Volume 67, Issue 1 p. 65-71
REVIEW ARTICLE
Free Access

Complications associated with peripheral or central routes for central venous cannulation

A. Pikwer

A. Pikwer

Specialist Registrar and PhD Student

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J. Åkeson

J. Åkeson

Consultant and Professor, Department of Clinical Sciences Malmö, Anaesthesiology and Intensive Care Medicine, Skåne University Hospital, Lund University, Malmö, Sweden

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S. Lindgren

S. Lindgren

Consultant, Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden

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First published: 04 October 2011
Citations: 93
Dr A. Pikwer
Email: [email protected]

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Summary

We undertook a review of studies comparing complications of centrally or peripherally inserted central venous catheters. Twelve studies were included. Catheter tip malpositioning (9.3% vs 3.4%, p = 0.0007), thrombophlebitis (78 vs 7.5 per 10 000 indwelling days, p = 0.0001) and catheter dysfunction (78 vs 14 per 10 000 indwelling days, p = 0.04) were more common with peripherally inserted catheters than with central catheter placement, respectively. There was no difference in infection rates. We found that the risks of tip malpositioning, thrombophlebitis and catheter dysfunction favour clinical use of centrally placed catheters instead of peripherally inserted central catheters, and that the two catheter types do not differ with respect to catheter-related infection rates.

Peripherally inserted central catheters (PICCs) are gradually replacing conventionally inserted tunnelled or non-tunnelled central venous catheters in several clinical settings. The PICC concept is far from new. As early as in 1912, a technique using upper extremity veins for central access was described, but from the 1940s the subclavian and jugular veins became the most common routes for central venous catheterisation [1]. It was not until the early 1970s that the use of PICCs became widespread, despite poor clinical outcome [2–4]. Some years later the results were improved with the introduction of specially designed silicone or polyurethane catheters for peripheral insertion, mainly intended for chemotherapy and parental nutrition [5, 6]. At this time teams of nurses specialised in PICC insertion emerged [7].

The increasing use of PICCs has, however, raised concerns [8, 9]. Although these catheters are inserted via peripheral veins, routine management to prevent complications differs markedly from that of conventional peripheral catheters, since the dimensions and locations of the tip of PICCs are similar to those of centrally placed catheters. Use of PICCs instead of central lines has been advocated on the basis of presumed cost and time benefits and fewer mechanical complications, despite a lack of convincing scientific evidence. During the last two decades several studies have been published regarding the rate of complications associated with PICCs and central lines. We undertook a systematic review of comparative studies assessing complications of centrally and peripherally inserted central venous catheters in various patient categories.

Methods

Studies published in English during the period 1966–2011 comparing complication rates for centrally inserted central venous catheters (including non-tunnelled and tunnelled catheters and subcutaneous central venous access ports) and PICCs in adult patients were considered for inclusion. The MEDLINE database was used to identify eligible studies using the MESH search terms ‘PICC’, ‘catheterisation, peripheral/adverse effects’ and ‘catheterisation, central venous/adverse effects’. Two reviewers (AP and SL) assessed independently the titles and abstracts of all eligible studies to determine if they met the criteria for inclusion. No search was made for unpublished data. The same two reviewers extracted data independently from the studies. Extracted data included numbers and characteristics of patients, types of catheters, study setting and design, whether or not diagnostic criteria were met, risks of bias, catheter indwelling time periods and complications including the main endpoints: catheter malpositioning; thrombophlebitis; catheter-associated infection; and catheter dysfunction, as well as pneumothorax (the latter was specific for centrally placed catheters). Data regarding thrombophlebitis, catheter-associated infection or catheter dysfunction were only included if mean catheter indwelling time periods could be determined.

For dichotomous data, we calculated the odds ratios (OR) and risk ratios (RR) with 95% CI using the Mantel–Haenszel random effects model and weighted averages. The significance level of the overall effect was calculated for the OR of each complication. Review Manager (RevMan) version 5.1 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) was used for statistical analysis.

Results

A total of 448 studies were found in the initial search. On assessment for eligibility, 436 studies were found not to meet the criteria for inclusion (Fig. 1). The remaining 12 studies, published between 1986 and 2011 and reporting 3116 PICCs, 2193 non-tunnelled and 819 tunnelled or venous access port centrally inserted lines, were included. The mean (range) group sizes were 260 (15–807) for PICCs, 244 (31–713) for non-tunnelled and 164 (13–285) for tunnelled or venous access port lines. All catheters were made of polyurethane or silicone and had predominantly one, two or three channels. The majority of PICCs (58%) were inserted by nurses, whereas all central lines were inserted by physicians (anaesthesia or surgery house officers, residents, or fellows).

