Pediatric Peripherally Inserted Central Catheter Malfunction / Malposition / Misposition / Misplacement

  • Etiology: Placed in patients who need central venous access
  • Imaging: Normal peripherally inserted central catheter (PICC) tip positions:
    — Scalp PICC and upper extremity PICC tip in the superior vena cava to right of spine
    — Note: Upper extremity PICC tip position can vary depending on arm position
    — Note: When PICC remains on the left side of the spine and does not cross to right side it is important to confirm if PICC is arterial or venous in location so pull PICC back to axilla and inject contrast – if PICC is arterial the contrast goes peripherally rather than centrally
    — Note: If a line is placed with its tip in the hemiazygos vein it should not be considered to be central
    — Lower extremity PICC tip in the inferior vena cava to right of spine
  • DDX:
  • Complications:
    — Scalp or upper extremity PICC tip not positioned in the superior vena cava
    — Lower extremity PICC tip not positioned in the inferior vena cava
    — Lower extremity PICC tip positioned in the spinal canal can lead to neurosurgical emergency
    — PICC tip in the right atrium which can lead to erosion of PICC through right atrium into pericardial space causing cardiac tamponade
    — PICC placed in artery rather than in vein
    — PICC perforation of vessel during placement
    — PICC tip thrombosis which can extend into any adjacent vein
    — Retained or embolized PICC catheter fragment
  • Treatment: Repositioning or removal of malpositioned catheter
  • Clinical:

Radiology Cases of Peripherally Inserted Central Catheter Malfunction / Malposition / Misposition / Misplacement

Radiology Cases of Scalp Peripherally Inserted Central Catheter Tip in Appropriate Position

CXR of normal position of scalp peripherally inserted central catheter / PICC
CXR AP shows a scalp PICC with its tip projecting over the superior vena cava.
CXR of upper extremity peripherally inserted central catheter / PICC in the superior vena cava
CXR AP shows a right upper extremity PICC whose tip projects over the superior vena cava.

Radiology Cases of Scalp or Upper Extremity Peripherally Inserted Central Catheter Tip Not in the Superior Vena Cava

CXR of high malposition of a scalp peripherally inserted central catheter / PICC
CXR AP shows a scalp PICC whose tip projects in the right internal jugular vein.
CXR of peripherally inserted central catheter / PICC in hemiazygous vein
CXR AP shows a right scalp PICC which crosses the midline and whose tip projects over the left pedicle of the spine at T7 either in the aorta or in the hemiazygous vein.
CXR of scalp peripherally inserted central catheter / PICC in the left atrium
CXR AP (left) shows a scalp PICC whose tip projects within the left atrium. After pulling back, repeat CXR AP (right) shows the PICC tip in the superior vena cava.
CXR of scalp peripherally inserted central catheter in the inferior vena cava
CXR AP shows a scalp PICC whose tip projects at the level of the L1 vertebral body within the inferior vena cava.
CXR of peripherally inserted central catheter / PICC projecting over the inferior vena cava
CXR AP shows a right upper extremity PICC tip projecting over the inferior vena cava.
CXR of peripherally inserted central catheter in the middle hepatic vein
CXR AP shows a left upper extremity PICC whose tip projects within the liver in the middle hepatic vein.
CXR of upper extremity peripherally inserted central catheter / PICC in an axillary vein
CXR AP shows a left upper extremity PICC looped back upon itself with its tip in a vein in the left axilla.
CXR of upper extremity peripherally inserted central catheter / PICC in the jugular vein
CXR AP shows the left upper extremity PICC tip to project over the left brachiocephalic vein. The new right upper extremity PICC tip projects over the right internal jugular vein.
CXR of peripherally inserted central catheter / PICC in the internal mammary vein
CXR AP and lateral shows a left upper extremity PICC whose tip projects over the left internal mammary vein.

