Comparison of Three PICC Insertion Techniques on Efficiency, Complications, and Patient Experience Among Oncology Patients: A Prospective Observational Study

Comparison of Three PICC Insertion Techniques on Efficiency, Complications, and Patient Experience Among Oncology Patients: A Prospective Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Comparison of Three PICC Insertion Techniques on Efficiency, Complications, and Patient Experience Among Oncology Patients: A Prospective Observational Study Ting Lu, Jiejing Wei, Yi Xu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8034764/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 11 You are reading this latest preprint version Abstract Background Peripherally inserted central catheters (PICCs) provide essential long-term intravenous access for oncology patients, but different insertion techniques may impact patient outcomes. We aimed to compare the efficiency, safety, and patient experience of three PICC insertion techniques—conventional ultrasound-guided non-tunneled, single-puncture subcutaneous tunneling, and double-puncture subcutaneous tunneling—in oncology patients. Methods A prospective observational study was conducted at a single tertiary oncology center in China from June 2022 to December 2023. A total of 418 cancer patients requiring PICC placement were consecutively allocated to the conventional group (n = 131), single-puncture tunneling group (n = 178), or double-puncture tunneling group (n = 109). Insertion efficiency (first-attempt success and procedure time), catheter-related complications, and patient-reported outcomes (pain and satisfaction scores) were assessed over a 16-week follow-up. Group outcomes were compared using one-way ANOVA and chi-square tests, with P 0.05). The first-attempt success rate was significantly higher in the conventional group (98.5%) compared with the double-needle group (90.8%, P < 0.05), with no difference between conventional and single-needle groups. Operation time differed significantly ( P < 0.001), being shortest in the conventional group (26.44 ± 4.73 min), followed by single-needle (31.69 ± 3.92 min) and double-needle (36.39 ± 2.48 min). The incidence of catheter-related thrombosis was lowest in the single-needle group (3.4%), significantly lower than conventional (8.4%) and double-needle (11.0%) approaches ( P = 0.034). Total complication rates were also lowest in the single-needle group (12.9%, P < 0.001). Pain scores were significantly lower in conventional (1.44 ± 0.57) and single-needle (1.71 ± 0.66) groups compared to double-needle (3.45 ± 0.99) ( P < 0.001), while satisfaction was highest in the single-needle group (8.78 ± 1.20, P < 0.001). Conclusions For oncology patients, the single-puncture subcutaneous tunneling technique achieved the best overall balance of safety, efficiency, and patient experience. It can be recommended as the preferred PICC insertion method in oncology nursing practice. The double-puncture technique offers greater catheter stability and may be reserved for patients at high risk of catheter migration, while the conventional non-tunneled approach remains the fastest option for urgent access but carries a higher complication risk. Biological sciences/Cancer Health sciences/Medical research Health sciences/Oncology PICC subcutaneous tunneling single-puncture technique double-puncture technique catheter-related complications oncology nursing patient satisfaction vascular access 1 Introduction Peripherally inserted central catheters (PICCs) are widely used in oncology patients for chemotherapy, parenteral nutrition, and targeted therapies, providing a safe and effective option for long-term intravenous access when peripheral veins are inadequate [ 1 ] . Compared with centrally inserted central venous catheters, PICCs can be placed at the bedside under ultrasound guidance with lower risks of insertion-related trauma (e.g., pneumothorax, hemothorax), making them particularly advantageous in oncology nursing practice [ 2 ] . However, conventional non-tunneled PICCs are associated with notable complications such as catheter-related bloodstream infections (CRBSIs), catheter-related thrombosis (CRT), mechanical dislodgement, and catheter migration, which can disrupt treatment schedules and adversely affect patient outcomes [ 3 ] . These limitations have prompted the exploration of modified PICC insertion techniques to enhance catheter stability, reduce complications, and improve patient safety. The tunneled PICC technique—adapted from tunneled central venous catheters—introduces a subcutaneous tract between the venipuncture site and the skin exit site, thereby separating the intravascular pathway from the external environment [ 4 ] . This design has been shown to reduce bacterial colonization at the insertion site, lowering the risk of CRBSIs and CRT and decreasing overall complication rates [ 5 ] . Tunneling may also improve catheter stability and patient comfort by reducing mechanical irritation and accidental dislodgement [ 6 ] . Previous studies have confirmed that tunneled PICCs are superior to traditional non-tunneled methods in reducing infection and thrombotic events and in improving long-term catheter maintenance [ 7 ] . Nevertheless, most existing research has compared “tunneled vs. non-tunneled” PICCs without systematically evaluating differences between tunneling techniques. Currently, two main PICC tunneling approaches are used in practice: the single-puncture (single-needle) and double-puncture (double-needle) techniques. Although both tunneling methods are intended to provide similar benefits, their procedural complexity, success rates, required insertion time, and patient experiences may differ. There is a paucity of evidence directly comparing all three insertion methods—conventional non-tunneled, single-puncture tunneled, and double-puncture tunneled—within a single study population. In practice, the choice of technique is often based on operator preference rather than standardized evidence. Moreover, PICC insertion and maintenance in oncology are predominantly nurse-led procedures, underscoring the need for research from a nursing perspective to determine which technique best optimizes patient care and nursing workflow. Therefore, this study aimed to comprehensively evaluate the efficiency, safety, and patient-reported outcomes of three PICC insertion techniques in oncology patients. The findings are intended to provide robust evidence to guide clinical decision-making and improve standardization of PICC insertion strategies in oncology nursing practice. 2 Methods 2.1 Study Design and Participants This prospective observational study was conducted in the Department of Oncology at a tertiary hospital in Nanning, China, between June 2022 and December 2023. Consecutive patients meeting the inclusion criteria were enrolled for PICC placement. Inclusion criteria were: (1) confirmed diagnosis of a malignant tumor requiring PICC for treatment; (2) age ≥ 18 years; and (3) fully conscious and able to communicate. Exclusion criteria were: (1) severe active infection or coagulation disorder; and (2) previous history of PICC placement. Patients were withdrawn from the study if they (1) chose to discontinue participation due to health status changes or (2) were lost to follow-up during the 16-week observation period. 2.2 Sample Size Calculation The sample size was calculated based on the primary outcome of overall catheter-related complication rate [ 5 , 8 ] , using PASS 15.0 software. Previous data indicated complication rates of approximately 30.5% with the conventional ultrasound-guided method, 18.6% with single-puncture tunneling, and 7.7% with double-puncture tunneling. Using α = 0.05 and β = 0.10, we determined that at least 49 patients per group were required to detect a significant difference. Allowing for a 20% dropout, a minimum of 62 patients per group was targeted. Ultimately, 418 patients were enrolled (131 in the conventional group, 178 in the single-puncture tunneling group, and 109 in the double-puncture tunneling group), meeting the target sample size. 2.3 PICC Insertion Techniques All insertions were performed by three certified PICC nurses, each with at least three years of clinical experience, using standardized techniques and equipment (Groshong® 4 Fr valve-type PowerPICC, Bard, USA; 3M Tegaderm transparent dressings). Pre-procedure platelet count and coagulation tests were performed to ensure values within normal limits. A maximal sterile barrier was maintained throughout. Tip position was confirmed by bedside X-ray or digital radiography, ensuring location in the lower third of the superior vena cava. 2.3.1 Conventional (Non-tunneled) Method PICC placement via direct ultrasound-guided venipuncture using the Seldinger technique. (1) Measurement : The required catheter length was estimated from the puncture site to the right sternoclavicular joint and then to the third intercostal space, adjusting for patient height and body habitus. (2) Vein selection : The basilic vein (preferred) or brachial vein was identified using ultrasound to assess vessel diameter, depth, and course. (3) Venipuncture : An introducer needle was advanced into the vein at a 20–30° angle under ultrasound guidance until blood return was observed. A guidewire was then inserted through the needle, leaving ~ 10–15 cm of the guidewire externalized. (4) Dilation and catheter insertion : After local infiltration of 0.2% lidocaine, a dilator and introducer sheath were inserted over the guidewire. The PICC was then threaded through the sheath to the predetermined length. (5) Confirmation and securement : The catheter tip position was confirmed radiographically. The catheter was trimmed as needed, connected to a needle-free connector, and secured with a sterile dressing. 2.3.2 Single-puncture Tunneling Technique PICC placement with creation of a short subcutaneous tunnel using a single skin puncture that also serves as the venous entry point. (1) Marking : The intended skin exit site was marked on the mid-upper arm. Under ultrasound guidance, the ideal venipuncture site was identified 2–4 cm proximal to the exit site and marked; this distance defined the tunnel length (generally ≤ 5 cm, or slightly shorter than the puncture needle length). (2) Anesthesia : After sterile preparation with maximal barrier precautions, 1% lidocaine was infiltrated subcutaneously along the planned tunnel path between the skin puncture and vein puncture sites. (3) Ultrasound assessment : A longitudinal ultrasound view was used to assess the vein’s course, valves, and surrounding structures, followed by a transverse view to confirm the vein’s location relative to the marks. (4) Tunnel and venipuncture : The introducer needle was inserted at the skin exit site at a shallow angle (≈ 5–10°) and advanced subcutaneously toward the venipuncture mark for approximately 2–4 cm. Upon approaching the venipuncture site, the needle angle was adjusted according to the vein depth, and the vein was punctured under real-time ultrasound guidance (longer tunnels required a shallower initial angle). (5) Catheter insertion : Once blood return confirmed vein entry, a modified Seldinger technique was used to insert the guidewire and then advance the PICC into position in the usual manner. 2.3.3 Double-puncture Tunneling Technique separate skin exit and vein entry points connected by a subcutaneous tunnel created with a tunneling needle. (1) Measurement and planning: The required catheter length and arm circumference were measured. A four-point marking method was used to define the skin exit site, vein puncture site, and tunnel course, ensuring alignment. (2) Venipuncture: After sterile preparation, the basilic vein was punctured. Once the guidewire entered the vessel (total length = puncture needle length + vein depth), the needle angle was lowered, and the guidewire was advanced until 10–15 cm remained outside the body. (3) Tunnel creation: Local anesthesia (2% lidocaine) was administered along the planned tunnel. The introducer sheath was advanced into the vessel, and the catheter was inserted to the measured length. The sheath was then fully withdrawn from the puncture site without creating a second skin breach. (4) Exit site creation: At a skin point 3–5 cm distal to the venipuncture site, 0.2% lidocaine was infiltrated locally. A metal tunneling needle was passed subcutaneously toward the puncture site, gently dissecting tissue. The catheter was threaded into the tunneling needle’s lumen and pulled out through the exit site. (5) Securing the catheter: After ensuring hemostasis, the catheter was trimmed, connected to the extension set, and secured with sterile dressing. Compression bandaging was applied for 24 hours. (6) Post-procedure care: The catheter was locked with 10 mL normal saline during infusion intervals. Dressing changes were performed weekly using an upward removal technique to minimize skin trauma. 2.4 Data Collection and Follow-up Baseline demographic and clinical data were recorded for each patient, including age, sex, education level, occupation, marital status, cancer diagnosis, and cancer stage. Details of the PICC placement (side of insertion, vein used) were also noted. These baseline variables were collected to verify that the groups were comparable and to identify any factors that might influence outcomes. After PICC insertion, patients were followed for 16 weeks (approximately 4 months) or until catheter removal, whichever came first. This follow-up duration was chosen to capture both early and intermediate-term complications, while minimizing the impact of planned PICC removals after completion of therapy. Follow-up was conducted through weekly outpatient PICC maintenance visits or telephone check-ins. During follow-up, the nursing team recorded any occurrence of catheter-related complications and evaluated patient-reported outcomes. The same trained nursing team was responsible for all follow-up assessments to ensure consistency in data collection. 