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| PICTORIAL ESSAY: CRITICAL CARE MEDICINE |
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| Year : 2014 | Volume
: 1
| Issue : 2 | Page : 104-123 |
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Radiology of ventilatory, feeding, and circulatory lines and tubes in the critically sick
Narainder K Gupta
Department of Radiology, Hospital of University of Pennsylvania and Perelman School of Medicine, Philadelphia PA 19010, USA
| Date of Web Publication | 31-Jul-2014 |
Correspondence Address:
Prof. Narainder K Gupta
Department of Radiology, Hospital of University of Pennsylvania and Perelman School of Medicine, Philadelphia PA 19010
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2349-0977.137854
A variety of supportive ventilatory, feeding and circulatory devices are employed in the management of critically sick patients. The hardware ranges from endotracheal, tracheostomy and chest tubes, nasogastric and nasoenteric feeding tubes, to central venous lines, umbilical venous and arterial catheters, pacers and automatic implantable cardioverter defibrillators, intraaortic balloon pumps and ventricular assist devices. The accurate positioning of this hardware is critical to the well being of a patient. However, these devices may not be positioned appropriately. Faults may occur at the time of their insertion, or the hardware may get dislodged while in use. A portable chest radiograph can be extremely useful in identifying such mishaps. This pictorial review captures some of the critical scenarios which must be known to radiologists and the treating intensivists. Keywords: Chest radiograph, intensive care unit, ventilatory tubes, feeding tubes, lines, circulatory assist devices
How to cite this article:
Gupta NK. Radiology of ventilatory, feeding, and circulatory lines and tubes in the critically sick. Astrocyte 2014;1:104-23 |
| Introduction | |  |
Chest X-ray (CXR) is the most common radiological study performed especially in the setting of intensive care unit (ICU). Routine daily chest radiographs in this setting is highly debated subject. Some of the groups recommend daily assessment with chest radiographs and other groups recommend that chest radiographs should be performed on demand rather than on a routine basis. The American College of radiology (ACR) appropriateness criteria has formulated the guidelines for imaging in the setting of line and tube placements. [1] According to the guidelines, a CXR immediately following placement of endotracheal tube (ETT), enteric/feeding tube and a chest tube is warranted. However, these guidelines do not support daily chest radiographs in the absence of any change in the clinical condition or suspected line or tube migration.
The chest radiographs are not only done for evaluation of tubes and lines but lung parenchyma and pleural findings are also an integral part of the report of radiologist. A systematic approach should be followed for the evaluation of the chest radiograph. This is to avoid any critical findings that may have bearing on the patient's outcome. This also helps to avoid being overwhelmed by other multitude of findings and overlying tubes and lines in ICU patients. In one of the studies, incorrectly positioned tubes or catheters were identified in 14% of the cases.
For the evaluation of tubes and lines, which is the focus of this pictorial review, a suggested scheme is to look where the tube/line starts, its end point, its course and any associated findings. If one is doubtful of a misplaced tube, line, or associated hardware, additional views should be obtained, and if even then a confident diagnosis cannot be reached reached, ultrasound and computed tomography (CT) scan may be warranted.
| Endotracheal and Tracheostomy Tubes | | |
ETT insertion is used for the short-term maintenance of the airway patency as well as to provide support. However for long-term maintenance, tracheostomy is used. The most common complication of endotracheal tube is malpositioning [Figure 1], which is seen in approximately 15% of the patients. [2] The acceptable position of tip of the ETT is approximately 5 cm above the carina provided the patient's head is in neutral position as there could be movement of the ETT inferiorly during flexion and superiorly during extension, respectively. [3],[4] On the chest radiograph, the ETT is recognized by a white opaque thin line for the length of the ETT. Carina can be located by following of the left and right main stem bronchus supero-medially and the point where they meet is the carina. Carina is located from T5-T7 in nearly 95% of the cases. The cuff should not be overinflated and should not expand the lumen of the trachea. | Figure 1: Misplaced Endotracheal Tubes in Two Cases. a) The frontal chest image shows termination of the endotracheal tube in the right bronchus intermedius (white arrow). There is atelectasis of the left lung. b) A contrast-enhanced coronal CT slice show the termination of the endotracheal tube in the right bronchus intermedius-RBI, right upper lobe-RUL bronchus takeoff from the trachea is also shown. ETT marks the endotracheal tube and T marks the trachea. c) In another patient, the endotracheal tube terminates in the left main stem bronchus and there is atelectasis of the right lung.
