Validation and Implementation of the Use of Peripherally Inserted Central Catheter (PICC) for the Administration of Peripheral Blood Stem Cells (PBSC): A Single-Institution Experience

Background:

Infusion of peripheral blood stem cell (PBSC) in patients undergoing autologous transplantation (ASCT) has been conventionally performed using central venous catheters (CVC) inserted through the subclavian or internal jugular vein. Peripheral inserted central catheters (PICC) are routinely used for infusion of blood products and medication, but its use for PBSC infusion has not been well established. Our study aimed to evaluate the feasibility and safety of using PICC to deliver PBSC for ASCT through an in-vitro lab-based validation process, followed by a clinical review.

Methods: 

• Lab based validation

In vitro infusion of 6 cryopreserved PBSCs was performed, 3 infused PICC whist 3 via CVC. Each product was thawed for the same amount of time and drained by gravity. Pre-infusion and post-infusion total nucleated cell counts (TNC), CD34 counts and CD34 viability of the PBSCs were analysed by flow-cytometry and compared using paired T test. In vitro infusion rates were also compared between PICC and CVC groups.

• Clinical Outcome Analysis

The clinical study included 31 patients (Lymphoma N=21, myeloma N=5, Others, N=4) who underwent ASCT at National University Cancer Institute, Singapore (NCIS) from September 2019 to July 2021. All patients had a 19G BARDS dual lumen PICC inserted in either the brachial or basilic veins and used for PBSC infusion. The PBSC infusion rate, infusion associated complications, time to absolute neutrophil count (ANC) >1, and platelet count engraftment >100K were analysed.

Clinical outcomes in the lymphoma cohort, who received BEAM conditioning (N=17) were also compared with a control group, matched for conditioning, cell dose and age, who had PBSC infused via CVC.

Results: 

• In vitro findings:

Overall flow rates for infusion through PICC was slower (mean 0.1mls/s vs 0.3mls/s, p < 0.05). However, there were no significant % differences in TNC counts (5% vs 9%, p=0.4), CD34 counts (17% vs 15%, p=0.9) and viability (4% vs 7%, p=0.2) between pre and post infusion samples for PICC and CVC..

• Clinical findings:

30 patients (Lymphoma N=21, myeloma N=5, N=4) were included. 15 (50% of patients) had a for ASCT while 15 (50%) had an existing PICC. For patients with an existing PICC, the median duration of catheter in situ was 86 days. New lines were inserted 2-7 days prior to the PBSC infusion. The median age of the patients was 54 (20-71) with 19 males (63%). . There were 5 infusion related complications, 2 in an existing PICC and 3 in new PICCs. 4 were related to slow flow rate and 1 was related to sediments seen in the line. None led to a need for alternative line for infusion. The median time to ANC recovery was 10 (range 9-14), 10 (range 9-11) and 11 days (range 10-12), while the median time to platelet engraftment was 18 (range 10-195), 20 (range 15-55) and 22 (16-85 days) for the lymphoma BEAM conditioning (N=17), lymphoma Carmustine/ Thiotepa conditioning (N=4), and the myeloma (N=5) cohorts respectively.

Clinical outcomes in the lymphoma cohort, who also compared with a control group matched for conditioning, cell dose and conditioning. The in-vivo infusion rate was slower in the PICC group, compared to the CVC group (3.1 mls/min vs 4.5mls/min, p<0.05).There was however no differences in engraftment with median time to ANC recovery 10 days (range 9-14) vs 11 days (range 9-13) (p>0.05) and median time to platelet engraftment 18 (range 14-195) vs 19 days (range 14 -57) (p>0.05) in the PICC vs CVC groups respectively.

Conclusion:

Our in-vitro and clinical findings confirmed that the use of PICC for PBSC infusion is safe and efficacious and reduces the need for CVC insertion. Our findings have led to change in clinical practice with utilization of PICCs for PBSC infusions for ASCT.