Peripherally inserted central catheter performance in oncology patients: A retrospective analysis in an outpatient setting

Abstract

Introduction:

Peripherally inserted central catheters (PICCs) are increasingly used in outpatient oncology care, with nurses playing a central role in management. This study aimed to describe PICC use, maintenance, and complication patterns in this setting.

Methods:

Single-center retrospective study conducted at the Fondazione IRCCS Istituto Nazionale dei Tumori. Adult patients with a PICC and at least one outpatient visit for PICC management between 1 January 2024 and 1 January 2025 were eligible.

Results:

Two hundred and thirty-one patients were included (mean age 58.5 years, SD ±16.4). Catheter removal was predominantly planned after treatment completion. Unplanned removals were uncommon and mainly related to complications, including suspected infection, occlusion, thrombosis, or accidental dislodgement. The estimated PICC survival probability was 95.1% at 6 months and 89.0% at 12 months.

Conclusions:

In outpatient oncology patients, PICCs showed sustained functionality, with removal mainly related to treatment completion, supporting continuity-based routine follow-up and tailored surveillance in clinically stable patients.

Keywords

Neoplasms catheterization central venous catheters catheter-related infections outpatients nursing care device removal

Introduction

According to the Global Cancer Observatory, approximately 20 million new cancer cases were estimated in 2022, alongside 9.7 million deaths but the number of new cases is expected to rise to 28.4 million by 2040.^1,2

Concurrently, advances in cancer diagnosis and treatment have improved both survival rates and quality of life, leading to a growing number of individuals living with cancer for many years after diagnosis.^3–5

As the population of cancer survivors grows, physical and psychosocial challenges associated with cancer and its treatments also increase, leading to greater complexity in supportive services and requiring coordinated care across cancer trajectories.^6–9 This evolving landscape places substantial demands on outpatient oncology services to deliver care that is efficient, sustainable, and centered on patient needs.^10–12

Within this context, patients often require one or more vascular access devices (VADs) that enable safe and continuous administration of treatments like chemotherapy, immunotherapy, parenteral nutrition. Selecting an appropriate venous access device is crucial in oncology, as it directly affects treatment efficacy, patient safety, and overall comfort.^13–15 Most evidence comes from the use of central venous catheters long-term venous access devices which minimize the discomfort associated with frequent venipuncture and cannulation.¹⁶

Among these devices, peripherally inserted central catheters (PICCs) have become increasingly used, also in outpatient oncology settings, as they are considered safe, cost-effective, and feasible for insertion at the bedside by trained oncology nurses in non-surgical environments.^17–23 PICCs are suitable for intermediate- to long-term use and can be effectively managed in outpatient environments through scheduled maintenance procedures.²⁴ Compared with totally implantable venous access ports (TIVAPs), PICCs are less invasive, require fewer resources, and can be maintained by nursing staff, thereby supporting continuity and accessibility of care.^23,25,26

Despite these advantages, PICCs may be associated with several complications, including catheter-related bloodstream infections (CLABSI), catheter-related thrombosis (CRT), occlusion, dislodgment, and medical adhesive-related skin injury (MARSI).^17,19,27,28 These events can lead to therapy interruption, unplanned catheter removal, and patient discomfort. MARSI, in particular, may cause pain, skin breakdown, and anxiety, especially in patients requiring long-term device use.^23,29 Although reported complication rates vary across studies, surveillance in adult outpatient oncology populations has documented CLABSI rates between 1.1 and 7.5 per 1000 catheter-days and symptomatic CRT in approximately 12% of patients.^17,19,30 These findings underscore the relevance of continuous nursing surveillance, evidence-based protocols, patient education, and systematic maintenance in outpatient vascular access care.³¹ In outpatient oncology settings, vascular access management requires a careful balance between clinical safety, patient adherence, and operational sustainability. Factors such as patients’ distance from treatment centers, the availability and type of informal caregiver support, and individual capacity for self-management may influence adherence to maintenance protocols and the timely detection of device-related problems.³² Digital health and telemonitoring solutions are increasingly recognized as valuable tools to support remote patient assessment, timely intervention, and bidirectional communication between oncology nurses and patients, thereby reducing unplanned complications and enhancing the safety, equity, and quality of supportive care.^33–35

Such approaches have the potential to enable more accurate and continuous monitoring, thereby enhancing safety and potentially reducing PICC-related complications. However, the effective implementation of technology-assisted and remote care strategies requires a robust understanding of real-world complication patterns in outpatient oncology populations and care practices. Generating context-specific evidence is essential to inform the development of innovative and sustainable interventions for PICC management and to support healthcare professionals in delivering clear information while empowering patients and caregivers to acquire the skills required for long-term device maintenance. This knowledge base is crucial to ensure the safe, effective, and sustainable use of PICCs in outpatient oncology care.