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ETT can be malpositioned either high or low [Figure 2]. A total of 10% of these misplaced ETTs are in the right main stem bronchus. [5],[6] Depending upon the position of the ETT, the other lung may be atelectatic as not being ventilated. The over inflation of one lung due to misplaced ETT can cause pneumothorax or tension pneumothorax. | Figure 2: High Termination of the Endotracheal Tube. A frontal examination show the termination (white arrow) of the endotracheal tube high above the thoracic inlet (Th. Inlet) and this patient therefore has increased chance of laryngeal and subglottic injury. This endotracheal tube needs to be advanced.
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Complications associated with the high termination of the ETT include accidental extubation or hypopharyngeal intubation that can cause ineffective ventilation and gastric distention. High placement can also lead to vocal cord injury. Therefore, the tip of the ETT should be approximately 3-4 cm below the vocal cords. Low termination of the ETT can cause main stem bronchial intubation, in majority of the cases in the right main stem bronchus. Therefore, total lung collapse, lobar collapse, and segmental collapse can happen depending upon the low position of the tip of the ETT. Due to the malpositioned ETT, the hyperaeration on the site of the malposition and atelectasis on the contralateral side can be identified on chest radiographs.
Esophageal intubation [Figure 3] is a very hazardous and sometimes fatal complication of endotracheal intubation. [7] On chest radiograph, this may present as gastric distention, esophageal distention, ETT lateral to the tracheal silhouette [Figure 4]. [3],[6] A right posterior oblique lateral radiograph may help diagnose this complication by showing ETT position outside the trachea and within the esophagus. [6]  | Figure 3: Esophageal Intubation with Endotracheal Tube. Esophageal intubation is identified in a child. White arrow marks the termination of endotracheal tube that is not within the trachea (Tr). The carina is shown with the letter C. There is prominent gastric distention with air (GB). This is an emergency and should be promptly communicated to a team member managing care of patient.
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 | Figure 4: Esophageal Intubation. a) The frontal chest radiographs show that the endotracheal tube-ETT is not taking the course of the trachea-T. b) The CT sagittal reconstruction clearly shows endotracheal tube within the esophagus and also the endotracheal tube bulb is overinflated.
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Overinflation of the ETT cuff [Figure 4] can cause tracheal injury and long-term complication of tracheomalacia and tracheal stenosis. Acute tracheal rupture due to overinflation could be a catastrophic complication. [8] Tracheal rupture usually involves the membranous portion of the trachea and there are certain signs on the chest radiographs that are indicative of tracheal rupture. These include bilateral pneumothoraces, massive subcutaneous emphysema, oblique orientation of the ETT to the right, inflation of the cuff beyond the boundaries of the tracheal walls as well as migration of the balloon cuff towards the tip of the ETT. [9] The tracheal rupture most commonly happens in distal 7 cm of the trachea and its posterior wall is the most common location. [3],[10] Hypopharyngeal rupture usually present with cervical subcutaneous emphysema, pneumomediastinum or pneumothorax, and the clinical findings include cervical crepitus. [11]
The complications associated with the use of ETT in spite of proper placement include barotrauma, which may cause interstitial emphysema, pneumothorax, or pneumomediastinum [Figure 5]. During the insertion of ETT, there may be aspiration pneumonitis. The ETT may be blocked with the blood clots as well as mucous plugging causing atelectasis. The other complications associated with endotracheal intubation are sinusitis, esophageal perforation, tracheal rupture, tracheoesophageal fistula, and esophageal hematoma. Tracheo-innominate artery fistula and trachea-aortic fistula are known complications and fatal. During ETT intubation, a loose tooth may be aspirated. | Figure 5: Pneumothorax and Pneumomediastinum as Complications of Endotracheal Intubation in two Prematurely Born Babies. a) In this premature baby, the endotracheal tube terminates low as indicated by the white arrow. In addition, this has caused right-sided moderate to large pneumothorax (PTX) as shown by the black arrowheads. Incidentally noticed is that the UV catheter is terminating high in SVC as is marked by the short black arrow. b) Another case demonstrating complication of endotracheal intubation in a premature baby. The large right-sided PTX is shown by white arrowheads. Pneumomediastinum (PMed) is shown with a short black arrow. The umbilical venous catheter terminates in the right atrium. An endotracheal tube and visualized nasogastric tube appear satisfactory. Also shown is mild granularity in both lungs consistent with mild RDS in this premature baby.
