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Review
. 2022 May 6:9:765935.
doi: 10.3389/fcvm.2022.765935. eCollection 2022.

ECG-Based Techniques to Optimize Peripherally Inserted Central Catheters: Rationale for Tip Positioning and Practical Use

Giuseppe Gullo  1   2 , Salah D Qanadli  1   2
Affiliations
Review

ECG-Based Techniques to Optimize Peripherally Inserted Central Catheters: Rationale for Tip Positioning and Practical Use

Giuseppe Gullo et al. Front Cardiovasc Med. .

Abstract

Intracavitary electrocardiography is an accurate guidance technique for peripherally inserted central catheters (PICC) tip location that is spreading widely among providers using non x-ray-based facilities. The principle behind this technology relies on the transmission of the electrocardiographic signal at the tip of the catheter and its use as an internal mobile electrode, allowing the system to identify the cavo-atrial junction (CAJ) through internal P-wave amplitude modulations. The gain in popularity of intracavitary electrography and its large diffusion have led manufacturers to offer various devices with heterogeneous properties, among which clinician who place PICCs have to choose. It is therefore important to understand differences between available techniques and devices. The potential impact might not only affect availability and costs but also the clinical impact through advantages and limitations regarding electric signal transmission PICC selection. Current perspectives on intracavitary electrocardiography will also be discussed, to give the reader a global view of the management of electrocardiographically guided PICCs, especially in an environment without x-ray support.

Keywords: ECG; PICC; central venous access; central venous catheters; intracavitary electrocardiogram; tip locating device; tip location.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

FIGURE 1
FIGURE 1
(A) Chest X-ray displaying CAJ localization. Catheter tip in T1 (tip within 1 cm of the CAJ) is optimal. Catheter tip in T2 (tip within 1–3 cm of the CAJ) is suboptimal. Catheter tip in T3 (tip more than 3 cm below the CAJ or not in the SVC) is inadequate, needing repositioning. (B) Intracavitary electrocardiogram with overlay of the QRS complex zone, T-wave zone, and P-wave zone. A catheter tip in T3 that is not in the SVC will feature this trace, equivalent to the superficial ECG trace. (C) Intracavitary electrocardiogram with increasing P-wave (equivalent to the T wave). This is representative of a catheter tip approaching the CAJ in T2. (D) Intracavitary electrocardiogram with maximal P-wave without initial negative deflection. The tip is optimally positioned at the CAJ in the T1 zone (within 1 cm of the CAJ). (E) Intracavitary electrocardiogram with decreasing P-wave and initial negative deflection. This is representative of a catheter tip beyond the CAJ, in the T2–T3 zone. CAJ, cavo-atrial junction; SVC, superior vena cava.
FIGURE 2
FIGURE 2
(A) PICC with a free-end-side trim point (technique A). Valved reverse-tapered device with solid-wire signal conduction. PUR material with high-flow injection properties. (B) PICC with a hub-side (outer part) trim point (technique B). Centrally valved straight device with solid-wire signal conduction and silicone material without high-flow injection properties. (C) PICC with a free-end-side trim point (technique A). Non-valved reverse-tapered device with liquid (saline) signal conduction. PUR material with high-flow injection properties. (D) PICC with a hub-side (outer part) trim point (technique B). Non-valved straight device with liquid (saline) signal conduction. PUR material with high-flow injection properties. PICC, peripherally inserted central catheter; PUR, polyurethane.
See this image and copyright information in PMC

References

    1. Chrisman HB, Omary RA, Nemcek AA, Ryu RK, Saker MB, Vogelzang RL. Peripherally inserted central catheters: guidance with use of US versus venography in 2,650 patients. J Vasc Interv Radiol JVIR. (1999) 10:473–5. 10.1016/s1051-0443(99)70067-9 - DOI - PubMed
    1. Gullo G, Colin A, Frossard P, Jouannic AM, Knebel JF, Qanadli SD. Appropriateness of replacing fluoroscopic guidance with ECG-electromagnetic guidance for PICC insertion: a randomized controlled trial. AJR Am J Roentgenol. (2021) 216:981–8. 10.2214/AJR.20.23345 - DOI - PubMed
    1. Mack V, Nißler D, Kasikci D, Malouhi A, Aschenbach R, Teichgräber U. Magnetic tracking and electrocardiography-guided tip confirmation system versus fluoroscopy for placement of peripherally inserted central catheters: a randomized, noninferiority comparison. Cardiovasc Intervent Radiol. (2020) 43:1891–7. 10.1007/s00270-020-02551-0 - DOI - PMC - PubMed
    1. Glauser F, Breault S, Rigamonti F, Sotiriadis C, Jouannic A-M, Qanadli SD. Tip malposition of peripherally inserted central catheters: a prospective randomized controlled trial to compare bedside insertion to fluoroscopically guided placement. Eur Radiol. (2017) 27:2843–9. 10.1007/s00330-016-4666-y - DOI - PubMed
    1. Pittiruti M, Scoppettuolo G, La Greca A, Emoli A, Brutti A, Migliorini I, et al. The EKG method for positioning the tip of PICCs: results from two preliminary studies. J Assoc Vasc Access. (2008) 13:179–86. 10.2309/java.13-4-4 - DOI

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