Aim

This study aimed to describe the use, maintenance, and complication patterns of PICCs in oncology patients managed in an outpatient setting, with particular attention to catheter durability, reasons for removal, and the temporal distribution of adverse events. Findings are intended to inform the development of nurse-led and technology-assisted models for vascular access care.

Methods

Study design and clinical setting

This single-center retrospective observational study was conducted at the outpatient oncology clinic Ambulatorio Infermieristico di Continuità Assistenziale (AICA4), at the Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Milan, Italy. AICA4 is a nurse-managed outpatient service providing scheduled follow-up and maintenance of vascular access devices for oncology patients. In this institutional context, vascular access device selection follows multidisciplinary clinical evaluation and is tailored to individual patient and treatment characteristics. PICC insertion was performed within the institutional vascular access service using ultrasound guidance and sterile precautions, with catheter tip position verified according to international recommendations. Maintenance was conducted through scheduled outpatient visits, including dressing changes, catheter flushing with saline, and routine assessment of catheter function and insertion site. The study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.^36,37

Study population

The electronic clinical records of all adult oncology patients aged 18 years or older who attended AICA4 at INT between 1 January 2024 and 1 January 2025 were considered for inclusion. Patients were eligible if they had a PICC and at least one documented outpatient visit related to its management or dressing. Patients were receiving care within medical oncology or oncohematology pathways, without any distinction regarding the type of oncological disease or comorbidities.

Exclusion criteria

Records were excluded if patients were younger than 18 years or if no outpatient visit related to PICC management was documented during the study period. Patients in whom a different type of central venous access device had been placed were also excluded.

Data collection

Data were collected retrospectively from electronic clinical records routinely used for outpatient oncology care at INT. Relevant information was extracted and entered into a structured REDCap database to ensure standardized and consistent data management. Collected variables included patient demographic characteristics (age and gender), cancer type and stage, and PICC-related features, such as the vein used for catheter insertion, catheter size, and number of lumens. Outpatients visit documentation was reviewed to capture the frequency and type of nursing interventions performed, including dressing changes, clinical assessments, and routine maintenance procedures. Data on PICC dwell time and documented complications were also extracted, including catheter-related thrombosis, catheter-related bloodstream infections, exit-site infections, occlusions, accidental dislodgement, and unplanned catheter removal. When available, information on informal caregivers (relationship to the patient, age, and educational level) was retrieved. Only data routinely collected as part of standard clinical practice were used for this study.

Data analysis

Descriptive statistics were used to summarize patient, caregiver, and PICC-related characteristics. Categorical variables were reported as frequencies and percentages, while continuous variables were described using means and standard deviations or medians and ranges, as appropriate. The primary outcome was time to PICC failure, defined as the interval between catheter insertion and unplanned catheter removal due to irreversible clinical complications, including catheter-related thrombosis, catheter-related bloodstream infection, severe occlusion, or accidental dislodgement. PICCs that were still in situ at the end of follow-up or removed due to completion of therapy or for reasons unrelated to direct catheter complications, were treated as censored observations. Time to PICC failure was analyzed using Kaplan–Meier survival analysis, with estimates of PICC survival probability reported at clinically relevant time points. Exploratory univariable Cox proportional hazards models were performed to assess potential associations between selected demographic and clinical variables and PICC failure. Given the limited number of irreversible failure events, multivariable modeling was not performed to avoid unstable estimates. The temporal distribution of PICC-related complications was explored using descriptive time-to-event analyses and graphical representations. In addition, the incidence and type of PICC-related complications, including infectious, thrombotic, mechanical, and medical adhesive–related skin injury events, were described using frequency distributions. Data management and statistical analyses were performed using Python and Jamovi statistical software.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki, as revised in 2024, and relevant international ethical standards. Ethical approval was obtained from the Comitato Etico Territoriale Lombardia 4 (approval number INT 32-25). Given the retrospective design based exclusively on the analysis of routinely collected electronic clinical records, informed consent was waived in agreement with the Data Protection Officer. All data were handled confidentially and analyzed in anonymized form.

