Comparison of Complication Rates of Midline Catheter versus Peripherally Inserted Central Catheter: An Update Systematic Review and Meta-Analysis.

Little is known about the safety of midline catheters vs peripherally inserted central catheters (PICCs) for outpatient parenteral antimicrobial therapy (OPAT). To compare outcomes from midline catheters vs PICCs for OPAT. This retrospective cohort study included patients who received antimicrobial therapy through a midline catheter or PICC between January 2017 and November 2023 across 69 Michigan hospitals. Because peripherally compatible OPAT was the indication of interest, vancomycin therapy was excluded. Data were analyzed from April to June 2024. Insertion of a midline catheter or PICC for OPAT following hospitalization. The primary outcome was major device complications (ie, catheter-related bloodstream infection or catheter-related venous thromboembolism). Secondary outcomes included minor device complications (eg, catheter dislodgement, occlusion, tip migration, infiltration, superficial thrombophlebitis, or exit site concerns) and device failure, defined as catheter removal following device complication. Cox proportional hazards regression models were fit to device type and outcomes, adjusting for patient and device confounders and device dwell. Of 2824 included patients, 1487 (53.5%) were male, and the median (IQR) age was 66.8 (55.9-77.1) years. Of 2824 devices placed for OPAT, 1999 (70.8%) were midline catheters and 825 (29.2%) were PICCs. The median (IQR) dwell time was 12 (8-17) days for midline catheters and 19 (12-27) days for PICCs (P < .001). A major device complication occurred in 44 patients (1.6%) overall, including 16 (0.8%) with midline catheters and 28 (3.4%) with PICCs (P < .001). OPAT delivered via midline catheters was associated with a lower risk of major complications vs PICCs (adjusted hazard ratio [aHR], 0.46; 95% CI, 0.23-0.91). Risks of minor complications and device failure were similar across device types (minor complications: 206 of 1999 [10.3%] vs 114 of 825 [13.8%]; aHR, 1.07; 95% CI, 0.83-1.38; device failure: 191 of 1999 [9.6%] vs 100 of 825 [12.1%]; aHR, 1.26; 95% CI, 0.96-1.65). For device dwell of 14 or fewer days, midline catheters were associated with a lower risk of major complications (12 of 1324 [0.9%] vs 16 of 304 [5.3%]; aHR, 0.29; 95% CI, 0.12-0.68) and similar risk of failure (151 of 1324 [11.4%] vs 52 of 304 [17.1%]; aHR, 0.79; 95% CI, 0.56-1.12) vs PICCs. For dwell longer than 14 days, no significant difference in rates of major complications (4 of 675 [0.6%] vs 12 of 521 [2.3%]; aHR, 0.42; 95% CI, 0.13-1.40) or device failure (40 of 675 [5.9%] vs 48 of 521 [9.2%]; aHR, 1.02; 95% CI, 0.64-1.61) were observed. In this study, midline catheters appeared to be safe alternatives to PICCs for OPAT, particularly if infusions were planned for 14 or fewer days.

The tunneling technique is currently widely used for placement of CVC. Recently, some clinicians have used this technique for peripherally inserted central catheters (PICC), or Midline catheters (MCs). To describe a safe antegrade tunneling technique for PICCs and MCs insertion with a blunt tunneler. This retrospective monocentric survey collected ASST Lodi hospital data from January 1st to December 31st, 2019. The indication for PICCs and MCs tunneled implant was to respect the correct vein/catheter ratio or special clinical situation (children, burns, wounds, and wider catheter 5/6 fr). Contraindications included the operator's low skills and severe risk of bleeding (INR > 3; Platelet count <50'000). About 390 PICCs (327 4 fr and 63 5 fr) and 183 MCs were placed. One hundred and sixty-five PICCs (42%) and 110 MCs (60%) were tunneled. Five fr PICCs were more present among tunneled catheters (54/165 [32.7%] vs 9/225 [4%] p < 0.0001). In the majority tunneling was necessary to respect the correct catheter/vein ratio. The exit site was shifted only for four special clinical situations: skin infections (one PICC and two MCs); burns (one MC). No early complication (intraprocedural, major bleeding), catheter related thrombosis, or device fractures occurred. Two catheter-related bloodstream infections (one PICC, one MC), nine dislocations (four PICCs, five MCs), one MC occlusion were recorded. The antegrade tunneling technique with blunt tunneler of PICCs and MCs is simple, rapid and is regarded as a safe maneuver. More in-depth and future prospective studies are needed to evaluate the impact of tunneling on early and late complications.