2.5 Outcome Measures We assessed three categories of outcomes: PICC insertion efficiency, catheter-related complications, and patient-reported experience. Specific measures within each category were defined as follows: Primary outcomes (safety – complication incidence) We tracked six types of catheter-related complications, defined according to the Infusion Therapy Standards of Practice (2016) and relevant clinical guidelines (1)Catheter-related thrombosis Development of venous thrombosis (clot) in the catheterized limb after PICC placement, confirmed by Doppler ultrasound. Patients with known pre-existing thrombosis were excluded from this count [ 9 ] . (2)Catheter-related infection This included local infection at the exit site or a catheter-related bloodstream infection (CRBSI). Diagnostic criteria were clinical signs (e.g., erythema, swelling, purulent discharge at site; fever) and, for CRBSI, laboratory evidence such as positive blood cultures with no other infection source [ 10 ] . (3)Catheter occlusion Partial or complete blockage of the catheter lumen, evidenced by inability to flush or aspirate blood, or resistance during infusion. Occlusions could be thrombotic or precipitate-related [ 11 ] . (4)Catheter malposition Unintended migration of the catheter tip from the initial verified position (e.g., into a smaller vein or undesirable location), usually confirmed by imaging and often requiring repositioning or catheter adjustment [ 12 ] . (5)Catheter dislodgement External movement or pull-out of the catheter from its original insertion, indicated by an increase in external catheter length or complete removal. This compromises catheter function and typically results from accidental traction on the line [ 13 ] . (6)Skin injury related to catheter Any persistent skin damage under or around the catheter dressing, such as blistering, skin erosion, maceration, or tears that last > 30 minutes after dressing removal. These injuries can result from adhesive irritation or mechanical trauma during dressing changes [ 14 ] . For each complication type, we calculated the incidence (%) as the number of patients experiencing that complication within 16 weeks divided by the total number of patients in the group, multiplied by 100%. Secondary outcomes: Patient-reported experience We measured patient comfort and satisfaction associated with the PICC procedure. Two self-reported metrics were used (1)Pain score – Immediately after PICC insertion (within 10 minutes), patients rated their pain during the procedure using a 0–10 visual analogue scale (VAS), where 0 = no pain and 10 = worst imaginable pain [ 15 ] . Nurses explained the scale beforehand and recorded the score once the procedure was completed. (2)Satisfaction score – On the day after insertion, patients completed a short questionnaire rating their overall satisfaction with the PICC insertion experience on a 0–10 scale (higher scores = more satisfied). This encompassed their comfort, trust in the catheter for ongoing therapy, and willingness to undergo the procedure again if needed. A higher score indicated a better patient experience. Insertion efficiency Two measures captured the technical efficiency of PICC placement (1)First-attempt success rate – whether the PICC was successfully placed in the superior vena cava on the first venipuncture attempt (yes/no). We calculated the percentage of patients in each group for whom the nurse achieved successful catheterization without requiring additional needle sticks. (2)Procedure time – the total duration of the insertion procedure, recorded in minutes from the start of preparation (skin antisepsis, etc.) to completion of dressing placement. This included time for ultrasound assessment, any tunneling steps, and troubleshooting. Nurses used a stopwatch or clock to note start and end times. 2.6 Statistical Analysis Data analysis was performed using IBM SPSS Statistics version 26.0. Continuous variables (e.g., age, procedure time, pain score, satisfaction score) were summarized as mean ± standard deviation (SD). We used one-way analysis of variance (ANOVA) to compare means across the three groups. If the ANOVA indicated a significant difference ( P < 0.05), we conducted post-hoc pairwise comparisons with Bonferroni correction to identify which groups differed. Categorical variables (e.g., success rate, incidence of each complication, overall complication rate, sex distribution) were summarized as counts and percentages, and compared using the chi-square test or Fisher’s exact test when expected cell counts were small. Relative risks with 95% confidence intervals were calculated for key outcomes as appropriate. All hypothesis tests were two-tailed, P < 0.05 was considered statistically significant for primary comparisons. Analyses were primarily descriptive and comparative; as this was an observational study, no adjustments were made for multiple outcomes beyond the planned Bonferroni adjustments in post-hoc tests. The results are presented with relevant test statistics (e.g., χ², F values) and P-values to provide transparency about the strength of evidence for differences observed. 3 Results 3.1 Baseline Characteristics A total of 418 oncology patients were included: 131 in the conventional ultrasound-guided group, 178 in the single-needle subcutaneous tunneling group, and 109 in the double-needle subcutaneous tunneling group. As shown in Table 1 , there were no statistically significant differences among the three groups in terms of sex distribution, mean age, educational level, occupation, marital status, primary diagnosis, tumor stage, puncture site, or puncture vein ( P > 0.05). This indicates that the baseline demographic and clinical characteristics were well balanced across groups, ensuring comparability for subsequent analyses. Table 1 General information of cancer patients with three PICC placement methods (n = 418) Variable Conventional method Single-needle tunneling Double-needle tunneling χ²/F P Sex, n (%) 5.528 0.063 Male 66(50.4) 111(62.4) 56(51.4) Female 65(49.6) 67(37.6) 53(48.6) Age (years, χ ± s) 52.19 ± 13.07 53.34 ± 13.82 52.06 ± 14.51 0.400 0.671 Education level, n (%) 1.527 0.822 Primary school or below 36(27.5) 55(30.9) 27(24.8) Junior/senior high school 69(52.7) 87(48.9) 57(52.3) College or above 26(19.8) 36(20.2) 25(22.9) Occupation, n (%) 4.965 0.548 Farmer/worker 63(48.1) 72(40.4) 41(37.6) Staff/public servant 18(13.7) 25(14.0) 20(18.3) Retired 22(16.8) 28(15.7) 19(17.4) Other 28(21.4) 53(29.8) 29(26.6) Marital status, n (%) 0.384 0.825 Married 112(85.5) 150(84.3) 90(82.6) Other 19(14.5) 28(15.7) 19(17.4) Diagnosis, n (%) 7.687 0.104 Digestive system malignancies 55(42.0) 58(32.6) 29(26.6) Hematological malignancies 45(34.4) 65(36.5) 49(45.0) Other 31(23.7) 55(30.9) 31(28.4) Clinical stage, n (%) 8.244 0.221 Stage I 6(4.6) 14(7.9) 7(6.4) Stage II 9(6.9) 19(10.7) 3(2.8) Stage III 22(16.8) 24(13.5) 19(17.4) Stage IV 94(71.8) 121(68.0) 80(73.4) Puncture site, n (%) 4.749 0.093 Left upper limb 98(74.8) 134(75.3) 70(64.2) Right upper limb 33(25.2) 44(24.7) 39(35.8) Punctured vein, n (%) 0.272 0.873 Basilic vein 76(58.0) 98(55.1) 61(56.0) Brachial vein 55(42.0) 80(44.9) 48(44.0) 3.2 Insertion Efficiency Insertion efficiency outcomes are summarized in Table 2 . The first-attempt success rate differed significantly among the three groups (χ² = 7.057, P = 0.029). Pairwise comparisons revealed that the conventional group achieved a significantly higher success rate (98.5%) compared with the double-needle group (90.8%, P 0.05) or between the single- and double-needle groups ( P > 0.05). Operation time varied significantly ( P < 0.001), being shortest in the conventional group (26.44 ± 4.73 min), followed by the single-needle group (31.69 ± 3.92 min) and the double-needle group (36.39 ± 2.48 min). All pairwise comparisons for operation time were statistically significant ( P < 0.001). Table 2 Comparison of the insertion efficiency of three PICC insertion methods (n = 418) Group Cases (n) First-Attempt Success Rate (%) Procedure Time(χ ± s) Conventional method 131 98.5 26.44 ± 4.727 Single-needle tunneling 178 94.4 31.69 ± 3.922 Double-needle tunneling 109 90.8 36.39 ± 2.476 F 7.057 1) 196.182 2) P 0.029 <0.001 Note: 1)χ², 2༉t 3.3 Catheter-Related Complications Catheter-related complication rates are presented in Table 3 . The incidence of catheter-related thrombosis showed significant differences among groups ( P = 0.034). Post-hoc analysis indicated that the single-needle group (3.4%) had a significantly lower rate than the conventional (8.4%, P < 0.05) and double-needle groups (11.0%, P 0.05). The rate of catheter migration also differed significantly (P = 0.021, Fisher’s exact test), with the double-needle group (0.9%) showing a lower rate than the conventional group (6.9%, P < 0.05); no other differences were statistically significant. For total complication rates, significant differences were observed (χ² = 19.088, P < 0.001). The single-needle group demonstrated the lowest overall complication rate (12.9%), significantly lower than the conventional group (33.6%, P < 0.05) and the double-needle group (25.7%, P 0.05). Table 3 Comparison of Complication Rates Among Three Catheterization Methods (n = 418) Group Case (n) Catheter-related Thrombosis, n (%) Catheter-related Infection, n (%) Catheter Occlusion, n (%) Catheter Malposition, n (%) Catheter Dislodgement, n (%) Skin Injury, n (%) Total Complications, n (%) Conventional method 131 11(8.4) 11(8.4) 5(3.8) 9(6.9) 4(3.1) 4(3.1) 44(33.6) Single-needle tunneling 178 6(3.4) 6(3.4) 3(1.7) 3(1.7) 3(1.7) 2(1.1) 23(12.9) Double-needle tunneling 109 12(11.0) 7(6.4) 2(1.8) 1(0.9) 2(1.8) 4(3.7) 28(25.7) χ² 6.738 3.649 1.664 - - 2.234 19.088 P 0.034 0.161 0.435 0.021 0.694 0.327 <0.001 Note : 1) χ² test; 2) Fisher’s exact test. 3.4 Patient Experience Patient-reported pain scores and satisfaction levels are shown in Table 4 . Pain scores differed significantly among groups ( P < 0.001). The double-needle group reported the highest pain score (3.45 ± 0.99), significantly higher than both the conventional group (1.44 ± 0.57, P < 0.001) and the single-needle group (1.71 ± 0.66, P 0.05). Satisfaction scores also differed significantly ( P < 0.001), with the single-needle group achieving the highest satisfaction (8.78 ± 1.20), significantly exceeding both the double-needle group (7.76 ± 0.97, P < 0.001) and the conventional group (7.01 ± 0.92, P < 0.001). Table 4 Comparison of Patient Experience Among Three PICC Insertion Methods (n = 418) Group Cases (n) Pain Score(χ ± s) Satisfaction Score(χ ± s) Conventional method 131 1.44 ± 0.570 7.01 ± 0.916 Single-needle tunneling 178 1.71 ± 0.657 8.78 ± 1.199 Double-needle tunneling 109 3.45 ± 0.986 7.76 ± 0.971 F 262.52 108.406 P <0.001 <0.001 4 Discussion In this study of 418 oncology patients requiring PICC placement, we directly compared three catheter insertion techniques: conventional ultrasound-guided non-tunneled placement, single-puncture subcutaneous tunneling, and double-puncture subcutaneous tunneling. Our results demonstrated that the conventional method achieved the highest first-attempt success rate and shortest procedure time, while both tunneling methods required longer insertion times. Importantly, the single-puncture tunneling technique was associated with the lowest overall incidence of catheter-related complications, particularly thrombosis and catheter migration, and also achieved the highest patient satisfaction. The double-puncture method showed intermediate complication rates but was associated with higher pain scores and longer procedure duration. These findings suggest that the single-puncture subcutaneous tunneling technique may represent the most favorable balance between procedural safety, complication prevention, and patient experience in oncology care. Complications Our study revealed distinct complication profiles among the three insertion techniques, highlighting both unique advantages and trade-offs. Catheter-related thrombosis was significantly reduced in the single-puncture tunneling group (3.4%) compared with both the conventional group (8.4%) and the double-puncture group (11.0%). This advantage may be attributed to the shorter subcutaneous tract and the avoidance of multiple puncture tracts, which together minimize vascular wall irritation and preserve local hemodynamics. Previous studies have reported conflicting results regarding thrombosis rates between tunneled and non-tunneled PICCs—for example, Maria et al [ 16 ] found no significant difference, whereas Sheng et al [ 5 ] observed a clear reduction with tunneling. Our findings extend this literature by demonstrating that not all tunneling methods are equivalent, and that a simplified single-puncture tract may mitigate thrombogenic risk more effectively than either the conventional or double-puncture approaches. Catheter migration, by contrast, was lowest in the double-puncture tunneling group (0.9%), compared with the single-puncture (1.7%) and conventional groups (6.9%). The separation of the venipuncture site and exit site creates a longer subcutaneous pathway, which serves as an “anchoring mechanism” that resists external traction and skin movement. This finding is consistent with the theoretical design rationale of double-puncture tunneling and aligns with prior reports that tunneling increases catheter stability [ 17 ] . However, this stability advantage came at the cost of increased thrombosis risk and a higher overall complication rate, suggesting that a longer subcutaneous tract may introduce greater tissue trauma and procedural complexity. The comparison also illustrates a trade-off: while the single-puncture method was superior in reducing thrombosis, it was relatively less effective than the double-puncture method in preventing migration. When examining overall complication rates, the single-puncture technique demonstrated the most favorable balance, achieving the lowest total adverse event rate (12.9%) compared with the conventional (33.6%) and double-puncture (25.7%) groups. This finding highlights the potential of single-puncture tunneling as a “comprehensive advantage” technique in oncology patients, where minimizing complications is paramount for uninterrupted treatment delivery. The mechanism underlying this balance may relate to its dual strengths: reducing vascular trauma (thereby lowering thrombosis) while avoiding the excessive dissection of double-puncture tunnels (which can increase other complications). Our results are further supported by a recent meta-analysis by Hong and Mao [ 18 ] , which synthesized 12 randomized controlled trials including 2,940 cancer patients (1,484 in the tunneled group and 1,456 in the control group). It demonstrated that tunneled PICCs significantly reduced all major complications—except catheter occlusion—compared with non-tunneled approaches, reinforcing the broad safety advantage of tunneling strategies. While the double-puncture approach may be preferable for patients at particularly high risk of catheter migration, our findings suggest that the single-puncture technique may represent the optimal default