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Tip of the tracheostomy tube should lie approximately one-half to two-thirds of the distance between stoma to the carina. [8],[12] Tracheostomy tube do not change position during flexion and extension and a small amount of subcutaneous emphysema or mediastinal emphysema can be normal after tracheostomy tube placement. Complications due to tracheostomy tube placement should be suspected in presence of large subcutaneous emphysema as well as large pneumomediastinum on chest radiographs. Complications associated with tracheostomy are recurrent laryngeal nerve injury, hemorrhage, subcutaneous emphysema, displacement, and obstruction of the tube. The other complications include tracheal stenosis, tracheomalacia, tracheoesophageal fistula, and tracheal innominate fistula. [13] Long-term sequelae like tracheomalacia and tracheal stenosis are more common with tracheostomy rather than endotracheal intubations. Tube dislodgment and loss of the airways before the stoma has healed is a known complication. There may be complete displacement (decannulation) or partial dislodgment from the tip of the tube, which migrates to a false passage anterior to the trachea [Figure 6]. | Figure 6: Misplaced a Tracheostomy Tube. A 43-year-old male was complaining of shortness of breath. a) The tracheostomy tube-Tr is to the right side of the trachea-T on this frontal image from the CT scout. b, c) Axial CT sections confirm that the tracheostomy tube is outside the trachea.
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Pneumothorax, pulmonary interstitial emphysema, pneumomediastinum can happen from ruptured alveolus from the high-pressure ventilation in spite of proper placement of airway tubes.
| Nasogastric/Feeding Tubes | | |
Placement of nasogastric/feeding tubes is done for the purposes of suction of gastric contents, drugs administration, and feeding. The side port of the nasogastric tube should be located below the gastro-esophageal junction and the tip of the nasogastric tube should be within the stomach beyond the cardia. The tip of the small bore nasogastric tube should ideally be located in the second part of the duodenum to avoid the increased risk of aspiration. [8],[11]
Ghahremani et al. reported complication rate of 7.6%. [14] Malpositioning is the most common complication including incomplete insertion, tube coiling within the esophagus or hypopharynx, misplaced tube within the tracheobronchial tree, within the lung parenchyma, pleural space and rarely extending through the diaphragm [Figure 7]. [11] These misplaced tubes may cause pulmonary laceration, pulmonary contusion, pneumothorax, hydropneumothorax, aspiration pneumonia, lung abscess, and empyema. [12],[15] When a nasogastric tube is removed from the lung/pleural space, a repeat chest radiograph should be obtained to exclude pneumothorax. Perforation of the pharynx, esophagus, or stomach can be associated with nasogastric or nasoenteric tube placement. On the chest radiograph, these present with extra esophageal placement, pneumomediastinum, pneumothorax, hydropneumothorax, mediastinal widening due to hematoma and/or mediastinal air-fluid levels. [11] Perforation located in the stomach may present with pneumoperitoneum. As chest radiograph include upper abdomen, dislodged gastrostomy and enterostomy bulbs can be seen sometimes [Figure 8]. Sometimes malpositioned tubes can be suggestive of some underlying associated abnormalities as was suspected in this baby with VACTERL (vertebral anomalies, anal atresia, cardiac defects, tracheo-esophageal fistula or esophageal atresia, renal and radial abnormalities and limb defects) constellation of congenital anomalies [Figure 9]. One has to be specifically careful inserting an enteric or feeding tube in the patients with base of the skull trauma or previous base of skull surgery. Fluroscopic guidance should always be used in these cases to avoid catastrophic placement [Figure 10]. | Figure 7: Two Cases of Misplaced Feeding Tube in the Respiratory System. a) A 78-year-old male with a history of adult respiratory distress syndrome and a feeding tube was placed for the feeding purposes. In this patient the feeding tube is misplaced taking the course of trachea, going through the bronchus intermedius (RIB) and the tip (white arrow) terminating in the right lower lobe. There is associated consolidation to suggest pneumonia (Pn) in this patient due to feeding through the misplaced tube. b) A 72-year-old male with a misplaced feeding tube in the left lower lobe (white arrow) and there is associated extensive pneumonia after patient was inadvertently fed through this misplaced tube.