Radiology Cases of Peripherally Inserted Central Catheter Placed in Right Atrium

CXR of upper extremity peripherally inserted central catheter changing in position as arms move
CXR AP with the left arm down (above) shows the tip of the left upper extremity PICC to project in the superior vena cava. CXR AP with the left arm up (below) obtained later the same day shows the tip of the PICC to have moved to deep within the right atrium.
CXR of scalp peripherally inserted central catheter / PICC in the right atrium
CXR AP shows a scalp PICC whose tip projects curled within the right atrium.
CXR of peripherally inserted central catheter / PICC deep in the right atrium
CXR AP (left) shows the tip of the left upper extremity PICC to project deep within the right atrium. CXR AP (right) obtained later the same day shows the tip of the PICC to have pulled back into the superior vena cava. There is ground glass opacity throughout the lungs.
CXR of peripherally inserted central catheter / PICC in the right atrium
CXR AP shows a left upper extremity PICC coiled within the right atrium.
CXR of a lower extremity peripherally inserted central catheter / PICC in the right atrium
CXR AP shows a lower extremity PICC tip projecting within the right atrium

Radiology Cases of Peripherally Inserted Central Catheter Placed in Pulmonary Artery

CXR of PICC line in the left pulmonary artery
CXR AP shows a left upper extremity PICC line whose tip projects over the left pulmonary artery.

Radiology Cases of Peripherally Inserted Central Catheter Placed in Aorta

Imaging exam of peripherally inserted central catheter / PICC in the aorta
CXR AP shows an umbilical arterial catheter in the aorta whose tip is at T6 and a left upper extremity PICC which courses parallel to the umbilical arterial catheter and whose tip projects at the level of L2.
CXR of PICC line in the aorta
CXR AP shows an umbilical arterial catheter in the aorta whose tip is at the level of the T8 vertebral body and a left upper extremity PICC which courses parallel to the umbilical arterial catheter and whose tip projects at the level of T8 as well.
CXR of PICC line in the aorta
CXR shows a left upper extremity catheter which courses over the left side of the spine and whose tip projects at T12.

Radiology Cases of Lower Extremity Peripherally Inserted Central Catheter Tip in Appropriate Position

AXR of normal position of lower extremity peripherally inserted central catheter / PICC in the inferior vena cava
AXR AP and lateral shows a right lower extremity PICC with its tip within the inferior vena cava anterior to the spine at the level of T11. The tip of the umbilical venous catheter is within the ductus venosus.
AXR of lower extremity peripherally inserted central catheter / PICC in a left-sided inferior vena cava in a patient with situs inversus
AXR AP shows a left lower extremity PICC and a right femoral venous catheter both of whose tips project over a left-sided inferior vena cava. An umbilical venous catheter tip projects over the ductus venosus. An umbilical arterial catheter tip projects at the level of T9. Nasogastric tube tip projects over the stomach in the right upper quadrant. Feeding tube tip projects transpylorically over the duodenal bulb. The cardiac apex is in the right chest.

Radiology Cases of Lower Extremity Peripherally Inserted Central Catheter Tip Not in the Inferior Vena Cava

