If a CT scan or an angiography detect an obstruction of the superior vena cava, placement of a PICC or a CICC may be difficult or impossible; in this case, the most appropriate medium term central VAD may be an ultrasound guided catheter via the common or superficial femoral vein (FICC), appropriately tunneled so to avoid the exit site at the groin.
When planning the insertion of a tunneled FICC, it will be inevitable the off-label use of devices commonly marketed as PICCs, since they will be ideal in terms of length (50 cm and more) and in terms of insertion technique (modified Seldinger).
As for any FICC, we should decide if the tip must be in the inferior vena cava (catheter used only for infusion and blood sampling) or in the right atrium (catheter used also for hemodynamic monitoring). In most cases, considering the clinical needs of the patients requiring a medium-term central VAD, the tip will be located in inferior vena cava.