Differential diagnosis of pediatric central venous catheter malfunction

• Initial malposition of catheter tip
• Port not accessed
• Port leaking
• Catheter broken
• Catheter leaking
• Catheter tip migrated and occluded against wall of vessel
• Catheter tip migrated out of vessel
• Fibrin sheath at catheter tip
• Thrombus at catheter tip
• Retained / embolized catheter fragment after catheter removal
• Retained / embolized fibrin sheath after catheter removal

Approach to the differential diagnosis of central venous catheter malfunction:

• First look at the CXR scout image to determine if
  — Port not accessed
  — Catheter broken
  — Catheter tip migrated and occluded against wall of vessel
  — Catheter tip migrated out of vessel
• Second fill the catheter with contrast to determine if
  — Port leaking
  — Catheter leaking
• Third inject contrast through the catheter focusing on the catheter tip to determine if there is
  — Fibrin sheath at catheter tip (Note: fibrin sheaths can be subtle)
  — Thrombus at catheter tip
• Finally realize that high density tubular structures on CXR scout images can be
  — Retained / embolized catheter fragment after catheter removal
  — Retained / embolized fibrin sheath after catheter removal