Analysis of tip malposition and correction of peripherally inserted central catheters under ultrasound-guidance: 5-year outcomes from a single center

Background: Peripherally inserted central catheter (PICC) has become a common procedure. Although ultrasound (US)-guidance has improved success rates, a small percentage of malposition is inevitable. The purpose of our study is to evaluate malposition rates of US-guided bedside PICC catheter insertion, and the clinical factors associated with malposition. Methods: This is a retrospective cohort study evaluating 5981 patients who had undergone ultrasound-guided bedside PICC placement from January 2017 to December 2021 at a single tertiary center. Final tip location was confirmed on chest radiograph. Results: Patients were categorized into optimal, suboptimal, and malposition groups according to final tip location. 4866 cases (81.7%) showed optimal tip position, 790 (13.3%) were suboptimal, and 299 (5.0%) were malpositioned. Logistic regression analysis identified six variables associated with tip malposition; height (odds ratio (OR) 1.044; 95% confidence interval (CI), 1.028–1.061; p < 0.001), body mass index (BMI) (OR 1.051; 95% CI, 1.017–1.087; p = 0.003), prior failure at accessing peripheral intravenous (IV) access (OR 1.718; 95% CI, 1.215–2.428; p = 0.002), side of the arm (OR 3.467; 95% CI, 2.457–4.891; p < 0.001), length of the catheter (OR 0.763; 95% CI, 0.734–0.794; p < 0.001), and number of previous central catheter insertions (OR 1.069; 95% CI, 1.004–1.140; p = 0.038). Malpositioned catheters were corrected by either bedside repositioning, bedside reinsertion, fluoroscopic reinsertion, switching to jugular catheters or catheter removal. No patient related factors were significantly associated with malposition or success of reposition. Conclusion: US-guidance can help reduce catheter malposition during bedside PICC insertion. Patients with risk factors such as multiple previous central vein insertions, failed peripheral line insertions, left arm insertion, or high BMI should undergo thorough sonographic evaluation of the arm vessels to prevent malposition.