DR. MAURO PITTIRUTI

1. A new trend in venous access programs:
PICC first
Mauro Pittiruti
Catholic University, Rome - Italy

2. PICC first
• A new worldwide strategy which is changing the
world of venous access
– PICC has become the first choice for both intra-
hospital and extra-hospital central venous access

3. Something’s changed after 2001…
…with regards to PICC insertion:
–HOW ? – US-guidance, EKG-guidance !
–WHY ? – safety and cost-effectiveness !
–WHEN ? – for any central line !
–BY WHOM ? – nurses !

4. HOW

5. PICC insertion
HOW ?
Ultrasound guidance
Microintroducer technique
Intracavitary EKG method

6. Ultrasound have changed the
fundamental features of PICCs
• Traditional PICCs vs US-guided PICCs:
– Two radically different devices, in terms of:
• Indication
• Technique of insertion
• Rate of complications at insertion
• Rate of late complications
• Patient’s comfort

7. PICC in XX century:
‘blind’ insertion
Basilic or cephalic vein
in the antecubital fussa
(veins which can be
seen or palpated)

8. “blind” PICC insertion
• Catheter through needle
(breakaway needle)
• Catheter through cannula
• Catheter over guidewire
(Seldinger diretto)
• Catheter through
introducer
(Seldinger ‘indiretto’)

9. PICC in the XX century
were inserted exclusively without US
• HIGH INCIDENCE OF COMPLICATIONS AT INSERTION
• Failure (even 30% !)
• Malpositions ( > 20%)
• HIGH INCIDENCE OF LATE COMPLICATIONS
• Infection
• Venous thrombosis
• MINIMAL PATIENT COMFORT

10. From 2001 on:
Micro-introducer
US Guidance

11. US-guided insertion of PICC
• Puncture of deep peripheral veins
located at the upper midarm
• Exit site: above the antecubital fussa
1. INSERTION IN ANY PATIENT (even in
patients with ‘no veins’)
2. VERY LOW INCIDENCE OF
COMPLICATIONS AT INSERTION
3. VERY LOW INCIDENCE OF LATE
COMPLICATIONS
4. OPTIMAL PATIENT COMFORT

12. Which veins ?
1.BASILIC vein
First choice
Adequate diameter (3 – 6 mm.)
Not in proximity of arteries or nerves
2.BRACHIAL veins
Second choice
Close to brachial artery and median
nerve
3.CEPHALIC veins
Only in selected patients (obese, etc,)
Too superficial
Too many valves
Non-linear trajectory

13. US anatomy
• training required
• Few, simple notions
Vein:
Round, empty
circle
Vein:
- Easy to collapse
- No pulsation

14. 1. Basilic vein
1 - 2 cm
3 – 6 mm

15. 2. Brachial veins
• “mickey mouse”
Brachial vein
brachial vein
Brachial artery
Basilic vein

16. 2. Brachial veins

17. 3. Cephalic vein
• Third choice
• Not a ‘deep’ vein
• Enters the axillary vein at 90°
• Higher risk of thrombosis
• Higher risk di malpositions
• Useful in morbidly obese patients

18. Traditional method for
estimation of the
distance between
puncture site and cavo-
atrial junction
Before PICC insertion
Midclav.
Distance between
midclavicular
point and 3°
intercostal space
Distance between
puncture site and
midclavicular point

19. Alternative method
(Ocado) for estimation of
the distance between
puncture site and cavo-
atrial junction
Before PICC insertion
Notch
Add 10 cm (right)
or 15 cm (left)
Distance between
puncture site and
suprasternal notch

20. Technical choices
• Relationship between vein and probe
– Short axis vs. long axis
• Relationship between vein and needle direction
– ‘In plane’ puncture vs. ‘out of plane’ puncture
• Needle guide
– Needle-guide vs. free hand

21. in short axis

22. Out of plane

23. in long axis

24. ‘Free hand’

