Use of oblique-axis view with in-plane venipuncture in PICC insertion: A case report

Peripherally inserted central catheters are increasingly utilized, but placement can be challenging due to anatomical constraints and the need for an adequate catheter-to-vein ratio and optimal exit site positioning. This paper presents a novel approach combining in-plane oblique axis ultrasound guidance with pseudotunneling for catheter insertion in a complex anatomical scenario. A patient requiring long-term venous access presented with a target vein located near the axillary cavity, positioned beneath the axillary artery and musculocutaneous nerve, precluding the standard short axis out-of-plane puncture. Therefore, an in-plane oblique axis technique was employed, enabling continuous real-time visualization of surrounding structures and the needle's trajectory. This approach facilitated safe vein cannulation while creating a subcutaneous pseudotunnel to relocate the exit site to the desired green zone. The technique, described through a clinical case, involved oblique probe angulation, in-plane needle insertion, and pseudotunnel creation. This method demonstrates the feasibility and safety of in-plane oblique-axis ultrasound guidance combined with pseudotunneling for catheter insertion in challenging anatomical conditions, ensuring an optimal catheter-to-vein ratio and appropriate exit site placement.