Background and Aims: Peripherally inserted central catheters (PICCs) and midline catheters (MCs) are essential for administering intravenous therapies. PICCs, which extend from peripheral veins to the central venous system, are effective for high-volume infusions but are associated with significant complications, including venous thromboembolism (VTE) and catheter-related bloodstream infections. In contrast, MCs (terminating in peripheral veins) could present a different thrombotic risk, although current evidence remains conflicting. This systematic review and meta-analysis was conducted to compare VTE rates between these two devices and clarify their safety profiles. Methods: A systematic literature search was performed across PubMed, Embase, Scopus, Web of Science, and The Cochrane Library following the PRISMA 2020 guidelines. Studies were eligible if they reported VTE outcomes (deep vein thrombosis, superficial venous thrombosis, pulmonary embolism) for both MCs and PICCs in adult patients, with a minimum of 15 catheters per type. Risk of bias was assessed using the Cochrane RoB2 tool for randomized controlled trials and the ROBINS-E tool for non-randomized studies. Subgroup and sensitivity analyses were also performed to explore potential sources of variability. Results: After screening 2878 records, 15 studies were included, encompassing 11,496 MCs and 13,344 PICCs. Among these, 2 were randomized controlled trials and 13 were cohort studies (12 retrospective and 1 prospective). Thrombotic events were observed in 468 MC cases (4.1%) and in 549 PICC cases (4.1%). The random-effects model revealed no significant difference in the risk of venous thromboembolism between MCs and PICCs (OR 1.06; 95% CI 0.81–1.38) (Figure 1). These findings remained consistent after excluding high risk-of-bias studies and in the leave-one-out sensitivity analysis. Subgroup analyses based on ICU setting, placement year, and hospitalization status yielded similar results to the overall analysis. However, when examining placement methods, there was an increased VTE risk for MCs compared to PICCs ECG-guided techniques and echo-guided techniques were used for placement (OR 1.57; 95% CI 1.25–1.97). Moreover, when the analysis has been restricted to catheter related thrombosis (CRT) events only (available in seven studies) we reported a non significant increased risk for MCs compared to PICCs (OR 1.30; 95% 0.88 – 1.82). Overall, the quality of the included studies was moderate to low regarding our outcome of interest. Conclusions: In summary, the overall rates of VTE were similar between MCs and PICCs across most analyzed sub populations. However, when advanced placement techniques were utilized, MCs were associated with an increased risk of VTE. Further high-quality studies are warranted to strengthen these findings.

