Will an X-ray (X-ray) show if a Peripherally Inserted Central Catheter (PICC) is tunneled or not?

X-ray Visualization of Tunneled PICCs

X-ray imaging can confirm catheter tip position but cannot reliably distinguish between tunneled and non-tunneled PICCs based on appearance alone. 1

Understanding Tunneled vs. Non-Tunneled PICCs

A Peripherally Inserted Central Catheter (PICC) can be placed using either a:

• Standard (non-tunneled) approach: Direct insertion through the skin into a peripheral vein
• Tunneled approach: Creating a subcutaneous tunnel before entering the vein

What X-ray Can and Cannot Show

X-ray imaging is primarily used to verify:

• Catheter tip position - Should be at the junction between the superior vena cava and the right atrium 1
• Catheter course - Path through the venous system
• Complications - Such as malposition or kinking

However, X-ray has significant limitations:

• Cannot visualize soft tissue tunnels - The subcutaneous tunnel created in tunneled PICCs appears similar to the entry path of non-tunneled PICCs 1
• Single-plane limitation - Standard chest X-rays provide only 2D visualization, making it difficult to appreciate the 3D path of tunneled catheters 1

Clinical Implications

When evaluating a PICC on X-ray:

• Tip position verification is essential and clearly visible on X-ray 1
• Entry site location may provide indirect clues (tunneled PICCs often exit further from the venipuncture site) but is not definitive 1
• Documentation review is necessary to confirm tunneling status, as this information should be recorded during placement 1

Alternative Methods to Determine Tunneling Status

Since X-ray alone is insufficient to determine tunneling:

1. Review procedural documentation - The most reliable method to confirm tunneling status
2. Physical examination - Visual inspection and palpation of the insertion site
3. Ultrasound - Can visualize the subcutaneous tunnel in real-time if needed

Key Points for Clinicians

• Do not rely solely on X-ray to determine if a PICC is tunneled
• Consult placement documentation for accurate information about catheter type
• Tunneled status affects management - Tunneled PICCs typically have lower infection rates and may be intended for longer-term use 1

Common Pitfalls

• Misidentifying catheter type based on X-ray appearance alone
• Assuming all PICCs are non-tunneled (tunneled PICCs are increasingly used, especially in pediatric populations and for long-term therapy) 2
• Overlooking the importance of tunneling status when planning catheter care and maintenance

Remember that while X-ray is excellent for confirming proper tip placement and detecting complications, it cannot reliably distinguish between tunneled and non-tunneled PICCs.