IS Case 284: Malpositioned central vein catheter

Neal Young, MD

Imaging Sciences URMC 2009
Publication Date: 2009-08-05

History

Patient is a 59 year-old male status post-right internal jugular (IJ) central vein catheter (CVC) placement.

Findings

In this patient, the catheter courses inferiorly in the right neck, but projects over the right upper lung zone, lateral to the expected location of the superior vena cava, which can be located with the dialysis catheter. Despite the extravascular placement of the CVC, a subsequent pneumothorax did not develop.

Diagnosis

Malpositioned central vein catheter

Discussion

Central venous catheters (CVC) are common among critical care patients and have many indications including:

  1. durable intravenous access,
  2. allow for administration of medications that would cause phlebitis if given peripherally,
  3. hemodynamic monitoring,
  4. transvenous cardiac pacing, and
  5. hemodialysis.

A post procedure chest radiograph confirming catheter course and tip position are standard of care, although some have questioned this necessity with right internal jugular catheters deemed successful by the clinician on the first needle pass. Traditionally, the catheter tip should be placed within the superior vena cava. This has recently become an issue of debate as many interventionalists have documented improved flow rates and durability of catheters placed in the right atrium. The most reliable radiographic landmark to define the borders of the SVC the angle created by the right main bronchus as it bifurcates from the trachea. A catheter tip positioned 3 cm below the right tracheobronchial angle will always be within the SVC.

Complications that the radiologist can diagnose and their reported occurrence rate are:

  1. malposition (up to 4% depending on the definition),
  2. pneumothorax (1%),
  3. subcutaneous hematoma (1%), and
  4. hemothorax (<1%).

References

  1. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003 Mar 20;348(12):1123-33. PMID: 12646670 [PubMed]
  2. Vesely T. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol. 2003 May;14(5):527-34. PMID: 12761305 [PubMed]

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