BackgroundBoth midline catheters (MCs) and peripherally inserted central catheters (PICCs) can cause venous thromboembolism (VTE), but the prevalence associated with each is controversial.ObjectiveTo compare the risk of VTE between MCs and PICCs with a systematic review and meta‐analysis.MethodsThe Web of Science Core Collection, PubMed, Scopus, Embase, the Cochrane Library and ProQuest were searched from inception to January 2020. All studies comparing the risk of VTE between MCs and PICCs were included. Selected studies were assessed for methodological quality using the Downs and Black checklist. Two authors independently assessed the literature and extracted the data. Any different opinion was resolved through third‐party consensus. Meta‐analyses were conducted to generate estimates of VTE risk in patients with MCs versus PICCs, and publication bias was evaluated with RevMan 5.3.ResultsA total of 86 studies were identified. Twelve studies were recruited, involving 40,871 patients. The prevalence of VTE with MCs and PICCs was 3.97% (310/7806) and 2.29% (758/33065), respectively. Meta‐analysis showed that the prevalence of VTE with MCs was higher than that with PICCs (RR=1.53, 95% CI: 1.33–1.76, p < .00001). Subgroup analyses by age showed that the prevalence of VTE with MCs was higher than that with PICCs in the adult group (RR=1.75, 95% CI: 1.38–2.22, p < .00001), and higher than that with PICCs in the other subgroups (RR=1.42, 95% CI: 1.19–1.69, p = .0001). Subgroup analyses by nation showed that the prevalence of VTE with MCs was higher than that with PICCs (RR=1.50, 95% CI: 1.30–1.73, p < .00001) in US subgroup and higher than that with PICCs (RR=2.87, 95% CI: 1.24–6.65, p = .01) in the other nations. The sensitivity analysis shows that the results from this meta‐analysis are robust and all studies have no significant publication bias.ConclusionsThis study provides the first systematic assessment of the risk of VTE between MCs and PICCs. MCs are associated with a higher risk of VTE than PICCs in all patients and adults. The findings of this study have several important implications for future practice. However, the risk of VTE between MCs and PICCs in children is unclear.

“comparative outcomes of midline versus peripheral intravenous catheters: A systematic review and meta-analysis.”

IntroductionIt is estimated that over 90 percent of hospitalized patients will receive some form of vascular access device (VAD) for their treatment. Currently, patients requiring medium-term catheterization often have peripherally inserted central catheters (PICCs) placed, which are expensive, time consuming and usually for long-term catheterization. Midline catheters (MCs) are VADs placed in deep peripheral veins, with a dwell time of up to 29 days. The study aimed to evaluate if using MCs over PICCs has any clinical and economic benefits.MethodsA cost-calculator was developed in Microsoft Excel 2013 to demonstrate the clinical and economic differences of using MCs over PICCs in an inpatient setting in Korea. A literature review was conducted and included eighteen studies that showed MCs have positive clinical, patient, economic, and institutional outcomes. The model captured clinical outcomes such as usage duration, complications, and costs. The time horizon was one year, and various model inputs were derived from the literature review.ResultsFor an annual catheter utilization of MCs over PICCs, the total cost-saving was USD 3,764,994. Total treatment costs for MCs were USD 7,230,825 and for PICCs were USD 8,987,922. The total treatment costs included device cost, complication cost and labor cost related to using both MCs and PICCs. For MCs versus PICCs, device costs were USD 6,554,317 versus USD 6,563,356, complication costs were USD 106,749 versus USD 982,417, and labor costs were USD 569,759 versus USD 1,442,149.ConclusionsIn both the base and sensitivity analyses, results showed that MCs can be an impressive cost-saving option among patients with unnecessary PICC use in Korea. Among patients who require medium-term catheterization and use PICCs even when not targeted for central line insertion, MCs are a more cost-effective option, and MCs will benefit these patients with lesser complication rates. MCs are a suitable alternative with clinical and economic benefits that could lead to lower burden on patients and healthcare systems.

Midline catheters (MCs) are widely used, but safety and efficacy compared with peripherally inserted central catheters (PICCs) has not been adequately evaluated. To compare the safety and efficacy of MCs with PICCs among adult patients with an anticipated intravenous therapy lasting from 5 to 28 days. This parallel, 2-group, open-label, randomized clinical trial (RCT) was conducted in Denmark from October 2018 to February 2022 at a single academic tertiary care center. Adult inpatients and outpatients were consecutively randomized. Patients were randomized in a 1:1 ratio to either the MC group or the PICC control group. The primary outcome was catheter-related bloodstream infection (CRBSI), analyzed using the Fisher exact test. Secondary outcomes were symptomatic catheter-related thrombosis and catheter failure, including mechanical cause, phlebitis, infiltration, pain in relation to drug or fluid administration, and leaking from the puncture site. Incidence rate ratios (IRRs) were calculated to assess between-group failure rates over device dwell time using Poisson regression. An intention-to-treat analysis was performed. A total of 304 patients (mean [SD] age, 64.6 [13.5] years; 130 [42.8%] female) were included in the analysis, and 152 patients were allocated to each catheter group. The incidence of CRBSI was low, with 0 in the MC group and 1 in the PICC control group (P > .99). The MC group had a higher catheter-related complication rate (20 [13.2%] vs 11 [7.2%]), and an IRR of 2.37 (95% CI, 1.12-5.02; P = .02) for complications compared with the PICC control group. In a post hoc analysis stratified by catheter dwell time, no significant difference in complication rate (IRR, 1.16; 95% CI, 0.50-2.68; P = .73) was found between the 2 groups for catheters used less than 16 days. In this RCT with patients who received medium- to long-term intravenous therapy, the incidence of CRBSI was low, with no difference between MCs and PICCs. The use of MCs resulted in a higher incidence of catheter-related complications compared with use of PICCs. This finding should be balanced in the decision of type of catheter used at the individual patient level. ClinicalTrials.gov Identifier: NCT04140916.

