material: Modern catheters are made of more flexible materials (polyurethane, silicone) which reduce risk of vascular erosion compared to older, rigid materials 1
• Single vs. multi-lumen: Single-lumen catheters are preferred to reduce infection risk 1
• Left vs. right approach: For left-sided catheters, placement of the tip below the carina is more likely to result in satisfactory placement 7
• Common pitfall: Placing the tip too high in the SVC increases thrombosis risk while placing it too deep in the right atrium near the tricuspid valve may lead to mechanical complications 1

Special Situations

• Right atrial placement: While traditionally avoided, recent evidence suggests that right atrial placement may be appropriate in adults without atrial arrhythmias 1
• Femoral insertion: Should be avoided when possible as it's associated with higher rates of sepsis (45%) compared to upper extremity insertions (18%) 4

By ensuring proper PICC tip positioning according to these guidelines, clinicians can significantly reduce the risk of serious complications including thrombosis, infection, and cardiac tamponade.