Details are in the caption following the image

Flow chart of study inclusion process.

The main characteristics of the included studies are summarised in Table 1. Nine studies compared PICCs with non-tunnelled central lines and five studies compared PICCs with tunnelled central lines or venous access ports. Study settings and definitions of clinical outcome were found to differ considerably between the studies. Two studies included only intensive care patients, and only one study was randomised (and scored three on the Jadad scale). The remaining eleven studies have inherent risks of selection bias due to their non-randomised design. Furthermore, outcome data were not assessed blindly, and in five studies the numbers of PICCs and centrally placed lines were unequal (ratio of two or more). The complications of centrally or peripherally inserted central venous catheters are summarised in Table 2.

Table 1. Main characteristics and diagnostic criteria used in studies assessing complications from centrally or peripherally inserted central venous catheters.
Study Catheter type (n; mean indwelling period) Catheters used for Diagnostic criteria used
Malposition Thrombophlebitis Infection Catheter dysfunction
Al Raiy et al. [27]Non-randomised, prospective, diverse units PICC (n = 622; 9 days)
CVC* (n = 638; 8 days)
Venous access NR NR Positive blood culture (organism not associated with infection at other site) NR
Alhimyary et al. [10]Retrospective, non-ICU PICC (n = 135; 10 days)
CVC*,† (n = 135; 8 days)
Parenteral nutrition Tip position not in superior vena cava Phlebitis or symptomatic central venous thrombosis Sepsis; not further specified Catheter occlusion or leakage
Bonizzoli et al. [28]Non-randomised, prospective, post-ICU PICC (n = 114; 35 days)
CVC* (n = 125; 22 days)
Venous access NR Thrombosis on ultrasound 7, 15 and 30 days after insertion NR NR
Cowl et al. [11]Randomised prospective, diverse units PICC (n = 51; 9 days)
CVC*,† (n = 51; 10 days)
Total parenteral nutrition Tip position not in superior vena cava Phlebitis or symptomatic central venous thrombosis confirmed by ultrasound or venography Local or systemic symptoms or positive blood culture Catheter occlusion or leakage
Duerksen et al. [12]Retrospective, non-ICU PICC (n = 209; 11 days)
CVC‡ (n = 285; 13 days)
Parenteral nutrition Tip position not in superior vena cava Phlebitis or symptomatic central venous thrombosis confirmed by ultrasound or venography Positive blood culture Leakage
Giuffrida et al. [13]Non-randomised, prospective, ICU PICC (n = 472; 5 days)
CVC* (n = 713; 6 days)
Routine monitoring;
total parenteral nutrition; vasopressors
NR NR‡‡ Symptoms; not further specified NR‡‡
Gunst et al. [24]Retrospective, ICU PICC (n = 37; 12 days)
CVC* (n = 263; 8 days)
Routine monitoring; total parenteral nutrition; vasopressors NR NR Symptom of infection and positive catheter tip culture and positive blood culture of the same organism NR
Kim et al. [29]Non-randomised prospective, diverse units PICC (n = 24; NR)
CVC§ (n = 155; NR)
Chemotherapy NR‡‡ NR NR NR
Mollee et al. [30]Retrospective, non-ICU PICC (n = 807; 52 days)
CVC‡ (n = 320; 30 days)
Chemotherapy NR NR Positive blood culture (organism not associated with infection at other site) NR
Smith et al. [14]
Retrospective, non-ICU
PICC (n = 555; 21 days)
CVC¶ (n = 283; 174 days)
Antibiotic therapy; chemotherapy; parenteral or hyperalimentation NR Phlebitis or symptomatic central venous thrombosis confirmed by ultrasound Exit wound or port pocket infection or suspected catheter infection Catheter occlusion; catheter embolus; or damage to external portion of catheter
Snelling et al. [15]
Retrospective, non-ICU
PICC (n = 15; NR)
CVC** (n = 13; NR)
Chemotherapy NR‡‡ NR NR NR
Worth et al. [25]
Non-randomised, prospective, diverse units
PICC (n = 75; 24 days)
CVC*,†† (n = 31; 19 days)
Chemotherapy NR Phlebitis or symptomatic central venous thrombosis confirmed by venography Positive blood culture (organism not associated with infection at other site) NR
  • *non-tunnelled CVC; †subclavian catheters; ‡non-tunnelled and tunnelled CVC and venous access ports; §non-tunnelled CVC and venous access ports; ¶tunnelled CVC and venous access ports; **tunnelled CVC; ††20% femoral catheters; ‡‡main outcome but diagnostic criteria not specified. CVC, central venous catheter; ICU, intensive care unit; NR, not reported; PICC, peripherally inserted central catheter.
Table 2. Complications of centrally or peripherally inserted central venous catheters.
Study Catheter type (n) Total indwelling days Malposition events (%) Events (%); rate per 10 000 indwelling days
Thrombophlebitis Infection Dysfunction
Al Raiy et al. [27] PICC (622) 5703 NR NR 13 (2); 23 NR
CVC (638) 4917 NR NR 12 (2); 24 NR
Alhimyary et al. [10] PICC (135) 1381 5 (4) 3 (2); 22 0 (0) 0 5 (4); 36
CVC (135) 1056 4 (3) 0 (0); 0 2 (1); 19 0 (0); 0
Bonizzoli et al. [28] PICC (114) 4024 NR 31 (27); 77 NR NR
CVC (125) 2747 NR 12 (10); 44 NR NR
Cowl et al. [11] PICC (51) 482 5 (10) 8 (16); 166 2 (4); 41 8 (16); 166
CVC (51) 533 1 (2) 1 (2); 19 3 (6); 56 2 (4); 38
Duerksen et al. [12] PICC (209) 2209 20 (10) 25 (12); 113 2 (1); 9 29 (14); 131
CVC (285) 3597 5 (2) 12 (4); 33 8 (3); 22 5 (2); 14
Giuffrida et al. [13] PICC (472) 2313 NR 57 (12); 246 2 (0.4); 9 35 (7); 151
CVC (713) 4421 NR 18 (3); 41 0 (0); 0 66 (9); 149
Gunst et al. [24] PICC (37) 455 NR NR 1 (3); 22 NR
CVC (263) 2167 NR NR 13 (5); 60 NR
Kim et al. [29] PICC (24) NR 8 (33) NR NR NR
CVC (155) NR 10 (6) NR NR NR
Mollee et al. [30] PICC (807) 41 876 NR NR 76 (9); 18 NR
CVC (320) 9638 NR NR 53 (17); 55 NR
Smith et al. [14] PICC (555) 11 814 NR 50 (9); 42 45 (8); 38 65 (12); 55
CVC (283) 49 365 NR 2 (1); 0.4 33 (12); 7 11 (4); 2
Snelling et al. [15] PICC (15) NR 2 (13) NR NR NR
CVC (13) NR 2 (15) NR NR NR
Worth et al. [25] PICC (75) 1815 NR 14 (19); 77 12 (16); 66 NR
CVC (31) 583 NR 2 (6); 34 6 (19); 103 NR
  • CVC, central venous catheter; NR, not reported; PICC, peripherally inserted central catheter.

