E5340. Inadequacy of Monoplanar Imaging for Central Venous Catheter Placement
  1. Muhammet Gökhan; Ankara Bilkent City Hospital Radiology Department; Ankara Yildirim Beyazit University Radiology Department
Central venous catheterization (CVC) is widely used by various clinics. Its application extends beyond interventional radiology and covers a wide range of healthcare providers, from emergency departments to ICU and dialysis centers. Radiological techniques play an important role not only in determining the appropriate insertion site, but also in confirming the precise placement of the catheter tip. In CVC, it is important to see the end point of the catheter as well as the vascular access in terms of both effective use and prevention of complications.

Educational Goals / Teaching Points
Malpositions of the catheter tip, anatomical situation and the difficulty of recognizing it in a monoplane imaging will be examined with case examples.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Malposition can occur at the levels of 3–32% in the absence of imaging, while it is seen at the 4% with imaging. Frequently malpositioned veins are stated as azygos, intercostal, contralateral subclavian and axillary veins. Although malposition often causes minor injury to the vessel wall, the most common severe complication is wall perforation that may lead to hemothorax and pneumothorax. The orifice of the right internal thoracic vein is close to the origin of superior vena cava (SVC). In CVC located within the right internal mammary vein, anterior radiographs can show a notch as the catheter enters the internal mammary vein. In the lateral view, they can be easily recognized by a distinct anterior course. The azygos vein, on the other hand, runs to the right of the vertebrates in the posterior and upper mediastinum and joins with the SVC. This course is best seen in the lateral projection. Right pericardiophrenic and superior abnormal pulmonary veins are also malpositions that can be encountered. Malpositions in the left-sided approach CVC can be more easily recognized on anterior imaging because the normal course is more typical. Catheter tip can sometimes be directed to the left superior intercostal vein. Anterior radiographs show a catheter running along a projection along the aortic knob. The lateral radiograph shows that the catheter has advanced posteriorly over the vertebrates and is easily recognizable. The catheter in the left internal thoracic vein, just to the left of the sternal border has a characteristic approach on the lateral chest radiograph, with the advancing anteriorly along the chest wall.

It is important to determine the position of the catheter tip clearly during or after the procedure to prevent possible complications. Confirming the location of the catheter tip with single-plane imaging is risky in terms of superposed incorrect locations especially in patients with right sided catheter. Radiologists have an important role not only in CVC placement but also in the determination of the correct position of the catheter tip, it is important to be aware of possible incorrect positions and to be sure of the position of the catheter with bi-plane images to prevent complications.