Infant with congenital diaphragmatic hernia on arterial-venous ECMO

CXR of arterial-venous extracorporeal membrane oxygenation (ECMO) — CXR shows normal position of the arterial catheter tip in the aortic arch and abnormal position of the venous catheter tip (represented by a radio-opaque point) in the superior vena cava. Further advancement of the tip into the right atrium is necessary.

The diagnosis was abnormal position of the venous ECMO catheter tip.

Teenager with viral pneumonia on arterial-venous (AV) ECMO

AXR of arterial-venous extracorporeal membrane oxygenation (ECMO) — AXR shows normal position of the arterial catheter tip in the right iliac artery and normal position of the venous catheter tip in the mid inferior vena cava.

The diagnosis was normal position of the AV ECMO catheter tips in a teenager.

Infant with viral pneumonia on venous-venous (VV)ECMO

CXR of venous-venous extracorporeal membrane oxygenation (ECMO) — CXR shows normal position of the venous catheter tip near the junction of the right atrium and the inferior vena cava.

The diagnosis was normal position of the VV ECMO catheter tip in an infant.

Newborn with persistent pulmonary hypertension on venous-venous (VV) ECMO

CXR of venous-venous extracorporeal membrane oxygenation (ECMO) — CXR shows normal position of the venous catheter tip in the right atrium.

The diagnosis was normal position of the VV ECMO catheter tip in a neonate.

Newborn with a left congenital diaphragmatic hernia on arterial-venous (AV) ECMO

CXR of arterial-venous extracorporeal membrane oxygenation (ECMO) — CXR shows normal position of the arterial catheter tip in the aortic arch and normal position of the venous catheter tip in the right atrium, both of which are shifted to the right by the diaphragmatic hernia. Note that the endotracheal tube, which is positioned between the two ECMO catheters, is also shifted to the right.

The diagnosis was normal position of the AV ECMO catheter tips in a neonate.

Newborn with persistent pulmonary hypertension on arterial-venous (AV) ECMO

CXR of arterial-venous extracorporeal membrane oxygenation (ECMO) — CXR shows normal position of the arterial catheter tip in the aortic arch (aa) and normal position of the venous catheter tip in the right atrium (ra).

The diagnosis was normal position of the AV ECMO catheter tips in a neonate.

Teenager status post central catheter placement

CXR showing central venous catheter tip malpositioned in the right internal thoracic vein — CXR AP obtained immediately after catheter placement (above) shows the catheter tip malpositioned in the right internal thoracic vein. CXR AP obtained after repositioning (below) shows catheter tip appropriately positioned in the superior vena cava.

The diagnosis was malpositioned catheter tip after placement.

Preschooler with a dual port central catheter whose white port is not working well

Line study showing dual port central venous catheter — Image from a line study while injecting the white port of the catheter (left lower) shows the lumen of the white port is one-third the diameter seen while injecting the red port of the catheter (right lower). No fibrin sheath or clot was seen.

The diagnosis was a normal appearance of a dual port central catheter.

School ager who presents with back pain after having a central venous catheter replaced 5 months ago

CXR and CT of embolized central venous catheter fragment — CXR AP shows the tip of the new catheter to be in appropriate location in the superior vena cava. There is a catheter fragment in the right lower lobe along with a large right pleural effusion. Axial CT with contrast of the chest shows the embolized catheter fragment in the periphery of the right lower lobe and to have eroded into the right pleural space, with an associated pleural effusion and atelectasis.

The diagnosis was an embolized catheter fragment after catheter removal.

Preschooler with a catheter that does not draw back

Line study of an occluded central venous catheter due to migration — CXR from 3 months before (above) shows the tip of the catheter in appropriate position in the superior vena cava. Scout image from the line study (below) shows interval migration of the tip of the catheter so that its tip now lies nearly flush against the lateral wall of the superior vena cava.

The diagnosis was occlusion of the catheter tip due to catheter migration.

School ager with a catheter that infuses but does not draw back

Line study of a thrombus on a central venous catheter — Scout image from a line study (above) shows migration of the tip of the catheter 90 degrees so that it now lies flush against the anterior wall of the superior vena cava. AP and lateral views from the line study after contrast injection shows staining of a long thin object resembling thrombus hanging off the tip of the catheter.

The diagnosis was thrombus of the catheter tip and occlusion of the catheter tip due to catheter migration.

Preschooler with a catheter that infuses but does not draw back

Line study of occluded central venous catheter due to migration — Scout image from a line study shows migration of the tip of the catheter so that it now lies flush against the lateral wall of the superior vena cava.

The diagnosis was occlusion of the catheter tip due to catheter migration.

Teenager with a catheter that infuses but does not draw back

Line study of a thrombus on a central venous catheter — Scout image from a line study (above) shows the tip of the catheter in the superior vena cava. Injection of contrast (below) shows staining of a large irregularly shaped object resembling thrombus at the tip of the catheter.

