When and how should a peripherally inserted central catheter (PICC) line be removed, including indications, contraindications, and technique, especially in patients on anticoagulation or with thrombocytopenia?

PICC Line Removal: Indications and Technique

Primary Recommendation

Remove a PICC line when it has not been used for any clinical purpose for 48 hours or longer, when the original indication has been met (e.g., antibiotic course completed), or when it is only used for routine blood draws in a hemodynamically stable patient with available peripheral veins. 1

Indications for PICC Removal

Clear Indications to Remove

• No clinical use for ≥48 hours - the line is no longer serving any therapeutic purpose 1
• Original indication fulfilled - such as completion of an antibiotic course or other prescribed therapy 1, 2
• Only used for phlebotomy - in hemodynamically stable patients when peripheral veins are accessible 1
• Confirmed line-related bloodstream infection - with objective evidence of bacteremia 1

PICC-Related DVT: Specific Removal Criteria

Remove the PICC in the setting of image-confirmed DVT when: 1

• The PICC is clinically no longer necessary
• Used only for phlebotomy when peripheral veins are available
• Symptoms of venous occlusion (arm pain, swelling) persist despite ≥72 hours of therapeutic anticoagulation
• Bacteremia with objective evidence of line-related infection exists

Do NOT remove the PICC with DVT when: 1

• Irritants or vesicant infusions remain necessary
• Poor peripheral venous access exists and frequent phlebotomy is required
• Minimal symptom improvement but therapeutic anticoagulation has been provided for ≤72 hours

Removal Technique

Pre-Removal Preparation

• Position the patient supine with the exit site below heart level to minimize air embolism risk 3
• Extend the arm to facilitate safe catheter removal 3
• Gather sterile supplies: sterile gloves, dressing materials, antiseptic solution 3
• Use chlorhexidine solutions with alcohol for skin preparation 3
• Remove any stabilization devices (e.g., Statlock) securing the catheter 3

Removal Procedure

• Apply sterile gloves and maintain aseptic technique throughout 3
• Clean the exit site with antiseptic solution and allow complete drying 3
• Remove any sutures if present 3
• Apply gentle, steady traction to remove the catheter - avoid excessive force that could cause breakage 3
• If the catheter cannot be removed with gentle traction, seek consultation from vascular surgery or interventional radiology - very long-term catheters may become attached to vessel walls 3, 4

Post-Removal Care

• Inspect the catheter to ensure it is intact and complete 3
• Apply firm digital pressure to the exit site for at least 5 minutes until hemostasis is achieved 3
• Apply a sterile occlusive dressing to protect against infection 3
• If persistent bleeding occurs, a skin stitch may be required 3
• Document the procedure, including exit site condition and catheter integrity 3

Special Considerations

Anticoagulation

Anticoagulation is NOT a contraindication to PICC removal. 1 The MAGIC guidelines specifically address removal in patients on therapeutic anticoagulation for PICC-related DVT, indicating removal is appropriate under specific circumstances even when patients are anticoagulated. Standard hemostasis techniques (firm pressure for ≥5 minutes) should be sufficient. 3

Thrombocytopenia

While not explicitly addressed in the guidelines, standard practice dictates applying prolonged pressure (>5 minutes) until hemostasis is achieved, with consideration for platelet transfusion if severe thrombocytopenia exists and bleeding risk is high. 3

Migrated Catheters

Never advance a migrated PICC back into position - this is rated as inappropriate regardless of how far the catheter has dislodged 1, 5, 6

• If no signs of infection exist, guidewire exchange is appropriate 1, 5
• If infection is suspected or confirmed, remove the catheter 1

Suspected Line Infection

• If catheter-related infection is suspected, collect appropriate cultures before removal to guide antibiotic therapy 3
• PICC removal in the absence of confirmatory evidence of line-related infection is rated as uncertain - clinical judgment based on pathogen, bacteremia intensity, and clinical stability is required 1

Critical Pitfalls to Avoid

• Never allow removal by clinicians trained only in CVC removal but not specifically in PICC removal - this is rated as inappropriate 1, 3
• Never forcefully pull if resistance is encountered - consult interventional radiology or vascular surgery 3, 4
• Never advance a dislodged PICC - perform guidewire exchange if no infection is present 1, 3, 5
• Do not remove PICCs without physician notification - unlike urinary catheters, this requires physician order 1