25. Needle guide

26. Technical choices
• Routine recommendations:
– Vein visualization in short axis (transversal,
panoramic view of all crucial structures)
– ‘Out of plane’ puncture (needle’s trajectory not
included in the plane of the probe)
– Free hand technique (more versatile and effective)
• needle guide only during training

27. US Guidance + microintroducer
technique

28. Modified
Seldinger
Minimal trauma
Microintroducer

29. US guidance is the state of the art for
CVC insertion

30. US guidance is the state of the art, not
only for CVCs, also for PICCs

31. AHRQ recommendations
2013

32. 2013

33. But US-guidance is not enough
• Successful puncture and cannulation of the vein is
not enough
• We need proper placement of the tip of the central
line:
EKG guidance

34. EKG-guide is becoming the state of the
art, not only for CVCs, also for PICCs

35.  Intracavitary ECG (lead II)
 The intracavitary electrode is
the tip of the catheter
 Based on changes of P wave
during the progression of the
catheter into the central veins
 CAVO-ATRIAL JUNCTION:
maximal peak of the P wave
(Stas, Yeon, Schummer,
Pittiruti, La Greca, etc,)
( = CRISTA TERMINALIS)
IC-EKG method

36. P increasing
Maximal P
P decreasing
and/or diphasic

37. A very old method…
Von Hellerstein HK
Recording of intracavitary potentials through a single-
lumen saline filled cardiac catheter. Proc Soc Exp Biol
Med 71:58-60, 1949

38. …which has come back.
JVA 2011JVA 2011

39. …which has come back.
JVA 2012JVA 2012

40. It can be done with any ECG monitor…

41. … and different types of connections

42. Applicability
- The IC-EKG method is applicable to any central
venous access, valved or not, peripherally inserted or
not, independently from the access technique.
- Current limit of IC-EKG method: it is applicable only
in patients with evident P wave in the surface ECG
This excludes 7 – 9 % of patients: atrial fibrillation,
pacemaker (if constantly active), so called ‘junctional
rhythm’, atrial flutter, etc.

43. Feasibility
Feasibility = in which % of cases do we get an ‘atrial
P’ in the intracavitary EKG?
•GAVeCeLT multicenter study 2012:
– 1440 patients, any type of VAD
– All pts with evident P on basal ECG
– Both saline technique and guidewire technique
– Overall feasibility 99.3 %
• Feasibility with the saline technique 99.9 %
• Feasibility with the guidewire technique 98.6 %

44. Feasibility
0.7 % of failure (not feasibility) depends on:
Technical problems of the connection between
monitor and catheter
Technical problems of the ECG monitor
Experience of the operator (ability to recognize
P changes)
Low signal (catheter < 3Fr)

45. Accuracy
Accuracy = in which % the ‘atrial P’ corresponds
to the cavo-atrial junction?
Almost 99%

46. IC-EKG - Is it accurate?
In the last two decades, many clinical studies
have proved the accuracy of the EKG method:
- Compared with radiological methods
- Compared with trans-esophageal
echocardiography (TEE)

47. Accuracy
Very high for echocardiography: TTE or TEE
Specially: TTE + CEUS
(contrast-enhanced ultrasonography)
Very low for fluoroscopy and chest x-ray
Subjective interpretation
No common criteria for CAJ
‘Interpretation of shadows’ (M.Costantino)

48. TEE vs IC-EKG
Cavoatrial junction = maximal P wave (EKG)
Cavoatrial junction = crista terminalis (TEE)
100% accuracy - In 30 patients, EKG = TEE
20042004
[12] International Anesthesia Research Journal

49. Tip at the cavoatrial junction

50. TIP in lower 1/3 of SVC

51. Tip in middle 1/3 of SVC

52. TEE vs. IC-EKG
54 patients Cavoatrial junction = crista terminalis
20062006

53. IC-EKG vs. X-Ray
147 pts – correct tip positioning in 96 % 20072007
[10] Journal of Anesthesia and Analgesia

54. TEE vs. IC-EKG vs. X-Ray
200 patients - accuracy 99% for EKG, 88% for X-ray20092009

55. GAVeCeLT Multicenter Study
20122012

56. GAVeCeLT Multicenter Study
8 hospitals, 1440 patients
Any type of central VAD
Intra-procedural IC- EKG vs. post-procedural X-
Ray
X-ray criteria for CAJ:
CAJ = 3 cm below the carina
Lower 1/3 SVC = 1-3 cm below the carina
Upper 1/3 RA = 3-5 cm below the carina
20122012