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 | Figure 8: Misplaced enterostomy bulb. A 73-year-old male with history of head and neck squamous cell carcinoma and on long-term nutritional support. a) Part of the chest radiograph shows that the enterostomy bulb (white arrow) is laying in the left-sided upper abdominal soft tissues and not within the abdominal cavity. The nasogastric tube terminates over gastric fundus. b, c) The coronal and axial reconstructions respectively confirm the extra peritoneal nature of the enterostomy bulb (white arrow).
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 | Figure 9: Misplaced Nasogastric Tube with the Other Features to Suggest VACTREL. In a newborn baby, there was placement of nasogastric tube, which is coiled in the esophagus (white arrows). Endotracheal tube is satisfactory in position. The umbilical venous catheter is extending above in the region of the left atrium (black arrow) and was later found to be due to atrial septal defect and therefore extending from the right atrium into the left atrium. There are 13 pairs of ribs. No gas bubble is identified. This patient had esophageal atresia. Overall this baby had VACTERL constellation of congenital anomalies.
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 | Figure 10: Spinal Placement of Feeding Tube. In a 62-year-old male obese patient a feeding tube was placed for oral nutritional supplements. a) The chest radiograph showed the very straight course of feeding tube without any deviation from the midline. The tip ends over upper lumbar spine (white arrow). This prompted a CT scan and sagittal reconstruction (b) and 3D reconstruction (c) Showed the placement of feeding tube in the central canal of spinal cord. This patient had previous history of base of the skull surgery for a sphenoid bone malignancy. Patient survived after a long hospital course.
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| Chest Tubes | | |
For drainage of a pneumothorax, the tip of the chest tube is usually placed in the anterior superior portion of the pleural space. For drainage of pleural fluid, the tip is usually placed in the posterior-inferior pleural space. [12],[16] In loculated pleural fluid, the tip of chest tube should be placed within loculated effusion. The chest tubes can be misplaced in the chest wall soft tissue totally or partially with the side holes in the subcutaneous tissue [Figure 11]. On the chest radiograph, malposition is suspected when the chest tube lies outside the rib cage or the side ports lay outside the rib cage. However, it has been noticed that in spite of side-port laying outside the rib cage in majority of the cases, the drainage is adequate. This may lead to massive subcutaneous emphysema or empyema necessitans. | Figure 11: Three Cases of Pigtail Pleural Catheters not within Pleural Space. a) A 73-year-old male with a history of pneumothorax postbiopsy of the left lung nodule (not shown). A pigtail catheter was placed for the drainage of left-sided pneumothorax. The axial CT scan on bone windows show that the pigtail catheter is in the subcutaneous tissue of the left lateral chest wall (white arrow). b) A 60-year-old patient, in whom two pigtail catheters were placed for the drainage of left-sided localized empyema. The superior pigtail catheter is in the left-sided pleural cavity marked by the white arrow however, the inferior and lateral pigtail catheter marked by the black arrow has fallen out of the pleural cavity and seen in the left-sided subcutaneous tissues. c) Another case of right sided pleural catheter not in pleural cavity after it has dislodged and moderate to large size pneumothorax (PTx) is present.
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The chest tube may be improperly placed into the fissure or into the lung parenchyma [Figure 12]. This is usually not evident on frontal chest radiographs but sometimes can be identified on the lateral views and further confirmation may be performed with a CT scan. This may cause herniation of the lung tissue into the lumen of the tube, therefore causing infarction. [17] Other complications include pulmonary laceration, hematoma, and bronchopleural fistula. [18] It has been said that there is no organ in the thorax that has not been punctured by the chest tube due to malpositioning. Kinking of the chest drainage tube may cause ineffective drainage. The tube may be blocked due to clots, debris or thick inflammatory/infectious exudate. Ineffective tube drainage may be seen with the tube tip abutting the mediastinum. [19] Rarely the chest tube placement has gone through the diaphragm when the portal of placement is low. Therefore, the laceration of the liver, spleen, and stomach has been reported with the chest tube placement. [16] Injury to the intercostal vessels can cause hemothorax or extrapleural hematoma [Figure 13]. Extrapleural hematomas remain fixed and do not change configuration with a change in patient position on chest radiograph. A CT chest can confirm both hemothorax as well as extrapleural hematoma. Reexpansion edema is not so common complication after placement of chest tube and accelerated drainage of pneumothorax or pleural fluid. [20],[21] On the chest radiograph, reexpansion edema present as unilateral pulmonary edema and clinical symptoms include from minimal symptoms to severe hypoxia and cardiorespiratory collapse.{Figure 11} | Figure 12: Parenchymal Insertion of a Left Chest Tube. A 57-year-old male with severe emphysema presented with pneumothorax. Initially the left apical chest drain was placed however the pneumothorax was not resolving and subcutaneous emphysema was increasing. Therefore a second left basilar chest drain was placed. a) The tip of both chest tubes shown by the black arrows. b) Left apical chest drain show partly intrafissural path (white arrow) and then in its distal portion it is intraparenchymal in location within the left posterior apex (white arrowheads).
