Higher rate of thromboembolism associated with PICCs versus other CVCs

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1. PICC-related deep vein thrombosis occurs in 2.7% of PICC patients, with highest frequency in patients who are critically ill and those with cancer.

2. PICCs are associated with a higher rate of deep vein thrombosis than other central venous catheters (CVCs), with a pooled OR of 2.55.

Evidence Rating Level: 2 (Good)

Study Rundown: In recent years, peripherally inserted central catheters (PICCs) have become increasingly popular among both hospitalized and non-hospitalized patients, with indications ranging from administration of intravenous antibiotics, chemotherapy, or total parental nutrition to hemodynamic monitoring. However, the risk of complications associated with PICC placement, notably venous thromboembolism, remains uncharacterized; rates of PICC-related deep venous thrombosis (DVT) range from 1% to 39%.  This large systematic review confirms that PICCs have a higher rate of DVT than other central venous catheters (CVCs). However, the overall rate was relatively low at 2.7% and PICCs were not found to incur any increased risk of pulmonary embolism (PE). Although this study is helpful in clarifying the complication risk of PICCs, the clinical implications are limited by the lack of data available on pharmacologic thrombosis prophylaxis. Further studies are needed to determine whether candidates for PICC placement, particularly those at high risk for DVT, would benefit from prophylaxis.

Click to read the study in The Lancet

Relevant Reading: Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence

In-Depth [systematic review and meta-analysis]: aimed to determine the frequency of venous thromboembolism associated with peripherally inserted central catheters (PICCs), and to compare the risk of this complication with PICCs versus other central venous catheters (CVCs). Sixty-four studies, 12 that directly compared PICCs versus other CVCs and 52 that analyzed PICCs alone, were included. The final study sample comprised both retrospective and prospective studies, but no randomized trials. The primary outcome, venous thromboembolism, was defined as deep vein thrombosis of the arm (brachial, axillary, subclavian, or internal jugular veins and detected by compression ultrasonography, venography, or CT scan) or pulmonary embolism (based on reports of diagnosis in each study).

PICCs were found to have a higher risk of DVT of the arm than other CVCs (OR 2.55, 1.54 – 4.23, p<0.0001), with the incidence highest among critically ill (13.91%, 95% CI 7.68 – 20.14) and cancer (6.67%, 4.69 – 8.64%) patients. Overall, the rate of PICC-related DVT was 2.7%. PICCs placed in the internal jugular vein had a lower incidence of DVT than those in arm veins. The risk of pulmonary embolism was not significantly different between PICCs and other CVCs, with no events reported.   

By Elizabeth Kersten and Andrew Bishara

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