A: US-guided Puncture Technique

The following outlines the basic steps for puncturing under US guidance. It is recommended to practice using a vessel model or simulator, especially if you are unfamiliar with this technique.

1. Position the US probe perpendicular to the target and pierce the skin at the edge of the US probe (Figure 1). Please note that the depth of the needle tip at the US beam changes with the angle between the probe and the skin (Fig. 2).
2. While identifying the needle tip, gradually advance the probe and the needle alternately to approach the target (Fig. 3).
3. Repeat procedure 2 until the needle reaches the target.

Fig 1: The US images of a simulator (A) and the upper arm of a patient (B), with the short-axis (top row) and the long-axis (bottom row). While the long-axis view may appear easier to perceive the needle, it requires skills to keep the probe aligned with the vessel. It is also important to note that the surrounding structures, such as an artery and a nerve, are not visible in the long-axis view. Therefore, the short-axis view is recommended for US-guided puncture of a vessel.

Fig 2: The illustration showing the correlation between the incision angle and the depth of a needle at the US beam. The optimal angle is determined by the target’s proximity and depth.

Fig 3: The images depicting the stepwise process of US-guided puncture on a simulator (A through G). After identifying the needle tip, slightly advance the probe while keeping the needle in the same position, causing the needle tip to disappear from the imaging plane (bottom row). Slowly advance the needle until it reaches the US beam, bringing the needle tip back into view (top row). Repeat the procedure until the needle reaches the target.

Identifying the needle tip in a clinical setting can be challenging due to the intricate subcutaneous structures (Fig. 4). Predicting its location can be aided by subtle movements in the surrounding tissue and the use of “jabbing” technique, which involves gently shaking the needle tip without advancing it.

As the needle tip approaches the vessel wall, it causes deformation that makes it easier to identify. Even if the needle tip appears to be inside the vessel, it is advisable to advance the needle through the vessel adjusting its tip at the cavity center, given the potential for vessel wall distension without puncture (Fig. 5). The Seldinger technique can be employed if the needle punctures the posterior wall.

Fig 4: The US image during the vessel puncture on a patient. Predicting its location can be aided by subtle movements in the surrounding tissue.

Fig 5: Left column: The US image and illustration of vessel deformation without puncture. Right column: The illustration of the Seldinger technique. When puncturing a vein, it is advisable to attach a syringe to the catheter to apply gentle negative pressure. This helps in recognizing when the tip is inside the vessel.

B: 9 Steps for PICC Line Insertion

Performing PICC line insertion with a team, comprising an operator, assistant, and circulating nurse, is considered optimal. While this guide primarily focuses on over-the-wire PICC insertion, most steps are applicable to others.

Step 1: Arm Selection

Determine the suitable arm for PICC insertion, considering factors such as post-operative status, the presence of arrhythmic devices, or arteriovenous fistulas. If a patient has undergone previous PICC insertion, choosing a different arm is advisable to prevent deep vein thrombosis (Fig. 6). Utilize CT images, if available, to check for any obstacles to PICC insertion. If no specific criteria apply, choosing the right side is generally reasonable for a shorter length. However, patient preferences or difficulties with one side may influence the decision.

Fig 6: A case of a 63-year-old female with a history of uterine cancer who underwent PICC placement three weeks prior to this procedure. A: The PICC catheter failed to advance from the axilla under fluoroscopy. B: Venography revealed obstruction of the subclavian vein. C: Post-contrast CT images showed massive deep vein thrombosis, likely attributed to the previous PICC placement. © Department of Radiology, Kameda Medical Center/ Japan 2023

Step 2: Room Setup and Posture Adjustment

Ideally, conduct PICC insertion in a fluoroscopy room for real-time monitoring. Attach an electrocardiogram monitor for observing arrhythmias. Arrange the room to enable the operator to easily view the electrocardiogram, ultrasound, and fluoroscopy monitors (Fig. 7). Externally extend and rotate the patient's arm, a crucial step for deep vein puncture. If the arm is too thin or in contracture, placing a towel underneath aids in stabilization.

