Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: A systematic review of the literature

Figures & data

Table I. Criteria of high-, moderate- and low quality studies according to the aim of the systematic review.

High quality with small risk for bias

Prospective randomised controlled study

• Defined routines for catheter insertion and care

• Presented indwelling time

• Established definitions for complications

• Complication per 1000 catheter days

• Established methods for analysing results of quantitative studies

∘ Patient satisfaction and health-related quality-of-life

∘ Costs and cost-effectiveness

Moderate quality with intermediate risk for bias

Prospective cohort study with adequate control group fulfilling the criteria above (apart from randomisation)

Low quality with high risk for bias

Prospective study not fulfilling the criteria above

Retrospective study

Figure 1. Flow chart of the literature search process.

Table II. Summary of the two studies of moderate quality.

Author Year Reference Country	Study design Sample characteristics	Intervention Control Sample Catheter time Drop-outs	Results	Study quality Comments
Bonizzoli M et al. 2010 [9] Italy	Cohort study with control group Single centre Inclusion: Adult ICU patients with continued need for central venous access after ICU discharge Primary outcome: Incidence of ultrasound- verified DVT with the use of central venous access Established DVT definition	No of patients: 239 PICC: 114 CVC: 125 Drop-outs: 0 Indwelling time (days): (Mean± SD): PICC: 35.3 ± 0.9 CVC: 22.5 ± 0.5	Incidence DVT per 1000 catheter days: PICC: 7.7 CVC: 4.4 (95% CI 1.58–5.02*)	The groups were included for two consecutive four-month periods. The groups were broadly comparable with respect to diagnosis, risk factors. Data was analysed using logistic regression. All patients were followed up with ultrasound. Unclear whether all consecutive patients were included. All patients were prescribed dalteparin prophylaxis
Revel-Vilk S et al. 2010 [10] Israel	Cohort study with control group Patients from three different centres Inclusion: Children and adolescents having cancer, chemotherapy Exclusion: No informed consent Primary outcome: Risk factors for symptomatic DVT related to central venous line Established definitions of thrombosis and catheter occlusion Insertion by surgeon or radiologist	No of patients: 262 No of catheters: 418 PICC: 188 t-CVC: 104 PORT: 126 Drop-outs: 5 catheters 1.2% Indwelling time (months): (Median, range): PICC: 3.1(2.2–4.0) t-CVC: 4.1(2.7–5.6) PORT: 9.8 (8.1–11.5)	DVT incidence for the total population: 0.13 per 1000 catheter days HR for DVT: PICC: 7.03 (95% CI 1.46–34.12) PORT/t-CVC: 1 HR for occlusion: PICC: 1 PORT: 1.8 (95% CI 1.11–2.96) t-CVK: 2.3 (95% CI 1.38–3.82)	Routines for catheter insertion and care are not defined. 30% drop-outs at inclusion for administrative reasons The groups were broadly comparable with respect to diagnosis. Adjustment for confounders was performed.

CI, confidence interval; CVC, central venous catheter; DVT, deep venous thrombosis; HR, hazard ratio; PICC, peripherally inserted central venous catheter; PORT, subcutaneous venous ports; SD, standard deviation; t-CVC, tunneled central venous catheter. *Calculated value for the difference in DVT/1000 catheter day.

Table III. Summary of results (GRADE); PICC in relation to other central venous lines.

Outcome population	Sample size (no of studies)	Risk in standard group, mean (min – max) Standard = other central venous lines?	Relative risk/hazard ratio (95% CI)	Absolute effect per 1000 catheter days	Scientific evidence	Comments
Successful insertion rate	Studies missing				(⊕○○○) Insufficient	Studies missing
Catheter occlusion Children and adolescents with having cancer treatment.	262 (1)	HR PORTS: 1.8 (1.11–2.96) HR t-CVC: 2.3 (1.38–3.82)	HR PICC: 1^4	Data missing	(⊕○○○) Insufficient	Precision in data (one study) —1
Catheter fracture	Studies missing				(⊕○○○) Insufficient	Studies missing
Catheter displacement	Studies missing				(⊕○○○) Insufficient	Studies missing
Early complications^1	Studies missing				(⊕○○○) Insufficient	Studies missing
Infection	Studies missing				(⊕○○○) Insufficient	Studies missing
Symptomatic deep venous thrombosis Children and adolescents with having cancer treatment.	262 (1)	HR: 1	HR: 7.03^2 (1.46–34.12)	Data missing	(⊕○○○) Insufficient	Precision in data (one study) —1
Deep venous thrombosis Adults after ICU discharge	239 (1)	9.6%	RR: 2.83^3 (2.22–3.45)	7.7 versus 4.4	(⊕○○○) Insufficient	Precision in data (one study) —1
Thrombophlebitis	Studies missing				(⊕○○○) Insufficient	Studies missing
Venous stenosis	Studies missing				(⊕○○○) Insufficient	Studies missing
Health-related quality of life	Studies missing				(⊕○○○) Insufficient	Studies missing
Patient satisfaction	Studies missing				(⊕○○○) Insufficient	Studies missing

HR, hazard ratio; ICU, intensive care unit; CI, confidence interval; PICC, peripherally inserted central venous catheter; RR, relative risk; t-CVK, tunneled central venous catheter.

¹Action-requiring bleeding, nerve injury, pneumothorax, haemothorax, cardiac tamponade, arrhythmias; ²Taking into account the number of catheter days; ³Not taking into account the number of catheter days, calculated value; ⁴PICC is the reference value.

Bonizzoli M, Batacchi S, Cianchi G, Zagli G, Lapi F, Tucci V, et al. Peripherally inserted central venous catheters and central venous catheters related thrombosis in post-critical patients. Intensive Care Med 2011;37:284–9.

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Revel-Vilk S, Yacobovich J, Tamary H, Goldstein G, Nemet S, Weintraub M, et al. Risk factors for central venous catheter thrombotic complications in children and adolescents with cancer. Cancer 2010;116:4197–205.

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