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 | Figure 13: Hematoma Following Chest Tube Placement. A 76-year-old male after trauma presented with right pneumothorax, therefore a right-sided chest tube was placed. There was drainage of the blood from the chest tube. a) On frontal chest radiograph there is airspace opacity in the right upper lung after placement of the right-sided chest drain. The tip of chest tube is marked with black arrow. b) After three hours, the opacity in the right upper lung progressed and got denser and was found to be a parenchymal hematoma (H).
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| Central Venous Catheters | | |
In critically ill patients, the central venous catheters (CVCs) are used for venous pressure monitoring. These are placed via a subclavian, internal jugular or rarely femoral vein route. Peripherally inserted central catheters (PICCs) are usually placed through the median cubital vein for long-term central venous access. The ideal position of CVCs is cavoatrial junction. [3],[6] Placement of CVC into the right atrium is fraught with the risks of myocardial perforation/rupture and cardiac tamponade. [3],[11] These fundamental principles are also applicable to the dialysis catheters.
CVC malposition [Figure 14] has been described in up to 40% of the cases. [6] Therefore proper positioning of CVC should be verified with the help of chest radiograph. Abnormal positioning of the CVC may not only interfere with the proper central venous pressure measurement but also can have adverse effects by the infusion of potentially toxic substances, which would otherwise be diluted in the properly placed CVC. [22],[23] Abnormal termination of the CVC can be seen within the azygos vein; CVC may be looped within the superior vena cava (SVC), crossing the midline and may terminate in the contralateral subclavian or internal jugular vein. Azygos placement can usually be diagnosed on the lateral view, which show the CVC coursing posteriorly in the region of the azygos vein below the level of the aortic arch. [11] The other unusual positioning of the CVC may be into internal mammary vein, superior intercostal vein [Figure 15], pericardiophrenic vein, or in any of the other tributaries. [24] Persistent left SVC may also be a cause of apparently misplaced CVC. An anomalous pulmonary vein, atrial or ventricular septal defects may contribute to aberrant course of the CVC. | Figure 14: Two Cases of Misplaced Jugular Central Lines. a) A right-sided jugular central line is coursing either within the right external jugular vein or one of the tributaries of internal jugular. The terminating tip is marked with a white arrow. The arrowheads mark the course of the right jugular central line in the right internal jugular vein. A left-sided jugular central catheter course is marked with black arrowheads with the tip terminating at the level of the medial end of the left clavicle as shown by the black arrow. This catheter does not cross the midline and therefore either it is short in the left internal jugular vein or it may be arterial in placement. b) A case of a 68-year-old male showing inappropriate placement of two right jugular central catheters. On the right, the right jugular central line is looping (white arrow) within the SVC which increases the risk of thrombus formation. On the left, the left internal jugular central line does not cross the midline and terminates over aortic knuckle and this may be in a left-sided duplicated SVC or could be arterial in placement. In both of these cases (a, b) further evaluation is warranted to exclude arterial placement.
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 | Figure 15: Abnormal Position of Left Jugular Central Line in Superior Intercostal Vein. a) The frontal chest radiograph show that left jugular catheter (white arrow) not crossing the midline to the right and taking an abnormal course at the edge of left superior mediastinum. b, c) Coronal and axial contrast enhanced CT show the venous location of catheter (white arrows) in the superior intercostal vein.