Fig 7: Images illustrating “Step 2: Room Setup and Posture Adjustment” in a fluoroscopy room. The electrocardiogram, ultrasound, and fluoroscopy monitors were arranged for optimal visibility by the operator. (A: Approach from the right. B: Approach from the left.)

Step 3: Vessel Assessment

Fully observe the target vessel and surrounding structures under ultrasonography (Fig. 8). The basilic vein is the preferred choice for PICC insertion due to its size, proximity, and absence of major nearby arteries (Fig. 9). The brachial vein is a secondary option, but caution is needed to avoid injury to the brachial artery and median nerve. The cephalic vein is a third choice, with occasional routing challenges (Fig. 10).

Mark the puncture point, ideally in the middle one-third of the upper arm. Avoiding proximity to the cubital fossa prevents catheter kinking and phlebitis. Similarly, avoiding proximity to the axilla prevents infection. Consider vessel diameter, aiming for a diameter three times that of the catheter to prevent deep vein thrombosis^[1,2].

Fig 8: The US image of the upper arm during compression. Veins are recognizable as they collapse under compression. Arteries may collapse in hypotensive patients, yet they are usually identifiable because of pulsation. Color flow Doppler also aids in differentiating arteries from veins.

Fig 9: Gross anatomy of the upper arm under ultrasonography. Note that the brachial vein is usually located deep beneath the skin surface and is surrounded by several other structures, including the brachial artery and median nerve. Due to this, the preferred vein for PICC insertion is usually the basilic vein. Observe the upper arm laterally to find the cephalic vein, which is located superficially and is prone to collapse under the US probe.

Fig 10: A case of an 88-year-old female with a stroke who underwent PICC insertion from the left cephalic vein. A: The guidewire failed to advance to the subclavian vein. B: Venography revealed a sharp angle between the cephalic vein and the subclavian vein. C: A fluoroscopy image after PICC insertion. The catheter failed to advance from the brachiocephalic vein, possibly due to the winding route (The catheter tip is indicated by the arrowhead). © Department of Radiology, Kameda Medical Center/ Japan 2023

Step 4: Sanitization and Maximal Sterile Barrier Precautions

Thoroughly sanitize the upper arm using chlorhexidine-alcohol. Cover the patient’s arm and body with a surgical drape. Both the operator and the assistant should wear a mask, cap, sterilized gloves, and a gown. Additionally, use a sterile cover for the US probe (Fig. 11). Prepare the PICC kit by injecting saline or heparinized saline into the catheter and guidewire cover.

Fig 11: Images illustrating “Step 4: Sanitization and Maximal Sterile Barrier Precautions”. A: Sanitizing the upper arm using chlorhexidine-alcohol. B: Covering the patient’s arm and body with a surgical drape. C: Using a sterile cover for the US probe. D: Preparing the PICC kit by injecting heparinized saline into the guidewire cover.

Step 5: US-guided Puncture

Apply a tourniquet to initiate the puncture. Administer local anesthesia with lidocaine at this point if the patient experiences severe pain, which may hinder the observation of the underlying structures. Use the previously discussed US-guided puncture technique (Fig. 12).

If the target vessel is deep, the catheter may dislodge when the operator releases skin tension. In such instances, maintain the catheter's position and pressure on the patient's upper arm, carefully inserting the guidewire after withdrawing the needle (Fig. 13).

Fig 12: Images illustrating “Step 5: US-guided Puncture”. Although the operator should primarily focus on the US screen, direct observation of the probe and needle is beneficial in cases of directional confusion. It is important to note that the return of blood to the flashback chamber may not always be observed, possibly due to occlusion by soft tissue.

Fig 13: Illustration showing how dislodgement occurs for a deep vein puncture (A, B). To avoid dislodgement, maintain the catheter's position and pressure on the patient's upper arm until inserting the guidewire (C).