57. GAVeCeLT Multicenter Study
IC-EKG (intra-op.) vs. Chest X-Ray (postop.)
Total Match (Accuracy): 95,4 %
Mismatch EKG/Xray = 3.8 % (55 cases)
in 44/55 cases, tip was higher on X-Ray
… but in most of these patients post-op- Chest X-Ray
had been performed in standing position

58. GAVeCeLT Multicenter Study
IC-EKG (intraop.) vs. Chest X-Ray (postop.)
…considering the confounding factor that
IC-EKG had been performed in supine
position and Chest X-Ray in standing
position:
Match (Accuracy): 99 %

59. Safety
Yes
GAVeCeLT Multicenter Study 2012:
1440 patients, any type of VAD
No complication - directly or indirectly related to the
EKG method – was reported
The overall incidence of arrhythmias was low (0.7%)
GAVeCeLT Pediatric Multicenter Study 2013:
309 children, any type of VAD
No complication - directly or indirectly related to the
EKG method – was reported

60. Easiness
Easy to perform
Easy to teach
Easy to learn

61. New defibrillators/ECG monitor: terrific for the EKG method…..

62. Small, portable ECG monitors

63. Nautilus
The method is easy… even easier with a dedicated monitor

64. The future: Wireless IC-ECG

65. Cost effectiveness
Low cost method
‘low cost’ training
Applicable even when X-Ray is contraindicated or
difficult or expensive (pregnancy, morbid obesity,
hospice, home care, etc.)
‘real time’ verification
i.v. treatment can start immediately after
Save money (cost of X-Ray, cost of repositioning)
65

66. Cost effectiveness
In its basic form: IC-EKG is inexpensive
(connection cables cost few euros)
Big saving comes from:
Avoiding expensive equipment (fluoroscopy, TEE)
Avoiding x-ray expenses (direct and indirect)
Avoiding delay due to post-procedural chest x-ray
or post-procedural TEE/TTE)
Avoiding need for reposition (it may happen with
post-procedural chest x-ray or post-procedural
TEE/TTE)

67. In conclusion: IC-EKG
• Applicable in 91-93% of adults and 99% of
children
• Feasible in 99%
• Safety 100%
• Accurate (maximal P = CAJ) in 91-99% of cases
– ‘real’ accuracy (IC-EKG vs TEE): 99%
– ‘standard ‘ accuracy (IC-EKG vs Xray): 91-98%

68. P r a c t i c a l d e c i s i o n a l t r e e
B a s a l E C G
P w a v e e v i d e n t P w a v e n o n -e v i d e n t ( A F , e t c .)
N o d i f f i c u l t y
D i f f i c u l t y
( a n t i c i p a t e d o r
e x p e r i e n c e d d u r i n g
t h e p r o c e d u r e )
T i p l o c a t i o n
b y I C - E C G
T i p n a v i g a t i o n b y C o r p a k
T i p l o c a t i o n b y I C -E C G
N a v i g a t o r ( C o r p a k ) f o r t i p n a v i g a t i o n
a n d f o r a p p r o x i m a t e d t i p l o c a t i o n
( 3 r d i n t e r c o s t a l s p a c e )
C o n f i r m a t i o n o f t i p l o c a t i o n
a f t e r t h e p r o c e d u r e
( c h e s t x -r a y i n a d u l t s
t r a n s -t h o r a c i c e c h o . i n c h i l d r e n )

