The landscape of vascular access is evolving rapidly, driven by new therapies, increasingly complex patient needs, and an ever‑stronger focus on safety and consistency. As clinicians strive to balance therapeutic effectiveness with minimising harm, high‑quality guidance becomes essential. At the end of 2025, two major publications answered that call: the Association of Anaesthetists’ Safe Vascular Access Guidelines 2025 and the Michigan Appropriateness Guide for Intravenous Catheters in Adult Patients with Cancer (MAGIC‑ONC).
These documents arrive at a pivotal moment. They bring together the latest scientific evidence with expert consensus to support clearer, more confident decision‑making, particularly in oncology, where vascular access is both indispensable and high-risk. MAGIC‑ONC alone assessed 1,422 clinical scenarios, providing one of the most comprehensive, detailed frameworks ever developed for device selection, insertion, maintenance, and complication management in adult cancer patients.
The summary below focuses on the key insights and recommendations from MAGIC‑ONC, giving you a practical, clinician‑friendly overview of what has changed, what’s new, and what this means for safe vascular access practice moving forward.
Why This Matters
Vascular access is essential for diagnostics, chemotherapy, blood products, antimicrobials, nutrition, and supportive treatments. Yet complications such as infection and thrombosis remain common and avoidable.
MAGIC‑ONC provides clinicians with clear, evidence‑based device selection principles aimed at:
- Reducing catheter‑related bloodstream infections (CRBSIs)
- Minimising catheter‑associated thrombosis
- Improving patient experience
- Supporting consistent, safe practice in both acute and ambulatory settings
Key Findings from MAGIC‑ONC
1. Cancer Type, Urgency, and Dwell Time Drive Device Choice
MAGIC‑ONC reviewed 1,422 real‑world clinical scenarios to understand how cancer type, urgency of treatment and expected dwell time influence vascular access decisions. Each scenario and access decision was then rated as either appropriate, uncertain or inappropriate. The results showed that 35% were considered appropriate, 28% were uncertain and 37% were deemed inappropriate.
Haematological cancers (acute leukaemia & aggressive lymphoma)
In haematological cancers such as acute leukaemia and aggressive lymphoma, according to MAGIC-ONC, the most appropriate vascular access options identified by MAGIC‑ONC are double‑lumen PICCs and double‑lumen tunnelled CVCs, as these patients require immediate treatment, often with vesicant or irritant drugs, alongside frequent blood product administration. Ports are considered ‘inappropriate’ in urgent situations because the procedure takes longer to arrange and early infection risk is higher in patients who are neutropenic or thrombocytopenic.
Indolent lymphoma & myeloma
For patients with indolent lymphoma and myeloma, MAGIC‑ONC identifies double‑lumen PICCs and tunnelled CVCs as appropriate for most treatment plans, while ports are suitable when vesicant therapy is required but not urgent. Midlines are generally considered ‘inappropriate’ in these settings as these patients often undergo multiple cycles of treatment, which increases the risk of venous depletion.
Solid tumours
For patients with solid tumours, MAGIC‑ONC identifies single‑lumen tunnelled CVCs and single‑lumen ports as the most appropriate options, and these remain suitable regardless of treatment intensity or duration. PICCs are considered ‘appropriate’ when treatment is urgent or expected to last fewer than three months, while triple‑lumen devices are viewed as ‘inappropriate’ because they carry a higher risk of infection and thrombosis.
2. Special Therapies: Apheresis, CAR T‑cell Therapy & Photopheresis
For specialised therapies, MAGIC‑ONC recommends specific devices based on flow and access requirements.
- Apheresis requires double‑lumen, large‑bore non-tunnelled CVCs because they can support the high flow rates needed.
- CAR T-cell therapy is best supported by double‑lumen PICCs or tunnelled CVCs.
- Photopheresis, double‑lumen tunnelled CVCs or ports are considered appropriate for repeated access.
- Midlines and ports are not suitable for apheresis, as they cannot achieve the necessary high flow.