Step 6: Guidewire Insertion

Insert the guidewire sufficiently long to prevent catheter dislodgment, then remove the tourniquet. Advance the guidewire under fluoroscopy if available (Fig. 14). In its absence, focus on any changes in wire resistance and patient discomfort, indicating potential migration into thinner vessels, given the numerous branching possibilities (Fig. 15). Tilting the patient's head toward the insertion side prevents neck migration. Pay attention to the electrocardiogram monitor for guidewire-induced arrhythmia. If it is observed, pull back the guidewire until the arrhythmia disappears, to avoid it becoming a persistent issue.

Fig 14: Images illustrating “Step 6: Guidewire Insertion” and “Step 7: Dilator Insertion”. Real-time monitoring with fluoroscopy is optimal to prevent guidewire-induced arrhythmia and migration of the guidewire. Considering a patient’s physique and the length of the guidewire may help to estimate the optimal length for insertion.

Fig 15: Illustration in the left column shows simplified vein anatomy (A: from the upper arm to the axilla, B: from the subclavian vein to the SVC). Veins with underlines represent common possibilities for migration. Pictures in the right column depict cases of migration (C: Guidewire migration to the right lateral thoracic vein, D: PICC migration to the right internal jugular vein). © Department of Radiology, Kameda Medical Center/ Japan 2023

Step 7: Dilator Insertion

If local anesthesia has not been applied, inject lidocaine into the skin before dilation. Insert the dilator over the guidewire to create an opening for PICC insertion (Fig. 14). A small incision may be required, especially in younger patients with elastic skin. If the PICC kit includes an introducer instead of a dilator, follow the same procedure to place the introducer.

Step 8: PICC Line Insertion

Insert the PICC line over the guidewire, ensuring the wire remains wet. Hold the proximal end of the wire to keep it straight for smooth delivery (Fig. 16). The guidewire may traverse a thin vessel instead of the subclavian vein (Fig. 17). In such a case, pull back the guidewire to the axilla to re-select the subclavian vein.

Advance the PICC to the level of the tracheal bifurcation as it aligns with the SVC. If inserted from the left side, the PICC tip may be slightly deeper to align with the SVC (Fig. 18). If the PICC fails to advance to the SVC, find a point where injection and blood sampling are smooth, considering its suitability for the patient.

Fig 16: Images illustrating “Step 8: PICC Line Insertion”. It is important to keep the catheter and guidewire straight for smooth delivery (A). Flushing the catheter just before holding the guidewire helps to keep the guidewire wet (B). The edge of the catheter is recognizable under fluoroscopy for its thickness compared to the guidewire (C). © Department of Radiology, Kameda Medical Center/ Japan 2023

Fig 17: A case of a 67-year-old female with a subarachnoid hemorrhage who underwent PICC insertion. Although the guidewire reached the SVC, the catheter would not advance from the axilla. Venography revealed that the catheter migrated into a very thin vessel, possibly a lymphatic duct, which connected to the subclavian vein (A). The axillary vein became visible by pulling the catheter backward to the upper arm (B). PICC was placed perfectly by selecting the correct route (C). © Department of Radiology, Kameda Medical Center/ Japan 2023

Fig 18: Fluoroscopy images of PICC tips. When approached from the left, the catheter needs to be deepened to align with the SVC (A-1,2). When approached from the right, the catheter tip is at the level of the tracheal bifurcation (C). (The arrowhead indicates the tracheal bifurcation in each image.) © Department of Radiology, Kameda Medical Center/ Japan 2023

Step 9: Fixation and Dressing

Suture use may vary with PICC kits, so carefully check the kit contents. Secure the PICC to form a loop away from the cubital fossa to prevent folding due to arm bending (Fig. 19). Ensure the catheter's wing is fixed, as the catheter's root is prone to bending.