69. Raccomandazioni AHRQ
20132013

72. US-PICC = a new venous access device
PICC
Very selected indications
High rate of failure at
insertion
High rate of malpositions
High rate of late
complications (infection,
thrombosis)
No comfort for the patient
US-PICC
Wide indications
Success rate at insertion
close to 100%
No malposition (IC-EKG)
Very low incidence of late
complications (infection,
thrombosis)
Maximal patient compliance

73. US-guided, EKG-guided insertion

74. Necessità di accesso venoso in paziente con
neoplasia avanzata del rinofaringe

89. Rimozione dell’introduttore

90. Verifica della posizione della punta: assenza del
catetere in giugulare

95. Key to uneventful insertion:
Use a bundle of evidence-based, cost-effective
strategies:
US assessment
US guidance
Intracavitary EKG guide
microintroducer technique
sutureless securement
…….

96. The SIP protocol
A GAVeCeLT bundle for the safe
implantation of PICCs

97. The SIP protocol
1. Hand washing, aseptic technique and maximal barrier
protection
2. Bilateral US scan of all veins at arm and neck
3. Choice of the appropriate vein at midarm (vein mm =
or > cath Fr)
4. Clear identification of median nerve and brachial artery
5. Ultrasound guided venipuncture
6. US scan of IJV during introduction of the PICC
7. EKG method for assessing tip position
8. Securing the PICC with a sutureless device

98. 1 - Hand washing, aseptic technique
and maximal barrier protection
• Maximal barrier protection include sterile gloves,
mask, hat, sterile gown and vast body drape over
the patient
• Clorhexidine 2% in alcoholic solution should be
preferred for skin preparation before PICC insertion

99. 2 - Bilateral US scan of all veins at
arm and neck
• Before deciding the vein to be cannulated, a
complete bilateral scan of most deep veins of the
arm (basilic, brachial) and the neck (axillary,
subclavian, internal jugular, brachio-cephalic)
should be performed, so to exclude major
abnormalities, to rule out pre-existing venous
thrombosis, and to choose the most appropriate
vein
• The deep veins of the arm should be evaluated with
and without tourniquet

100. 3 - Choice of the appropriate vein at
midarm (vein mm = or > cath Fr)
• To minimize the risk of local ‘peripheral’ venous
thrombosis, catheters should be inserted in veins
whose diameter is at least three times larger than
the catheter itself:
– 3 Fr catheter: 9 Fr (3 mm) vein or larger
– 4 Fr catheter: 12 Fr (4 mm) vein or larger
– 5 Fr catheter: 15 Fr (5 mm) vein or larger
– 6 Fr catheter: 18 Fr (6 mm) vein or larger

101. 4 - Clear identification of median
nerve and brachial artery
• The most effective method to avoid accidental
nerve injury is the direct visualization of the nerve
before and during venipuncture
• The most effective method to avoid accidental
arterial puncture is to identify and visualize the
brachial artery before and during any venipuncture

102. 5 - Ultrasound guided venipuncture
• Real time ultrasound guided venipuncture of a deep
vein (basilic or brachial) at midarm is the preferred
choice
• A micro-introducer kit is recommended, preferably
with a small gauge (21G) echogenic needle and a
0.018” soft straight tip nitinol guidewire

103. 6 - US scan of IJV during introduction
of the PICC
• While inserting the catheter into the introducer, the
ipsilateral internal jugular vein should be
compressed by the US probe, so to facilitate the
passage of the catheter from the subclavian vein
into the brachio-cephalic vein
• After the maneuvre, evidence of absence of the
catheter in the internal jugular veins of both sides
should be obtained by US scan

104. 7 - EKG method for assessing tip
position
• The EKG method is an inexpensive, effective, simple and
safe methodology for a real time assessment of the position
of the tip of the catheter during the procedure itself.
• A correct position of the tip (in the proximity of the cavo-atrial
junction) reduces the risk of catheter malfunction, fibrin
sleeve and catheter-related ‘central’ venous thrombosis
• Intra-procedural assessment of tip position avoids the costs
and risks associated with repositioning the PICC

