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Year : 2013  |  Volume : 29  |  Issue : 3  |  Page : 397-400

Role of chest X-ray in citing central venous catheter tip: A few case reports with a brief review of the literature

1 Department of Anaesthesiology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
2 Department of Imageology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India

Date of Web Publication27-Aug-2013

Correspondence Address:
Achuthan Nair Venugopal
Department of Anaesthesiology, Regional Cancer Centre, Thiruvananthapuram - 695 011, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9185.117114

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Central venous catheter (CVC) insertions are increasingly performed in surgical patients and intensive therapy. A simple and invasive procedure performed under strict sterile precautions with complications ranging from arrhythmias; infections; and life-threatening complications such as pericardial tamponade, cardiac perforation and even death. A post-procedure chest X-ray (CXR), though does not accurately assess the tip of the catheter in relation to the superior vena cava (SVC) and right atrium (RA), can detect malpositions, safety of catheter tip, pneumothorax and kinking. We would like to share some of the malpositions we encountered in our centre, their management and a brief review of the literature on optimal catheter tip location.

Keywords: Central venous catheterization, complications, heart, malpositions, radiology

How to cite this article:
Venugopal AN, Koshy RC, Koshy SM. Role of chest X-ray in citing central venous catheter tip: A few case reports with a brief review of the literature. J Anaesthesiol Clin Pharmacol 2013;29:397-400

How to cite this URL:
Venugopal AN, Koshy RC, Koshy SM. Role of chest X-ray in citing central venous catheter tip: A few case reports with a brief review of the literature. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2022 Sep 28];29:397-400. Available from:

  Introduction Top

The incidence of central venous catheter (CVC) malpositions ranges from 3.6 to 14%. [1] Ultrasound has reduced some of the complications during its insertion, but cannot locate the catheter tip in relation to heart. Only transesophageal echocardiography can accurately detect a CVC tip in relation to superior vena cava (SVC) and right atrium (RA), [2],[3] but its availability as a bedside tool is limited to major hospitals. In our centre, we routinely perform a post-procedure chest X-ray (CXR) to confirm the tip of the catheter and we could detect some of the catheter malpositions that are illustrated below. A brief review of the literature suggesting optimal CVC tip position with the carina as the radiological landmark is worth mentioning, [4] and some of the safe practice guidelines for CVC placement are also discussed.

  Case Reports Top

We are illustrating seven cases of abnormal CVC tip positions encountered over a period of 1 year.

Case no. 1: A peripherally inserted CVC (PICC) getting coiled in the ipsilateral axillary vein. Since aspiration did not yield blood, it was removed and reinserted through the opposite side in the ICU [Figure 1].
Figure 1: A PICC (45 cm) with the tip found coiled in the ipsilateral axillary vein

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Case no. 2: A triple-lumen CVC inserted via right internal jugular vein (IJV) getting coiled there itself. Aspiration did not yield blood in any of the lumens and it was therefore removed and reinserted [Figure 2].
Figure 2: A triple-lumen 7 Fr. Right IJV CVC with the tip coiled in the lower part of the IJV itself

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Case no. 3: A PICC with the tip reaching the ipsilateral IJV. It was detected in the post-anesthesia care unit where it was removed and reinserted via right IJV [Figure 3].
Figure 3: A right-sided PICC (45 cm) with tip reaching the same-side IJV

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Case no. 4: A triple-lumen CVC inserted via right subclavian vein with the tip reaching the ipsilateral IJV. It was pulled back up to the 5-cm mark and pushed with the head turned to the same side and applying pressure to the supraclavicular area [Figure 4].
Figure 4: A triple-lumen CVC inserted via right subclavian vein, with the tip reaching right IJV

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Case no. 5: A triple-lumen CVC inserted via right IJV going into the ipsilateral subclavian vein. It was pulled back again and reinserted confirming its correct position in a repeat CXR [Figure 5].
Figure 5: A triple-lumen 7 Fr. CVC inserted via right IJV whose tip was found to be in the ipsilateral subclavian vein

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Case no. 6: Normal position. A triple-lumen CVC inserted via left IJV with the tip near the SVC-RA junction. Note the parallel placement of the catheter in the SVC, with the tip below the carina (arrow mark) [Figure 6].
Figure 6: Correctly positioned CVC tip

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Case no. 7: A triple-lumen CVC was inserted into the left IJV by Seldinger technique but blood could not be aspirated from the most proximal lumen. A check CXR revealed a kinked catheter with its tip in the left IJV. We decided to correct the kink using a "push pull" improvised technique. Under strict aseptic precautions, the proximal straight end of an ethylene oxide-sterilized J tip guide wire was inserted into the distal end of the triple-lumen catheter until resistance was felt-probably the site of the kink. The catheter was pulled out slowly while simultaneously pushing in the guide wire in a similar way. The catheter was pulled out by 4 cm to undo the kink. Now the guide wire could be freely advanced up to 15 cm. The catheter was fully withdrawn over the guide wire and was reinserted again. The guide wire was removed and blood was aspirated from all three lumens. A repeat CXR revealed the tip of the catheter in the SVC. Thus the catheter was salvaged and additional cost burden to the patient was avoided.