The diagnosis was thrombus of the catheter tip.

Teenager with a catheter that infuses but does not draw back

Line study of a fibrin sheath on a central venous catheter — Image from a line study (above) with the catheter filled with contrast shows a mild dilation in the diameter of the distal catheter, suggesting the contrast is inside a sheath encasing the distal catheter. When contrast is injected through the catheter (below), a sheath is seen to flip off the tip of the catheter to the left.

The diagnosis was fibrin sheath of the catheter tip.

School ager with a catheter that does not infuse and does not draw back

Line study of a central venous catheter port that was not correctly accessed — Image from a catheter injection (below) shows extravasation of contrast into the soft tissues of the chest wall adjacent to the tip of the needle. Closer review of the CXR scout (above) shows the tip of the needle being used to access the port is not within the port.

The diagnosis was the port was not correctly accessed.

Preschooler with a catheter that is difficult to infuse

Line study of a fibrin sheath on a central venous catheter — CXR obtained 6 months before (above left) compared to the scout image obtained before the line study (above right) shows the tip of the catheter has migrated proximally the height of one vertebral body between the two exams. Image from the line study (below) shows contrast outlining a sheath where the catheter tip used to be.

The diagnosis was fibrin sheath where the tip of the catheter was previously.

Preschooler who is immune suppressed with a fever who had their catheter replaced 9 months ago

CT of an embolized fibrin sheath from a central venous catheter — CXR shows no evidence of pneumonia, but suggests the presence of a tubular structure in the inferior aspect of the left hilum that was not present on a prior CXR obtained before the catheter was replaced. Coronal image from a CT with contrast of the chest better demonstrates the high density tubular structure.

The diagnosis was an embolized fibrin sheath from the prior catheter which was determined by an angiogram.

School ager with a catheter that does not infuse

Line study of a leaking central venous catheter port — AP and lateral views from a line study shows contrast leaking out of and all around the port into the subcutaneous tissues with no contrast entering the catheter.

The diagnosis was a leaking central venous catheter port.

Infant with catheter that infuses but does not draw back

Line study of central venous catheter with an occluded tip — CXR from 2 weeks earlier (above) shows the tip of the catheter in appropriate position at the junction of the superior vena cava and the right atrium. Scout image from a line study (below) shows the tip of the catheter has migrated backwards in the interval and its tip now rests against the wall of the superior vena cava.

The diagnosis was occlusion of the catheter tip due to catheter migration.

Preschooler with catheter that infuses but does not draw back

Line study of a fibrin sheath on a central venous catheter — Image from a line study (above) shows a subtle dilation in the diameter of the distal catheter, which is better seen on the magnified view (below), suggesting the contrast is inside a sheath encasing the distal catheter.

The diagnosis was fibrin sheath of the catheter tip.

Preschooler with catheter that has pain with infusion and that does not draw back

Line study of a leaking central venous catheter — Image from a line study while injecting contrast shows leakage of contrast out of the proximal portion of the catheter.

The diagnosis was leaking catheter.

Teenager with catheter that infuses but does not draw back

Line study of a fibrin sheath on a central venous catheter — Scout from a line study (above) shows the tip of the catheter to be abnormally positioned in the right subclavian vein rather than in the superior vena cava. Injection of the catheter (below) shows a dilation in the diameter of the distal catheter, suggesting the contrast is inside a sheath encasing the distal catheter.

The diagnosis was fibrin sheath of the catheter tip.

School ager with catheter that infuses but does not draw back

Line study of a central venous catheter tip that has migrated out of the vessel — CXR from 1 month before (above) shows the tip of the catheter in a left-sided superior vena cava. Scout image from a line study (below left) shows the tip of the catheter has apparently migrated out of the left-sided superior vena cava. Injection of the catheter (below right) shows contrast extravasating into the mediastinum.

The diagnosis was migration of the catheter tip out of the vessel into the mediastinum.

Teenager in a motor vehicle accident with chest pain

CXR and CT and angiogram of thoracic aortic injury — CXR AP shows widened mediastinum. Axial CT with contrast of the chest shows dilated caliber of the thoracic aorta at the level of the diaphragm with surrounding mediastinal fluid (above) and normal caliber of the abdominal aorta with evidence of retrocrual hemorrhage tracking into the abdomen (below). Angiogram shows a pseudoaneurysm of the aorta at the level of the diaphragm.

The diagnosis was thoracic aortic injury.

Teenager shot by sibling with pellet gun one day ago with progressive dyspnea and chest pain

CXR and CT of pericardial effusion — CXR AP shows an enlarged cardiac silhouette, bilateral pleural effusions and radioopaque pellets in the right thorax near the hilum and left axilla. Axial and coronal CT with contrast of the chest shows a large amount of fluid in the pericardial space.

The diagnosis was traumatic pericardial effusion.