In some situations placement of a PICC is not feasible, typically because of unavailability of the veins of the arm due to vascular issues (thrombosis, ischemia, small venous caliber both in the green zone and in the yellow zone, etc.), lymphatic problems (total axillary lymphadenectomy for breast cancer surgery), neuromuscular disease (paresis or chronic plegia paralysis, which are associated with muscular hypotrophy and therefore vascular hypoplasia), osteo-articular abnormalities (fractures, ankyloses, etc.). PICC is also contraindicated in patients with chronic renal failure of stage 3b, 4 and 5 (i.e., patients on chronic periodic hemodialysis or at high risk to be directed towards a chronic hemodialysis treatment).
When a medium-term central VAD is indicated, but PICCs are contraindicated, there is clear indication for the placement of a centrally inserted central venous catheter (CICC), by puncture and cannulation of a deep vein of the supra/infra-clavicular area. As the venous access is required for weeks or months, a tunneled, non-cuffed CICC should be preferred, so to decrease the risk of infection .