Umbilical Venous Catheter Malfunction / Malposition / Misposition / Misplacement

Etiology: Placed in premature newborns and term newborns who need central venous access for intravenous fluids or medications or total parental nutrition and central venous pressure monitoring
Imaging:
— Normal umbilical venous catheter (UVC) course is umbilical vein to left portal vein to ductus venosus to left hepatic vein to inferior vena cava (in and cephalad on an AP image) while coursing obliquely through the liver on the lateral image
— Catheter tip should be at junction of right atrium and inferior vena cava
— Usually projects over the right side of the spine on an AP image
DDX:
Complications:
— Catheter tip positioned too high in the heart especially in the right atrium
— Catheter tip positioned within liver in a hepatic vein or ductus venosus or portal vein
— Catheter tip positioned below liver in umbilical vein
— Catheter tip thrombosis which can extend into any adjacent vein and if in portal vein can result in portal hypertension
— Perforation of vessel during catheter placement leading to hepatic laceration or hematoma or hemoperitoneum (should be suspected when the umbilical arterial catheter projects over no known arterial vessel)
— Hepatic infarction or necrosis if hypertonic fluid is extravasated into liver
— TPNoma if total parenteral nutrition is extravasated into liver
— Necrotizing enterocolitis
— Cardiac injury can include laceration or tamponade or arrhythmia
— Pulmonary injury can include infarct if catheter is in pulmonary artery or hemothorax if pulmonary artery is lacerated
— Air embolism
Treatment: Repositioning or removal of malpositioned catheter
Clinical: Use for less than 1 week and then replace with peripherally inserted central catheter

Radiology Cases of Umbilical Venous Catheter Malfunction / Malposition / Misposition / Misplacement

Radiology Cases of Umbilical Venous Catheter Tip in Appropriate Position

AXR of umbilical venous catheter in appropriate position — AXR AP and cross-table lateral shows normal course of the umbilical venous catheter from umbilical vein to left portal vein to ductus venosus to left hepatic vein to inferior vena cava (in and cephalad on the AP view) while coursing through the liver on the lateral view with the catheter tip positioned at the junction of the inferior vena cava and right atrium. The umbilical arterial catheter has a normal course from umbilical artery to internal iliac artery to common illiac artery to aorta (in and caudad and then cephalad on the AP view) while coursing anterior to the spine on the lateral view with the catheter tip at T5.

AXR of low malposition of an umbilical arterial catheter — AXR supine shows an umbilical arterial catheter that loops back upon itself in the aorta and whose tip projects in the right iliac artery at S3. The umbilical venous catheter tip projects at the junction of the inferior vena cava and the right atrium.

CT of umbilical venous catheter in normal position — Sagittal CT with contrast of the chest shows the umbilical venous catheter to course through the umbilical vein into the liver to the left portal vein to the ductus venosus to the left hepatic vein to the inferior vena cava with its tip near the junction of inferior vena cava and the right atrium.

Radiology Cases of Umbilical Venous Catheter Tip Positioned Above Junction of Inferior Vena Cava and Right Atrium

CXR of umbilical venous catheter in a pulmonary vein — CXR AP shows the umbilical venous catheter coursing into the right atrium, through a patent foramen ovale, into the left atrium and then into a left pulmonary vein. The umbilical arterial catheter tip is at T4. There is faint ground glass opacity in the lungs.

CXR of umbilical venous catheter in the left pulmonary vein — CXR AP shows one umbilical venous catheter coursing into the right atrium, through a patent foramen ovale, into the left atrium and then into a left pulmonary vein. Another umbilical venous catheter has its tip projecting intrahepatically within the main portal vein. The umbilical arterial catheter tip is at T8.

AXR of umbilical venous catheter in the right subclavian vein — CXR AP shows the tip of one umbilical venous catheter to be in the superior vena cava with the tip of the other umbilical venous catheter curled within the right atrium. The tip of the endotracheal tube is in the right mainstem bronchus. The lungs have ground-glass opacity.

CXR of umbilical venous catheter in right atrium and superior vena cava — CXR AP shows the tip of one umbilical venous catheter to be in the superior vena cava with the tip of the other umbilical venous catheter curled within the right atrium. The tip of the endotracheal tube is in the right mainstem bronchus. The lungs have ground-glass opacity.

AXR of umbilical venous catheter tip in the superior vena cava — CXR AP shows the tip of the umbilical venous catheter to be in the superior vena cava. The tip of the umbilical arterial catheter projects at the level of the T6 vertebral body.

CXR of umbilical arterial catheter in left subclavian artery — CXR AP shows the tip of the umbilical arterial catheter to be in the left subclavian artery. The tip of the umbilical venous catheter is deep within the right atrium. The lungs show minimal ground-glass opacity.

CXR of nasogastric tube in mid-esophagus — CXR AP shows the tip of the nasogastric tube in the mid esophagus. The tip of the umbilical venous catheter is too high in the right atrium and the tip of the umbilical arterial catheter is too high in the aortic arch.