Radiographic malpositioning of the catheter tip (as determined by five studies reflecting 432 PICCs and 641 centrally placed lines) occurred more often after PICC placement (9.3% vs 3.4%; OR 3.76 (95% CI 1.75–8.07); RR 3.39 (95% CI 1.75–6.54); p = 0.0007; Fig. 2). Thrombophlebitis (seven studies, based on 24 038 PICC and 62 302 central-placed line indwelling days) was reported more often with PICCs (78 vs 7.5 per 10 000 indwelling days; OR 5.82 (95% CI 2.37–14.2); RR 5.76 (95% CI 2.36–14.04); p = 0.0001; Fig. 3). There was no difference in the catheter-associated infection rate (nine studies reflecting 68 048 PICCs and 76 277 centrally placed line indwelling days) (22 vs 17 per 10 000 indwelling days; OR 0.83 (95% CI 0.28–2.50); RR 0.83 (95% CI 0.28–2.49); p = 0.74; Fig. 4, for PICCs and central lines, respectively).

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Forest plot of peripheral (PICC) vs centrally placed (CVC) lines for catheter malpositioning.

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Forest plot of peripheral (PICC) vs centrally placed (CVC) lines for thrombophlebitis.

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Forest plot of peripheral (PICC) vs centrally placed (CVC) lines for catheter-associated infection.

Catheter dysfunction (six studies, reflecting 18 199 PICC and 58 972 centrally placed line indwelling days) occurred more often during PICC use (78 vs 14 per 10 000 indwelling days; OR 6.02 (95% CI 1.1032.9); RR 5.76 (95% CI 1.0932.7); p = 0.04; Fig. 5). The incidence of pneumothorax in patients undergoing centrally placed line insertion was reported in six studies [10–15] and was 16 events in 1481 insertions (1.1% (95% CI 0.65–1.76%)). The total complication rate including catheter malposition, thrombophlebitis, catheter-associated infection, catheter dysfunction and pneumothorax (all 12 studies, reflecting 3116 PICCs and 3013 centrally placed lines) was higher for PICCs (17% vs 10%; OR 2.02 (95% CI 1.26–3.24); RR 1.76 (95% CI 1.20–2.56); p = 0.003; Fig. 6).