Fig 19: Images illustrating “Step 9: Fixation and Dressing”. It is easier to control the PICC’s orientation if someone helps while dressing, but be careful not to compromise sterility. Ensure the catheter's wing is fixed, as the catheter's root is prone to bending.

C: Post-Insertion Complications and Successful Maintenance with PICC Team

Even with a perfectly inserted PICC, complications can jeopardize its functionality. Major post-insertion complications and issues include:

1. Occlusion: PICC occlusion is a common issue without proper care (Fig. 20). Pulsatile flushing and positive pressure locking after each use are crucial to prevent occlusion, especially when the catheter lacks a backflow prevention valve (Fig. 21).

Fig 20: Images of occluded PICCs found during ward rounds. A, B: PICCs had several bends (indicated by the arrowhead). C: A PICC had a lumen completely occluded with a blood clot.

Fig 21: The video (animated gif) of the pulsatile flush and the positive pressure locking. It is important to use both techniques every time after PICC use. PICCs tend to become occluded especially after blood sampling, transfusion, and infusion of thick solutes such as total parenteral nutrition. Therefore, it is advisable to flush 20 mL of saline in such cases.

2. Migration: The PICC’s position may shift as patients move their arms, so excessive movement can cause migration (Fig. 22). While PICC breakage is uncommon, emergency IVR is necessary for salvage if it occurs (Fig. 23).

Fig 22: A case of a 46-year-old male with diffuse large B-cell lymphoma who underwent PICC insertion. A: A CT scan taken two days prior to death showed the PICC tip initially located in the SVC. B: Autopsy imaging CT revealed that the PICC migrated into the azygous vein, possibly due to cardiopulmonary resuscitation measures (the cause of death was invasive candidiasis after chemotherapy, not related to PICC migration). © Department of Radiology, Kameda Medical Center/ Japan 2023

Fig 23: A case of a 78-year-old female with pyelonephritis who underwent PICC insertion. The PICC was accidentally cut by a physician while attempting to remove the occluded PICC with an incision to the skin. The broken PICC was identified under fluoroscopy (A) and ultrasonography (B). Emergency IVR was performed to salvage the broken PICC with a snare catheter (C). The broken PICC was successfully removed (D). To remove a PICC, gently pull it while supporting the incision site with the other hand (E). Some resistance may be felt, but an incision to the skin is seldom required. © Department of Radiology, Kameda Medical Center/ Japan 2023

3. Deep Vein Thrombosis and Infection: Despite appropriate care, these complications can still occur at varying rates^[3,4] (Fig. 24). Regularly checking the PICC insertion site is crucial for early detection.

Fig 24: A case of a 16-year-old male with acute leukemia who underwent PICC insertion. The PICC was inserted from the right side, two weeks prior to the initial CT scan (A). In the first post-contrast CT image, thrombi were retrospectively identified around the PICC (B). In the subsequent post-contrast CT, taken two weeks after the initial scan, deep vein thrombosis was confirmed (C). Although the removed PICC was intact, a linear high-attenuating structure, likely a fibrin sheath, was observed within the thrombi. After one month of anticoagulant therapy, the thrombus completely resolved, leaving calcifications in the right subclavian vein (D). © Department of Radiology, Kameda Medical Center/ Japan 2023

With the rising number of PICC insertions in our hospital, we formed a specialized “PICC Team” comprising certified nurses for insertion and management. While team members refined the overall insertion process, ward rounds were conducted to identify issues with inserted PICCs, which was a challenging task when a few radiologists managed PICC insertions alongside image interpretation. The team organized study sessions to educate ward nurses on PICC maintenance, significantly reducing occlusion rates.

As the team expanded, maintaining consistent quality and motivation became challenging. Time was allocated after insertion for feedback from senior members to enhance skills. Adult education techniques, such as sandwich feedback and coaching, proved useful. Team meetings were held every two months to share concerns and establish common goals, fostering unity within the team. As the PICC team is a pioneering initiative in Japan, we are actively involved in continuous improvement.