Peripherally Inserted Central Catheters (PICCs) Implantation in the Clinical Management of Oncohematologic Patients: Results of a Large Multicenter, Retrospective Study of the REL Group (Rete Ematologica Lombarda - Lombardy Hematologic Network, Italy)
Authors: Fracchiolla Nicola Stefano , Todisco Elisabetta , Bilancia Andrea , Gandolfi Sara , Mancini Valentina , Marbello Laura , Bernardi Massimo , Assanelli Andrea , Orofino Nicola , Cassin Ramona , Sciumè Mariarita , Guidotti Francesca , Cairoli Roberto , Ciceri Fabio , Santoro Armando , Cortelezzi Agostino , Rossi Giuseppe 
Published: October 2019

Abstract
Background: PICCs are vascular devices inserted from a peripheral vein of the upper third of the arm under ultrasound guide, and provide a central venous access (CVA) with an intermediate duration between short term central venous catheters (CVCs), such as jugular or subclavian CVCs, and long term ones (port-a-caths).
PICC insertion is ease and safe with no pneumothorax or hemothorax risk. Their extremity reaches a central vein, and can be used for cytostatic drugs, hyperosmolar solutions, and antibiotics infusion. Furthermore, patients (pts) at high risk of hemorrhage for thrombocytopenia or coagulopathy are eligible for PICC insertion.
Nevertheless, some concern exists about the risk of infectious and thrombotic complications associated with PICC use in immunocompromised cancer pts characterized by a prothrombotic state.
In particular, few clinical data from large oncohematologic pts series are available on PICCs' implants and their complications.
Aims: To analyze the results of a large multicenter, retrospective study of the REL group (Rete Ematologica Lombarda-Lombardy Hematologic Network, Italy) aimed at clinically characterizing PICC use in oncohematologic patients management.
Methods: Four REL Hematology Centers participate to the study. The clinical data of 453 implanted PICCs from January 2010 to June 2015, were retrospectively collected, for a total of 44,577 catheter days.
Pts median age was 61 yrs (range 10-88).
Patients' diagnoses were 197 non-Hodgkin's lymphoma, 10 chronic lymphocytic leukemia, 105 acute myeloid leukemia, 45 acute lymphoblastic leukemia, 33 Hodgkin's lymphoma, 39 multiple myeloma, 12 myelodysplastic/myeloproliferative syndrome, 6 miscellaneous.
All pts received intravenous chemotherapy, long term anti infectious drugs (antibiotics and antifungals), and hypertonic solutions.
PICCs were inserted by ultrasound-guided puncture of a peripheral vein of the arm, by microintroducer technique, under strict asepsis.
Chest X-ray was performed to verify correct tip location (ideally in the proximity of cavo-atrial junction).
Data on PICCs' lumen number are available in 423 cases: 292 (69%) were single-lumen and 131 were double-lumen (31%).
Results: Median PICC life-span was 90 days (range 1-760, Kaplan-Meier method). No major insertion-related complications were observed.
Late complications occurred in 172/453 PICCs (38%, 3.8/1000 catheter days): 93 infectious (20%, 2/1000 catheter days), 38 thrombotic (8%, 0.8/1000 catheter days), 37 mechanical (8%, 0.8/1000 catheter days), 5 (1%, 0.1/1000 catheter days) miscellaneous complications (patient intolerance, local pain and hematoma).
Among infectious complications, we reported 24 cases (5%, 0.5/1000 catheter days) of fever of unknown origin (FUO) and 69 (15%, 1.5/1000 catheter days) catheter-related bloodstream infections.
Mechanical complications consisted of 3 (1%) catheter dislocations, 19 accidental removals (4%), 16 (3%) lumen occlusions and 3 (1%) breakages of the external section of PICC.
In 376/453 (83%) cases PICC was removed due to end of intravenous therapy in 160 patients (35%), death in 98 (22%) and to various complications in 118 (26%) cases. Specifically, FUO lead to PICC removal in 10 (2%), infection in 40 (9%), venous thrombosis in 25 (5%) cases, catheter dislocation or accidental removal in 22 (5%), lumen occlusion in 13 (3%), breakage of the external section of PICC in 2 (0,5%), other mechanical complication in 4 (1%), local pain and miscellaneous 2 (0,5%) each.
In the case of a complication occured, the incidence of PICC removal was 68% (118/172): FUO/infections represented the removal cause in 50/172 (29%), mechanical complications in 40/172 (23%), thrombosis in 25/172 (14%) cases.
Conclusions: Traditional CVCs are associated with significant complications, reported at varying frequencies in highly heterogeneous oncohematologic pts series: infections are reported from 4.6 to 23% and thromboses from 1.2 to 30.2% of the cases.
We have clinically characterized a large series of PICCs in oncohematologic patients. Our data suggest that their implant, as an alternative to traditional CVCs, is a safe and effective way to provide oncohematologic patients at high risk of hemorrhagic and infective complications with a CVA. PICCs compare favorably with traditional CVCs reported complications, and facilitate the proper management of complex and prolonged therapeutic programs.

Disclosures
No relevant conflicts of interest to declare.