We recommend to use non-cuffed PICC, either tunneled or not, depending on the vein availability.
The presence of a vein of adequate internal caliber (at least three times the external diameter of the catheter) located in Dawson's green area allows the placement of a non-tunneled PICC. Although the non-tunneled PICC is normally considered an appropriate access for duration of a few months, there are reports in the literature of non-tunneled PICCs left in place and functioning for two to three years.
The tunneling of PICCs is a very recent strategy (developed in thelast few years). The rationale can be twofold:
1) when no appropriate vein in terms of caliber and accessibility is visualized in Dawson's green zone, the clinician may choose to puncture a vein (basilica, axillary, etc.) located in the yellow zone. However, this area is not appropriate as an exit site, due to its proximity to the armpit. In this case, tunneling allows to have the ideal puncture site and simultaneously also the ideal exit site. In other words, Dawson's ZIM (Zone Insertion Method) helps to define when to tunnel (i.e.: when the ideal venipuncture site is in the yellow zone) but also how long should the tunnel be (i.e.: long enough to locate the exit site in the green zone).
2) tunneling, by moving the exit site far from the catheter entrance into the vein, also has a direct protective effect against the risk of extraluminal bacterial contamination. In selected cases, tunneling can be adopted programmatically to reduce infectious risk.
For both tunneled and non-tunneled PICCs, the insertion technique strictly implies the use of ultrasound guidance for venipuncture; though, ultrasound is very useful and cost-effective also for the 'tip navigation'; wherever possible, the 'tip location' should be performed with the intracavitary electrocardiographic method. Fluoroscopy should be avoided as 'tip location' method, since is less safe, less accurate and less cost-effective than intracavitary ECG or ecocardiography. The principles of the insertion technique are those summarized in the SIP protocol (Safe Insertion of PICCs), developed by the GAVeCeLT (see our website).
It is always preferable to use PICC power injectable, in latest-generation polyurethane, open-ended, non-valved. The evidences of the literature show that the silicon PICCs have no advantage over those in polyurethane, but only disadvantages (greater incidence of dislocations and rupture). There is no evidence of any advantage in the use of valved PICCs (which in fact are associated with an increased risk of malfunctions and higher costs).