AXR of a peripherally inserted central catheter / PICC in a superficial epigastric vein
AXR AP and lateral shows a right lower extremity PICC tip projecting over a superficial epigastric vein in the anterior abdominal wall.
AXR of a peripherally inserted central catheter / PICC in a superficial epigastric vein
AXR AP and lateral shows a right lower extremity PICC tip projecting over a superficial epigastric vein in the anterior abdominal wall.
AXR of lower extremity peripherally inserted central catheter / PICC in the femoral vein
AXR AP shows a right lower extremity PICC which is curled back upon itself and whose tip projects over the right femoral vein. The tip of the umbilical venous catheter projects within the umbilical vein.
AXR of lower extremity peripherally inserted central catheter / PICC in the iliac vein
AXR AP shows a left lower extremity PICC which courses across the midline and down the right common iliac vein. The tip of the umbilical venous catheter projects over the umbilical vein. The tip of the umbilical arterial catheter projects at T6.
AXR of PICC line in left gonadal vein
AXR AP shows a right lower extremity PICC line whose tip projects over the scrotum, presumably in the left gonadal vein.
AXR of lower extremity peripherally inserted central catheter / PICC in a thoracoepigastric vein
AXR AP and lateral shows a left lower extremity PICC coursing along in a thoracoepigastric vein along the left lateral abdominal wall. The umbilical arterial catheter tip projects at T10.
AXR of peripherally inserted central catheter / PICC in the renal vein in a patient with gastroschisis
AXR AP and lateral shows a right lower extremity PICC coursing across the midline with its tip projecting over the left renal vein. The abdomen appears to be bulging and protruberant in both medial-lateral and anterior-posterior dimensions. The tip of the bladder catheter projects high within the pelvis within a dilated bladder
Radiograph of PICC line in right renal vein
AXR shows a left lower extremity PICC line whose tip projects in the region of the right renal vein.

Radiology Cases of Peripherally Inserted Central Catheter Tip Positioned in the Spinal Canal

AXR of peripherally inserted central catheter / PICC in spinal canal
AXR AP shows a right lower extremity PICC whose tip projects at the level of L1 and that projects within the spinal canal on the lateral radiograph.
AXR of peripherally inserted central catheter / PICC in spinal canal
AXR AP shows a left lower extremity PICC whose tip projects at the level of L4 while looping in an unusual manner and that projects within the spinal canal on the lateral radiograph.
AXR of peripherally inserted central catheter / PICC in the spinal canal
AXR AP shows a left lower extremity PICC that does not follow the course of the iliac vein and whose tip projects at the level of L3 and that projects within the spinal canal on the lateral radiograph. The only gas within the abdomen is in the stomach while all of the small bowel is in a silo outside the abdomen.
AXR of PICC line tip in spinal canal
AXR lateral (left) shows the tip of a right lower extremity PICC line looping back upon itself and projecting over the spinal canal. AXR AP (right) after reposition of the line shows the tip projecting over the inferior vena cava. The patient also has a large anterior abdominal wall defect containing loops of bowel which is covered by a membranous sac.
AXR of PICC line tip misposition in the spinal canal
AXR AP (left) shows a wavy appearance to the right lower extremity PICC line. Lateral radiograph (right) shows the PICC line tip projecting over the spinal canal.

Radiology Cases of Peripherally Inserted Central Catheter Perforation of Vessel

Radiology Cases of Peripherally Inserted Central Catheter Tip Thrombosis

CT of inferior vena cava thrombus caused by peripherally inserted central catheter / PICC
AXR AP obtained after PICC placement shows a left lower extremity PICC tip projecting near the bifurcation of the iliac veins. Axial CT with contrast of the abdomen obtained two months later shows a thin filling defect throughout the entire inferior vena cava which extended to the left iliac vein, seen as a round high density lesion in the medial aspect of the proximal inferior vena cava (above right) and as a round low density lesion centrally in the distal inferior vena cava (below right).
CXR and US of inferior vena cava thrombus caused by peripherally inserted central catheter / PICC
AXR AP shows the tip of a lower extremity PICC projecting within the inferior vena cava with its tip at T11 with a long tubular calcification extending from the PICC tip to the level of the right atrium. Transverse US of the liver at the level of the hepatic veins draining into the inferior vena cava shows a round echogenic lesion with posterior shadowing within the inferior vena cava that extended from the tip of the PICC to the cavo-atrial junction.

Radiology Cases of Peripherally Inserted Central Catheter Retained Fragment

Radiograph of broken PICC line
AXR AP (left) and lateral (right) show a discontinuous catheter fragment in the left femoral and iliac veins.
Lower extremity radiograph of retained PICC line fragment
AP radiograph of the right lower extremity shows a retained fragment of a PICC line in the posterior soft tissues of the right calf.