PICC Line Complications: Prevention, Recognition, and Management

PICC lines carry a distinct complication profile that differs from other vascular access devices. The most clinically significant PICC-specific complications are upper extremity deep vein thrombosis (UEDVT), CLABSI, and catheter occlusion. Understanding the incidence, risk factors, prevention strategies, and management protocols for each complication is essential for any clinician involved in PICC care.

Parent guide: PICC Lines: Complete Clinical Reference

Complication Overview Table

PICC-Associated Upper Extremity DVT (UEDVT)

Incidence

PICC-associated UEDVT is the most clinically significant non-infectious PICC complication. Published rates vary widely depending on definition and surveillance method:

• Symptomatic UEDVT: 1–5% of PICC-bearing patients
• Subclinical (ultrasound-detected): 10–38% in studies using routine surveillance ultrasound
• Clinically significant DVT requiring anticoagulation: approximately 5% in large registry studies

Chopra et al. (2013, Lancet) found that PICC placement was associated with a significantly higher UEDVT risk compared to non-tunneled CVCs or PORTs, driven primarily by the long-dwell peripheral venous course and catheter-to-vein diameter ratio.

Risk Factors

• Catheter-to-vein ratio >45%: Using a 5 Fr PICC in a vein with diameter <3.5 mm is the strongest modifiable DVT risk factor. Select the smallest catheter French size that meets clinical need; confirm vein diameter with ultrasound before insertion.
• Multi-lumen PICC: Triple-lumen PICCs have higher thrombosis rates than single-lumen.
• Prior DVT or thrombophilia: Personal or family history of DVT, known factor V Leiden, antiphospholipid antibody syndrome, active malignancy (hypercoagulable state).
• Critically ill patients: ICU patients have higher baseline DVT risk from immobility, inflammatory state, and medication effects.
• Left-sided PICC insertion: Marginally higher DVT rate than right-sided in some studies, related to longer intravascular course through left brachiocephalic vein.
• Oncology patients: Active cancer carries significantly elevated PICC-DVT risk (up to 4× baseline).

Prevention

Catheter-to-vein ratio optimization (primary intervention):

• Measure vein diameter with ultrasound before catheter selection
• Select smallest French size that meets lumen count needs: single-lumen 4 Fr preferred if only 1 lumen needed
• Target catheter-to-vein ratio ≤45% (catheter diameter / vein diameter × 100)

Basilic vein preferred: Basilic vein is the largest diameter upper arm vein; brachial vein is smaller. Prioritize basilic access for all PICC insertions.

Correct tip position: CAJ tip position is associated with lower DVT rate than proximal malposition.

Routine pharmacologic prophylaxis is NOT recommended for all PICC patients — evidence does not support prophylactic anticoagulation for PICC placement alone. High-risk patients (malignancy, prior DVT, hypercoagulable state) should have thromboprophylaxis discussed with the treating team independent of PICC indication.

Recognition

Symptoms: Arm pain, swelling, erythema, warmth along the catheter course, palpable cord in the antecubital fossa or upper arm.

Diagnostic workup: Upper extremity duplex ultrasound of the ipsilateral arm and shoulder. Sensitivity and specificity for UEDVT >95% with ultrasound.

Management

Remove PICC: If the PICC is no longer clinically necessary, remove it — this is the primary intervention. DVT resolution is faster with device removal.

Retain PICC if still needed: If the PICC is essential for ongoing therapy (e.g., OPAT, cancer treatment), retain it with anticoagulation. The decision to retain vs. remove should balance thrombosis treatment against ongoing access need.

Anticoagulation: Per ACCP/CHEST guidelines (2016) for UEDVT associated with central venous catheters: anticoagulate for at least 3 months or for as long as the catheter remains in place, whichever is longer. Anticoagulation options include LMWH, rivaroxaban, apixaban (INR-monitored warfarin is an alternative but less commonly used).

PICC-Associated CLABSI

Incidence

CLABSI rates for PICCs average 0.5–2.0 per 1,000 catheter-days in surveillance data, which is lower than non-tunneled CVCs (2–5 per 1,000 catheter-days) but significantly higher than peripheral IVs (no CLABSI rate). Home care PICCs typically have lower CLABSI rates than hospital PICCs (0.2–0.4 per 1,000 catheter-days).

Prevention: Insertion Bundle

The 5-element PICC insertion bundle per CDC/INS:

1. Hand hygiene before insertion
2. Maximal sterile barrier (gown, gloves, drape, mask, cap)
3. CHG-based skin antisepsis with adequate dry time
4. Optimal tip position (CAJ)
5. Daily necessity review — remove PICC when no longer needed

Prevention: Maintenance Bundle

1. Scrub-the-hub: Every needleless connector access must be preceded by 15-second friction scrub with 70% isopropyl alcohol pad. Allow 15–30 seconds dry time.
2. CHG-impregnated dressings: CHG gel patch (Biopatch equivalent) at insertion site under TSM dressing; change weekly with standard dressing change interval (or sooner if wet/soiled/lifting).
3. CHG bathing: Daily chlorhexidine gluconate bathing of the arm bearing the PICC reduces skin bioburden at insertion site.
4. Needleless connector management: Change per institutional policy; no routine change schedule (change with tubing change or per schedule). Do not submerge connectors in antiseptic solution.
5. Administration set changes: Per INS 2021 — continuous infusions every 96 hours (non-lipid, non-blood); lipid emulsions and blood products every 24 hours; blood products within 4 hours of transfusion.
6. Remove when no longer needed: Daily necessity documentation is required; PICC removal on the day clinical indication ends reduces CLABSI risk.

Recognition and Response

Signs of CLABSI: Fever without identifiable source in a PICC-bearing patient, chills during infusion, local signs at insertion site (redness, purulence, tenderness).