Results

Study population and baseline characteristics

A total of 231 adult oncology patients with a PICC were included in the study. The mean age of the cohort was 58.5 years (SD ±16.4), with a balanced distribution between female (52.4%) and male (47.6%) patients. Most patients were of Italian nationality (83.1%) and were affected by solid tumors (80.1%), while hematological malignancies accounted for approximately one fifth of the sample. Overall, the study population showed a low burden of comorbidities, with more than 90% of patients reporting no relevant chronic conditions. When present, arterial hypertension (25.1%), diabetes mellitus (9.1%), and chronic obstructive pulmonary disease (6.5%) were the most frequently documented comorbidities. At baseline, 15.6% of patients were receiving anticoagulant therapy, although this information was not available for 29% of the sample. From a care context perspective, most patients lived with family members (71.9%) and reported the presence of an informal caregiver (79.2%), highlighting the central role of family support for patients. Detailed baseline characteristics are reported in Table 1.

Table 1.

Baseline demographic, clinical, and caregiving characteristics of the study population (N = 231).

Variable	n (%)/statistic
Age (years)
Mean (SD)	58.5 (16.4)
Gender
Female	121 (52.4)
Male	110 (47.6)
Nationality
Italian	192 (83.1)
Non-Italian	25 (10.8)
Unknown	14 (6.1)
Cancer type
Solid tumors	185 (80.1%)
Hematological malignancies	46 (19.9%)
ECOG performance status
Median (range)	0 (0–3)
Comorbidities
None	216 (93.5)
≥1 comorbidity	15 (6.5)
Type of comorbidity^†
Hypertension	58 (25.1)
Diabetes mellitus	21 (9.1)
Chronic obstructive pulmonary disease (COPD)	15 (6.5)
Chronic liver disease	5 (2.2)
Moderate or severe renal failure	3 (1.3)
HIV infection	2 (0.9)
Other comorbidities	7 (3.0)
Baseline anticoagulant therapy
Yes	36 (15.6)
No	128 (55.4)
Unknown	67 (29.0)
Care context
Living with family	166 (71.9)
Presence of informal caregiver	183 (79.2)

†

Percentages refer to the total study population; categories are not mutually exclusive.

PICC characteristics

The majority of PICCs were 4 Fr single-lumen devices. Securement was achieved using sutureless system in just over half of cases, while SecurAcath was used in the remaining patients. The brachial vein was the most common insertion site, mainly on the right side, followed by the basilic vein (Table 2).

Table 2.

Characteristics of peripherally inserted central catheters (PICCs; N = 231).

Variable	n (%)
Catheter gauge
4 Fr	160 (69.3)
5 Fr	60 (26.0)
Unknown	11 (4.8)
Number of lumens
Single lumen	228 (98.7)
Double lumen	2 (0.9)
Triple lumen	1 (0.4)
Securement system
Sutureless securement device	126 (54.5)
SecurAcath	105 (45.5)
Insertion vein
Right brachial vein	158 (68.4)
Left brachial vein	20 (8.7)
Right basilic vein	46 (19.9)
Left basilic vein	3 (1.3)
Right axillary vein	1 (0.4)
Other	3 (1.3)

Outpatient PICC management and care

PICC management was primarily delivered through scheduled outpatient visits focused on routine maintenance. Patients attended the nurse-managed clinic a median of two times during the study period, with most visits related to dressing changes. At the first outpatient assessment, aspiration and/or infusion through the PICC was performed in nearly all cases, and transparent polyurethane dressings were predominantly used. Clinical assessment of the insertion site showed intact skin without signs of inflammation in the majority of patients (Table 3).

Table 3.

Outpatient PICC management and care characteristics (N = 231).

Variable	n (%)/statistic
Outpatient visits
Number of AICA4 visits for PICC dressing in 2024
Mean	3.43
SD	3.97
Median	2
Range	1–24
Reason for AICA4 visit
Routine PICC maintenance	228 (98.7)
Blood sampling	1 (0.4)
Unknown	2 (0.9)
PICC management at first visit
Aspiration and/or infusion performed	225 (97.4)
No aspiration/infusion	6 (2.6)
Dressing type at first visit
Transparent polyurethane dressing	218 (94.4)
Tegaderm™ CHG	6 (2.6)
Gauze	2 (0.9)
Extra-thin hydrocolloid	1 (0.4)
Chlorhexidine patch	2 (0.9)
Sorbaview™	1 (0.4)
Other	1 (0.4)
Insertion site condition at first visit
Grade 0: intact skin, no signs of inflammation	212 (91.8)
Grade 1: erythema <1 cm, fibrin present	14 (6.1)
Grade 2: erythema >1 cm, fibrin present	1 (0.4)
Grade 3: erythema with secretion or pus	1 (0.4)
Unknown	3 (1.3)

PICC outcomes and catheter removal

At the end of the observation period, the vast majority of patients were alive, and slightly less than half of the PICCs had been removed. Catheter removal was predominantly planned and occurred mainly after completion of oncological treatment. Unplanned removals were relatively uncommon and were primarily related to device-associated complications, including suspected infection, occlusion, thrombosis, and accidental dislodgement. In the three cases of catheter damage or rupture, clinical documentation reported mechanical catheter failure; however, the specific precipitating mechanism was not detailed. The category “Other” (n = 14, 13.1%) corresponded to the original classification recorded in the electronic clinical documentation, without further specification of the reason for removal in the available records. Overall, these findings indicate a high rate of PICC retention and planned discontinuation in this oncology outpatient cohort (Table 4).

