Over the Wire Technique vs. Modified Seldinger Technique in Insertion of PICC

Over the Wire Technique vs. Modified Seldinger Technique in Insertion of PICC Deniz Kasikci Department of Radiology, Jena University Hospital Friedrich-Schiller-University, Jena, Germany

Disclosure Speaker name: Deniz Kasikci I have no potential conflicts of interest to report.

Outline Introduction Implantation technique Seldinger Technique Insertion with an assistant Insertion without an assistant Modified Seldinger Technique (Direct Insertion) Complications Results Conclusions

Introduction A randomized controlled non-inferiority monocentric study in adults including 60 patients (30 per arm) comparing insertion via Modified Seldinger Technique (direct insertion) and Seldinger Technique Aim of the study is the evaluation of effectiveness of both methods primarily assessed by implantation time. Secondary endpoints are placement accuracy (tip localization) and safety (rate of periprocedural and early complications) Correct tip position was defined at the cavoatrial junction confirmed by using fluoroscopy and chest X-ray (a virtual point of two vertebral bodies below the carina is considered as correct tip position ) Implantation of PICC has started in March 2018. Until now 37 patients have been recruited. The study is ongoing. Preliminary results of the study will be demonstrated. Source: Own Picture

Initially a pilot study has been performed to compare both Seldinger and Modified Seldinger Technique (direct insertion) Two different methods for the Seldinger technique were compared (Seldinger with assistance and Seldinger without assistance) At the end of the pilot study, Seldinger insertion without assistance was chosen for the final study. The reason will be explained later.

1. Venous access with a needle Source: Own Picture

1. Venous access with a needle 2. Guidewire insertion (145 cm) Source: Own Picture

Measurement Marking at 60 cm Source: Own Picture

1. Venous access with a needle 2. Guidewire insertion (145 cm) 3. Removing the needle Source: Own Picture

1. Venous access with a needle 2. Guidewire insertion (145 cm) 3. Removing of the needle 4. Skin nick Source: Own Picture

1. Venous access with a needle 2. Guidewire insertion (145 cm) 3. Removing of the needle 4. Skin nick 5. Insertion of the dilator/introducer sheath which is threaded over the guidewire 6. Catheter is advanced over the guidewire through the introducer Source: Own Picture

Source: Own Video Over the Wire Technique without assistance

Over the Wire Technique without assistance - Helpful in anatomically complicated situations - In these cases - Time effective - Causing less vascular trauma More difficult implantation Mostly time ineffective Periprocedural bleeding much more in comparison to the Modified Seldinger Technique, especially in patients using blood-thinning medication

Over the Wire Technique with assistance Source: Own Video

Over the Wire Technique with assistance - Working with an assistant with clinical routine with a long guidewire eases the procedure of catheter insertion While holding the guidewire the assistant has to put sterile gloves on so that other actions during this time are limited Fluoroscopy unit has to be moved to the optimal position before the assistant puts the sterile gloves on, change of the position of the fluoroscopy unit if needed while insertion is complicated Alternatively a sterile cover can be put over the control panel of the fluoroscopy unit Insertion may be complicated by lack of clinical routine/ experience of the assistant (for example pulling the guidewire out while inserting the catheter)

1. Venous access with a needle 2. Guidewire insertion (70 cm) 3. Removing of the needle 4. Skin nick 5. Insertion of the dilator/introducer sheath which is threaded over the guidewire 6. The guidewire and dilator are then removed 7. Catheter is advanced directly through the introducer 8. Introducer is removed Source: Own Picture

Source: Own Video Modified Seldinger Technique (Direct Insertion)

Modified Seldinger Technique (Direct Insertion) - Simple implantation - Lower risk of contamination - Time effectiveness - Nearly no periprocedural bleeding More difficult insertion in anatomically complicated situations. In those cases, a secondary procedure to convert Seldinger technique with an additional long guidewire may be required - In these cases - Time loss - More vascular trauma

Complicated Insertion Anatomical variations central veins (left SVC or doubled SVC) Space-occupying mediastinal/ pulmonary process with shift or compression of the vessels Source: Own Picture

Workflow Modified Seldinger Technique Removal of the short guidewire Insertion of the catheter directly 5-8 min. Ultrasound guided puncture Insertion of Peal-away sheath Fixation with Stabilization Device Source: Own Picture Seldinger Technique Insertion of the catheter over the long guidewire 8-12 min. Time has been recorded from the insertion of the guidewire into the needle till fixation with the stabilization device

Complications Follow-up with the referring physicians about possible complications is conducted in 24 h to 2 weeks Periprocedural Complications Arterial Puncture Malpositioning Bleeding Pain Early Complications Dislocation Catheter-Thrombosis/ Occlusion Infection Skin necrosis Hemorrhage

Periprocedural Bleeding Seldinger Technique vs. Modified Seldinger Technique (Direct Insertion) Source: Own Picture

Results According to pilot study and preliminary results, both methods are accurate, safe and feasible for positioning the tip of peripherally inserted central venous catheters in adult patients There is inferiority of the Seldinger Technique in regard to time saving and periprocedural bleeding End results : to be continued.

Conclusion Seldinger Technique and Modified Seldinger Technique show no difference in cost-effectiveness, tip location and most common complications (Infection, Thrombosis) Major advantage of Modified Seldinger Technique is the simple implantation, lower risk of contamination and time effectiveness Major advantage of the Seldinger technique is in anatomically complicated situations, which are seldom But (!) in a complicated situation Modified Seldinger Technique can be converted to a Seldinger Technique by using an extra long guidewire