Catheter-related (CR) thrombosis is a significant complication of midline catheters (MCs)and peripherally inserted central catheters (PICCs). Limited existing data for MCs suggesta favorable complication profile for MCs. To compare incidence of CR thrombosis betweenMCs and PICCs and to evaluate the impact of quantity of lumens and catheter diameter on CRthrombosis. This was a retrospective comparison spanning 13 months of MCs and PICCs forsymptomatic CR thrombosis at an 1100 bed tertiary care academic medical center. Adultpatients who had an MC or a PICC placed by the were included. Data were collected usingthe electronic medical record. Statistical analysis was performed using SAS software. Atotal of 2577 catheters were included in the analysis with 1094 MCs and 1483 PICCs. Onehundred thirty (11.88%) MCs developed CR thrombosis (deep vein thrombosis [DVT] orsuperficial venous thrombophlebitis [SVT]) as compared to 112 (6.88%) PICCs (odds ratio[OR]: 1.82; P < .0001). Midline catheters had a 53% greater odds ofdeveloping CR DVT than PICCs (7.04% MCs and 4.72% PICCs; OR: 1.53; P =.0126). For CR SVT, MCs have a 2.29-fold greater odds of developing CR SVT than PICCs(4.84% MCs and 2.16% PICCs; OR: 2.29; P = .0002). For MCs and PICCs, theincidence of CR thrombosis was 13.50% for double lumen/5F lines and was 6.92% for singlelumen/4F lines (OR: 2.10; P = <.0001). Symptomatic CR thrombosis is aserious, life-threatening complication that occurs more frequently in MCs compared toPICCs. Inserters should consider placement of single lumen catheters with the smallestdiameter to reduce this risk when a midline is used.

ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (access, care, diagnosis and therapy of complications)

Highlights Popularity of PICCs and concerns about their overuse have increased in recent years. A VAT was established at a large, tertiary care hospital to meet growing PICC demand. MC and USGPIV placement was eventually added to the VAT’s capabilities. VAT-placed MC and USGPIV reduced hospital-wide PICC use. Abstract Purpose: Deep vein thrombosis (DVT) and central line-associated bloodstream infection (CLABSI) are serious complications of peripherally inserted central catheters (PICCs). Because of these risks, midline catheters (MCs) and ultrasound-guided peripheral intravenous catheters (USGPIVs) were added to the capabilities of the host institution’s nursing-based venous access team (VAT), which operates under the direction of Interventional Radiology (IR). This report evaluates this effort to reduce PICCs and MCs through appropriate patient-centered device choice. Materials: A retrospective analysis of PICCs, MCs, and USGPIVs placed in inpatients in a large tertiary care academic hospital was conducted, using the VAT’s record supplemented with data from the IR quality assurance database. Analysis of hospital records of upper extremity DVT and CLABSI was also performed. Results: The VAT documented 33,113 PICC, 12,135 MC, and 14,300 USGPIV placements from September 2001 to March 2018. From the peak of PICC placements in 2006 to the peak of MCs in 2010, PICCs decreased 23% (P &lt; 0.01), while MCs increased 93% (P &lt; 0.001). Following full implementation of USGPIV in January 2016, MCs decreased 34% from 2015 to 2016 (P &lt; 0.01) with no concurrent decrease in PICCs (P = 0.72). CLABSI rates per 1000 central venous catheter days decreased from 1.5 to 0.44 (P &lt; 0.01), coinciding with an unrelated CLABSI reduction initiative. No interpretable trends in DVT counts were discovered. Conclusions: Appropriate use of MCs and USGPIVs by an IR-supported VAT significantly decreased PICCs and MCs, respectively.