Table 4.

PICC outcomes and reasons for catheter removal (N = 231).

Variable	n (%)
Vital status at last follow-up
Alive	215 (93.1)
Deceased	16 (6.9)
Catheter removed
No	124 (53.7)
Yes	107 (46.3)
Reason for catheter removal (n = 107)
End of treatment	62 (57.9)
Catheter damage/rupture	3 (2.8)
Death	13 (12.1)
Accidental dislodgement	1 (0.9)
Malfunction	3 (2.8)
Occlusion	2 (1.9)
Suspected sepsis	5 (4.7)
Replacement with another device	3 (2.8)
Thrombosis	1 (0.9)
Other	14 (13.1)

Time to PICC failure

During the observation period, the median time to PICC failure was not reached, indicating that more than half of the devices remained functional without irreversible complications throughout follow-up. The estimated probability of PICC survival was 95.1% at 6 months and 89.0% at 12 months, reflecting a high functional durability of PICCs in the ambulatory oncology setting (Figure 1). The time to onset of PICC-related complications varied according to complication type (Figure 2). Pain and infection were observed later after PICC insertion, with median times to onset of 127 and 119 days, respectively. CRT also showed a relatively late onset, with a median time of 112 days. In contrast, MARSI and occlusion tended to occur earlier, with median times to onset of 55 and 42.5 days, respectively, and exhibited greater variability in time to onset, with events ranging from early to late occurrences (Figure 2). A comprehensive distribution of both reversible and irreversible PICC-related complications, including their timing of onset, is reported in Supplemental Table 1. Exploratory univariable Cox regression analysis did not identify any demographic or clinical variables significantly associated with PICC failure in Supplemental Table 2.

Figure 1.

Kaplan–Meier curve showing time to PICC failure in the overall study population. Shaded areas represent 95% confidence intervals.

Figure 2.

Time to onset of PICC-related complications by complication type.

Discussion

This retrospective study provides real-world evidence on the management of PICC in a nurse-managed outpatient oncology setting, showing high catheter durability and a limited burden of severe complications. In the present cohort, most PICCs remained functional throughout follow-up, and catheter removal occurred predominantly as a planned event related to completion of oncological treatment rather than device-related failure. The median time to PICC failure was not reached, and catheter survival remained high over time, with an estimated probability of maintenance close to 90% at 12 months. These findings describe a pattern in which the PICC commonly supports patients throughout the planned course of oncological treatment without interruption due to device-related failure, supporting its feasibility for prolonged use in clinically stable outpatient oncology populations. Subgroup survival analyses stratified by cancer type or treatment characteristics were limited by the low number of irreversible failure events and would require larger cohorts to provide stable and clinically meaningful estimates.

In this context, the low number of major complications observed in this study warrants careful contextual interpretation. Infectious and thrombotic events were infrequent and accounted for only a small proportion of outcomes, while non-infectious complications such as medical adhesive-related skin injury and catheter occlusion represented the most frequently documented events, albeit with modest incidence. Rather than indicating an absence of risk, this profile reflects a distinct pattern of complications associated with outpatient oncology care, where patient clinical stability and scheduled nursing surveillance may limit progression from minor issues to irreversible catheter failure. Previous prospective outpatient data have shown that, even within structured care pathways, PICC-related complications remain clinically relevant, with approximately 15% of devices requiring removal due to adverse events over time.³⁰ In contrast, large multicentre studies conducted in hospitalized oncology populations have reported a substantially higher burden of major PICC-related complications, underscoring the influence of patient acuity and care setting on observed outcomes.¹⁷ The characteristics of the devices used and the organizational model of care provide further insight for the favorable outcomes observed. The near-universal use of single-lumen PICCs in the present cohort is consistent with evidence indicating that device-related factors, particularly the number of lumens, play a relevant role in infection risk, with multilumen PICCs independently associated with higher rates of bloodstream infection.¹⁹ Moreover, all patients were followed within a dedicated nurse-managed outpatient clinic providing standardized maintenance procedures and systematic assessment of catheter function and insertion site conditions. Evidence from surveillance-based models suggests that structured follow-up and interdisciplinary monitoring are associated with low rates of severe infectious and non-infectious complications.²⁴ From a care-context perspective, most patients lived with family members and reported the presence of an informal caregiver. Although caregiver support did not emerge as a determinant of PICC outcomes in this study, their presence may have facilitated adherence to scheduled visits and timely reporting of local or mechanical issues. This observation is consistent with evidence showing that continuity and timeliness of catheter care are key factors in preventing complications, while delays in scheduled maintenance are associated with increased infection risk.²¹ In this framework, family support should be interpreted as complementary to professional nursing surveillance rather than as an independent protective factor. It is plausible that caregiver support, which may have partially contributed to the favorable outcomes observed in this study, could provide a foundation for the development of nurse-led remote vascular access management models, in which nurses remain the primary educators and coordinators of care, particularly for patients who are clinically stable over the course of their treatment trajectory. Importantly, the present study does not evaluate such models directly; however, the described outcome profile provides a necessary empirical foundation for their future development and evaluation within nurse led vascular access services.