choice, offering both safety and practicality. Taken together, these findings emphasize that the choice of tunneling strategy should be individualized, with attention to patient risk profiles, operator expertise, and the relative weighting of thrombosis prevention versus migration control. Insertion Efficiency Efficiency outcomes also varied between groups. The conventional method achieved the highest first-attempt success rate and the shortest procedure time, consistent with its simplicity and operator familiarity. Both tunneling methods prolonged insertion time, which can be attributed not only to their more complex steps but also to the relative novelty of tunneling in our center, where operator proficiency is still developing. Importantly, within tunneling methods, the single-puncture technique required less time than the double-puncture approach, reflecting its simpler tract creation and avoidance of extensive tissue dissection. These results are consistent with Zheng B et al. [ 19 ] , who reported that procedural complexity is directly correlated with longer operating times. However, our findings contrast with those of Kim IJ et al [ 7 ] , who reported that subcutaneous tunnel creation did not significantly prolong procedural time, suggesting that differences in operator training, patient population, and procedural standardization may account for the discrepancy. From a broader perspective, these findings may also reflect the learning curve associated with newly introduced techniques. As tunneling becomes more widely practiced and operator experience accumulates, the time gap between tunneling and conventional methods is expected to narrow, reducing the efficiency penalty currently observed. Furthermore, although the double-puncture tunneling method was associated with longer procedure times, this disadvantage may be offset in selected clinical contexts. For example, in patients requiring long-term catheter retention or those at particularly high risk of catheter migration, the additional stability conferred by the longer subcutaneous tract may justify the longer insertion duration. In this sense, insertion efficiency should not be interpreted solely in terms of absolute procedure duration but rather weighed against downstream clinical benefits [ 20 ] . Looking ahead, future improvements may further mitigate the efficiency gap. Enhanced operator training, standardized procedural protocols, and the introduction of specialized tunneling instruments may help shorten insertion times without compromising safety. Integration of simulation-based learning and competency assessment could accelerate the acquisition of tunneling proficiency, thereby reducing the current learning curve. Thus, while the conventional method remains the fastest, the single-puncture tunneling technique represents a pragmatic compromise, balancing manageable insertion times with improved safety, whereas the double-puncture method may be strategically reserved for patients in whom long-term catheter stability is prioritized over procedural expediency. Patient Experience Patient-reported outcomes provided an essential dimension to evaluate technique selection, particularly in oncology patients who often require long-term chemotherapy and repeated vascular access. In this context, patient experience is not only a measure of procedural comfort but also a determinant of adherence to treatment protocols and overall quality of care. Pain scores were lowest in the conventional and single-puncture tunneling groups, suggesting that minimizing the number of punctures and tissue dissection directly contributes to procedural comfort. In contrast, the double-puncture method was associated with significantly greater discomfort, reflecting its higher degree of invasiveness and extended tract creation. These differences highlight the importance of procedural design in influencing immediate patient experience. Satisfaction scores, however, revealed a more nuanced picture. Although the conventional method provided relative comfort during insertion, its higher complication rate likely diminished long-term satisfaction and patient confidence in the device. In comparison, the single-puncture tunneling technique achieved the highest satisfaction scores, suggesting that patients value not only comfort during the procedure but also the perceived safety and reliability of the catheter in the weeks following placement. This aligns with reports from Sheng et al [ 5 ] , which demonstrated that subcutaneous tunneling not only reduces catheter-related complications but also enhances procedural comfort and patient satisfaction—emphasizing that minimizing procedural invasiveness and complications significantly improves patient acceptance. Finally, long-term acceptance of vascular devices is especially critical in oncology care, where patients undergo repeated cycles of chemotherapy and depend on uninterrupted central access [ 21 ] . Our findings suggest that the single-puncture tunneling method best integrates procedural safety, comfort, and reliability, offering an optimal balance that supports sustained treatment adherence. Conversely, the double-puncture technique, while providing stability against catheter migration, may be penalized by increased procedural discomfort, potentially limiting its acceptance in routine oncology care. These insights underscore the need to consider patient-reported outcomes alongside clinical efficacy when selecting catheterization strategies, reinforcing the centrality of patient-centered decision-making in vascular access management. Limitations This study has several limitations that should be acknowledged when interpreting the results. First, as an observational (non-randomized) study from a single center, there is a possibility of selection bias and unmeasured confounding. We tried to mitigate this by enrolling consecutive patients and showing that baseline characteristics were similar, but without random assignment of techniques, we cannot completely rule out that certain patient factors influenced the choice of method and outcomes. Second, all insertions were performed at a single tertiary hospital with an experienced PICC team; the results may not generalize to settings with less specialized nursing staff or different patient populations. The complication rates and success rates observed here could vary in other institutions. Third, the follow-up duration was 16 weeks, which captures the mid-term outcomes but not very long-term complications (some PICCs stay in for 6–12 months in oncology). We may have missed late complications beyond 4 months or differences in catheter lifespan between techniques. Additionally, patient satisfaction was measured only the day after insertion; longer-term satisfaction or quality of life related to the catheter was not assessed. Lastly, while our sample size was relatively large overall, the double-puncture group had the smallest number of patients (n = 109), which could limit the power to detect differences for rarer outcomes or in subgroup analyses. Larger multicenter studies or randomized controlled trials would strengthen the evidence base by addressing these limitations. Despite these limitations, our study provides valuable real-world data comparing all three PICC techniques and offers practical insights for nursing practice. The consistency of many of our findings with existing literature lends credibility to our conclusions. Implications for Nursing Practice The results of this study have direct implications for oncology nursing practice, particularly for nurses who place and manage PICC lines. By understanding the relative advantages and drawbacks of each PICC insertion technique, nurses can make evidence-informed decisions to enhance patient care. Key practice recommendations based on our findings include: Adopt single-puncture tunneling as the first-line technique for most oncology patients requiring medium- to long-term PICCs. This method optimally balances safety and patient comfort, resulting in significantly fewer complications (especially thrombosis) and higher patient satisfaction compared to the conventional approach. Reserve the double-puncture tunneling technique for patients at high risk of catheter migration or dislodgement, such as those with high body mass index (obesity with abundant subcutaneous tissue), very active patients, or those who have had prior catheter movement issues. In these cases, the added stability of a longer tunnel is beneficial, even though the insertion is more invasive. Utilize the conventional PICC method for situations where rapid catheter placement is critical or if tunneling is contraindicated. For example, in emergency chemotherapy initiation or when resources/time are limited, the conventional technique’s speed and simplicity are advantageous. However, plan to closely monitor these patients for complications and consider an early switch to a tunneled PICC if long-term use is needed. In addition to technique selection, there are broader nursing practice implications: Hospitals and oncology units should ensure that PICC insertion teams (often nurse-led) are trained in both tunneling techniques. Education and competency development in the single-puncture and double-puncture methods will allow nurses to confidently perform these procedures and select the appropriate method per patient. Simulation training or supervised practice can shorten the learning curve for tunneling, thereby improving insertion efficiency and outcomes. Nurses should also incorporate patient education, explaining the chosen technique to patients including why it’s recommended for them (for instance, “we’ll do a tunneled PICC to reduce the chance of infection or clot”). This can help manage patient expectations and improve their satisfaction. From a policy perspective, nursing leadership may update PICC insertion protocols and guidelines to reflect evidence-based preferences. For example, a protocol might state that single-puncture tunneling is the default for all new PICCs unless specific criteria for using double-puncture or conventional are met. This kind of standardization can lead to more consistent outcomes across practitioners. Furthermore, the findings support the value of specialized PICC nurse teams – their expertise enables utilization of advanced techniques like tunneling, which ultimately benefits patient care. In summary, implementing the evidence from this study can lead to safer PICC practices, with oncology nurses playing a pivotal role in advancing vascular access outcomes through technique selection and patient-centered care. 5 Conclusion This prospective study provided a comprehensive head-to-head comparison of three PICC insertion techniques in an oncology setting: conventional ultrasound-guided non-tunneled insertion, single-puncture subcutaneous tunneling, and double-puncture subcutaneous tunneling. Our findings indicate that the single-puncture tunneled PICC is the most advantageous technique for routine use in oncology patients, as it significantly lowered the overall complication rate (particularly reducing thrombosis incidence) and achieved the highest patient satisfaction, all while maintaining a reasonable insertion time. The double-puncture tunneled PICC was effective in preventing catheter migration and may be particularly useful for patients in whom catheter stability is a top priority, although nurses should be mindful of its longer placement time and higher patient discomfort during insertion. The conventional PICC method, while fastest and simplest, carried a higher risk of complications over time, making it less ideal for long-term therapy when compared to the tunneled approaches. It may still be suitable in short-term or urgent situations or in settings where tunneling cannot be performed. The novelty of our study lies in the direct comparison of both tunneling subtypes within one study cohort, demonstrating that tunneled PICCs are not a uniform category – the specifics of the tunneling technique substantially influence outcomes. Based on our results, we propose an evidence-based practice framework for PICC placement in oncology: use single-puncture tunneling as the default approach for most patients, employ double-puncture tunneling selectively for those at elevated risk of line dislodgement, and reserve conventional PICC insertion for cases where speed or simplicity is paramount. Adopting this tailored approach can help maximize patient safety (fewer infections and thromboses), ensure catheter reliability, and enhance patient comfort and satisfaction with their central line. Future research should build on these findings by exploring long-term outcomes and generalizability. Multi-center randomized controlled trials would be valuable to confirm the superiority of single-puncture tunneling and to further quantify the circumstances where double-puncture offers net benefit. Investigations into cost-effectiveness (balancing the slightly longer procedure vs. savings from fewer complications) and quality-of-life assessments for patients with each PICC type would also be informative. Additionally, studying interventions to reduce the learning curve for tunneling (such as novel devices or training programs) could facilitate wider adoption of these techniques. In conclusion, improving vascular access in oncology care requires not only technological and procedural innovations but also the evidence-based selection of techniques by skilled nursing professionals. By integrating efficient practices with patient-centered considerations, oncology nurses can significantly impact treatment continuity and patient well-being. Declarations Ethics Approval The study was approved by the Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University (No. 2022-KY-(001)) and conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants. Conflict of Interest Statement The authors declare that they have no conflicts of interest relevant to this study. Ethics approval and consent to participate This study was approved by the Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University (Approval No. 2022-KY-(001)). All procedures were conducted in accordance with the Declaration of Helsinki. Written informed consent to participate was obtained from all patients prior to enrollment. Consent for publication Not applicable. This study did not involve identifiable personal data from any individual participant. Competing interests The authors declare that they have no competing interests. Funding This research was supported by the Self-funded Research Project of the Guangxi Zhuang Autonomous Region Health Commission (Grant No. Z20201111). The funding body had no role in the design of the study, data collection, analysis, interpretation, or in writing the manuscript. Authors’ contributions LT and WJ contributed equally to this work and are co-first authors. Lu Ting (LT) and Wei Jiejing (WJ) were involved in the study conception and design, performed the PICC insertions and data collection, and drafted the initial manuscript. Xu Yi (XY) supervised the study, provided expert guidance on PICC insertion techniques, and critically revised the manuscript for important intellectual content. XY is the corresponding author and guarantor of the work. All authors read and approved the final manuscript. Clinical trial number Not applicable. Author Contribution LT and WJ contributed equally to this work and are co-first authors. Lu Ting (LT) and Wei Jiejing (WJ) were involved in the study conception and design, performed the PICC insertions and data collection, and drafted the initial manuscript. Xu Yi (XY) supervised the study, provided expert guidance on PICC insertion techniques, and critically revised the manuscript for important intellectual content. XY is the corresponding author and guarantor of the work. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank all the patients who participated in this study and the nursing staff of the oncology department for their support and dedication to improving PICC practices. Data Availability The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. References Gravdahl Eva Haugen Dagny Faksvåg,Fredheim Olav Magnus.Use of peripherally inserted central venous catheters and midline catheters for palliative care in patients with cancer: a systematic review[J]. Support Care Cancer 2024 , 32 (7):464 . Gonella, S. Antonuzzo Andrea,Bossi Paolo.Peripherally or centrally inserted central catheters: what is the best vascular access device for cancer patients?[J]. Support Care Cancer 2021 , 29 (6):2803–2806 . Yuanli, S. Wu Xiangchun.Complications of implanted port catheters and peripherally inserted central catheters in chemotherapy-treated cancer patients: A meta-analysis[J]. Adv. Clin. Exp. Med. 2023 , 32 (5):523–532 . Li, J. H. et al. Lin A Randomized Controlled Trial to Compare Peripherally Inserted Central Catheter Tunnel Lengths in Adult Patients With Cancer[J].Clin J Oncol Nurs,2023,27(3):295–304. Wu, S. Y. Y. L. H. Implementation of Tunneled Peripherally Inserted Central Catheters Placement in Cancer Patients: A Randomized Multicenter Study[J]. Clin. Nurs. Res. 33 (1), 19–26 (2024). Peripherally inserted tunnelled. catheters: a new option for venous access[J]. Minim. Invasive Ther. Allied Technol. 2001 , 10 (4):231–234 . Kim Il Jung,Shim Dong Jae,Lee Jae Hwan. et al.Impact of subcutaneous tunnels on peripherally inserted catheter placement: a multicenter retrospective study[J].Eur Radiol,2019, 29 (5):2716–2723 . Wei Jiejing, L. & Zhouwei, L. Ting, et al. Clinical application of two-needle subcutaneous tunnel method in patients with PICC catheterization [J].Chinese General Practice Nursing,2022,20(12). Pinelli, F. Muzzi Mirko,Pittiruti Mauro.Should ultrasound evaluation for catheter-related thrombosis always be required before PICC removal?[J]. J. Vasc Access. 25 (3), 697–702 (2024). Li, W. C. J. D. Y. L. et al. Risk factors and prediction model construction for peripherally inserted central catheter-related infections[J].Heliyon,2024, 10 (8):e29158 . Zhu, Y. et al. Li Diwen,Li Yunfei,. Predictive Model for PICC Occlusion Risk for Patients in Intensive Care Units: A Retrospective Clinical Study[J].Altern Ther Health Med,29(8):278–285. (2023). Luo Mengna,Wu Zhenming,Fan Yuying.Peripherally inserted central catheter malposition into the azygos vein: A case series report and review of the literature[J]. J. Vasc Access. , 26 (3):975–981. (2025). Briant Fohlen Audrey, R. & Dutheil Jean Jacques. Complications of peripherally inserted central catheters in adult hospitalized patients and outpatients in the KTFIXPICC study: A randomized controlled trial evaluating a fixation device KT FIX Plussystem[J]. Am. J. Infect. Control . 50 (8), 916–921 (2022). Ferraz-Torres Marta,Sancho-Sena Elena,Corcuera-Martinez María Inés, et al.Complications Related to the Securement Device in Peripheral Intravenous Catheters: A Randomized Study[J]. J. Infus Nurs. , 47 (6):391–396. (2024). Qu, M. et al. Zhao Jialai,Zhang Yiling,. Utilizing the visual analogue scale (VAS) to monitor and manage pain in post-operative skin wounds after thoracic surgery[J].Int Wound J,21(3):e14503. (2024). Maria Kapritsou,Theodoros Katsoulas,Maria Bastaki. Implementation of tunneled versus not tunneled peripherally inserted central catheters[J]. J. Vasc Nurs. 37 (2), 132–134 (2019). Saijo, F. et al. Odaka Yoshinobu,Mutoh Mitsuhisa,. A novel technique of axillary vein puncture involving peripherally inserted central venous catheters for a small basilic vein[J].J Vasc Access,19(3):311–315. (2018). Jiana, H. Mao Xiaodan.Complications of tunneled and non-tunneled peripherally inserted central catheter placement in chemotherapy-treated cancer patients: a meta-analysis[J]. Front. Surg. 11 , 1469847 (2024). Zheng, B., Panton Ormond, N. M. & Al-Tayeb Thamer A.Operative length independently affected by surgical team size: data from 2 Canadian hospitals[J]. Can. J. Surg. 55 (6), 371–376 (2012). Li, X. M. F. X. C. Q. et al. Subcutaneous tunneling technique to improve outcomes for patients undergoing chemotherapy with peripherally inserted central catheters: a randomized controlled trial[J]. J. Int. Med. Res. 2021 , 49 (4):3000605211004517 . Pinelli Fulvio,Barbani Francesco,Defilippo Barbara. et al.Quality of life in women with breast cancer undergoing neoadjuvant chemotherapy: comparison between PICC and PICC-port[J].Breast Cancer,2024, 31 (5):945–954 . Additional Declarations No competing interests reported. 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Compared with centrally inserted central venous catheters, PICCs can be placed at the bedside under ultrasound guidance with lower risks of insertion-related trauma (e.g., pneumothorax, hemothorax), making them particularly advantageous in oncology nursing practice\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. However, conventional non-tunneled PICCs are associated with notable complications such as catheter-related bloodstream infections (CRBSIs), catheter-related thrombosis (CRT), mechanical dislodgement, and catheter migration, which can disrupt treatment schedules and adversely affect patient outcomes\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. These limitations have prompted the exploration of modified PICC insertion techniques to enhance catheter stability, reduce complications, and improve patient safety.\u003c/p\u003e \u003cp\u003eThe tunneled PICC technique\u0026mdash;adapted from tunneled central venous catheters\u0026mdash;introduces a subcutaneous tract between the venipuncture site and the skin exit site, thereby separating the intravascular pathway from the external environment\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. This design has been shown to reduce bacterial colonization at the insertion site, lowering the risk of CRBSIs and CRT and decreasing overall complication rates\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Tunneling may also improve catheter stability and patient comfort by reducing mechanical irritation and accidental dislodgement\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Previous studies have confirmed that tunneled PICCs are superior to traditional non-tunneled methods in reducing infection and thrombotic events and in improving long-term catheter maintenance\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Nevertheless, most existing research has compared \u0026ldquo;tunneled vs. non-tunneled\u0026rdquo; PICCs without systematically evaluating differences between tunneling techniques.\u003c/p\u003e \u003cp\u003eCurrently, two main PICC tunneling approaches are used in practice: the single-puncture (single-needle) and double-puncture (double-needle) techniques. Although both tunneling methods are intended to provide similar benefits, their procedural complexity, success rates, required insertion time, and patient experiences may differ. There is a paucity of evidence directly comparing all three insertion methods\u0026mdash;conventional non-tunneled, single-puncture tunneled, and double-puncture tunneled\u0026mdash;within a single study population. In practice, the choice of technique is often based on operator preference rather than standardized evidence. Moreover, PICC insertion and maintenance in oncology are predominantly nurse-led procedures, underscoring the need for research from a nursing perspective to determine which technique best optimizes patient care and nursing workflow. Therefore, this study aimed to comprehensively evaluate the efficiency, safety, and patient-reported outcomes of three PICC insertion techniques in oncology patients. The findings are intended to provide robust evidence to guide clinical decision-making and improve standardization of PICC insertion strategies in oncology nursing practice.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design and Participants\u003c/h2\u003e \u003cp\u003eThis prospective observational study was conducted in the Department of Oncology at a tertiary hospital in Nanning, China, between June 2022 and December 2023. Consecutive patients meeting the inclusion criteria were enrolled for PICC placement. Inclusion criteria were: (1) confirmed diagnosis of a malignant tumor requiring PICC for treatment; (2) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; and (3) fully conscious and able to communicate. Exclusion criteria were: (1) severe active infection or coagulation disorder; and (2) previous history of PICC placement. Patients were withdrawn from the study if they (1) chose to discontinue participation due to health status changes or (2) were lost to follow-up during the 16-week observation period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003e2.2 Sample Size Calculation\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eThe sample size was calculated based on the primary outcome of overall catheter-related complication rate\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e, using PASS 15.0 software. Previous data indicated complication rates of approximately 30.5% with the conventional ultrasound-guided method, 18.6% with single-puncture tunneling, and 7.7% with double-puncture tunneling. Using α\u0026thinsp;=\u0026thinsp;0.05 and β\u0026thinsp;=\u0026thinsp;0.10, we determined that at least 49 patients per group were required to detect a significant difference. Allowing for a 20% dropout, a minimum of 62 patients per group was targeted. Ultimately, 418 patients were enrolled (131 in the conventional group, 178 in the single-puncture tunneling group, and 109 in the double-puncture tunneling group), meeting the target sample size.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 PICC Insertion Techniques\u003c/h2\u003e \u003cp\u003eAll insertions were performed by three certified PICC nurses, each with at least three years of clinical experience, using standardized techniques and equipment (Groshong\u0026reg; 4 Fr valve-type PowerPICC, Bard, USA; 3M Tegaderm transparent dressings). Pre-procedure platelet count and coagulation tests were performed to ensure values within normal limits. A maximal sterile barrier was maintained throughout. Tip position was confirmed by bedside X-ray or digital radiography, ensuring location in the lower third of the superior vena cava.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Conventional (Non-tunneled) Method\u003c/h2\u003e \u003cp\u003ePICC placement via direct ultrasound-guided venipuncture using the Seldinger technique. (1) \u003cem\u003eMeasurement\u003c/em\u003e: The required catheter length was estimated from the puncture site to the right sternoclavicular joint and then to the third intercostal space, adjusting for patient height and body habitus. (2) \u003cem\u003eVein selection\u003c/em\u003e: The basilic vein (preferred) or brachial vein was identified using ultrasound to assess vessel diameter, depth, and course. (3) \u003cem\u003eVenipuncture\u003c/em\u003e: An introducer needle was advanced into the vein at a 20\u0026ndash;30\u0026deg; angle under ultrasound guidance until blood return was observed. A guidewire was then inserted through the needle, leaving\u0026thinsp;~\u0026thinsp;10\u0026ndash;15 cm of the guidewire externalized. (4) \u003cem\u003eDilation and catheter insertion\u003c/em\u003e: After local infiltration of 0.2% lidocaine, a dilator and introducer sheath were inserted over the guidewire. The PICC was then threaded through the sheath to the predetermined length. (5) \u003cem\u003eConfirmation and securement\u003c/em\u003e: The catheter tip position was confirmed radiographically. The catheter was trimmed as needed, connected to a needle-free connector, and secured with a sterile dressing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Single-puncture Tunneling Technique\u003c/h2\u003e \u003cp\u003ePICC placement with creation of a short subcutaneous tunnel using a single skin puncture that also serves as the venous entry point. (1) \u003cem\u003eMarking\u003c/em\u003e: The intended skin exit site was marked on the mid-upper arm. Under ultrasound guidance, the ideal venipuncture site was identified 2\u0026ndash;4 cm proximal to the exit site and marked; this distance defined the tunnel length (generally\u0026thinsp;\u0026le;\u0026thinsp;5 cm, or slightly shorter than the puncture needle length). (2) \u003cem\u003eAnesthesia\u003c/em\u003e: After sterile preparation with maximal barrier precautions, 1% lidocaine was infiltrated subcutaneously along the planned tunnel path between the skin puncture and vein puncture sites. (3) \u003cem\u003eUltrasound assessment\u003c/em\u003e: A longitudinal ultrasound view was used to assess the vein\u0026rsquo;s course, valves, and surrounding structures, followed by a transverse view to confirm the vein\u0026rsquo;s location relative to the marks. (4) \u003cem\u003eTunnel and venipuncture\u003c/em\u003e: The introducer needle was inserted at the skin exit site at a shallow angle (\u0026asymp;\u0026thinsp;5\u0026ndash;10\u0026deg;) and advanced subcutaneously toward the venipuncture mark for approximately 2\u0026ndash;4 cm. Upon approaching the venipuncture site, the needle angle was adjusted according to the vein depth, and the vein was punctured under real-time ultrasound guidance (longer tunnels required a shallower initial angle). (5) \u003cem\u003eCatheter insertion\u003c/em\u003e: Once blood return confirmed vein entry, a modified Seldinger technique was used to insert the guidewire and then advance the PICC into position in the usual manner.