3. Chronic Kidney Disease + Cancer
To support vein preservation in patients with chronic kidney disease, MAGIC‑ONC recommends nephrology consultation for anyone with CKD stage 3B+ or higher and advises avoiding PICCs whenever possible.
The guidance also outlines device choice based on expected duration of use:
- Up to 14 days: a non-tunnelled CVC is suitable
- For 15 days or longer: a tunnelled CVC is appropriate
- For over 30 days: a port is recommended.
4. Safer Insertion Practices
MAGIC‑ONC notes that patient preference for both the device type and insertion site is considered appropriate, and it highlights the right internal jugular vein as the preferred site for CVC placement.
Internal jugular ports are favoured over subclavian ports to avoid the risk of pinch‑off syndrome, and for patients with head and neck cancer, chest ports are preferred to keep the device away from radiation fields. In the context of neutropenia, ports are rated as neutral, while all other vascular access devices are considered appropriate.
The guidance also sets out thrombocytopenia thresholds to support safe insertion: PICCs and non-tunnelled CVCs may be placed at platelet counts of at least 10 ×10⁹/L, whereas tunnelled CVCs and ports require counts of at least 30 ×10⁹/L.
5. Maintenance & Infection Prevention
MAGIC‑ONC advises that ports can be safely flushed at intervals of between four and twelve weeks, and it recommends the use of normal saline rather than heparin for routine maintenance. The guidance states that antimicrobial lock solutions such as ethanol, taurolidine and hydrochloric acid are ‘inappropriate’ for routine use, while citrate locking is considered ‘neutral’. Routine prophylactic antibiotics are not recommended for either insertion or ongoing maintenance. Devices should be removed if exit‑site or tunnel infections are present, and infectious diseases specialists should be consulted when continued access is required.
6. Thrombosis: What Not to Do
MAGIC‑ONC also highlights several important considerations for thrombosis prevention and management, outlining which practices should be avoided and which are appropriate in high‑risk situations.
Inappropriate for Thrombosis:
- Routine ultrasound surveillance
- Routine anticoagulation for all VADs
Appropriate for Thrombosis:
- Low Molecular Weight Heparin (LMWH), apixaban, or rivaroxaban for high‑risk cancer patients
- Full‑dose anticoagulation ≥50×10⁹/L platelets
- Prophylactic dosing 20–30×10⁹/L
- Hold anticoagulation <20×10⁹/L
Overall Implications for Clinical Practice
MAGIC‑ONC highlights that vascular access choice is itself a modifiable risk factor for cancer patient outcomes.
Its guidance supports:
- Standardised decision pathways
- Reduced variation in practice
- Improved safety and reduced complications
- Better alignment between oncology, vascular access specialists, nursing, and pharmacy
The authors also note strong potential for future quality metrics, such as appropriateness scoring, infection rates, thrombosis rates, and lumen‑number benchmarking.
Conclusion
MAGIC-ONC provides a much‑needed framework to support safer and more consistent vascular access decisions for adults with cancer. By examining real clinical scenarios and identifying what is appropriate across different cancers, therapies and clinical circumstances, it gives teams a practical reference that can be applied at the bedside and across multidisciplinary services. Its guidance on device selection, insertion, maintenance and thrombosis management reinforces the importance of tailoring decisions to the individual patient while reducing unnecessary variation in practice.
Together with the Association of Anaesthetists’ Safe Vascular Access Guidelines, it offers clinicians a clearer pathway for improving safety, preventing complications and supporting better outcomes for patients who depend on reliable vascular access throughout their treatment.
References
Chopra V, Swaminathan L, LeDonne J, Becker C, Krein SL, et al.
The Michigan Appropriateness Guide for Intravenous Catheters in Adult Patients With Cancer (MAGIC‑ONC): Results from a multispecialty panel using the RAND/UCLA Appropriateness Method.
Ann Intern Med. 2025;178(Suppl 12):S1.
Johnston AJ, Simpson MJ, McCormack V, Barton A, Bennett J, Chalisey A, et al.
Association of Anaesthetists guidelines: safe vascular access 2025.
Anaesthesia. 2025;80(11):1381–1396. doi:10.1111/anae.16727.