04:03 PM Abstract No. 360 Introduction of nursing-placed MLCs and USGIVs promotes safer catheter selection

Comparison of complication rates between midline catheters and peripherally inserted central catheters: a systematic review and meta-analysis of randomized controlled trials

Specialized registered nurses play a key role in the insertion and management of peripherally inserted central catheters (PICCs) and midline catheters in Anglo-Saxon countries. From the German-speaking area no data on the use of PICCs and midline catheters are available. The aim of this study was to describe the types and frequencies of complications of PICCs and midline catheters which were inserted by specialized registered nurses in a South Tyrolean district hospital. We performed a retrospective cohort study of PICCs and midline catheters inserted between 2013 and 2015 in one surgical unit in the district hospital Bruneck (South Tyrol / Italy). Data from 900 catheters (421 midline catheters and 479 PICCs) inserted in 686 adult patients (404 women, 282 men) were analysed. The cumulative incidence was 29.2 % complications for midline catheters (incidence rate: 13 complications / 1000 catheter days) and 16.0 % for PICCs (incidence rate: 3 complications / 1000 catheter days). The most frequent complication was the removal of the catheter by the patients (PICCs: 6.7 %, midline catheters: 15.7 %). Other less frequent complications were mechanical complications, occlusions, infections and thromboses. This study in one district hospital revealed similar types and frequencies of complications as previous international studies. Specialized and clinically competent nurses in German-speaking countries could develop advanced roles in the insertion and management of PICCs and midline catheters.

Which trial do we need? Infectious and non-infectious complications of peripherally inserted central venous catheters and midline catheters

Peripherally inserted central catheters (PICC) and midline catheters (MC) are widely used for intravenous infusions in oncology and critically ill patients. However, controversy remains regarding which method is superior. This meta-analysis systematically compares the safety differences between these 2 methods of intravenous catheterization. Eligible studies comparing PICC and MC were identified through searches in 6 databases. Thrombosis is the primary endpoint, while secondary endpoints include other complications, cost, and satisfaction rate. Fourteen studies with 20,675 patients were analyzed. Based on patient data, the MC group exhibited higher rates of catheter-related superficial vein thrombosis (SVT) (risk ratio [RR]: 0.42 [0.28, 0.64]), infiltrations (RR: 0.27 [0.12, 0.62]), and leaks (RR: 0.16 [0.05, 0.53]). In contrast, the PICC group had more catheter-related bloodstream infections (RR: 1.95 [1.15, 3.32]). Considering catheter days, the MC group showed increased total complications (RR: 0.51 [0.26, 0.99]), catheter-related thrombosis (deep vein thrombosis [DVT]+SVT) (RR: 0.41 [0.18, 0.95]), and leaks (RR: 0.17 [0.05, 0.64]). In the PICC group, the top 3 complications were catheter occlusions (20 per 1,000 catheter days [CDs]), pain (15 per 1,000 CDs), and phlebitis (11 per 1,000 CDs); for the MC group, they were leaks (33 per 1,000 CDs), premature removals (22 per 1,000 CDs), and catheter-related DVT (22 per 1,000 CDs). Additionally, the PICC group had higher dissatisfaction rates (RR: 4.77 [2.33, 9.77]) and increased costs. Compared to MC, PICC appears to be a safer intravenous catheterization option for adult patients, exhibiting fewer complications. However, the higher associated costs and lower satisfaction rates of PICC warrant serious attention.