105. 8 - Securing the PICC with a
sutureless device
• The PICC should be secured at the exit site
not by standard suture but by a sutureless
device, so to decrease the risk of infection,
dislocation and local thrombosis

106. Goals of the SIP bundle
– Minimize complications related to venipuncture:
• Failure, repeated punctures, nerve injury, arterial injury
– Minimize malpositions
– Minimize venous thrombosis
– Minimize dislocation
– Minimize infection

107. US- guided PICC in 3yr child, PICU

110. PICC in obese patients

112. Double lumen, power injectable
PICC

113. 3-lumen, power injectable PICC in ICU

114. WHY

115. Why should we use a PICC and not a central
line ?

116. Advantages of US-PICCs vs. CVCs
• Absolutely safe insertion, even in fragile and
high-risk patients (coagulation abnormalities,
tracheostomy, cardio-respiratory disorders, etc.)
• Low cost insertion (nurse-based, bedside)
• Low rate of bacteremic infections (CRBSI)
• More comfortable exit site
• Longer duration
• Appropriate also for extrahospital management

117. No patient is ‘veinless’

118. US-PICC = low risk of infection
Why ?
-Exit site is distant from nasal/oral/tracheal
secretions
-Low contamination of arm skin
-Physical characteristics of arm skin (dry, thin)
-Exit site allows better cleaning and better
stabilization of the dressing

119. US-PICC = low risk of infection
Studies on CRBSI with ultrasound-guided PICCs
-0/1000 days (Gebauer 2004 – pts on PN)
-0.4/1000 days (Pittiruti 2006 – pts on PN)
-0/1000 days (Harnage 2006)
-0.3/1000 days (Scoppettuolo 2010 – infect.dis.pts)
-0/1000 days (Cotogni 2013 – cancer pts on HPN)
-0/1000 days (Botella 2013 – cancer pts on HPN)

120. Cost-effectiveness
• US-PICC means saving money
• To compare PICC vs. CVC is not just comparing
the raw cost of two devices, but to compare the
costs of two different clinical strategies:
– PICCs = lower insertion cost, lower maintenance costs
due to lower rate of complications, longer duration of
the line, etc.

121. Cost-effectiveness
Cost-effectiveness depends also on WHERE the US-PICC is inserted,
HOW and by WHOM (Smith, Wisconsin University 2011):
WHO WHERE HOW
$ 5000 surgeon operating
room
fluoroscopy + nurse
$ 2800 radiologist radiology suite fluoroscopy + technician
$ 1800 anaesthesist bedside no fluoro
$ 875 nurse bedside no fluoro

122. Cost-effectiveness
Cost-effectiveness of US PICCs (Catholic University, Rome, Italy
2011):
WHO WHERE HOW
€ 2500 surgeon operating room fluoroscopy + nurse
€ 1850 radiologist radiology suite fluoroscopy + technician
€ 280 nurse bedside IC-EKG

123. Myth
• ‘high incidence of thrombosis…’
NO
- if we consider only US-guided PICCs
- if we do a proper insertion (SIP protocol),
matching the vein diameter with the PICC
diameter
(Simcock 2008, ESPEN guidelines 2009)

124. Myth
• ‘low flow device…’
NO
if we use power polyurethane PICCs, we can get
up to 5 ml/sec !

125. Myth
• ‘high rate of lumen occlusion…’
NO
- if we use power polyurethane PICCs
- if we adopt a proper policy of flushing (saline
only)

126. Myth
• ‘cannot measure the CVP…’
NO
- if we use power polyurethane PICCs
- if we adopt a proper policy of flushing (saline
only)
- if we use open-ended, non-valved PICCs

127. WHEN

128. PICC indications
• They have expanded:
– Use of insertion bundles and maintenance bundles
– Widespread use of power poliurethane PICCs
• High resistance
• Low rate of obstruction
• High flow
• Available as single, double or triple lumen
– New methods, such as tunnelling

