1009998

research-article2021
JVA0010.1177/11297298211009998The Journal of Vascular AccessBertoglio

Editorial
JVA The Journal of
Vascular Access

The Journal of Vascular Access

Reverse tapered versus non-tapered

1­–3
© The Author(s) 2021
Article reuse guidelines:
peripherally inserted central catheters: sagepub.com/journals-permissions
https://doi.org/10.1177/11297298211009998
DOI: 10.1177/11297298211009998

A narrative review journals.sagepub.com/home/jva

Sergio Bertoglio

Abstract
Introduced over 20 years ago, the reverse tapering design for PICC catheters is supposed to have some benefits in
terms of both efficacy and safety. In particular, it would ensure less postoperative bleeding at the exit site and greater
effectiveness in preventing kinking or twisting of the same. Since its introduction, these hypothesized advantages have
never been demonstrated in clinical studies, however very scarce, which have highlighted neither advantages nor
disadvantages of reverse tapered catheters when compared to non-reverse tapered ones. This narrative review analyzes
some aspects of the use of reverse tapered PICCs, also paying attention to some possible undesirable effects that have
arisen from the introduction into clinical practice of new subcutaneous systems of securement of PICCs to the skin.
Clinicians should be aware of the fact that reverse tapering design does not represents a sure improvement in terms of
safety and efficacy of PICCs and its adoption should be weighed against possible clinical disadvantages.

Keywords
Peripherally inserted central catheters, biomaterials, cyanoacrylate glue, catheter securement

