Chest radiography has a standard role to assess for the position of central venous lines and pulmonary artery catheters following their insertion.
Some postinsertion complications can be identified or excluded by chest radiography.
Determining malposition of catheters and tubes constitutes a forte of chest radiography and is mandatory following their insertion and repositioning.
To avoid mechanical irritation (from the catheter tip) and chemical irritation (from infusate) of the right atrium, the catheter tip of a central venous line should be further than the junction of the internal jugular vein and subclavian veins (near the level of the first thoracic rib). In addition, the tip should not be further in than the junction of the superior vena cava and right atrium. Central venous catheters that are intended to record central venous pressure should lie distal to the last venous valves (in the subclavian and internal jugular veins, 2.5 cm proximal to the beginning of the brachiocephalic vein) and before the right atrium. The ideal position of the tip of a peripherally inserted central catheter (PICC) line is in the distal superior vena cava.
Anteroposterior chest radiograph of a patient with ischemic cardiomyopathy with severe heart failure. There is an implantable cardioverter defibrillator lead, dual chamber pacing, leads, and a coronary venous cardiac resynchronization lead. There are old sternotomy wires and left internal thoracic bypass graft clips. A right internal jugular central venous catheter has its tip in the right atrium. An attempt to enter the left internal jugular vein by catheter insertion has instead occurred as a left common carotid artery puncture with the tip of the catheter in the distal aortic arch.
Post–aortocoronary bypass. The endotracheal tube, left and right chest tubes, pericardial drainage chest tube, and nasogastric tubes are in their correct positions. A central line inserted via the right subclavian vein has pursued a course into the right internal jugular vein.
A central venous line inserted from the left internal jugular vein is malpositioned in the left subclavian vein. Another central venous line has been inserted via the left subclavian vein.
Anteroposterior chest radiograph of a patient with an inadvertent intra-arterial insertion of a right central venous line. The line is inserted down the right common carotid artery into the innominate artery and likely into the aortic arch.
A central line has been inserted via the right common carotid artery down the innominate artery into the aorta. There is pulmonary edema.
There is a pulmonary artery catheter inserted via the right internal jugular vein, in good position, as well as a central venous line inserted via the left subclavian vein, with its tip at the top of the superior vena cava. The patient is intubated and has a nasogastric tube, bilateral chest tubes, and a mediastinal tube, as well as transverse sternotomy wires. There is pulmonary edema and subcutaneous emphysema.
A central venous line is looped within the right internal jugular vein. The patient’s head is turned to the right, resulting in the different projection of the internal jugular line, the endotracheal tube, and the nasogastric tube.
Post–right pneumonectomy. There are central venous lines inserted via both internal jugular veins, the endotracheal tube tip is down into the left mainstem bronchus, and the nasogastric tube is in the stomach.
A central venous line inserted via the left subclavian vein is located in the left superior intercostal vein. The tip of the central line inserted via the right internal jugular vein is in the superior vena cava. This intubated patient has severe pulmonary edema.
In this patient with an implantable cardioverter defibrillator, dual chamber pacer leads, and a coronary sinus lead, with prior left internal mammary artery bypass grafting, the central line inserted via the right internal jugular vein has its tip in the right atrium. The central line inserted in the left neck is in the left common carotid artery, and its tip is in the aortic arch.
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