Ultrasound-Guided Implantation of Peripherally Inserted Central Catheters at the Bedside and Without Fluoroscopy: A Prospective Observational Study

Central venous access is essential in the context of chemotherapy and parenteral nutrition. As a medium-term to long-term alternative to port implantation, peripherally inserted central venous catheters (PICC) are used. The Seldinger technique is used to thread these lines via the basilic vein or the brachial vein into the superior vena cava, mostly guided by fluoroscopy (1). The internationally common bedside technique enables radiation-free PICC insertion under ultrasound control alone (2). This lowers the radiation load and spares resources as no angiographic intervention room is required. Since prospective data on patient relevant endpoints are lacking in the German speaking region, we initiated this study.

Methods

This monocenter prospective observational study at University Medical Center Göttingen was approved by the local ethics committee (No. 12/12/20) and registered in the German Clinical Trials Register (DRKS00027432).

Patients at the department of gastroenterology, gastrointestinal oncology, and endocrinology who required central venous access between January and October 2022, but in whom port implantation was not indicated or possible, were included in the study once they had given consent.

The implantation was carried out at the patient’s bed or in the sonography department by the lead investigator, a specialist in internal medicine, who had already established the technique. For reasons of capacity, x-ray controlled PICC insertions were carried out only in individual cases in the study period. Therefore, where an investigator was available, the ultrasound guided method was given primary priority. The primary endpoint was the correct position in the superior vena cava, verified by bubble test (agitated saline solution) and thoracic x-ray (3). The observation was prospective—up to the removal of the line or a patient’s death.

Results

Between January and October 2022, 64 patients (34.4% female) were included in the study (Table 1). The most common underlying conditions were malignancies (46/64; 71.9%). The predominant indication was intravenous chemotherapy (41/64; 64.1%). In 20/64 patients (31.3%), difficult peripheral venous access necessitated the insertion of a PICC. Although a central venous access was already present in 30/64 patients, this was often no longer usable because of dislocation or thrombosis. Insertion was technically successful except in one case (procedure stopped due to unknown thrombosis) (Table 2). The bubble test was positive in 57/64 patients (89.1%). In 54/64 patients (84.4%) , correct positioning of the line without the need for correction was confirmed on radiology; in 10/64 (15.6%) the catheter needed repositioning. Of these, four catheters (6.3% of all patients) were merely advanced too far into the atrium, which required simple retraction. Repositioning procedures were carried out under ultrasound guidance with subsequent radiological control.

Table 1

Patient data (n = 64)

Table 2

Data regarding PICC insertion

48/64 patients (75%) were followed up to the point of removal (mean indwelling period: 66 days). The most common reason for removal was—in spite of patients being mostly middle aged (95% confidence interval: [55.4; 64.1] years)—the death of the patient (26/48; 54.2%), which reflects the high burden of disease (>71% oncological diagnoses). Elective removal took place in 16/48 patients (33.3%) and complication-related removals—for example, because of infection or material failure—in 6/48 patients (12.5%).

Discussion

This prospective study confirms that ultrasound-guided PICCs can be safely implanted by experienced clinicians. Although the study is based on a selective population, the results are consistent with those of other, international, studies (2, 4). While the angiographic standard method is also low in complications (5) it causes radiation exposure and ties up valuable intervention spaces. The bedside technique has logistical advantages in this setting. Furthermore, the bubble test indicates a reliable prediction of the catheter placement. If further prospective studies confirm its equivalence, omitting the post-procedural x-ray could—in addition to avoiding radiation exposure—also save time and costs. This study shows that implantation without fluoroscopy is a safe and resource-efficient alternative to the standard approach.

Sören Matthias Buchholz, Kathrin Adler, André Sasse, Volker Ellenrieder, Marius Adler

Conflict of interest statement:
The authors declare that no conflict of interest exists.

Manuscript received on 24 June 2025, revised version accepted on 17 December 2025.

Translated from the original German by Birte Twisselmann, PhD.

Cite this as: Buchholz SM, Adler K, Sasse A, Ellenrieder V, Adler M: Ultrasound-guided implantation of peripherally inserted central catheters at the bedside and without fluoroscopy: A prospective observational study. Dtsch Arztebl Int 2026; 123: 196–7. DOI: 10.3238/arztebl.m2025.0240

References

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2. Kwon S, Son SM, Lee SH, et al.: Outcomes of bedside peripherally inserted central catheter placement: A retrospective study at a single institution. Acute Crit Care 2020; 35: 31–7

3. Duran-Gehring PE, Guirgis FW, McKee KC, et al.: The bubble study: Ultrasound confirmation of central venous catheter placement. Am J Emerg Med 2015; 33: 315–9.

4. Matsushima K, Frankel HL: Bedside ultrasound can safely eliminate the need for chest radiographs after central venous catheter placement: CVC sono in the surgical ICU (SICU). J Surg Res 2010; 163: 155–61.

5. Vidal V, Muller C, Jacquier A, et al.: Évaluation prospective des complications des PICCs. J Radiol 2008; 89: 495–8.