Moving Vascular Access Forward: Thoughts from a Clinician in Rome

VC: Prof. Antonio LaGreca is a surgeon at Catholic University in Rome. We recently held an Open Discussion regarding the MAGIC recommendations at WoCoVA. Our exchange led to a number of important points, many of which pertain not only to the contrarian point of view with respect to PICCs but also nuances regarding vascular access devices. I therefore invited him to consider submitting a blog for ImprovePICC.

Dr. LaGreca has indicated the following conflicts of interest with respect to this blog: "I am a member of the Italian Study Group on Vascular Access (GAVeCeLT). This a non-profit association aimed at deepening and spreading knowledge and practice on vascular access."
 
VC: Your views regarding the safety of PICCs differ from mine. Tell my why?
AG: I tried to underline that, from a conceptual point of view, PICCs are not something different from CICCs (centrally inserted central catheters) or FICCs (femoral inserted central catheters), as we like to classify central VADs. The difference lies in the approach, not in the vascular access device (VAD), and the approach makes a big difference. If we look back to the genesis of PICCs, they were born as second choice devices. When placed at the elbow, their clinical performance was so unsatisfying (early massive thrombophlebitis as high as 70% at 3 days, mechanical problems such as dislocation, rupture, occlusion, high failure rates at insertion) that they could not be considered a first line approach. After introducing the mid arm approach under ultrasound guidance, a revolution occurred: success rates improved, indications widened, and the ability to obtain a CENTRAL line without facing potentially life-threatening complications of a cervical or thoracic approach (e.g., pneumothorax, vessel injury, etc.) extended the range of operators that could feel (or try to feel) confident with the procedure.
 
VC: Interesting - how do you think this influenced the adoption of PICCs?
AG: The culture of patient safety in the field of vascular access has always grown with the introduction of new and enthusiastic operators involved in insertion and management of new devices. This was true for central venous catheters, and in todays era, we have to thank PICCs for this.
 
VC: So are there no problems, in your opinion, when it comes to PICCs?
AG: Well, PICCs have faced several technical and procedural problems in the recent past. Some of these problems have been overcome thanks to a huge cultural and technical effort by clinicians and companies.

Technical problems may be summarized as follows:

• They are small bore and long lines, offering resistance to flow as compared to conventional CVCs. This has been overcome by the introduction of power-injectable devices and the widespread use of infusion pumps, leaving a relative contraindication to PICCs use in patients needing very high-volume infusions (emergency, trauma, septic shock) or a great number of lumens.
  
  
• Primary malposition rates are reported to be as high as 30% (totally unacceptable) if lines are inserted without any intra-procedural control, because of their flexibility and the long track to the target position; this has been overcome by the introduction of a simple and cost-effective method for intraoperative tip location, the intracavitary ECG, leaving concerns only for malposition’s occurring secondarily after line insertion.
  
  
• They are also inserted in small and delicate veins, which don't forgive the operator in case of mistakes in choice of the device (large bore as compared to the vein size = thrombosis), in puncture technique (inadequate needle control under ultrasound guidance and consequently more than one attempt at cannulating the vein = thrombosis). This has been partially overcome by emphasizing ultrasound use training and strict adherence to the principle of not occupying a great amount of the vessel lumen (the catheter-to-vein ratio concept), but we still need to diffuse these concepts.

 
 
Procedural problems include correct indications and choice of device for each patient, wise proactive vascular planning, standardization of safe and effective insertion techniques.
 
In this context, numbers without wisdom can make the difference. If operators dealing with a new procedure increase, numbers may increase irrespective of actual needs and benefits, safe insertion and care procedures and cost-effectiveness. This may harm patients and health systems as well. I use to present a brief paradoxical example of what can happen if we consider the same issue from two different points of view: I call it "the rule of the numerator”…
 
In 2010, the vascular team of a small hospital inserts 100 PICCs, with a global complication rate of 10%. In 2013, the same team is able to insert 1000 PICCs with a global complications rate of 5%. The absolute percentage of complications looks much better in 2013, but if we look at the actual numbers of patients harmed - we had 10 complications in 2010 as compared to 50 in 2013.  If the average complication costs 25,000 euros (as it happens for a single CR-BSI), we are facing a global cost of 1,250,000 Euros in 2013, as compared to 250,000 Euros in 2010. Is this balanced by an actual increase in patients outcomes and/or reduction in other expense sections such as procedural costs, operators’ workload etc.?