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.3 Double-puncture Tunneling Technique\u003c/h2\u003e \u003cp\u003eseparate skin exit and vein entry points connected by a subcutaneous tunnel created with a tunneling needle. (1) Measurement and planning: The required catheter length and arm circumference were measured. A four-point marking method was used to define the skin exit site, vein puncture site, and tunnel course, ensuring alignment. (2) Venipuncture: After sterile preparation, the basilic vein was punctured. Once the guidewire entered the vessel (total length\u0026thinsp;=\u0026thinsp;puncture needle length\u0026thinsp;+\u0026thinsp;vein depth), the needle angle was lowered, and the guidewire was advanced until 10\u0026ndash;15 cm remained outside the body. (3) Tunnel creation: Local anesthesia (2% lidocaine) was administered along the planned tunnel. The introducer sheath was advanced into the vessel, and the catheter was inserted to the measured length. The sheath was then fully withdrawn from the puncture site without creating a second skin breach. (4) Exit site creation: At a skin point 3\u0026ndash;5 cm distal to the venipuncture site, 0.2% lidocaine was infiltrated locally. A metal tunneling needle was passed subcutaneously toward the puncture site, gently dissecting tissue. The catheter was threaded into the tunneling needle\u0026rsquo;s lumen and pulled out through the exit site. (5) Securing the catheter: After ensuring hemostasis, the catheter was trimmed, connected to the extension set, and secured with sterile dressing. Compression bandaging was applied for 24 hours. (6) Post-procedure care: The catheter was locked with 10 mL normal saline during infusion intervals. Dressing changes were performed weekly using an upward removal technique to minimize skin trauma.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Collection and Follow-up\u003c/h2\u003e \u003cp\u003eBaseline demographic and clinical data were recorded for each patient, including age, sex, education level, occupation, marital status, cancer diagnosis, and cancer stage. Details of the PICC placement (side of insertion, vein used) were also noted. These baseline variables were collected to verify that the groups were comparable and to identify any factors that might influence outcomes.\u003c/p\u003e \u003cp\u003eAfter PICC insertion, patients were followed for 16 weeks (approximately 4 months) or until catheter removal, whichever came first. This follow-up duration was chosen to capture both early and intermediate-term complications, while minimizing the impact of planned PICC removals after completion of therapy. Follow-up was conducted through weekly outpatient PICC maintenance visits or telephone check-ins. During follow-up, the nursing team recorded any occurrence of catheter-related complications and evaluated patient-reported outcomes. The same trained nursing team was responsible for all follow-up assessments to ensure consistency in data collection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Outcome Measures\u003c/h2\u003e \u003cp\u003eWe assessed three categories of outcomes: PICC insertion efficiency, catheter-related complications, and patient-reported experience. Specific measures within each category were defined as follows:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePrimary outcomes (safety \u0026ndash; complication incidence)\u003c/strong\u003e \u003cp\u003e We tracked six types of catheter-related complications, defined according to the Infusion Therapy Standards of Practice (2016) and relevant clinical guidelines\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e(1)Catheter-related thrombosis\u003c/strong\u003e \u003cp\u003eDevelopment of venous thrombosis (clot) in the catheterized limb after PICC placement, confirmed by Doppler ultrasound. Patients with known pre-existing thrombosis were excluded from this count\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e(2)Catheter-related infection\u003c/strong\u003e \u003cp\u003eThis included local infection at the exit site or a catheter-related bloodstream infection (CRBSI). Diagnostic criteria were clinical signs (e.g., erythema, swelling, purulent discharge at site; fever) and, for CRBSI, laboratory evidence such as positive blood cultures with no other infection source \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e(3)Catheter occlusion\u003c/strong\u003e \u003cp\u003ePartial or complete blockage of the catheter lumen, evidenced by inability to flush or aspirate blood, or resistance during infusion. Occlusions could be thrombotic or precipitate-related \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e(4)Catheter malposition\u003c/strong\u003e \u003cp\u003eUnintended migration of the catheter tip from the initial verified position (e.g., into a smaller vein or undesirable location), usually confirmed by imaging and often requiring repositioning or catheter adjustment \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e(5)Catheter dislodgement\u003c/strong\u003e \u003cp\u003eExternal movement or pull-out of the catheter from its original insertion, indicated by an increase in external catheter length or complete removal. This compromises catheter function and typically results from accidental traction on the line \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e(6)Skin injury related to catheter\u003c/strong\u003e \u003cp\u003eAny persistent skin damage under or around the catheter dressing, such as blistering, skin erosion, maceration, or tears that last\u0026thinsp;\u0026gt;\u0026thinsp;30 minutes after dressing removal. These injuries can result from adhesive irritation or mechanical trauma during dressing changes \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eFor each complication type, we calculated the incidence (%) as the number of patients experiencing that complication within 16 weeks divided by the total number of patients in the group, multiplied by 100%.\u003c/p\u003e \u003cp\u003eSecondary outcomes:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePatient-reported experience\u003c/strong\u003e \u003cp\u003eWe measured patient comfort and satisfaction associated with the PICC procedure. Two self-reported metrics were used\u003c/p\u003e \u003c/p\u003e \u003cp\u003e(1)Pain score \u0026ndash; Immediately after PICC insertion (within 10 minutes), patients rated their pain during the procedure using a 0\u0026ndash;10 visual analogue scale (VAS), where 0\u0026thinsp;=\u0026thinsp;no pain and 10\u0026thinsp;=\u0026thinsp;worst imaginable pain\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Nurses explained the scale beforehand and recorded the score once the procedure was completed.\u003c/p\u003e \u003cp\u003e(2)Satisfaction score \u0026ndash; On the day after insertion, patients completed a short questionnaire rating their overall satisfaction with the PICC insertion experience on a 0\u0026ndash;10 scale (higher scores\u0026thinsp;=\u0026thinsp;more satisfied). This encompassed their comfort, trust in the catheter for ongoing therapy, and willingness to undergo the procedure again if needed. A higher score indicated a better patient experience.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInsertion efficiency\u003c/strong\u003e \u003cp\u003eTwo measures captured the technical efficiency of PICC placement\u003c/p\u003e \u003c/p\u003e \u003cp\u003e(1)First-attempt success rate \u0026ndash; whether the PICC was successfully placed in the superior vena cava on the first venipuncture attempt (yes/no). We calculated the percentage of patients in each group for whom the nurse achieved successful catheterization without requiring additional needle sticks.\u003c/p\u003e \u003cp\u003e(2)Procedure time \u0026ndash; the total duration of the insertion procedure, recorded in minutes from the start of preparation (skin antisepsis, etc.) to completion of dressing placement. This included time for ultrasound assessment, any tunneling steps, and troubleshooting. Nurses used a stopwatch or clock to note start and end times.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Statistical Analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using IBM SPSS Statistics version 26.0. Continuous variables (e.g., age, procedure time, pain score, satisfaction score) were summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). We used one-way analysis of variance (ANOVA) to compare means across the three groups. If the ANOVA indicated a significant difference (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), we conducted post-hoc pairwise comparisons with Bonferroni correction to identify which groups differed. Categorical variables (e.g., success rate, incidence of each complication, overall complication rate, sex distribution) were summarized as counts and percentages, and compared using the chi-square test or Fisher\u0026rsquo;s exact test when expected cell counts were small. Relative risks with 95% confidence intervals were calculated for key outcomes as appropriate. All hypothesis tests were two-tailed, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for primary comparisons.\u003c/p\u003e \u003cp\u003eAnalyses were primarily descriptive and comparative; as this was an observational study, no adjustments were made for multiple outcomes beyond the planned Bonferroni adjustments in post-hoc tests. The results are presented with relevant test statistics (e.g., χ\u0026sup2;, F values) and P-values to provide transparency about the strength of evidence for differences observed.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Baseline Characteristics\u003c/h2\u003e \u003cp\u003eA total of 418 oncology patients were included: 131 in the conventional ultrasound-guided group, 178 in the single-needle subcutaneous tunneling group, and 109 in the double-needle subcutaneous tunneling group. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, there were no statistically significant differences among the three groups in terms of sex distribution, mean age, educational level, occupation, marital status, primary diagnosis, tumor stage, puncture site, or puncture vein (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This indicates that the baseline demographic and clinical characteristics were well balanced across groups, ensuring comparability for subsequent analyses.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral information of cancer patients with three PICC placement methods (n\u0026thinsp;=\u0026thinsp;418)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConventional method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSingle-needle tunneling\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDouble-needle tunneling\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eχ\u0026sup2;/F\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.528\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.063\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66(50.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e111(62.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56(51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65(49.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67(37.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53(48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years, χ\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52.19\u0026thinsp;\u0026plusmn;\u0026thinsp;13.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.34\u0026thinsp;\u0026plusmn;\u0026thinsp;13.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.06\u0026thinsp;\u0026plusmn;\u0026thinsp;14.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.822\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36(27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55(30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27(24.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior/senior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69(52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87(48.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57(52.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26(19.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36(20.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25(22.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.965\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.548\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarmer/worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63(48.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72(40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41(37.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff/public servant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18(13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25(14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20(18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22(16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28(15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19(17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28(21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53(29.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29(26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.825\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e112(85.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150(84.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90(82.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19(14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28(15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19(17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.687\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDigestive system malignancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55(42.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58(32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29(26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematological malignancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45(34.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65(36.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49(45.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31(23.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55(30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31(28.