Key messages
Peripherally inserted central catheters (PICCs) are associated with serious complications, a high failure rate, and negative aftereffects for patients and healthcare systems.
There is a lack of strong evidence to evaluate the benefits and risks of PICC design and material (e.g. silicone versus polyurethane) to prevent catheter complications, infection, and failure.
Future research in this area should focus on the effectiveness of surface-modified catheter material (anti-clot barrier), antimicrobial coating (anti-infection barrier), and new developments in catheter designs (e.g. polyurethane catheters with pressure valves) to reduce catheter failure, as well as looking at any unwanted effects of these treatments.
What is a peripherally inserted central catheter, and what is it used for?
A PICC is a tube that is inserted in a peripheral vein with the catheter tip advanced to a central vein in adults and children requiring medical treatment such as fluid, blood products, or medication. These invasive medical devices are typically inserted in patients requiring therapy that is harmful to smaller, peripheral veins and/or for those needing therapy for more than seven days.
PICCs are commonly complicated by infection, catheter blockage, and breakage. These complications lead to device failure, removal, and interruption of medical treatment.
PICC failures necessitating PICC reinsertions are associated with increased complications and increased procedural complexity due to vascular anatomical changes. In children, subsequent PICC placement is associated with an increased risk of deep vein thrombosis.
What did we want to find out?
We wanted to know if different PICC material (what the PICC is made from) or design (e.g. valve or no valve) reduces the occurrence of PICC complications and device failure.
What did we do?
We searched medical databases up to 16 May 2023 for randomised controlled trials (a type of study where participants are randomly assigned to one of two or more treatment groups) that compared different PICC material and designs in patients of any age.
What did we find?
We found 12 trials (including approximately 2913 participants) of different catheter material and designs used to prevent catheter complications and infections. Overall, there was not enough information to determine what catheter material or design should be used to prevent catheter complications such as blood clots and catheter infections.
There may be a slightly reduced risk of the catheter breaking or failing when an open-ended tip is used. Use of a proximal valve may also slightly reduce the risk of the catheter breaking or failing. More research is needed with larger groups of people to confirm whether different PICC materials and designs are effective at preventing complications and infections. Patients should talk to their doctor about the different catheter materials and designs available, and which one is best for them based on their individual needs and risks.
What are the limitations of this evidence?
We are not confident in the evidence because most trials were small (fewer than 300 people) with few complication events. There is a need for trials with many hundreds or even thousands of people included to find out if these catheter materials or designs help prevent complications and infection. Further, methods used to randomly assign participants to treatment groups and blinding of outcome assessors to the treatment received were not well documented and should be improved in future trials.
How up-to-date is the evidence?
The evidence is current to 16 May 2023.
There is limited high-quality RCT evidence available to inform clinician decision-making for PICC materials and design. Limitations of the current evidence include small sample sizes, infrequent events, and risk of bias. There may be little to no difference in the risk of VTE, PICC-associated BSI, occlusion, or mortality across PICC materials and designs. Further rigorous RCTs are needed to reduce uncertainty.
Peripherally inserted central catheters (PICCs) facilitate diagnostic and therapeutic interventions in health care. PICCs can fail due to infective and non-infective complications, which PICC materials and design may contribute to, leading to negative sequelae for patients and healthcare systems.
To assess the effectiveness of PICC material and design in reducing catheter failure and complications.
The University of Queensland and Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the WHO ICTRP and ClinicalTrials.gov trials registers to 16 May 2023. We aimed to identify other potentially eligible trials or ancillary publications by searching the reference lists of retrieved included trials, as well as relevant systematic reviews, meta-analyses, and health technology assessment reports. We contacted experts in the field to ascertain additional relevant information.
We included randomised controlled trials (RCTs) evaluating PICC design and materials.
We used standard Cochrane methods. Our primary outcomes were venous thromboembolism (VTE), PICC-associated bloodstream infection (BSI), occlusion, and all-cause mortality. Secondary outcomes were catheter failure, PICC-related BSI, catheter breakage, PICC dwell time, and safety endpoints. We assessed the certainty of evidence using GRADE.
We included 12 RCTs involving approximately 2913 participants (one multi-arm study). All studies except one had a high risk of bias in one or more risk of bias domain.