129. Tunnelling PICCs

130. US-PICCs = first-option central line
in hospitalized patients
• With few exceptions:
– Central line needed in the emergency room
– Patients with AV-fistula
– Patients with bilateral local contraindications to PICC
insertion (axillary node dissection, deep vein < 3mm,
skin or bone abnormalities, deep venous thrombosis,
etc.)
– Patients needing a central line with > 3 lumens
– Superior vena cava obstruction

131. Power polyurethane PICCs
• ideal central line for intra-hospital PN
• ideal central line for ‘chronic’ ICU patients
• ideal central line in the perioperative period

133. Other options when PICC cannot be
inserted in the arm
• US-guided insertion of PICC in the axillary vein
(infraclavicular exit site)
• US-guided insertion of PICC in the brachio-
cephalic, subclavian or internal jugular veins
(supraclavicular exit site)
• US guided insertion of PICC in the femoral vein
(exit site at the groin is avoided by tunnelling)

137. What about non-hospitalized
patients?

139. Power polyurethane PICC
• ideal central line for short term extra-hospital PN
• ideal central line for palliative care
• ideal central line for advanced-stage cancer
patients at home or in hospice

140. US-PICCs = first-option central line
in non-hospitalized patients
• With few exceptions:
– Patients needing episodic, non-frequent venous access
(1/week or less frequent)
• Central PORT or PICC-PORT is recommended
– Patients needing a long term venous access for life-
time home parenteral nutrition due to benign disease
• Central tunneled/cuffed catheter is recommended
(though, it might be a tunneled/cuffed PICC !)

141. US-PICC in extrahospital setting
• Home care, Hospice, Day Hospital, etc.
• Different options
– Standard PICC
– Tunneled PICC
– Tunneled/cuffed PICC
– PICC port

142. Standard PICC

144. Tunneled PICC

149. Cuffed / tunneled PICC

153. PICC port

159. BY WHOM

160. PICC insertion
WHO ?
A well trained health operator !
(physician or nurse)

161. Who is inserting?
• Surgeons, anesthestiologists, oncologists,
radiologists, etc.
• Nurses of different areas (anesthesia, pediatrics,
intensive care, oncology, etc.)
The important is:
• APPROPRIATE METHODOLOGY
• ADEQUATE TRAINING

162. Appropriate Methodology
Safety, cost-effectiveness, efficacy
•THE ‘SIP’ BUNDLE

163. Adequate Training
See the GAVeCeLT ‘4 x 4’ training protocol (for
both nurses and physicians)
-4 hrs of theory
-4 hrs of practice on simulators
-4 insertions seen and discussed with the tutor
-4 insertions done under supervision of the tutor
-Learning curve ( > 25 ins., < 3 mo.)
-Final audit

165. Nurses or physicians?
The spreading of PICC use is clearly linked to the
philosophy of nurse-based venous access
The overall cost-effectiveness of PICCs may be
limited if the insertion is physician-based (even
worse if radiologist-based)

166. PICC/yr
• USA 2,500,000 nurses allowed
• UK 120,000
• Italy 33,000
• Spain 15,000
• Scandinavia 13,000
• France 7,000 nurses not allowed
• Benelux 5,000
• Germany 2,000

167. Italy, 2013
• Approximately 35,000 PICC/yr
– Every year, approx. + 25%
– 80% inserted by nurses
– > 100 hospitals have an active PICC team
– 100% of PICC teams are mixed nurses+physicians
– Intense activity of training/education in PICCs
• University Masters, Intensive courses both universitary
and/or organized by dedicated multiprofessional societies
(GAVeCeLT, WINFOCUS, etc.)

168. Catholic University, Rome - 2013
• More than 3500 PICC/yr for both intra-hospital
use (1300 beds) and extra-hospital use
• One PICC team (3 physicians + 9 nurses)
• 15 nurses specifically trained and formally
authorized for US-guided PICC insertion
• 90% PICCs are inserted by nurses
• Insertion of PICCs in all wards (intensive and
non-intensive, pediatrics and adults, etc.)

