Can a Peripherally Inserted Central Catheter (PICC) line be placed in an upper extremity with a Deep Vein Thrombosis (DVT)?

PICC Line Placement in an Upper Extremity with DVT

Generally, a PICC line should NOT be placed in an upper extremity with an existing DVT, and placement in the contralateral arm is strongly preferred after at least 3 months of anticoagulation. 1

Primary Recommendation

Avoid PICC placement in the affected extremity with DVT. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) panel specifically rated PICC insertion as inappropriate in patients who experienced PICC-related DVT within the past 30 days, given the high risk for recurrent thrombosis. 1

When PICC Placement is Absolutely Necessary After Recent DVT

If a PICC is unavoidable in a patient with recent upper extremity DVT, the following approach should be taken:

Timing and Location

• Wait at least 3 months after initiating anticoagulation for the DVT before considering PICC placement 1
• Place the PICC in the contralateral arm (the arm without DVT) whenever possible 1
• If bilateral DVT or only one arm available, consider alternative access routes (tunneled CVC, port, femoral access) 1

Device Selection to Minimize Risk

• Use the smallest gauge catheter possible - larger diameter PICCs (5-Fr and 6-Fr) significantly increase DVT risk compared to 4-Fr catheters (OR 2.74 and 7.40 respectively) 2
• Use the minimum number of lumens required - multi-lumen catheters increase thrombosis risk 1
• Place via right-sided approach when possible - left-sided placements have higher DVT incidence 1

Anticoagulation Requirements

• Patient must be on therapeutic anticoagulation for at least 3 months before considering new PICC placement 1
• Continue anticoagulation throughout the duration the PICC remains in place 1
• Low molecular weight heparin (LMWH) is recommended for minimum 3 months for catheter-related thrombosis 1

Alternative Access Options to Consider First

Before placing a PICC in a patient with upper extremity DVT history, strongly consider:

• Midline catheter for parenteral antibiotics lasting 10+ days 1
• Tunneled central venous catheter for long-term access >3 months 3
• Implantable port for long-term intermittent access 3
• Femoral venous access as an alternative central access site 1

Specific Clinical Scenarios Where PICC is Inappropriate

The MAGIC panel rated PICC insertion as inappropriate when: 1

• Indication is frequent phlebotomy and peripheral access is available
• Patient request for comfort in non-end-of-life settings
• Patient requires surgery lasting ≥1 hour (heightened DVT risk)
• Recent PICC-DVT within 30 days

Management of Existing PICC with New DVT

If a patient develops DVT with a PICC already in place, the approach differs:

Keep the PICC if:

• The catheter is functioning AND clinically necessary (e.g., vesicants, irritants, poor peripheral access) 1
• Patient can receive therapeutic anticoagulation 1
• Symptoms improve within 72 hours of therapeutic anticoagulation 1

Remove the PICC if:

• No longer clinically necessary 1
• Only being used for phlebotomy with available peripheral veins 1
• Persistent symptoms despite 72+ hours of therapeutic anticoagulation 1
• Confirmed line-related infection 1

Critical Risk Factors to Consider

Patients at highest risk for PICC-DVT include those with: 2, 4, 5

• History of prior DVT (OR 1.70-8.99)
• Active malignancy
• Recent surgery >2 hours while PICC in place (OR 2.17)
• Multi-lumen catheters
• Another central venous catheter already present

Common Pitfalls to Avoid

• Do not place PICCs for convenience in patients with DVT history - the 3.18% symptomatic DVT rate becomes unacceptable when the indication is weak 5
• Do not assume prophylactic anticoagulation is sufficient - therapeutic dosing is required for patients with active DVT 1
• Do not place in the same extremity as recent DVT within 3 months, even with anticoagulation 1
• Avoid left-sided placement when possible due to higher thrombosis rates 1