Case no. 8: One PICC line inserted for chemotherapy by the cut down method probably went straight into the thoracic duct as chyle could be aspirated. It was corrected by withdrawing the catheter by 1-2 cm.

  Discussion Top

The traditionally preferred position of the catheter tip is in the distal third of the SVC to minimize complications such as catheter migration, extravasation of irritant agents, vascular perforation, local vein thrombosis, catheter malfunction and cranial retrograde injection. [5] The junction of the SVC and RA was considered to be located at the intersection of the right lateral margin of the SVC and the superior border of the RA (cardiac silhouette). [1] It should be recognized that the length of the catheter inserted through right IJV to position the tip properly in the SVC will vary according to the height of the patient and puncture site, and is about 3-5 cm more when it is passed from the left IJV compared with the right. [6]

The right IJV has been the route preferred by anesthesiologists for CVC placement for various reasons, like fewer complications with a success rate of approximately 90-99%. [7],[8] Catheters passed through the left IJV must traverse the left brachiocephalic vein and enter the SVC perpendicularly, and their distal tip may impinge on the right lateral wall of the SVC, thereby increasing the potential for vascular injury. Many authors are of the opinion that a right-sided IJV catheter is better placed up in the SVC or in the innominate vein, whereas a left-sided one is safer in the lower part of the SVC or RA. [3] An in vitro study has shown that an acute angle of >40° with the wall of the SVC results in a markedly increased risk of vessel perforation. [9] This might explain the higher risk of perforation with left-sided catheters. [10] All these necessitate a radiographic confirmation of the CVC tip, which can easily be accomplished with a simple CXR.

The carina is radiologically identifiable in about 96% of all CXRs at the interspace between the fourth and fifth thoracic vertebrae. Stonelake and Bodenham [4] in their retrospective audit of the position of the CVC tip on routine post-procedure CXRs of ICU patients suggested three different zones for safe catheter placement. Accordingly, zone-A represents lower SVC and upper RA, zone-B represents upper SVC and the area around the junction of both innominate veins, and zone-C represents the left innominate vein proximal to the SVC. They found that all left-sided IJV catheter tips can be ensured of their placement being parallel to the SVC wall if they are in zone-A but at a rare chance of pericardial tamponade. Another risk in this area is that the azygos vein joins the SVC where the CVC can pass into this venous system. They recommend that all right-sided CVCs are safe if placed in zone-B. Left-sided catheters will enter this area at a steep angle and can abut the lateral wall of the SVC, and hence should be advanced to lower SVC (zone-A). CVC tip in zone-C has been suggested for Central Venous Pressure monitoring and fluid therapy. They conclude that for safety reasons all right-sided catheters are placed with their tips sited above the carina and all left-sided ones below the carina. Existing guidelines recommend that the CVC tip should be located in the SVC outside the pericardial sac to avoid complications, but it should always be remembered that the upper limit of the pericardial reflection on the SVC cannot be seen on CXR. Schuster et al., [11] in their study of embalmed cadavers suggested that the pericardium crosses the SVC below the carinal level and emphasized that the lateral wall of the SVC was weaker, explaining the chance for erosion. They suggested that the CVC tip in the SVC above the level of the carina is ideal and safe. In a similar study but of fresh cadavers, Albrecht et al., [12] confirmed that the carina is a reliable, simple anatomical landmark for safe CVC tip placement. They confirmed that the pericardial reflection on the SVC was much below the carina compared with that reported by Schuster et al., enhancing safety even if the tip is a little below.

In various studies regarding catheter tip distance down from the carina Wirsing et al., [13] and Aslamy et al., [14] found that 55 and 29 mm were acceptable cut-off values to ensure extra-atrial catheter position. In a study using computed tomographic angiography of SVC, the carina was found approximately midway in relation to the SVC [15] and it was suggested that keeping the catheter tip at or just below the carina assumes placement in the SVC and 4 cm below the carina represents the cavoatrial junction.

Many authors are of the opinion that electrocardiogram-guided CVC tip placement at the SVC-RA junction has an accuracy of 95-100% in confirmation with transesophageal echocardiography. [3],[16],[17],[18] CXR on the other hand is less accurate (parallax error is greater and more variable in a portable CXR - anteroposterior view) but offer a cheap and least sophisticated imaging technique to assess a CVC tip in relation to the carina, which is well accepted as a bedside reliable and cost-effective tool. [11],[18],[19] These two techniques are feasible in all major hospitals. Ultrasound-guided venous puncture and fluoroscopy/C-arm-guided CVC tip placement showed a technical success rate of 98%, [20] but they are not feasible for all major hospitals. Use of transesophageal echocardiography was shown to have 100% accuracy, [2] but confined only to tertiary hospitals.