Details are in the caption following the image

Forest plot of peripheral (PICC) vs centrally placed (CVC) lines for catheter dysfunction.

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Forest plot of peripheral (PICC) vs centrally placed (CVC) lines for all complications.

Discussion

In this systematic review of twelve studies assessing complication rates of PICC vs centrally placed central lines we found that the available data favour central lines over PICCs for tip malpositioning, thrombophlebitis and catheter dysfunction. There was no difference in catheter-associated infection rates.

Use of PICCs is widespread and has increased despite little evidence of greater safety than with conventional centrally placed central lines. The presumed lower risk of some complications associated with central cannulation, such as pneumothorax and carotid or subclavian arterial cannulation, have been used as a reason to favour PICCs [9]. A greater risk of long-term complications associated with PICC use may, however, have been overlooked in earlier non-comparative studies. Previous reviews supporting PICC use have not adequately considered long-term complications [16]. A well-designed recent review challenges the use of PICCs in surgical in hospital patients [9]. This study is, to our knowledge, the only systematic review of all the available articles comparing, in different patient categories, the full spectrum of relevant complications associated with the use of PICCs and centrally placed lines.

For short-term catheter use, the catheter tip position is probably of little clinical importance [17]. For long-term use, the catheter tip position is, however, more important because of the increased risks of central venous thrombosis [18], pulmonary embolism [19] and catheter dysfunction [20] when the tip is not positioned in the right atrium or lower part of the superior vena cava. Catheter malpositioning is, according to our review, almost three times more common after PICC insertion compared with centrally placed line insertion. In clinical practice, malpositioning is demonstrated on a post-procedural x-ray and usually results in further procedures associated with additional time expenditure, risks and patient discomfort. Cowl et al. concluded that in the elderly the proposed cost advantages of PICCs over central lines are partly outweighed by the costs associated with frequent malpositioning and complicated re-cannulations [11]. Thrombophlebitis due to indwelling central catheters may result in patient inconvenience, need for anticoagulation therapy (with its attendant side-effects), early catheter removal, re-cannulation and higher costs. Most venous thromboses are asymptomatic but they may, nevertheless, later result in pulmonary embolism [19], or in vascular stenosis rendering subsequent venous access more difficult [21]. Venous stenosis is of particular concern in patients in whom long-term venous access may be required (for example, patients with short-bowel syndrome or chronic renal failure). We found the incidence of thrombophlebitis to be ten times higher during PICC use than during centrally placed catheter use. Catheter-related infection is an important clinical issue associated with high costs and increased morbidity and mortality [22]. Based on non-comparative studies, it has been proposed that catheter-related infections are more common with centrally placed catheters [23]. We found that there was no difference in the odds ratio for this complication between the two routes. The two largest studies reviewed [24, 25] report diverging results. Mollee et al. [24] and Smith et al. [25] found infection rates of 1.8 and 4.7, and of 3.8 and 0.67 cases per 1000 indwelling catheter days, respectively, for PICCs and centrally placed lines. One possible explanation for these opposing results is the strong selection bias, reflected in unequal ratios of catheter types used and in different clinical definitions of catheter-associated infection.

Catheter dysfunction, mainly caused by catheter occlusion or leakage and often requiring catheter removal and reinsertion, occurs more than five times more often with PICCs. The greater risk of catheter dysfunction or malpositioning with PICCs may reflect their greater length and smaller diameter, and the higher incidence of thrombophlebitis is probably associated with the use of a peripheral insertion site where considerably smaller vessels are used for cannulation and the intravascular route to the central circulation is necessarily longer [3, 5, 26]. The higher risks of malpositioning, thrombophlebitis and catheter dysfunction associated with PICC insertion and use must be weighed against more infrequent, but potentially severe, complications such as pneumothorax or arterial injury associated with central venous cannulation. The overall complication rate was found to be two times higher for PICCs compared with centrally placed lines even after including pneumothorax in the calculation.

Like other reviews, our review is at risk of bias in relation to the studies included. In the studies themselves, selection bias may be an important factor as only one study was randomised. Different definitions of various complications studied may further reduce the credibility of our review. However, our use of a random effects model may have compensated, in part, for this.

In conclusion, we found that there are few comparative studies of complications associated with the use of PICCs vs centrally placed lines, and that all studies but one are at risk of selection bias due to their non-randomised design. We found that the risks of tip malpositioning, thrombophlebitis and catheter dysfunction favour clinical use of centrally placed catheters instead of PICCs, and that the two catheter types do not differ with respect to catheter-related infection rates.

Competing interests

No external funding and no competing interests declared.