Clinical Use of Sherlock-3CG for Positioning Power Injectable PICCs

Background: While in the XX century centrally inserted central catheters (CICC) were only inserted into the internal jugular or subclavian vein, in our century after the introduction of ultrasound (US) guidance we have other options, including the infra-clavicular approach to the axillary vein (AV). Purpose: In our courses on CICC insertion we are currently proposing the US guided infra-clavicular approach to the AV as the first option for all CICC placements in adult patients, with the only exception of dialysis catheters. Project description: In our theoretical-practical courses, we have introduced a focused discussion on the advantages of AV (easy US identification of the vein below the clavicle; puncture with different techniques, either in short axis or in long axis; very low risk of insertion-related complications), more specifically for short term CICCs (ideal location of the exit site), for totally implantable venous ports (no risk of pinch off syndrome; optimal cosmetic result; minimal local trauma) and for tunneled cuffed CICCs (easy tunneling). Technical tips are also discussed (placement of the arm in abduction, so to increase the vein diameter; catheter caliber appropriate to the caliber of AV; micro-introducer kits and modified Seldinger technique; US control of the supra-clavicular area during the passage of the catheter; intraprocedural US control of the pleura, so to rule out pneumothorax; intra-cavitary ECG technique for tip location; securement by sutureless device, glue and transparent adhesive dressing). Results and implications: The practice of CICC insertion will be strongly affected by this new central venous approach that minimized all early and late complications possibly related to the insertion technique. Conclusions: The impact of US in reducing complications during jugular venipuncture is well known. The effects of US in terms of changing venous approach (from jugular/subclavian to AV) deserve an increased attention in the next future.