  Conclusion Top

Bedside CXR is still considered the gold standard for identifying catheter malpositions and complications such as pneumothorax. Use of transesophageal echocardiography, fluoroscopy and C-arm can detect a catheter tip more readily and accurately compared with CXR. ECG guidance while insertion and a post-procedure CXR can ensure CVC tip placement above or a little below the carina, which can enhance patient safety.

  References Top

1.Pikwer A, Baath L, Davidson B, Perstoft I, Akeson J. The incidence and risk of central venous catheter malpositioning: A prospective cohort study in 1619 patients. Anaesth Intensive Care 2008;36:30-7.  Back to cited text no. 1
2.Andropoulos DB, Stayer SA, Bent ST, Campos CJ, Bezold LI, Alvarez M, et al. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Anesth Analg 1999;89:65-70.  Back to cited text no. 2
3.Schummer W, Schummer C, Schelenz C, Schmidt P, Fröber R, Hüttemann E. Modified ECG-guidance for optimal central venous catheter tip positioning. A transesophageal echocardiography controlled study. Anaesthesist 2005;54:983-90.  Back to cited text no. 3
4.Stonelake PA, Bodenham AR. The carina as a radiological landmark for central venous catheter tip position. Br J Anaesth 2006;96:335-40.  Back to cited text no. 4
5.Vesely TM. Central venous catheter tip position: A continuing controversy. J Vasc Interv Radiol 2003;14:527-34.  Back to cited text no. 5
6.Peres PW. Positioning central venous catheters: A prospective survey. Anaesth Intensive Care 1990;18:536-9.  Back to cited text no. 6
7.Sanford TJ Jr. Internal jugular vein cannulation versus subclavian vein cannulation. An anaesthesiologist's view: The right internal jugular vein. J Clin Monit 1985;1:58-61.  Back to cited text no. 7
8.Oliver WC Jr, Nuttall GA, Beynen FM, Raimundo HS, Abenstein JP, Arnold JJ. The incidence of artery puncture with central venous cannulation using a modified technique for detection and prevention of arterial cannulation. J Cardiothorac Vasc Anesth 1997;11:851-5.  Back to cited text no. 8
9.Gravenstein N, Blackshear RH. In vitro evaluation of relative perforating potential of central venous catheters: Comparison of materials, selected models, number of lumens, and angles of incidence to simulated membrane. J Clin Monit 1991;7:1-6.  Back to cited text no. 9
10.Schummer W, Schummer C, Rose N, Niesen WD, Sakka SG. Mechanical complications and malpositions of central venous cannulations by experienced operators. A prospective study of 1794 catheterizations in critically ill patients. Intensive Care Med 2007;33:1055-9.  Back to cited text no. 10
11.Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B. The carina as a landmark in central venous catheter placement. Br J Anaesth 2000;85:192-4.  Back to cited text no. 11
12.Albrecht K, Nave H, Breitmeier D, Panning B, Tröger HD. Applied anatomy of the superior vena cava: The carina as a landmark to guide central venous catheter placement. Br J Anaesth 2004;92:75-7.  Back to cited text no. 12
13.Wirsing M, Schummer C, Neumann R, Steenbeck J, Schmidt P, Schummer W. Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? Chest 2008;134:527-33.  Back to cited text no. 13
14.Aslamy Z, Dewald CL, Heffner JE. MRI of central venous anatomy: Implications for central venous catheter insertion. Chest 1998;114:820-6.  Back to cited text no. 14
15.Mahlon MA, Yoon HC. CT angiography of the superior vena cava: Normative values and implications for central venous catheter position. J Vasc Interv Radiol 2007;18:1106-10.  Back to cited text no. 15
16.Chu KS, Hsu JH, Wang SS, Tang CS, Cheng KI, Wang CK, et al. Accurate central venous port-A catheter placement: Intravenous electrocardiography and surface landmark techniques compared by using transesophageal echocardiography. Anesth Analg 2004;98:910-4.  Back to cited text no. 16
17.Gebhard RE, Szmuk P, Pivalizza EG, Melnikov V, Vogt C, Warters RD. The accuracy of electrocardiogram-controlled central line placement. Anesth Analg 2007;104:65-70.  Back to cited text no. 17
18.Lee JH, Bahk JH, Ryu HG, Jung CW, Jeon Y. Comparison of the bedside central venous catheter placement techniques: Landmark vs electrocardiogram guidance. Br J Anaesth 2009;102:662-6.  Back to cited text no. 18
19.Kujur R, Rao MS, Mrinal M. How correct is the correct length for central venous catheter insertion. Indian J Crit Care Med 2009;13:159-62.  Back to cited text no. 19
[PUBMED]  Medknow Journal  
20.Gebauer B, Teichgräber UM, Werk M, Beck A, Wagner HJ. Sonographically guided venous puncture and fluoroscopically guided placement of tunneled, large-bore central venous catheters for bone marrow transplantation: High success rates and low complication rates. Support Care Cancer 2008;16:897-904.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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