VC: I see - what about major problems like bloodstream infection?
AG: In the middle between technical and procedural problems, catheter related blood-stream infections are still a concern, related to numbers as well as correct indications, care protocols and use of supporting devices (dressings, sutureless devices, etc.). In this field we have good quality evidence and devices, but still need to better incorporate these data into practice. This is especially relevant in the case of PICCs given the wider adoption of these devices and the growing availability of dedicated operators and staff to maintain them.
 
VC: So how to move this forward so that everyone inserts and cares for PICCs safely, much like you do in in Rome?
AG: A huge cultural effort by clinicians and technological effort by companies could further improve results as follows:

• Insisting on the use of ultrasound as a tool to guide the operator in choosing the right device in the right vein with the right approach for that specific patient and not only to guide the needle.
  
  
• Adopting the “vessel health” concept (led by Nancy Moureau here and here) that may take advantage of continued technical training of operators, allowing them to adopt minimally invasive insertion techniques, as well as technology such as use of minimally invasive devices (microintroducers, small bore and soft guidewires, small gauge needles).
  
  
• Taking a comprehensive view of patient safety, aimed at preventing the whole spectrum of complications in someway depending on the operator’s choices and behavior before and during insertion.
  
  
• Developing a structured approach for use of IV devices that incorporate correct and appropriate indications and appropriate care, especially in patients at high risk of inappropriateness. Some examples include:
  
  
  • Inappropriate indications: repeated peripheral IV cannulas until complete superficial veins exhaustion, PICC line insertions for very short   planned therapies or difficult venous access, tunneled/cuffed or totally implanted catheters inserted for in-hospital patients are all areas of concern.
    
    
  • With respect to catheter use and care, unwarranted removal of central lines at the first unproven suspicion of catheter related-bloodstream infection (CR-BSI), unwarranted retention of IV devices because of "theoretical" difficulty in obtaining new access despite a   strong indication for removal, sub-optimal tip position are frequent behaviors at risk for patients’ and health systems’ harm.

 
These are all avoidable in my opinion, as follows: first we need to define and adopt an evidence-based, but comprehensive algorithm for choosing the right device in each patient. We are proposing our hospital algorithm throughout the country: it includes indications and contraindications, and provides a reasonable approach to the problem. Maybe an international approach, one that began with the MAGIC paper that can be further modified and integrated to the local context could work even better.

• Encouraging use of intracavitary electrocardiogram (ECG) as a cost-effective tool to monitor the position of the tip during insertion (see papers here).

• The discovery and implementation of better performing materials - aspects such as flexibility, lowered thrombogenicity, decreased protein adhesion, protection against sleeve and biofilm formation, power injectability to improve flow rates and patency, etc.
  
  
• Continued innovations in a number of areas including locking solutions, neutral displacement needle-free connectors, port protectors.
  
  
• Improve training, in order to reach the vast majority of operators and to grant continuing education and spreading of innovations.

 
VC: What do you see as the major challenges in the field today?
AG: There are several important issues that need resolution:

• The field has focused on improving operator performance, but are we improving patient outcomes as well?
  
  
• What would happen if the same cultural and market effort be applied to old “conventional” CVCs ? In this sub-field, operators and kits still look similar to those of the late 90s.
  
  
• If a procedure needs maximal efforts to get its expected results, shouldn’t we consider this a concern?
  
  
• What happens in the real world, far from the landmark centers like yours and mine? How do we diffuse best practice to all those that operate, insert and care for these devices?

 
 
VC: Your thoughts are very interesting. What final words of wisdom do you have for our readers?
 AG:  I told you in Lisbon that I see myself as a good clinician, not as a researcher: so tell me what do and I will do it the best I can. I haven’t got answers yet, but only some ideas. One of these is, if one of the major concerns is thrombosis, we need a big multicenter study with a very homogenous insertion protocol throughout the centers, including a strict indication for catheter-to-vein ratio. This is feasible and will give a definitive answer as concerns pathogenesis of catheter related thrombosis and related consequences on practice. Also, we need better cost-effectiveness studies and data regarding empiric outcomes. The field should work on a simple, but effective algorithm for indication and choice of vascular access devices to be spread all over the world of operators. I hope we can work together to provide answers and conduct these types of studies.