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical stage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.221\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6(4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14(7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7(6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19(10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3(2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22(16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24(13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19(17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94(71.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e121(68.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80(73.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuncture site, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.749\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft upper limb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98(74.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e134(75.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70(64.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight upper limb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33(25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44(24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39(35.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePunctured vein, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.873\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasilic vein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76(58.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98(55.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61(56.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrachial vein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55(42.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80(44.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48(44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Insertion Efficiency\u003c/h2\u003e \u003cp\u003eInsertion efficiency outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The first-attempt success rate differed significantly among the three groups (χ\u0026sup2; = 7.057, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029). Pairwise comparisons revealed that the conventional group achieved a significantly higher success rate (98.5%) compared with the double-needle group (90.8%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while no significant difference was observed between the conventional and single-needle groups (94.4%, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) or between the single- and double-needle groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Operation time varied significantly (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), being shortest in the conventional group (26.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.73 min), followed by the single-needle group (31.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.92 min) and the double-needle group (36.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.48 min). All pairwise comparisons for operation time were statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the insertion efficiency of three PICC insertion methods (n\u0026thinsp;=\u0026thinsp;418)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCases (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFirst-Attempt Success Rate (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProcedure Time(χ\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConventional method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.727\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle-needle tunneling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.922\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDouble-needle tunneling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.476\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.057\u003csup\u003e1)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e196.182\u003csup\u003e2)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: 1)χ\u0026sup2;, 2༉t\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Catheter-Related Complications\u003c/h2\u003e \u003cp\u003eCatheter-related complication rates are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The incidence of catheter-related thrombosis showed significant differences among groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.034). Post-hoc analysis indicated that the single-needle group (3.4%) had a significantly lower rate than the conventional (8.4%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and double-needle groups (11.0%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while no difference was observed between the conventional and double-needle groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The rate of catheter migration also differed significantly (P\u0026thinsp;=\u0026thinsp;0.021, Fisher\u0026rsquo;s exact test), with the double-needle group (0.9%) showing a lower rate than the conventional group (6.9%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05); no other differences were statistically significant.\u003c/p\u003e \u003cp\u003eFor total complication rates, significant differences were observed (χ\u0026sup2; = 19.088, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The single-needle group demonstrated the lowest overall complication rate (12.9%), significantly lower than the conventional group (33.6%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and the double-needle group (25.7%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No significant difference was detected between the conventional and double-needle groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Complication Rates Among Three Catheterization Methods (n\u0026thinsp;=\u0026thinsp;418)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCatheter-related Thrombosis, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCatheter-related Infection, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCatheter Occlusion, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCatheter Malposition, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCatheter Dislodgement, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSkin Injury, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTotal Complications, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConventional method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11(8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11(8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5(3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9(6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e44(33.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle-needle tunneling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6(3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6(3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2(1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e23(12.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDouble-needle tunneling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12(11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7(6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2(1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1(0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2(1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4(3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e28(25.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eχ\u0026sup2;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.738\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.664\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e19.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.435\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.694\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eNote\u003c/em\u003e: 1) χ\u0026sup2; test; 2) Fisher\u0026rsquo;s exact test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Patient Experience\u003c/h2\u003e \u003cp\u003ePatient-reported pain scores and satisfaction levels are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Pain scores differed significantly among groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The double-needle group reported the highest pain score (3.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99), significantly higher than both the conventional group (1.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and the single-needle group (1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while no significant difference was found between conventional and single-needle groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Satisfaction scores also differed significantly (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with the single-needle group achieving the highest satisfaction (8.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20), significantly exceeding both the double-needle group (7.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and the conventional group (7.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Patient Experience Among Three PICC Insertion Methods (n\u0026thinsp;=\u0026thinsp;418)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCases (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePain Score(χ\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSatisfaction Score(χ\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConventional method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.570\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.916\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle-needle tunneling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.657\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.199\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDouble-needle tunneling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.971\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e262.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e108.406\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eIn this study of 418 oncology patients requiring PICC placement, we directly compared three catheter insertion techniques: conventional ultrasound-guided non-tunneled placement, single-puncture subcutaneous tunneling, and double-puncture subcutaneous tunneling. Our results demonstrated that the conventional method achieved the highest first-attempt success rate and shortest procedure time, while both tunneling methods required longer insertion times. Importantly, the single-puncture tunneling technique was associated with the lowest overall incidence of catheter-related complications, particularly thrombosis and catheter migration, and also achieved the highest patient satisfaction. The double-puncture method showed intermediate complication rates but was associated with higher pain scores and longer procedure duration. These findings suggest that the single-puncture subcutaneous tunneling technique may represent the most favorable balance between procedural safety, complication prevention, and patient experience in oncology care.\u003c/p\u003e \u003cp\u003e \u003cb\u003eComplications\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOur study revealed distinct complication profiles among the three insertion techniques, highlighting both unique advantages and trade-offs. Catheter-related thrombosis was significantly reduced in the single-puncture tunneling group (3.4%) compared with both the conventional group (8.4%) and the double-puncture group (11.0%). This advantage may be attributed to the shorter subcutaneous tract and the avoidance of multiple puncture tracts, which together minimize vascular wall irritation and preserve local hemodynamics. Previous studies have reported conflicting results regarding thrombosis rates between tunneled and non-tunneled PICCs\u0026mdash;for example, Maria et al\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e found no significant difference, whereas Sheng et al\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e observed a clear reduction with tunneling. Our findings extend this literature by demonstrating that not all tunneling methods are equivalent, and that a simplified single-puncture tract may mitigate thrombogenic risk more effectively than either the conventional or double-puncture approaches.\u003c/p\u003e \u003cp\u003eCatheter migration, by contrast, was lowest in the double-puncture tunneling group (0.9%), compared with the single-puncture (1.7%) and conventional groups (6.9%). The separation of the venipuncture site and exit site creates a longer subcutaneous pathway, which serves as an \u0026ldquo;anchoring mechanism\u0026rdquo; that resists external traction and skin movement. This finding is consistent with the theoretical design rationale of double-puncture tunneling and aligns with prior reports that tunneling increases catheter stability\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. However, this stability advantage came at the cost of increased thrombosis risk and a higher overall complication rate, suggesting that a longer subcutaneous tract may introduce greater tissue trauma and procedural complexity. The comparison also illustrates a trade-off: while the single-puncture method was superior in reducing thrombosis, it was relatively less effective than the double-puncture method in preventing migration.\u003c/p\u003e \u003cp\u003eWhen examining overall complication rates, the single-puncture technique demonstrated the most favorable balance, achieving the lowest total adverse event rate (12.9%) compared with the conventional (33.6%) and double-puncture (25.7%) groups. This finding highlights the potential of single-puncture tunneling as a \u0026ldquo;comprehensive advantage\u0026rdquo; technique in oncology patients, where minimizing complications is paramount for uninterrupted treatment delivery. The mechanism underlying this balance may relate to its dual strengths: reducing vascular trauma (thereby lowering thrombosis) while avoiding the excessive dissection of double-puncture tunnels (which can increase other complications). Our results are further supported by a recent meta-analysis by Hong and Mao\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, which synthesized 12 randomized controlled trials including 2,940 cancer patients (1,484 in the tunneled group and 1,456 in the control group). It demonstrated that tunneled PICCs significantly reduced all major complications\u0026mdash;except catheter occlusion\u0026mdash;compared with non-tunneled approaches, reinforcing the broad safety advantage of tunneling strategies. While the double-puncture approach may be preferable for patients at particularly high risk of catheter migration, our findings suggest that the single-puncture technique may represent the optimal default choice, offering both safety and practicality. Taken together, these findings emphasize that the choice of tunneling strategy should be individualized, with attention to patient risk profiles, operator expertise, and the relative weighting of thrombosis prevention versus migration control.