Several limitations should be acknowledged. The retrospective design relied on routinely collected clinical documentation, and missing data limited the analysis of some variables, particularly those related to social and treatment-related characteristics. Some clinically relevant variables such as detailed oncological treatment regimens, infusion intensity, and venous anatomical or hemodynamic parameters were not systematically recorded and therefore could not be included in the analysis. The low number of irreversible complications constrained the feasibility of more robust inferential analyses and multivariable modeling, limiting the assessment of potential risk factors for PICC failure. Finally, the monocentric nature of the study may limit the generalizability of the findings to other organizational contexts with different patient populations or care models. Caregiver involvement and continuity based follow up were part of the outpatient care framework; however, these components were not analyzed as independent variables in the present study. Overall, the findings suggest that, in clinically stable oncology patients managed in an outpatient setting, PICC outcomes are more frequently characterized by planned catheter discontinuation at the end of treatment than by device-related failure.

Conclusions

This study shows that, in oncology patients managed in an outpatient setting, PICCs maintained sustained functionality over time, with catheter discontinuation predominantly related to completion of oncological treatment rather than device-related failure. From a clinical perspective, the findings suggest that PICC care in clinically stable patients may be organized around continuity of follow-up and routine monitoring across the entire catheter lifespan, rather than intensive surveillance focused on early failure prevention. From a research perspective, the low incidence of irreversible complications and their heterogeneous timing highlight the need for larger prospective and multicentric investigations aimed at refining risk stratification and defining tailored follow-up intensity in outpatient PICC management, to support care models that balance catheter safety with efficient use of healthcare resources.

Supplemental Material

sj-docx-1-jva-10.1177_11297298261443384 – Supplemental material for Peripherally inserted central catheter performance in oncology patients: A retrospective analysis in an outpatient setting

Supplemental material, sj-docx-1-jva-10.1177_11297298261443384 for Peripherally inserted central catheter performance in oncology patients: A retrospective analysis in an outpatient setting by Letteria Consolo, Francesca Solimeni, Martina Bruno, Ilaria Basile, Carmen Greco and Silvia Pazzaglia in The Journal of Vascular Access

Footnotes

Acknowledgements

The authors wish to thank the team responsible for managing the REDCap platform, Dr. Paolo Baili and Dr. Ilaria Cavallo, for their support.

Author contributions

LC, SP, and MB designed the study and structured the methodology. CG and LC liaised with the ethics committee for approval of the study. FS and LC collected and analyzed the data, consulting with the entire research team. LC and IB reviewed the draft manuscripts to prepare them for publication. All authors read and approved the final version of the manuscript.

Data availability statement

All data generated or analyzed during this study are included in this published article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research and authorship of this article.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki (2024 revision) and relevant ethical standards. Ethical approval was granted by the Comitato Etico Territoriale Lombardia 4 (approval no. INT 32-25). Owing to the retrospective design, informed consent was waived in agreement with the Data Protection Officer. All data were processed confidentially and analyzed in anonymized form.

Consent to participate

Informed consent was waived due to the retrospective nature of the study and the exclusive use of anonymized routinely collected clinical data, in accordance with the approval of the Ethics Committee and the Data Protection Officer.

Consent for publication

Not applicable. All data were analyzed and reported in anonymized form, with no identifiable personal information.

ORCID iDs

Letteria Consolo

Francesca Solimeni

Martina Bruno

Ilaria Basile

Silvia Pazzaglia

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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