Date received: 14 February 2021; accepted: 23 March 2021

Peripherally inserted central catheters (PICCs) have been
used in clinical practice for more than 30 years. Their use
of has steadily grown over the years because of the percep-
tion of an easy placement procedure with less periopera-
tive complications compared to traditional central venous
access and totally implantable port devices.1–6 The original
configuration of PICCs was a constant outer diameter
(from the connection hub to the catheter tip) ranging in
size from 3French (F) to 7F, depending on different clini-
cal needs. Commonly used catheter materials are silicone
and new-generation polyurethanes, with a growing preva-
lence of the latter during the years.
PICCs are associated with a clinically acceptable risk of
post-insertion complications such as postoperative bleed-
ing from the exit site, catheter-related venous thrombosis
(CRT), central line associated bloodstream infection
(CLABSI), occlusion of the catheter lumen, as well as
mechanical complications, of which the most frequent are
kinking of the extravascular tract of the catheter, dislodg-
ment, or rupture of the catheter. Provided that the clinical
efficacy and safety are assessed, there are no specific
standards or requirements regarding the design of the cath-
eters. During the last decade of the XX century, some
PICC manufacturers introduced a modification of the cath-
eter design that consisted in a reverse tapering of the proxi-
mal portion of the catheter, so that the size of the catheter
tract closer to the wing and to the extensions was 2Fr wider
(or more) if compared to the rest of the catheter. Thus, in a
reverse tapered PICC, though the declared size of the cath-
eter is 4F, the proximal end may be as large as 6F or even
more (5–7F). This design feature was mainly originated by
the request of some radiologists to obtain an easier manip-
ulation of such thin catheters. Though, reverse tapering
rapidly became a successful marketing idea, justified by
the theory that a larger proximal tract of the catheter might
act as a tamponade on the site of venipuncture, preventing
post-insertion bleeding from the site; also, it was assumed
that the extravascular tract of the catheter may become less
prone to twisting and kinking, because of its greater
Department of Surgical Sciences, University of Genova, Genova, Italy
Corresponding author:
Sergio Bertoglio, Department of Surgical Sciences, University of
Genova, Largo Benedetto XV, Genova 16132, Italy.
Email: sergio.bertoglio@unige.it
2 The Journal of Vascular Access 00(0)
resistance and robustness. These changes of the catheter
design were approved by the U.S. Food and Drug
Administration (FDA), without any requirement of sup-
plementary research such as clinical trials investigating
their safety and effectiveness. In fact, this new design fea-
ture did not apparently affect the flow dynamic or the per-
formance of the device. Since then, reverse tapered PICCs
have been produced by all main manufacturers.
Since the adoption of reverse tapering for PICCs, some
doubts and concerns have been raised inside the scientific
community about its actual efficacy in reducing postopera-
tive bleeding from the exit site and/or mechanical compli-
cations. It is worth noting that the alleged reduction of
postoperative bleeding risk has not been demonstrated in
controlled clinical trials, and that there are no bibliographic
references available in this regard. Moreover, cyanoacr-
ylate-based glues are increasingly utilized for sealing the
exit site after PICC insertion, so that postoperative local
bleeding has become infrequent, clinically irrelevant and
easily preventable.6,7 Similarly, the introduction in clinical
practice of new sutureless stabilization devices and the
possible option to tunnel catheters with the exit site away
from the vein access site has significantly reduced both the
risk of mechanical complications (kinking/twisting) of the
external tract of PICCs and postoperative insertion
bleeding.
In recent years, reverse tapering design has been indi-
cated as a possible risk factor for CRT, considering that a
catheter to vein ratio >0.45 or >0.33 (as reported by dif-
ferent guidelines) is currently considered to be predictive
for such complication.8,9 In fact, for the purpose of reduc-
ing CRT risk, a 4F PICC should be preferably inserted in a
4 mm vein; but, if the reverse tapered tract of the catheter
(which may be 6F or larger) is located in a 4 mm vein, this
will exceed the recommended catheter to vein ratio and
could be associated with increased risk of CRT (more spe-
cifically, the risk of venous thrombosis at the site of veni-
puncture). Two recent studies have addressed this issue, in
particular for larger triple lumen 6F tapered PICC.10,11 In a
first prospective study,10 the incidence of CRT was shown
to increase up to 20% if compared to the standard ranges
reported in the literature for this complication. It is worth
mention that the results of this single center observational
study were somehow weak from the statistical point of
view and thus considered non-conclusive. This issue has
been further addressed in the only randomized clinical trial
available in the literature,11 that found no significant dif-
ferences in post-insertion bleeding or CRT or mechanical
complications, when comparing reverse tapered vs. non-
tapered PICCs.
Also, interestingly, peel-away introducers of reverse
tapered PICCs are somehow greater in size than introduc-
ers of non- tapered PICCs of the same size. Thus, although
not yet clinically investigated, the insertion of larger intro-
ducers may be probably associated with major trauma to
the vein wall and increased risk of CRT.
In summary, though reverse tapering may theoretically
have some potential benefits or some potential risks, at this
moment there is no available evidence in the literature in
favor or against its safety and/or clinical effectiveness.
In our personal experience - more than 20 years of PICC
insertions in cancer patients under active treatment,
accounting for 200–300 devices per year - we have been
using both reverse tapered and non-tapered PICCs. Before
2010, we used mainly non-tapered PICCs and since then
mainly tapered PICCs, this switch being based not on clin-
ical ground but the overall conversion of most PICC man-
ufacturers to the reverse tapering design. Data from our
continuous monitoring of PICCs outcomes have not shown
significant differences of the two different catheter design
in terms of safety and efficacy.
It is our perception that all the most relevant improve-
ments in the last decade have mainly been based on the
amelioration of the implant procedures, nursing protocols,
dressing materials, etc., regardless of the tapered or non-
tapered design. Nowadays, the risk of postoperative bleed-
ing can be almost completely avoided by sealing the exit
site with cyanoacrylate glue; the risk of CRT can be mini-
mized by using a proper insertion bundle including (a)
consideration of the catheter/vein ratio, (b) ultrasound-
guided venipuncture with micro-introducer kits, (c) intrap-
rocedural location of the catheter tip by intracavitary ECG,
(d) proper sutureless stabilization at the exit site; the risk
of dislodgment can be minimized by using the subcutane-
ously anchored sutureless devices, recently introduced in
the clinical practice.
A particular mention should be made about the anchor-
ing devices - strongly recommended by a recent consensus
panel of international experts on vascular accesses12—
which could be somehow affected by the concomitant use
of a reverse tapered PICC. In fact, such devices are specifi-
cally designed for each catheter size: a 4F anchoring
device might not fit the 6F tapered tract of a 4F PICC.
In conclusion, clinicians should be aware of the fact
that reverse tapering design does not represents an
improvement in terms of safety and efficacy of these
devices; the adoption of reverse tapered PICCs should be
weighed against their possible disadvantages.
Declaration of conflicting interests
The author declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, author-
ship, and/or publication of this article.
Bertoglio 3
ORCID iD
Sergio Bertoglio https://orcid.org/0000-0001-7235-3444
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