Etiology: Central venous catheter (CVC) placed in patients who require long-term infusions, most commonly chemotherapy
Imaging CXR: Catheter tip should be pointing inferiorly in superior vena cava or at cavo-atrial junction — Note: Azygous location of catheter can be suspected on CXR AP if catheter deviates medially from expected location of superior vena cava while on CXR lateral catheter extends posteriorly — Note: If a line is placed with its tip in the hemiazygos vein it should not be considered to be central
Imaging Fluoroscopy: — Fibrin sheath: Contrast does not flow out of the tip of the catheter but instead flows back up the catheter and spills out a level above the tip which results in the distal catheter having a bulging appearance during contrast injection — Residual fibrin sheath: Tubular filling defect within a vessel that previously contained a catheter — Thrombus: Contrast does flow out of the tip of the catheter and stains the thrombus at the tip
DDX:
Complications: — Initial malposition of catheter tip — Port leaking — Catheter broken or leaking — Catheter tip migrated either out of vessel or occluded against wall of vessel — Fibrin sheath or thrombus at catheter tip — Retained or embolized catheter fragment or residual fibrin sheath after catheter removal
Treatment: — Fibrin sheath and thrombus treated with tissue plasminogen activator (TPA) infusion — Repositioning or removal of malpositioned catheter
Clinical: Presents with failure to infuse or draw back through catheter
Radiology Cases of Central Venous Catheter Malfunction / Malposition / Misposition / Misplacement
Radiology Cases of Central Venous Catheter Normal Appearance
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.
Radiology Cases of Central Venous Catheter Malposition
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.
Radiology Cases of Central Venous Catheter Port 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.
Radiology Cases of Central Venous Catheter Port Leaking
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.Scout image (above) shows the tip of the central venous catheter in the superior vena cava. AP (below left) and oblique (below right) images obtained during contrast injection through the catheter show leakage of contrast outside of and all around its port into the subcutaneous tissues with no contrast entering the catheter.
Radiology Cases of Central Venous Catheter Leaking
Image from a line study while injecting contrast shows leakage of contrast out of the proximal portion of the catheter.
Radiology Cases of Central Venous Catheter Migrated and Occluded Against Wall of Superior Vena Cava
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.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.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.CXR AP (above) shows the tip of the central venous catheter to be flush against the wall of the superior vena cava. Image taken during contrast injection of the central venous catheter (below) show the tip of the catheter has moved away from the wall of the superior vena cava during injection.
Radiology Cases of Central Venous Catheter Migrated and Occluded Against Wall of Subclavian Vein
CXR AP from one month ago (above) shows the tip of the central venous catheter to be at the junction of the superior vena cava and the right atrium. CXR AP today (below) shows the tip of the central venous catheter to have migrated back into the right subclavian vein and the tip of the catheter is occluded against the wall of the subclavian vein.
Radiology Cases of Central Venous Catheter Migrated Out of 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.
Radiology Cases of Central Venous Catheter Fibrin Sheath
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.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.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.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.Image from a central line study after the injection of a small amount of contrast (left) shows that the distal portion of the catheter is thicker in diameter than the proximal portion of the catheter. Image obtained after the injection of a small amount of additional contrast (right) shows contrast flowing not from the tip of the catheter but rather contrast flowing from the right side of the catheter just above where the catheter thickening begins in the left image.AP image from a central venous catheter injection shows widening of the diameter of the distal end of the catheter. Contrast did not flow out of the tip of the catheter but instead flowed out of the catheter in a more superior location, at approximately the level where the catheter enters the superior vena cava, where a linear collection of contrast can be seen to the right of the catheter.
Radiology Cases of Central Venous Catheter Thrombus
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.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.Scout image from a fluoro exam (left) shows the catheter is radiographically intact with its tip in the brachiocephalic vein. Images obtained during contrast injection (center and right) show contrast filling and outlining an irregularly shaped object at the tip of the catheter.
Radiology Cases of Central Venous Catheter Fracture
CXR AP when the catheter was placed one year ago (left) shows the tip of the catheter at the cavoatrial junction in correct position. CXR AP today (right) shows the catheter is now fractured and discontinuous and has embolized into the right atrium.
Radiology Cases of Central Venous Catheter Retained Fragment
CXR AP shows the tip of the new right central venous catheter to be in the superior vena cava. Also seen is a short piece of catheter in the left brachiocephalic vein.
Radiology Cases of Central Venous Catheter Embolized 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.
Radiology Cases of Central Venous Catheter Embolized Fibrin Sheath After Catheter Removal
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.
