Differential diagnosis of pediatric central venous catheter malfunction

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