What are the risks of brachiocephalic Peripherally Inserted Central Catheter (PICC) placement versus Superior Vena Cava (SVC) placement?

From the Guidelines

Brachiocephalic PICC placement carries a significantly higher risk of thrombosis and mechanical complications compared to superior vena cava (SVC) placement, and therefore, SVC placement is recommended. The main concerns with brachiocephalic placement include increased risk of thrombosis, catheter malposition, and mechanical complications. According to a study published in the Journal of the American College of Radiology 1, the risk of thrombosis increases with the number of catheter lumens used, and venous thrombosis is more common in catheters inserted from the left side with the tip in the subclavian or innominate veins compared with tip placement in the SVC or right atrium.

Some key points to consider when deciding between brachiocephalic and SVC placement include:

• The catheter tip should be placed in the caudal SVC to minimize the risk of thrombosis and mechanical complications 1
• Right-sided access is preferable to a left-sided approach with respect to risk for thrombotic complications 1
• The ideal tip location is the lower third of the SVC near the cavoatrial junction to maximize benefits and minimize complications
• Ultrasound-guided placement minimizes endothelial damage and reduces the risk of catheter-associated thrombosis at the puncture site 1

Overall, the available evidence suggests that SVC placement is generally preferred due to its lower risk of thrombosis and mechanical complications, and its ability to provide better hemodilution of infused medications and more stable catheter positioning. Therefore, SVC placement should be prioritized over brachiocephalic PICC placement whenever possible.

From the Research

Risks of Brachiocephalic PICC Placement versus SVC

• The risks associated with brachiocephalic PICC placement versus SVC placement are not directly compared in the provided studies.
• However, the studies discuss the risks and complications associated with PICC placement in general, such as catheter-related thrombosis (CRT) 2, and the importance of proper placement techniques to minimize complications 3, 4.
• The study by 5 mentions that left-sided placement, including brachiocephalic vein placement, may increase the risk of thrombotic complications.
• Another study 6 discusses the management of PICC-related venous thrombosis, but does not specifically compare the risks of brachiocephalic PICC placement versus SVC placement.
• The provided studies suggest that the risks and complications associated with PICC placement can be minimized with proper placement techniques, patient selection, and management of catheter-related thrombosis 2, 3, 4, 6, 5.

Complications of PICC Placement

• Catheter-related thrombosis (CRT) is a common complication of PICC placement, with a reported incidence of symptomatic thromboembolic complications in 5% or less of general oncology patients 5.
• Other complications of PICC placement include infection, occlusion, and mechanical complications such as catheter malposition or migration 3, 4.
• The study by 2 reports that patients treated with PICC removal alone were more likely to develop progressive thrombosis, while those treated with PICC removal and anticoagulation were more likely to experience major bleeding.

Management of PICC-Related Complications

• The management of PICC-related complications, such as CRT, typically involves catheter removal and anticoagulation therapy 2, 6, 5.
• The study by 6 describes a technique for direct thrombolysis using the lumen of the PICC line to facilitate the insertion of the infusion catheter.
• The study by 5 suggests that thromboprophylaxis may be appropriate and safe for selected high-risk patients, but notes that prospective, randomized, controlled trials are needed to identify the safest and most effective anticoagulant agents and treatment durations.