PICC Insertion Procedure

Department of Radiology and Imaging
Hospital for Special Surgery


Below is a list of some frequently asked questions, but please feel free to contact us if you need additional information. We are always pleased to assist you.

What is a PICC or PIC line?

PICC stands for "Peripherally Inserted Central venous Catheter." This intravenous catheter is inserted through the skin, into a vein in the arm, in the region above the elbow and below the shoulder. This is a peripheral insertion. The catheter is a long, thin tube that is advanced into the body in the veins until the internal tip of the catheter is in the superior vena cava, one of the central venous system veins that carries blood to the heart. This tube may have one or two openings, called lumens, that are used to deliver medication.

When is a PICC Insertion Necessary? Who orders the PICC?

A PICC must be ordered by your primary physician/surgeon or their consulting colleague. The purpose of the PICC insertion procedure is to provide Intravenous therapy through an intravenous catheter. The benefit of a PICC is that the catheter can remain for a long period, typically 2-6 weeks, over which a course of medication such as antibiotics can be delivered. The patient may be discharged to a rehabilitation facility or to their home with home care nursing arranged for the completion of intravenous therapy with the PICC in place. The PICC can also be used for short intervals in a patient with difficult vein access. In some instancies a PICC is used.

Typical IV therapies administered through a PICC include:

  • Antibiotics
  • Total parenteral nutrition (define)
  • Blood products
  • Immunoglobulins
  • Chemotherapy

What is so special about your PICC insertion at HSS?

PICC Insertion procedures are performed by HSS radiologists and qualified and specially trained radiology nurses, radiology physician assistants and radiology nurse practitioners trained to safely use ionizing radiation, ultrasound and interventional vascular procedures.

PICC catheters come in single lumen (channel) or double lumen types. The PICC commonly used at HSS has a patented Groshong valve, which offers an advantage of not requiring a blood thinner to be mixed with the saline flushes.

The final position of the PICC is confirmed by the radiologist on a chest x-ray obtained at the time of the procedure. When leaving HSS, the patient is provided with an information book, phone number and a pager number for contact to address any questions or concerns about the PICC.

Who inserts the PICC?

At HSS, PICCs are inserted by board-certified radiologists trained in vascular interventional procedures; qualified and specially trained radiology nurses; radiology physician assistants and radiology nurse practitioners. PICCs are inserted using imaging guidance under ultrasound and fluoroscopyto provide safe and accurate placement of the PICC.

How is the procedure performed?

After written informed patient consent is obtained, the procedure is performed in a radiology interventional procedure room and takes about an hour. The patient is advised to lie on their back on a procedure table with the arm chosen for insertion resting on an arm board support. A tourniquet is placed around the arm just below the shoulder. The vein for the PICC acces is selected using ultrasound. Under sterile conditions,Lidocaine 1%, a common local anesthetic, is injected at the skin surface. Local anesthesia may sting or burn for a few seconds but after that becomes numb, so only a pressure sensation is felt when the PICC is being inserted.

Under ultrasound guidance a thin needle is used to enter the vein. A thin safety guidewire with a floppy safety tip is inserted through the needle, into the vein, and the tourniquet is loosened. The needle is then removed and the catheter is advanced through the vein over the guide wire to the superior vena cava. The indwelling guide wire is removed and an injection cap is attached to the catheter hub.

The catheter is tested for blood return and then flushed with sterile, normal saline. A final chest x-ray is performed to confirm catheter tip position. The catheter is secured at the entry site with a suture wing and 2 sutures.The insertion site is cleaned with an alcohol-based solution. Sterile gauze is applied and covered with clear plastic adhesive dressing, and the upper arm circumference is measured to be used as a baseline.

How to Prepare for a PICC Procedure?

Prior to the procedure, information on medications like anticoagulant therapies such as Coumadin or Heparin is required. A blood test to check for potential bleeding complications may be requested.

What are the contraindications for the PICC procedure?

Patients on anticoagulant therapy who have an INR blood test result greater than 2.0 cannot undergo the procedure. An upper extremity vein cannot be used for a PICC insertion if there is a history of any of the following in the region of that upper extremity:

  • major shoulder surgery
  • vascular surgery
  • radiation therapy
  • venous thrombosis
  • axillary lymph node dissection
  • Local dermatitis, cellulitis, burn injury, abscess, or infection at or near the region of the planned insertion site, are contraindications for using that site.

What are the risks/possible complications?

The risks involved with the PICC procedure involve:

  • Introduction of infection: risk is low (approximately 2%)
  • Bleeding: risk is usually minimal and very easy to control.
  • Clotting of blood in the vein around the catheter or at the wall of the vein: risk is approximately 20-40 percent of the time but is usually so minimal, it is not clinically evident or significant.
  • Increased venous thrombosis: risk is extremely rare.
  • Pulmonary embolus: risk is not common.
  • Allergic reactions to the local anesthetic, latex, sterile preparation solutions, flushing solutions, or iodinated contrast agents (rarely used): risk is uncommon and patients are questioned about allergies prior to the procedure and precautions taken.
  • Breakage of materials such as guide wire or catheters during the procedure: risk is extremely rare.

Pain can be expected during the injection of the local anesthetic and discomfort, or pain, may occur related to table positioning during the procedure. Adherence of the catheter within the venous system at the time of removal can occur when the catheter has been in dwelling for a long periods of time, although this is a rare occurrence

What are the alternatives to the PICC procedure?

Oral antibiotic therapy is an alternative in some cases, but may not be effective against certain types of infection or against infections in certain locations. Inadequate treatment of an infection could result in the further spreading or increasing severity of the infection.

IV therapy can be performed with peripheral IV catheters but these have to be replaced at least every 3 days and the veins typically become increasingly difficult to catheterize over time. Long-term intravenous therapy can be performed with other central venous catheters (e.g. tunneled catheters or buried port catheters). Compared to the PICC, insertion of these catheters is more invasive and the removal can be more complicated.

What to Expect After the PICC Procedure

The patient is given a catheter information book with phone numbers and a pager number to call in the event of a question or emergency related to the PICC.

Report any obstruction of flow, leakage of fluid, drainage at entry site or suture sites, soft tissue swelling, or pain to a nurse. If they are unavailable, call the numbers listed in your PICC booklet.

Mild soreness can be expected at the entry site for one to two days after the procedure. There may be bleeding at the entry site, especially on the first or second day. If the gauze becomes soaked with blood, a nurse should be told to change the dressing. It is important to keep the dressing and the external tubing dry. If showering, cover the dressing and external tubing with a waterproof material, such as plastic wrap secured with tape or a commercially available waterproof cast cover. Do not submerge the entry site under water. If the dressing gets wet, have a nurse change it as soon as possible.

Strenuous exercise should be done with caution to protect the PICC and only if permitted by your physician. The PICC should be flushed before and immediately after each use and flushing instructions must be followed carefully. Do not allow the external catheter to have hairpin turns, kinks, or twists, and be aware that the sutures should remain in until the PICC is removed.

PICC removal is a simple procedure in almost all cases.

Possible Followup Tests?

At the end of the procedure, a fluoroscopic chest film is taken to document final position of the catheter tip.

Reviewed by Teresita Leynes and Helene Pavlov, MD, FACR

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