When a PICC is controindicated, the best option as medium-term central VAD in a non-hospitalized child is CICC placed via ultrasound-guided puncture and cannulation of a vein in the supra-clavicular area (internal jugular, brachio-cephalic, or subclavian vein) or in the infra-clavicular area (axillary vein). The younger the child, the more the choice of vein will be restricted to larger veins, such as the brachio-cephalic and the internal jugular. In infants, the easiest and safest vein will almost always be the brachio-cephalic.
The exit site should be in the subclavicular area (a very favorable site in terms of risk of infection, thrombosis and dislocation); another fundamental point is that the catheter must be tunneled. The international guidelines advise against the use of non-tunneled CICCs in the non-hospitalized patient, due to the high risk of dislocations and infections.
We recommend the off-label use of catheters marketed as PICCs, which have the advantage of considerable length (50 cm and more) and insertion with modified Seldinger technique (which simplifies the tunneling maneuver). The catheter will be placed in the best available central vein (the one whose puncture appears easier, and therefore safer) after an ultrasound evaluation of the region (RaCeVA), following a standardized implant protocol, such as the SICA-Ped protocol (Safe Insertion of Central Access in Pediatric patients) developed by GAVeCeLT.