Central Venous Line Placement in the Superior Vena Cava and the Azygos Vein: Differentiation on Posteroanterior Chest Radiographs

Haygood, Tamara Miner; Brennan, Patrick C.; Ryan, John; Yamal, José Miguel; Liles, Lindsay; O’Sullivan, P.J.; Costelloe, Colleen M.; Fitzgerald, Nancy E.; Murphy, William A.

doi:10.2214/ajr.10.4681

Cited by 21 publications

(15 citation statements)

References 12 publications

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“…Reports of CVC tip misplacements range from 3.3% to as high as 14%. [6][7][8][9][10] Chest radiography (CXR) is the current criterion standard for detecting post-CVC placement complications of CVC malposition. Performance and interpretation of the post-CVC CXR is associated with time delay, additional radiation exposure, and additional costs.…”

Section: Discussionmentioning

confidence: 99%

Central Vascular Catheter Placement Evaluation Using Saline Flush and Bedside Echocardiography

Weekes

Johnson

Keller

et al. 2014

Academic Emergency Medicine

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Objectives: Central venous catheter (CVC) placement is a common procedure in critical care management. The authors set out to determine echocardiographic features during a saline flush of any type of CVC. The hypothesis was that the presence of a rapid saline swirl in the right atrium on bedside echocardiography would confirm correct placement of the CVC tip, similar to the accuracy of the postplacement chest radiograph (CXR).Methods: This was a prospective convenience sample of emergency department (ED) and intensive care unit (ICU) patients who had CVCs placed. Investigators used subcostal or apical four-chamber echocardiography windows to evaluate the onset and appearance of turbulent flow in the right atrium when the distal port of the CVC was flushed with 10 mL of saline. Onset was rated as "immediate" (within 2 seconds), "delayed" (2 to 6 seconds), or "absent" (did not appear within 6 seconds). Appearance was rated as "prominent," "speckling," or "absent." Digital video review was used later to objectively determine precise timing of turbulence onset. The rapid atrial swirl sign (RASS) was defined as the echo appearance of turbulence entering the right atrium immediately (within 2 seconds) after the saline flush of the CVC distal port. The observance of RASS ("positive") was considered "negative" for CVC malposition. Echocardiographic results were compared to CVC tip locations within predetermined zones on the CXR. Superior vena cava (SVC) region was considered the optimal CVC tip position for subclavian and internal jugular CVC. Left CVC tips within the mid left innominate vein were also considered appropriately placed.Results: A total of 142 patients enrolled, yielding 152 CVCs. Two CVCs were excluded from analysis due to incomplete data. Both CXR and echocardiographic images for 107 internal jugular CVCs and 28 subclavian CVCs were available for analysis. Saline flush echo evaluations were also performed on 15 femoral CVCs. Either 16-cm triple-lumen or 20-cm PreSep CVCs were used. CVC malposition was discovered on CXR in four of 135 (3.0%) of the subclavian and internal jugular CVCs. RASS for subclavian and internal jugular CVC evaluations versus CXR results for CVC tip malposition yielded 75% sensitivity, 100% specificity, positive predictive value (PPV) 100% (95% confidence interval [CI] = 29.24% to 100%), and negative predictive value (NPV) 99.24% (95% CI = 95.85% to 99.98%). Mean (AESD) time for onset of saline flush turbulence was 1.1 (AE0.3) seconds for subclavian and internal jugular CVC tips within the target CXR zone. Conclusions:The rapid appearance of prominent turbulence in the right atrium on echocardiography after CVC saline flush serves as a precise bedside screening test of optimal CVC tip position.ACADEMIC EMERGENCY MEDICINE 2014; 21:65-72 © 2013 by the Society for Academic Emergency Medicine C entral venous catheter (CVC) placement is a common procedure in the management of critically ill patients. Ultrasound (US)-guided CVC placement has been shown to improve success rates (ov...

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Section: Discussionmentioning

confidence: 99%

Central Vascular Catheter Placement Evaluation Using Saline Flush and Bedside Echocardiography

Weekes

Johnson

Keller

et al. 2014

Academic Emergency Medicine

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“…This could be attributed to the age of the patient and the compliance of the vein: the catheter is lodged into a vein of a very young patient, thus not stiff, producing this pronounced convex-to-the-right course. On the contrary, a catheter correctly placed into the superior vena cava would follow a straightforward craniocaudal path 1 10…”

Section: Discussionmentioning

confidence: 99%

“…This is responsible for the characteristic ‘hook image’ on posteroanterior X-rays (figures 1 and 3A). A catheter properly placed in the superior vena cava does not have this radiological appearance 10…”

Section: Discussionmentioning

confidence: 99%

Azygos vein cannulation after catheterisation of the left internal jugular vein in a toddler

et al. 2019

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Central venous catheterisation is routinely performed in paediatric patients to facilitate therapeutic management when long-term vascular access is needed. Misplacement of the catheter tip in thoracic vessels other than the superior vena cava has been described, along with related complications. Hereby, a case of a 15-month-old child is presented with a fully functional Hickman catheter introduced via the left internal jugular vein. The tip of the catheter was misplaced into the azygos vein. Intraoperative spot fluoroscopic images and anatomical explanations for the course of the catheter are presented. An understanding of the aetiology of the radiological appearance may help to increase recognition of such cases and avoid complications.

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“…The postulated mechanism of injury to the atrial wall is a combination of pressure necrosis, osmotic injury and thrombus formation adhering the line tip to the myocardial wall. A 'curved tip' sign may also occur when the catheter is sited in the azygos vein [7] or the pericardio-phrenic vein, which has also been associated with cardiac tamponade [8]. A literature review of a series of papers suggests that the exact location of perforation is unknown in many cases; Collier noted the exit position in 21 of 25 cases [9].…”

Section: Discussionmentioning

confidence: 99%

Peripherally inserted central catheter causing life‐threatening cardiac tamponade

Ridler

Nixon

2014

Anaesthesia Cases

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We report a 60-yr-old female who had a peripherally inserted central catheter (PICC) for parenteral nutrition (TPN). Insertion was uneventful although the line was seen to extend into the right ventricle. The line was re-positioned but soon after commencing TPN she collapsed. Computerised tomography pulmonary angiography (CTPA) demonstrated a pericardial effusion with a high fat content. Pericardiocentesis revealed fluid with a high triglyceride content and confirmed pericardial placement of ther tip of the catheter. The patient subsequently made an uneventful recovery. We could only find one other case in the literature of pericardial tamponade after PICC placement in an adult. The exact anatomical course of this line remains unclear despite careful review of radiological imaging. We discuss methods to gauge appropriate line length, possible signs on chest radiography and the immediate management of pericardial tamponade. Resuscitation via a malpositioned line may prove catastrophic; if doubt exsists the line should not be used.

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Central Venous Line Placement in the Superior Vena Cava and the Azygos Vein: Differentiation on Posteroanterior Chest Radiographs

Cited by 21 publications

References 12 publications

Central Vascular Catheter Placement Evaluation Using Saline Flush and Bedside Echocardiography

Central Vascular Catheter Placement Evaluation Using Saline Flush and Bedside Echocardiography

Azygos vein cannulation after catheterisation of the left internal jugular vein in a toddler

Peripherally inserted central catheter causing life‐threatening cardiac tamponade

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