What imaging would be done if the Peripherally Inserted Central Catheter (PICC) line is suspected to be problematic?

Imaging for Suspected PICC Line Problems

When a PICC line is suspected to be problematic, a chest X-ray should be performed as the first-line imaging modality to verify catheter tip position and identify potential complications. 1

Initial Imaging Assessment

Chest X-ray

• Standard anteroposterior (AP) chest X-ray is the primary imaging modality for evaluating PICC line position and complications
• Right posterior oblique (RPO) view may be added if the tip position is difficult to visualize on the AP view 2
• Should be performed when:
  • Line function is compromised (difficulty flushing, aspirating)
  • Patient experiences pain during infusion
  • Signs of catheter migration are present
  • Symptoms of complications occur (dyspnea, chest pain)

What to Look For on Imaging

• Proper tip position: lower third of superior vena cava (SVC) or at the atrio-caval junction 1
• Common malposition sites to check:
  • High SVC
  • Internal jugular vein
  • Subclavian vein
  • Innominate vein
  • Right atrium (too deep)
  • Right ventricle
  • Peripheral veins (e.g., inferior thyroid vein) 3
• Signs of complications:
  • Kinking or looping of catheter
  • Fracture or fragmentation
  • Venous thrombosis
  • Pneumothorax (if recently placed)

Advanced Imaging Options

If chest X-ray findings are inconclusive or additional information is needed:

1. Linogram (contrast study via catheter)

   • Helpful when subtle malposition is suspected but not clearly visible on X-ray 1
   • Can identify occlusion, leakage, or fibrin sheath formation

2. Ultrasound

   • Useful for evaluating:
     • Venous thrombosis
     • Catheter position in neck or upper chest veins
     • Exit site complications

3. CT scan with contrast

   • For complex cases where X-ray and ultrasound are inconclusive
   • When complications like thrombosis, infection, or extravasation are suspected

Special Considerations

• ECG-guided PICC placement: If the PICC was placed with ECG guidance and proper documentation exists from within the past 2 days, routine radiographic verification may not be necessary 4

• Tip confirmation systems: Modern technologies like the Sherlock 3CG Tip Confirmation System can provide real-time confirmation of proper placement, potentially reducing the need for post-insertion X-rays 5

Common Pitfalls to Avoid

• Failing to obtain imaging when a patient reports pain during infusion
• Missing subtle malpositions that may lead to complications
• Overlooking signs of thrombosis or infection on imaging
• Unnecessary repeated imaging for properly functioning and documented catheters 4
• Attempting to advance migrated catheters (never recommended) 4

Management Based on Imaging Findings

• Malposition: Consider guidewire exchange if the catheter has migrated 4
• Thrombosis: Anticoagulation therapy with LMWH is preferred 1
• Infection with normal position: Consider antibiotic lock therapy while maintaining the line 1
• Severe complications: Remove the catheter and consider replacement at a different site

By following this imaging approach, clinicians can effectively diagnose and manage PICC line complications, ensuring patient safety and optimal line function.