Integrated valve technology compared to no valve technology for peripherally inserted central catheter design
Integrated valve technology may make little or no difference to VTE risk when compared with PICCs with no valve (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.19 to 2.63; I² = 0%; 3 studies; 437 participants; low certainty evidence). We are uncertain whether integrated valve technology reduces PICC-associated BSI risk, as the certainty of the evidence is very low (RR 0.20, 95% CI 0.01 to 4.00; I² = not applicable; 2 studies (no events in 1 study); 257 participants). Integrated valve technology may make little or no difference to occlusion risk when compared with PICCs with no valve (RR 0.86, 95% CI 0.53 to 1.38; I² = 0%; 5 studies; 900 participants; low certainty evidence). We are uncertain whether use of integrated valve technology reduces all-cause mortality risk, as the certainty of evidence is very low (RR 0.85, 95% CI 0.44 to 1.64; I² = 0%; 2 studies; 473 participants).
Integrated valve technology may make little or no difference to catheter failure risk when compared with PICCs with no valve (RR 0.80, 95% CI 0.62 to 1.03; I² = 0%; 4 studies; 720 participants; low certainty evidence). We are uncertain whether integrated-valve technology reduces PICC-related BSI risk (RR 0.51, 95% CI 0.19 to 1.32; I² = not applicable; 2 studies (no events in 1 study); 542 participants) or catheter breakage, as the certainty of evidence is very low (RR 1.05, 95% CI 0.22 to 5.06; I² = 20%; 4 studies; 799 participants).
Anti-thrombogenic surface modification compared to no anti-thrombogenic surface modification for peripherally inserted central catheter design
We are uncertain whether use of anti-thrombogenic surface modified catheters reduces risk of VTE (RR 0.67, 95% CI 0.13 to 3.54; I² = 15%; 2 studies; 257 participants) or PICC-associated BSI, as the certainty of evidence is very low (RR 0.20, 95% CI 0.01 to 4.00; I² = not applicable; 2 studies (no events in 1 study); 257 participants). We are uncertain whether use of anti-thrombogenic surface modified catheters reduces occlusion (RR 0.69, 95% CI 0.04 to 11.22; I² = 70%; 2 studies; 257 participants) or all-cause mortality risk, as the certainty of evidence is very low (RR 0.49, 95% CI 0.05 to 5.26; I² = not applicable; 1 study; 111 participants).
Use of anti-thrombogenic surface modified catheters may make little or no difference to risk of catheter failure (RR 0.76, 95% CI 0.37 to 1.54; I² = 46%; 2 studies; 257 participants; low certainty evidence). No PICC-related BSIs were reported in one study (111 participants). As such, we are uncertain whether use of anti-thrombogenic surface modified catheters reduces PICC-related BSI risk (RR not estimable; I² = not applicable; very low certainty evidence). We are uncertain whether use of anti-thrombogenic surface modified catheters reduces the risk of catheter breakage, as the certainty of evidence is very low (RR 0.15, 95% CI 0.01 to 2.79; I² = not applicable; 2 studies (no events in 1 study); 257 participants).
Antimicrobial impregnation compared to non-antimicrobial impregnation for peripherally inserted central catheter design
We are uncertain whether use of antimicrobial-impregnated catheters reduces VTE risk (RR 0.54, 95% CI 0.05 to 5.88; I² = not applicable; 1 study; 167 participants) or PICC-associated BSI risk, as the certainty of evidence is very low (RR 2.17, 95% CI 0.20 to 23.53; I² = not applicable; 1 study; 167 participants). Antimicrobial-impregnated catheters probably make little or no difference to occlusion risk (RR 1.00, 95% CI 0.57 to 1.74; I² = 0%; 2 studies; 1025 participants; moderate certainty evidence) or all-cause mortality (RR 1.12, 95% CI 0.71 to 1.75; I² = 0%; 2 studies; 1082 participants; moderate certainty evidence).
Antimicrobial-impregnated catheters may make little or no difference to risk of catheter failure (RR 1.04, 95% CI 0.82 to 1.30; I² = not applicable; 1 study; 221 participants; low certainty evidence). Antimicrobial-impregnated catheters probably make little or no difference to PICC-related BSI risk (RR 1.05, 95% CI 0.71 to 1.55; I² = not applicable; 2 studies (no events in 1 study); 1082 participants; moderate certainty evidence). Antimicrobial-impregnated catheters may make little or no difference to risk of catheter breakage (RR 0.86, 95% CI 0.19 to 3.83; I² = not applicable; 1 study; 804 participants; low certainty evidence).