AXR of normal position of an umbilical arterial catheter — AXR AP and cross-table lateral shows normal course of the umbilical arterial catheter from umbilical artery to internal iliac artery to common illiac artery to aorta (in and caudad and then cephalad on the AP view) while coursing anterior to the spine on the lateral view with the catheter tip appropriately positioned at T7. The umbilical venous catheter has a normal course from umbilical vein to left portal vein to ductus venosus to left hepatic vein to inferior vena cava (in and cephalad on the AP view) while coursing through the liver on the lateral view with the catheter tip positioned in the right atrium

CXR of congenital dilated cardiomyopathy — CXR AP shows cardiomegaly with normal pulmonary vascularity. The umbilical venous catheter tip projects over the right atrium.

Radiology Cases of Umbilical Venous Catheter Tip Within Liver

AXR of umbilical arterial catheter perforation — Supine AXR shows the tip of the umbilical arterial catheter to project in the left abdomen over no known arterial vessel. The tip of the umbilical venous catheter projects within the liver.

AXR of umbilical venous catheter in the right portal vein — Initial AXR AP (left) shows the umbilical venous catheter tip in the main portal vein and the tip of the umbilical arterial catheter at T8. Later AXR AP (right) shows the umbilical venous catheter tip in the right portal vein.

CXR of umbilical arterial catheter malposition — CXR AP shows the tip of the umbilical arterial catheter to be at T3 near the aortic arch. The tip of the umbilical venous catheter is in the right portal vein. The lungs show diffuse ground-glass opacity.

AXR of umbilical venous catheters in the left portal vein and right portal vein — AXR AP shows the tip of the first umbilical venous catheter curled back upon itself in the right portal vein with the tip of the second umbilical venous catheter in the left portal vein. The tip of the umbilical arterial catheter is at T7.

AXR of portal venous gas from an umbilical venous catheter in the right portal vein — CXR AP shows the tip of the umbilical venous catheter to be in the right portal vein. There is air in the portal venous system. The umbilical arterial catheter projects at T9. There is mild ground-glass opacity in the lungs.

AXR of umbilical venous catheter in the right portal vein — AXR AP (above) and cross-table lateral AXR (below) shows the tip of the umbilical venous catheter to be positioned deep within the right portal vein. The tip of the umbilical arterial catheter is at T4.

AXR of umbilical venous catheter in right portal vein — CXR AP shows the tip of the umbilical venous catheter within the right portal vein. The tip of the umbilical arterial catheter is at T5. There is ground-glass opacity in the lungs.

AXR of umbilical venous catheter in right portal vein — AXR AP shows the tip of the umbilical venous catheter within the right portal vein. The tip of the umbilical arterial catheter is at T8.

AXR of umbilical venous catheter in the left portal vein — AXR AP shows the tip of the umbilical venous catheter projecting over the left portal vein. The tip of the umbilical arterial catheter projects at T9.

AXR of umbilical venous catheter in the left portal vein — CXR AP shows the tip of the umbilical venous catheter projecting over the left portal vein. The tip of the umbilical arterial catheter projects at T6. There is hazy ground glass opacity in the lungs.

AXR of umbilical venous catheter misplacement in umbilical vein — AXR AP shows the tip of the umbilical venous catheter curling back upon itself within the umbilical vein. The tip of the umbilical arterial catheter projects at T6. The proximal small bowel is massively dilated.

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.

Radiology Cases of Umbilical Venous Catheter Tip Beneath Liver

AXR of umbilical venous catheter misplacement in the inferior mesenteric vein — AXR AP shows the tip of the first umbilical venous catheter coursing inferiorly deep into the inferior mesenteric vein and the tip of the second umbilical venous catheter projecting over the umbilical vein. The tip of the umbilical arterial catheter projects at T6.

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.

Radiology Cases of Umbilical Venous Catheter Perforation of Vessel

AXR of umbilical venous catheter perforation out of vein — Supine AXR (upper left) shows the umbilical venous catheter tip coursing to the left of midline. Cross-table lateral AXR (upper right) shows the umbilical venous catheter tip projecting over the anterior abdomen with air bubbles along the catheter tract. CXR taken after placement of a second umbilical venous catheter (below) shows the new umbilical venous catheter tip in the right or left atrium and the first umbilical venous catheter tip projecting over the left upper quadrant over no known vein with air bubbles along its tract. US subsequently showed the tip of the first umbilical venous catheter was in the subcutaneous tissues of the anterior abdominal wall.

Radiology Cases of Umbilical Venous Catheter Perforation of Vessel With Formation of TPNoma

AXR and CT of extravasation of TPN into the liver due to umbilical venous catheter perforation out of the vein — AXR AP shows the tip of the umbilical venous catheter to project over the left portal vein. Axial CT with contrast of the abdomen shows multiple low density lesions which appear to be joined together in the left lobe of the liver.

US of TPNoma — Initial AXR AP (above left) shows the umbilical venous catheter (UVC) tip to project over the liver and not to project at the junction of the inferior vena cava and right atrium. The UVC did not work well and was removed several days later. AXR 2 weeks later (above right) shows interval development of hepatomegaly. Transverse (below left) and sagittal (below right) US of the liver show a large septated and complex fluid collection within the liver.

Radiology Cases of Umbilical Venous Catheter Tip Thrombus

CXR and CT of portal vein thrombosis due to umbilical venous catheter — CXR AP (above) shows a calcification in the liver just to the right of the L1 vertebral body. Axial CT with contrast of the abdomen (below) shows the dense calcification to be in the left portal vein.