When a PICC is contraindicated, the best option as a medium-term central VAD in a non-hospitalized patient is a CICC placed by ultrasound-guided cannnulation of a vein in the supra-clavicular area (internal jugular, brachio-cephalic or subclavian vein) or in the infra-clavicular area (axillary vein).
A key point is that the exit site must be in the infra-clavicular area (a very favorable site in terms of controlling the risk of infection, thrombosis and dislocation)- Another fundamental point is that the catheter must be always tunneled. The international guidelines advise against the use of non-tunneled CICCs in non-hospital setting, due to the high risk of dislocations and infections.
Also, the removal of a non-tunneled CICC in the home setting is potentially associated with complications, sometimes even severe (such as air embolism, due to the entry of air into the venous system; or bleeding, in the event that the exit site is no adequately compressed); such complications are quite unlikely in the course of removing a tunneled non-cuffed CICC.
As a type of catheter, since tunneling is necessary, we recommend the off-label use of use catheters sold as PICCs, which are particularly suitable for tunneling both for their length (around 50 cm) and for their insertion technique (modified Seldinger). The catheter will be positioned in the best available central vein (the one whose puncture appears easiest, and therefore safest) after an ultrasound scan of all veins of the cervico-thoracic are (RaCeVA: Rapid Central Vein Assessment).
Also for CICC insertion, a well-designed and standardized insertion bundle should be adopted, such as the SICA protocol (Safe Insertion of Central Access), developed by GAVeCeLT.