Action: Draw blood cultures (peripherally and through PICC), notify provider, assess for PICC removal. Do not remove PICC until blood cultures are drawn. See Vascular Access Device-Related Infections for full protocol.

Catheter Occlusion

Types

Thrombotic occlusion: Blood clot or fibrin sheath obstructing catheter lumen. Most common. Presents as sluggish flow, absent blood return, resistance to flushing.

Non-thrombotic occlusion: Medication precipitate (calcium-phosphate, phenytoin), lipid deposits, or mechanical kinking. Presents similarly to thrombotic occlusion.

Partial occlusion (withdrawal occlusion): Catheter flushes but no blood return. Often caused by fibrin tail or tip migration against vessel wall.

Prevention

SASH protocol (Saline-Administer-Saline-Heparin or Saline-Administer-Saline):

• Saline flush before and after each medication administration
• Pulsatile (push-pause) flushing technique creates turbulence that clears catheter lumen
• Positive pressure maintained on syringe plunger when withdrawing to prevent blood reflux into catheter tip

Heparin lock (for multi-lumen PICCs and ports): 10 units/mL heparin lock per lumen after each use (per institutional policy). Evidence for heparin vs. saline lock for PICCs is mixed; many institutions use saline-only flushing with appropriate technique.

Drug compatibility: Never co-infuse incompatible medications through the same lumen. Phenytoin, diazepam, and calcium-phosphate combinations precipitate. Consult pharmacy for compatibility before co-infusing.

Management: Alteplase

Alteplase (2 mg/2 mL) is the FDA-approved thrombolytic for restoring patency in occluded CVADs.

Protocol:

1. Assess occlusion: attempt gentle aspiration and flush; if resistance, do not force
2. Instill alteplase 2 mg/2 mL into occluded lumen
3. Dwell 30 minutes; aspirate to confirm patency restoration
4. If unsuccessful after 30 minutes, allow to dwell additional 60–90 minutes (up to 120 minutes total)
5. Aspirate and discard 5 mL before flushing; flush with 20 mL normal saline
6. Second dose may be instilled if first dose unsuccessful

Efficacy: 85–90% restoration of patency with alteplase in appropriately selected thrombotic occlusions.

When alteplase will not work: Non-thrombotic occlusion (precipitate, lipid) will not respond to alteplase. If alteplase fails and malposition has been excluded, consider sodium bicarbonate (for acidic precipitates) or 70% ethanol lock (for lipid occlusion) — per pharmacy protocol.

PICC-Associated Phlebitis

Incidence and Types

Phlebitis in PICC patients may be mechanical (catheter movement causing vein irritation), chemical (infusate incompatibility or osmolarity), or bacterial (infection-related). Overall phlebitis incidence in PICC patients is lower than peripheral IVs due to the insertion site being in larger upper arm veins, but still occurs in 10–20% of cases in some series.

Post-insertion phlebitis: Occurs within the first 24–72 hours after insertion; related to insertion trauma or catheter-to-vein ratio mismatch.

Delayed mechanical phlebitis: Occurs after prolonged dwell; related to catheter movement and friction on the vessel endothelium.

Assessment: INS Phlebitis Scale

Management

• Grade 1: monitor closely; warm compress; consider repositioning securement
• Grade 2+: remove PICC and re-insert if ongoing access needed; apply warm moist compresses
• Grade 3–4: culture drainage if purulent; notify provider; wound care; consider antibiotics if infectious phlebitis suspected

Mechanical Complications

Catheter Damage/Fracture

External catheter damage from kinking, scissors injury, or clamp damage can result in catheter embolism. Prevention:

• Never use a clamp with metal teeth on a PICC catheter
• Never place PICC under a blood pressure cuff (cuff inflation can shear the catheter)
• Store catheter slack (do not run it under a tight dressing)
• If damage is identified, repair kits (per manufacturer instructions) or catheter exchange over guidewire may be options

Suspected catheter embolism: Obtain CXR immediately; if catheter fragment identified, escalate to interventional radiology emergently for retrieval.

MARSI (Medical Adhesive-Related Skin Injury)

Repeated dressing removal over the life of a PICC (typically weekly changes over weeks to months) causes progressive skin injury, particularly in elderly, immunocompromised, or corticosteroid-treated patients.

Prevention:

• Use non-alcohol-based adhesive remover for dressing removal
• Apply gentle tension (parallel to skin surface) when removing dressings — do not peel perpendicular
• Consider alternative securement methods for patients with severe MARSI (self-adherent wrap, sutureless securement with gentler adhesive formulation)
• Rotate dressing placement slightly at each change to avoid concentrating skin stress

Air Embolism at Removal

PICC removal carries a specific air embolism risk if Valsalva maneuver precautions are not followed. See PICC Care and Maintenance for removal technique.

Related Resources

Related guides:

• PICC Care and Maintenance
• Catheter-Associated Thrombosis
• Catheter Complications: Complete Reference

Related policies:

• Catheter-Associated Thrombosis
• Vascular Access Device-Related Infections
• Catheter Damage, Embolism, Repair, and Exchange
• Flushing and Locking Vascular Access Devices

References

1. Chopra V, et al. (2013). Risk of venous thromboembolism associated with PICCs. Lancet, 382(9889):311–325.
2. Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice. J Infus Nurs, 44(Suppl 1).
3. Kearon C, et al. (2016). Antithrombotic therapy for VTE disease: CHEST guideline. Chest, 149(2):315–352.
4. Baskin JL, et al. (2009). Thrombolytic therapy for CVAD occlusion. Haematologica, 94(2):273–281.
5. Moureau NL & Trick N. (2012). Catheter-related infection. J Vasc Access, 13(2).