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInsertion Efficiency\u003c/b\u003e \u003c/p\u003e \u003cp\u003eEfficiency outcomes also varied between groups. The conventional method achieved the highest first-attempt success rate and the shortest procedure time, consistent with its simplicity and operator familiarity. Both tunneling methods prolonged insertion time, which can be attributed not only to their more complex steps but also to the relative novelty of tunneling in our center, where operator proficiency is still developing. Importantly, within tunneling methods, the single-puncture technique required less time than the double-puncture approach, reflecting its simpler tract creation and avoidance of extensive tissue dissection. These results are consistent with Zheng B et al.\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e, who reported that procedural complexity is directly correlated with longer operating times. However, our findings contrast with those of Kim IJ et al\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e, who reported that subcutaneous tunnel creation did not significantly prolong procedural time, suggesting that differences in operator training, patient population, and procedural standardization may account for the discrepancy.\u003c/p\u003e \u003cp\u003eFrom a broader perspective, these findings may also reflect the learning curve associated with newly introduced techniques. As tunneling becomes more widely practiced and operator experience accumulates, the time gap between tunneling and conventional methods is expected to narrow, reducing the efficiency penalty currently observed. Furthermore, although the double-puncture tunneling method was associated with longer procedure times, this disadvantage may be offset in selected clinical contexts. For example, in patients requiring long-term catheter retention or those at particularly high risk of catheter migration, the additional stability conferred by the longer subcutaneous tract may justify the longer insertion duration. In this sense, insertion efficiency should not be interpreted solely in terms of absolute procedure duration but rather weighed against downstream clinical benefits\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLooking ahead, future improvements may further mitigate the efficiency gap. Enhanced operator training, standardized procedural protocols, and the introduction of specialized tunneling instruments may help shorten insertion times without compromising safety. Integration of simulation-based learning and competency assessment could accelerate the acquisition of tunneling proficiency, thereby reducing the current learning curve. Thus, while the conventional method remains the fastest, the single-puncture tunneling technique represents a pragmatic compromise, balancing manageable insertion times with improved safety, whereas the double-puncture method may be strategically reserved for patients in whom long-term catheter stability is prioritized over procedural expediency.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatient Experience\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePatient-reported outcomes provided an essential dimension to evaluate technique selection, particularly in oncology patients who often require long-term chemotherapy and repeated vascular access. In this context, patient experience is not only a measure of procedural comfort but also a determinant of adherence to treatment protocols and overall quality of care.\u003c/p\u003e \u003cp\u003ePain scores were lowest in the conventional and single-puncture tunneling groups, suggesting that minimizing the number of punctures and tissue dissection directly contributes to procedural comfort. In contrast, the double-puncture method was associated with significantly greater discomfort, reflecting its higher degree of invasiveness and extended tract creation. These differences highlight the importance of procedural design in influencing immediate patient experience. Satisfaction scores, however, revealed a more nuanced picture. Although the conventional method provided relative comfort during insertion, its higher complication rate likely diminished long-term satisfaction and patient confidence in the device. In comparison, the single-puncture tunneling technique achieved the highest satisfaction scores, suggesting that patients value not only comfort during the procedure but also the perceived safety and reliability of the catheter in the weeks following placement. This aligns with reports from Sheng et al\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e, which demonstrated that subcutaneous tunneling not only reduces catheter-related complications but also enhances procedural comfort and patient satisfaction\u0026mdash;emphasizing that minimizing procedural invasiveness and complications significantly improves patient acceptance.\u003c/p\u003e \u003cp\u003eFinally, long-term acceptance of vascular devices is especially critical in oncology care, where patients undergo repeated cycles of chemotherapy and depend on uninterrupted central access\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Our findings suggest that the single-puncture tunneling method best integrates procedural safety, comfort, and reliability, offering an optimal balance that supports sustained treatment adherence. Conversely, the double-puncture technique, while providing stability against catheter migration, may be penalized by increased procedural discomfort, potentially limiting its acceptance in routine oncology care. These insights underscore the need to consider patient-reported outcomes alongside clinical efficacy when selecting catheterization strategies, reinforcing the centrality of patient-centered decision-making in vascular access management.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study has several limitations that should be acknowledged when interpreting the results. First, as an observational (non-randomized) study from a single center, there is a possibility of selection bias and unmeasured confounding. We tried to mitigate this by enrolling consecutive patients and showing that baseline characteristics were similar, but without random assignment of techniques, we cannot completely rule out that certain patient factors influenced the choice of method and outcomes. Second, all insertions were performed at a single tertiary hospital with an experienced PICC team; the results may not generalize to settings with less specialized nursing staff or different patient populations. The complication rates and success rates observed here could vary in other institutions. Third, the follow-up duration was 16 weeks, which captures the mid-term outcomes but not very long-term complications (some PICCs stay in for 6\u0026ndash;12 months in oncology). We may have missed late complications beyond 4 months or differences in catheter lifespan between techniques. Additionally, patient satisfaction was measured only the day after insertion; longer-term satisfaction or quality of life related to the catheter was not assessed. Lastly, while our sample size was relatively large overall, the double-puncture group had the smallest number of patients (n\u0026thinsp;=\u0026thinsp;109), which could limit the power to detect differences for rarer outcomes or in subgroup analyses. Larger multicenter studies or randomized controlled trials would strengthen the evidence base by addressing these limitations.\u003c/p\u003e \u003cp\u003eDespite these limitations, our study provides valuable real-world data comparing all three PICC techniques and offers practical insights for nursing practice. The consistency of many of our findings with existing literature lends credibility to our conclusions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplications for Nursing Practice\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe results of this study have direct implications for oncology nursing practice, particularly for nurses who place and manage PICC lines. By understanding the relative advantages and drawbacks of each PICC insertion technique, nurses can make evidence-informed decisions to enhance patient care. Key practice recommendations based on our findings include: Adopt single-puncture tunneling as the first-line technique for most oncology patients requiring medium- to long-term PICCs. This method optimally balances safety and patient comfort, resulting in significantly fewer complications (especially thrombosis) and higher patient satisfaction compared to the conventional approach. Reserve the double-puncture tunneling technique for patients at high risk of catheter migration or dislodgement, such as those with high body mass index (obesity with abundant subcutaneous tissue), very active patients, or those who have had prior catheter movement issues. In these cases, the added stability of a longer tunnel is beneficial, even though the insertion is more invasive. Utilize the conventional PICC method for situations where rapid catheter placement is critical or if tunneling is contraindicated. For example, in emergency chemotherapy initiation or when resources/time are limited, the conventional technique\u0026rsquo;s speed and simplicity are advantageous. However, plan to closely monitor these patients for complications and consider an early switch to a tunneled PICC if long-term use is needed.\u003c/p\u003e \u003cp\u003eIn addition to technique selection, there are broader nursing practice implications: Hospitals and oncology units should ensure that PICC insertion teams (often nurse-led) are trained in both tunneling techniques. Education and competency development in the single-puncture and double-puncture methods will allow nurses to confidently perform these procedures and select the appropriate method per patient. Simulation training or supervised practice can shorten the learning curve for tunneling, thereby improving insertion efficiency and outcomes. Nurses should also incorporate patient education, explaining the chosen technique to patients including why it\u0026rsquo;s recommended for them (for instance, \u0026ldquo;we\u0026rsquo;ll do a tunneled PICC to reduce the chance of infection or clot\u0026rdquo;). This can help manage patient expectations and improve their satisfaction.\u003c/p\u003e \u003cp\u003e From a policy perspective, nursing leadership may update PICC insertion protocols and guidelines to reflect evidence-based preferences. For example, a protocol might state that single-puncture tunneling is the default for all new PICCs unless specific criteria for using double-puncture or conventional are met. This kind of standardization can lead to more consistent outcomes across practitioners. Furthermore, the findings support the value of specialized PICC nurse teams \u0026ndash; their expertise enables utilization of advanced techniques like tunneling, which ultimately benefits patient care. In summary, implementing the evidence from this study can lead to safer PICC practices, with oncology nurses playing a pivotal role in advancing vascular access outcomes through technique selection and patient-centered care.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThis prospective study provided a comprehensive head-to-head comparison of three PICC insertion techniques in an oncology setting: conventional ultrasound-guided non-tunneled insertion, single-puncture subcutaneous tunneling, and double-puncture subcutaneous tunneling. Our findings indicate that the single-puncture tunneled PICC is the most advantageous technique for routine use in oncology patients, as it significantly lowered the overall complication rate (particularly reducing thrombosis incidence) and achieved the highest patient satisfaction, all while maintaining a reasonable insertion time. The double-puncture tunneled PICC was effective in preventing catheter migration and may be particularly useful for patients in whom catheter stability is a top priority, although nurses should be mindful of its longer placement time and higher patient discomfort during insertion. The conventional PICC method, while fastest and simplest, carried a higher risk of complications over time, making it less ideal for long-term therapy when compared to the tunneled approaches. It may still be suitable in short-term or urgent situations or in settings where tunneling cannot be performed.\u003c/p\u003e \u003cp\u003eThe novelty of our study lies in the direct comparison of both tunneling subtypes within one study cohort, demonstrating that tunneled PICCs are not a uniform category \u0026ndash; the specifics of the tunneling technique substantially influence outcomes. Based on our results, we propose an evidence-based practice framework for PICC placement in oncology: use single-puncture tunneling as the default approach for most patients, employ double-puncture tunneling selectively for those at elevated risk of line dislodgement, and reserve conventional PICC insertion for cases where speed or simplicity is paramount. Adopting this tailored approach can help maximize patient safety (fewer infections and thromboses), ensure catheter reliability, and enhance patient comfort and satisfaction with their central line.\u003c/p\u003e \u003cp\u003eFuture research should build on these findings by exploring long-term outcomes and generalizability. Multi-center randomized controlled trials would be valuable to confirm the superiority of single-puncture tunneling and to further quantify the circumstances where double-puncture offers net benefit. Investigations into cost-effectiveness (balancing the slightly longer procedure vs. savings from fewer complications) and quality-of-life assessments for patients with each PICC type would also be informative. Additionally, studying interventions to reduce the learning curve for tunneling (such as novel devices or training programs) could facilitate wider adoption of these techniques. In conclusion, improving vascular access in oncology care requires not only technological and procedural innovations but also the evidence-based selection of techniques by skilled nursing professionals. By integrating efficient practices with patient-centered considerations, oncology nurses can significantly impact treatment continuity and patient well-being.