Chest X-ray - Tubes - CV Catheters - Position

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• Introduction
• Principles
• ET Tubes - Position
• ET Tubes - Complications
• NG Tubes - Position
• NG Tubes - Complications
• CV Catheters - Position
• CV Catheters - Complications
• Chest Drains - Position
• Chest Drains - Complications
• Tutorial conclusion

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Key points

• The carina is clearly visible on most chest X-rays and so is used as a landmark to help determine central venous catheter (CVC) location
• Correct positioning of a CVC tip depends on the side of entry
• Correct positioning of a CVC tip also depends on the intended use of the catheter
• Identifying the exact position of a catheter tip is limited by the quality of the X-ray

Catheter positioning

Positioning the tip of a central venous catheter (CVC) within the superior vena cava (SVC) at or just above the level of the carina is generally considered acceptable for most short-term uses, such as fluid administration or monitoring of central venous pressure. Ideally the distal end of a CVC should be orientated vertically within the SVC.

CVCs placed for the purpose of long term chemotherapy may be placed more inferiorly at the cavo-atrial junction - the junction of the SVC and right atrium (RA). Catheters used for haemodialysis may be placed at the cavo-atrial junction or even in the RA itself.

Positioning the catheter tip too proximally, for example in the right or left brachiocephalic veins, is associated with increased risk of line infection and thrombosis.

Anatomy

The lower part of the SVC is surrounded by the pericardial reflection; this is where the upper pericardium folds back on itself to form a sac. Positioning a CVC tip within the SVC and below the level of the pericardial reflection is associated with a small risk of pericardial tamponade.

Neither the SVC nor the pericardial reflection are visible on a chest X-ray. As the carina is a visible structure, which is located above the level of the pericardial reflection, it can be used as an anatomical landmark to help determine the level of a CVC tip within the SVC and above the pericardial reflection.

Superior vena cava (SVC) anatomy

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SVC anatomy - detail

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Right-sided catheters

CVCs are most commonly inserted via the right internal jugular vein. Right internal jugular catheters are positioned on the right side of the neck, and pass vertically from a position above the clavicle.

Right internal jugular vein catheter

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Catheters inserted into the subclavian vein pass below the clavicle and then curve into the SVC.

Right subclavian vein catheter

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Left-sided catheters

Left-sided catheters approach the SVC at a shallow angle such that they may abut the right lateral wall of the SVC (see next page). They may need to be inserted further so the distal end obtains a vertical orientation. This may mean locating the tip below the level of the carina. In this position the risk of vessel wall erosion is reduced, but with a small increased risk of pericardial tamponade.

Left subclavian vein catheter

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Long-term catheters

Catheters which are used for long-term administration of chemotherapy drugs (inserted either from the right or left) are usually positioned more inferiorly, at the level of the cavo-atrial junction. These catheters are usually inserted by radiologists or other specially trained staff.

Long term catheter - PICC line

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Radiographic quality

Obtaining good quality X-rays in patients with CVCs is often technically difficult. Variance of radiographic quality factors, such as patient rotation or incomplete inspiration, means that identifying anatomical landmarks is often difficult. If in doubt about catheter location, ask a senior colleague or a radiologist.

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Page author: Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist - Salisbury NHS Foundation Trust UK (Read bio)

Last reviewed: July 2019