169. Catholic University, Rome - 2013
• Education and training
– University Master on Venous Access for nurses
– University Master on Venous Access for physicians
– 15 University courses (4x4) every year, focused
exclusively on PICC insertion
Education/training for both nurses and physicians

170. So, who is inserting?
• The answer is
– THE MULTIDISCIPLINARY,
MULTIPROFESSIONAL PICC TEAM
– Patient-oriented collaboration between nurses and
physicians can cover all possible aspects of venous
access management (definition of indications and
insertion/maintenance policies, prevention and
management of any possible complication, etc.)

171. CONCLUSIONS

172. The keys to a highly effective and
highly efficient venous access team
- ‘PICC first’ strategy
- Specifically trained PICC team
- Bedside approach
- Well defined insertion bundle (SIP bundle!) including:
Ultrasound assessment and ultrasound guidance
Intracavitary EKG guidance

173. My venous access team…

174. WoCoVA
3rd World Congresson
Vascular Access
Berlin, Germany
June 18 -19 - 20, 2014
Be rlinerC ongre ssC ente r,June,18 -2 0 ,2 014
www.wocova.com
Following the success of the 1st and 2nd World
Congress of Vascular Access in 2010 and
2012, WoCoVA is proud to offer a 3rd World
Congress in June, 2014, again highlighting
global vascular access issues, technology
advances, evidence-based practices and an
opportunity to network with professionals
around the world.
All health care professionals interested in the
field of short and long term venous access are
warmly invited to attend this meeting. Scientific
and educational sessions hosted by
international experts will again offer an
exceptional occasion for updating knowledge in
this field, share experiences and learn of future
trends in the area of VADs. Posters and
abstracts will again be an important integral
part of the educational process.
History
WoCoVA, established in 2009 as a foundation
to create an independent platform to organize
worldwide congresses on vascular access, en-
courages all individuals and organizations
around the world involved in this specialty to
participate.
As a multidisciplinary and multi-professional
congress, WoCoVA strives to educate and
share all aspects of vascular access:
indications for the choice of the device,
insertion tech- niques, tip location methods and
prevention and management of all vascular
access device (VAD) related complications,
new technologies, and latest scientific research.
The World Congress on Vascular Access is
organized by the WoCoVA Foundation
P.O. Box 675, 3720 AR Bilthoven
The Netherlands
Berliner Congress Center
Alexanderstr. 11,
10178 Berlin,
Germany
There is a wide variety of accommodations close to the
Berliner Congress Center and the sparkling activities of
the city center.
Organizing Committee
Ton van Boxtel, Chairperson
Mauro Pittiruti, Scientific Committee Chairperson
Jacoline Zilverentant, Project Manager
Corine de Blank, Treasurer
Paul Blackburn, Strategic Planning Committee
Josie Stone, Strategic Planning Committee
Jan Ouwerkerk, Dutch Society Infusion Technology
Australia - Meron Bower /
Tim Spencer
Belgium - Lieve Goossens
Brazil - Pietro Rigamonti
Canada - Erin Davidson /
Sharon Armes
China - Henry Huang
Czech Republic - Martin
Stritesky
France - Eric Desruennes
Germany - Wolfram
Schummer
Italy - Mauro Pittirutti
Iran - Marteza Khavanin
Zadeh
Japan - Yuri Mukai
Mexico - Diego Amaya
New Zealand - Lynette
Lennox
Poland - Marek Pertkiewicz
Romania - Sorin Grunwald
South Africa - Tara
Emmenes
South Korea - Stephanie
Yoon
Spain - Maria Carmen
Carrero Caballero
Sweden - Karin Johansson
Switzerland - Ishan Inan
The Netherlands - Ton van
Boxtel
United Kingdom - Lisa
Dougherty / Carmel Streater
USA - Paul Blackburn / Josie
Stone
Global Committee
The Congress will be held June 18 - 20, 2014 in the
Berliner Congress Center, in the center of the beautiful
eastern part of the city of Berlin, Germany.

175. mauro.pittiruti@rm.unicatt.it
Thank you
for your attention