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics Approval\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University (No. 2022-KY-(001)) and conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest relevant to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University (Approval No. 2022-KY-(001)). All procedures were conducted in accordance with the Declaration of Helsinki. Written informed consent to participate was obtained from all patients prior to enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study did not involve identifiable personal data from any individual participant.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research was supported by the Self-funded Research Project of the Guangxi Zhuang Autonomous Region Health Commission (Grant No. Z20201111). The funding body had no role in the design of the study, data collection, analysis, interpretation, or in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLT and WJ contributed equally to this work and are co-first authors. Lu Ting (LT) and Wei Jiejing (WJ) were involved in the study conception and design, performed the PICC insertions and data collection, and drafted the initial manuscript. Xu Yi (XY) supervised the study, provided expert guidance on PICC insertion techniques, and critically revised the manuscript for important intellectual content. XY is the corresponding author and guarantor of the work. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eClinical trial number\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eLT and WJ contributed equally to this work and are co-first authors. Lu Ting (LT) and Wei Jiejing (WJ) were involved in the study conception and design, performed the PICC insertions and data collection, and drafted the initial manuscript. Xu Yi (XY) supervised the study, provided expert guidance on PICC insertion techniques, and critically revised the manuscript for important intellectual content. XY is the corresponding author and guarantor of the work. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors would like to thank all the patients who participated in this study and the nursing staff of the oncology department for their support and dedication to improving PICC practices.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGravdahl Eva Haugen Dagny Faksv\u0026aring;g,Fredheim Olav Magnus.Use of peripherally inserted central venous catheters and midline catheters for palliative care in patients with cancer: a systematic review[J]. \u003cem\u003eSupport Care Cancer 2024\u003c/em\u003e, \u003cb\u003e32\u003c/b\u003e(7):464 .\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGonella, S. Antonuzzo Andrea,Bossi Paolo.Peripherally or centrally inserted central catheters: what is the best vascular access device for cancer patients?[J]. \u003cem\u003eSupport Care Cancer 2021\u003c/em\u003e, \u003cb\u003e29\u003c/b\u003e(6):2803\u0026ndash;2806 .\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuanli, S. Wu Xiangchun.Complications of implanted port catheters and peripherally inserted central catheters in chemotherapy-treated cancer patients: A meta-analysis[J]. \u003cem\u003eAdv. Clin. Exp. Med. 2023\u003c/em\u003e, \u003cb\u003e32\u003c/b\u003e(5):523\u0026ndash;532 .\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi, J. H. et al. Lin A Randomized Controlled Trial to Compare Peripherally Inserted Central Catheter Tunnel Lengths in Adult Patients With Cancer[J].Clin J Oncol Nurs,2023,27(3):295\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu, S. Y. Y. L. H. Implementation of Tunneled Peripherally Inserted Central Catheters Placement in Cancer Patients: A Randomized Multicenter Study[J]. \u003cem\u003eClin. Nurs. Res.\u003c/em\u003e \u003cb\u003e33\u003c/b\u003e (1), 19\u0026ndash;26 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeripherally inserted tunnelled. catheters: a new option for venous access[J]. \u003cem\u003eMinim. Invasive Ther. Allied Technol. 2001\u003c/em\u003e, \u003cb\u003e10\u003c/b\u003e(4):231\u0026ndash;234 .\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim Il Jung,Shim Dong Jae,Lee Jae Hwan. et al.Impact of subcutaneous tunnels on peripherally inserted catheter placement: a multicenter retrospective study[J].Eur Radiol,2019,\u003cb\u003e29\u003c/b\u003e(5):2716\u0026ndash;2723 .\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWei Jiejing, L. \u0026amp; Zhouwei, L. Ting, et al. Clinical application of two-needle subcutaneous tunnel method in patients with PICC catheterization [J].Chinese General Practice Nursing,2022,20(12).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinelli, F. Muzzi Mirko,Pittiruti Mauro.Should ultrasound evaluation for catheter-related thrombosis always be required before PICC removal?[J]. \u003cem\u003eJ. Vasc Access.\u003c/em\u003e \u003cb\u003e25\u003c/b\u003e (3), 697\u0026ndash;702 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi, W. C. J. D. Y. L. et al. Risk factors and prediction model construction for peripherally inserted central catheter-related infections[J].Heliyon,2024,\u003cb\u003e10\u003c/b\u003e(8):e29158 .\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu, Y. et al. Li Diwen,Li Yunfei,. Predictive Model for PICC Occlusion Risk for Patients in Intensive Care Units: A Retrospective Clinical Study[J].Altern Ther Health Med,29(8):278\u0026ndash;285. (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo Mengna,Wu Zhenming,Fan Yuying.Peripherally inserted central catheter malposition into the azygos vein: A case series report and review of the literature[J]. \u003cem\u003eJ. Vasc Access.\u003c/em\u003e, \u003cb\u003e26\u003c/b\u003e(3):975\u0026ndash;981. (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBriant Fohlen Audrey, R. \u0026amp; Dutheil Jean Jacques. Complications of peripherally inserted central catheters in adult hospitalized patients and outpatients in the KTFIXPICC study: A randomized controlled trial evaluating a fixation device KT FIX Plussystem[J]. \u003cem\u003eAm. J. Infect. Control\u003c/em\u003e. \u003cb\u003e50\u003c/b\u003e (8), 916\u0026ndash;921 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerraz-Torres Marta,Sancho-Sena Elena,Corcuera-Martinez Mar\u0026iacute;a In\u0026eacute;s, et al.Complications Related to the Securement Device in Peripheral Intravenous Catheters: A Randomized Study[J]. \u003cem\u003eJ. Infus Nurs.\u003c/em\u003e, \u003cb\u003e47\u003c/b\u003e(6):391\u0026ndash;396. (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQu, M. et al. Zhao Jialai,Zhang Yiling,. Utilizing the visual analogue scale (VAS) to monitor and manage pain in post-operative skin wounds after thoracic surgery[J].Int Wound J,21(3):e14503. (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaria Kapritsou,Theodoros Katsoulas,Maria Bastaki. Implementation of tunneled versus not tunneled peripherally inserted central catheters[J]. \u003cem\u003eJ. Vasc Nurs.\u003c/em\u003e \u003cb\u003e37\u003c/b\u003e (2), 132\u0026ndash;134 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaijo, F. et al. Odaka Yoshinobu,Mutoh Mitsuhisa,. A novel technique of axillary vein puncture involving peripherally inserted central venous catheters for a small basilic vein[J].J Vasc Access,19(3):311\u0026ndash;315. (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiana, H. Mao Xiaodan.Complications of tunneled and non-tunneled peripherally inserted central catheter placement in chemotherapy-treated cancer patients: a meta-analysis[J]. \u003cem\u003eFront. Surg.\u003c/em\u003e \u003cb\u003e11\u003c/b\u003e, 1469847 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng, B., Panton Ormond, N. M. \u0026amp; Al-Tayeb Thamer A.Operative length independently affected by surgical team size: data from 2 Canadian hospitals[J]. \u003cem\u003eCan. J. Surg.\u003c/em\u003e \u003cb\u003e55\u003c/b\u003e (6), 371\u0026ndash;376 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi, X. M. F. X. C. Q. et al. Subcutaneous tunneling technique to improve outcomes for patients undergoing chemotherapy with peripherally inserted central catheters: a randomized controlled trial[J]. \u003cem\u003eJ. Int. Med. Res. 2021\u003c/em\u003e, \u003cb\u003e49\u003c/b\u003e(4):3000605211004517 .\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinelli Fulvio,Barbani Francesco,Defilippo Barbara. et al.Quality of life in women with breast cancer undergoing neoadjuvant chemotherapy: comparison between PICC and PICC-port[J].Breast Cancer,2024,\u003cb\u003e31\u003c/b\u003e(5):945\u0026ndash;954 .\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"PICC, subcutaneous tunneling, single-puncture technique, double-puncture technique, catheter-related complications, oncology nursing, patient satisfaction, vascular access","lastPublishedDoi":"10.21203/rs.3.rs-8034764/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8034764/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePeripherally inserted central catheters (PICCs) provide essential long-term intravenous access for oncology patients, but different insertion techniques may impact patient outcomes. We aimed to compare the efficiency, safety, and patient experience of three PICC insertion techniques\u0026mdash;conventional ultrasound-guided non-tunneled, single-puncture subcutaneous tunneling, and double-puncture subcutaneous tunneling\u0026mdash;in oncology patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA prospective observational study was conducted at a single tertiary oncology center in China from June 2022 to December 2023. A total of 418 cancer patients requiring PICC placement were consecutively allocated to the conventional group (n\u0026thinsp;=\u0026thinsp;131), single-puncture tunneling group (n\u0026thinsp;=\u0026thinsp;178), or double-puncture tunneling group (n\u0026thinsp;=\u0026thinsp;109). Insertion efficiency (first-attempt success and procedure time), catheter-related complications, and patient-reported outcomes (pain and satisfaction scores) were assessed over a 16-week follow-up. Group outcomes were compared using one-way ANOVA and chi-square tests, with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBaseline characteristics were comparable across groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The first-attempt success rate was significantly higher in the conventional group (98.5%) compared with the double-needle group (90.8%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with no difference between conventional and single-needle groups. Operation time differed significantly (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), being shortest in the conventional group (26.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.73 min), followed by single-needle (31.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.92 min) and double-needle (36.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.48 min). The incidence of catheter-related thrombosis was lowest in the single-needle group (3.4%), significantly lower than conventional (8.4%) and double-needle (11.0%) approaches (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.034). Total complication rates were also lowest in the single-needle group (12.9%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Pain scores were significantly lower in conventional (1.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57) and single-needle (1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66) groups compared to double-needle (3.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while satisfaction was highest in the single-needle group (8.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eFor oncology patients, the single-puncture subcutaneous tunneling technique achieved the best overall balance of safety, efficiency, and patient experience. It can be recommended as the preferred PICC insertion method in oncology nursing practice. The double-puncture technique offers greater catheter stability and may be reserved for patients at high risk of catheter migration, while the conventional non-tunneled approach remains the fastest option for urgent access but carries a higher complication risk.\u003c/p\u003e","manuscriptTitle":"Comparison of Three PICC Insertion Techniques on Efficiency, Complications, and Patient Experience Among Oncology Patients: A Prospective Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-16 07:20:58","doi":"10.21203/rs.3.rs-8034764/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-20T01:58:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-19T06:01:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201513692368358632968812532461913461786","date":"2026-05-12T08:33:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312565114439348955859710369382829779048","date":"2026-03-12T15:21:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-21T04:19:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21470422467528037737596494700151016775","date":"2025-12-11T04:38:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-11T03:59:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-20T21:00:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-06T11:22:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-06T11:21:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-11-05T06:16:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4846df04-e28d-4c71-959c-a7a71621f6a5","owner":[],"postedDate":"December 16th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-20T01:58:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-19T06:01:32+00:00","index":118,"fulltext":""},{"type":"reviewerAgreed","content":"201513692368358632968812532461913461786","date":"2026-05-12T08:33:06+00:00","index":116,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[{"id":59459206,"name":"Biological sciences/Cancer"},{"id":59459207,"name":"Health sciences/Medical research"},{"id":59459208,"name":"Health sciences/Oncology"}],"tags":[],"updatedAt":"2026-05-20T02:09:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-16 07:20:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8034764","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8034764","identity":"rs-8034764","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}