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Arterial placement of a CVC [Figure 16] may cause pulsatile blood flow in the catheter but it is not a universal phenomenon as sometimes the arterial flow can be dampened with arterio-venous fistulous communication. Abnormal position of the catheter on chest radiograph is one of the indicators that CVC may be placed arterially or extra-vascularly. Ultrasound may be performed for further evaluation in the superficial course of the CVC. Extravascular placement after vascular perforation can be life-threatening and can be diagnosed on chest radiograph by abnormal course of the catheter. There may be associated apical capping due to extra-pleural hematoma, new effusion due to hemothorax and mediastinal widening due to mediastinal hematoma [Figure 17]. [3]  | Figure 16: Arterial Location of a Right Subclavian Central Catheter. In this well centered frontal chest radiograph the right subclavian catheter (white arrowheads) is crossing the midline and ending (white arrow) in the region of ascending aorta. Arterial placement was confirmed on contrast enhanced CT scan and this catheter was removed by vascular surgery team.
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 | Figure 17: Extravascular Placement of Left Jugular Central Line. A 72-year-old male with history of chronic renal failure. A dialysis catheter has been placed through the left jugular venous route. a) The left jugular dialysis catheter does not cross the midline towards the right of the patient and therefore it is either extravascular, or it could be arterial in placement going into the descending thoracic aorta. The black arrows clearly show the pathway of left subclavian, left brachiocephalic and SVC entering into the right atrium as is evident by the pacer/AICD placement. The left-sided dialysis catheter is marked with white arrowheads. There is slight bulge of the left side of the mediastinal contours marked with a white arrow suggestive of hematoma (H). b) A portable chest radiograph two hours later definitely showed increased widening of the left upper mediastinal contour and this was highly suggestive of enlarging hematoma (H). c) For comparison purposes, the portable chest radiograph before the dialysis catheter placement has been shown and this does not show any suspicious widening of the mediastinal contours. d) A contrast-enhanced CT scan with coronal reconstruction clearly identified extra vascular placement of the left jugular dialysis catheter within the mediastinum marked by lower white arrowhead. The mediastinal hematoma (H) is clearly seen.
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Impaction of the CVC tip against the vessel wall may suggest impending perforation. [3],[11] Extravascular placement can be confirmed by injecting contrast in the vessel or performing a contrast enhanced CT scan. It is important to note that any arterial placement should be correctly removed under the supervision of vascular surgery as this may be complicated by catastrophic bleeding during or after removal.
Pneumothorax [Figure 18] rate in CVC placement has been quoted at 5%. [6] To identify the pneumothorax, chest radiograph is obtained in majority of the cases after CVC placement. On the chest radiograph, small pneumothoraces can be seen on upright chest radiographs that can enlarge especially in patients who are on positive pressure ventilation. On supine radiograph, the pneumothorax can be seen as a deep sulcus sign as it is not possible to take an upright chest radiograph in majority of the ICU patients. | Figure 18: Pneumothorax as Complication of Central Line Placement. An elderly man with a history of recent placement of right jugular central line. a, b) The tip of the right jugular central line terminates over distal SVC as marked by the black arrow. The routine chest radiograph after placement of right jugular catheter show mild-to-moderate pneumothorax indicated by white arrowheads.
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The other rarer complications of CVC placement include locking, looping, and kinking of catheter. Venous thrombosis can be seen in patients who are on long-term CVC placement and thrombosis can cause pulmonary thromboembolism. Pinch-Off Syndrome which is due to compression of catheter between the first rib and the clavicle, may be seen. This may also cause fragmentation of the catheter and catheter can migrate and may result in vascular injury, pulmonary embolism, and very rarely death. [6]
On chest radiograph if CVC extends to the left of the trachea, considered left-sided SVC [Figure 19] versus arterial CVC placement. All left-sided SVC must be confirmed with cross-sectional imaging or angiography. In addition, an ultrasound can also help in determination of the PICC placement, whether arterial or venous in nature.  | Figure 19: Left Sided Superior Vena Cava (SVC) Placement of Left Central Catheter. a,b) Show termination of catheter (white arrows) to the left of midline without crossing to the right side of midline as well as slightly posterior course of catheter respectively (black arrow). This is clearly not in ascending or descending thoracic aorta. A left sided SVC was suspected and a previous CT scan confirmed the left SVC presence (c).
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| Port-A-Cath System | | |
Repeated cannulation of the suitable peripheral veins may be very painful and distressing experience for a patient. Implantable venous access devices are therefore used to improve the quality of life in these patients. The associated complications for Port-A-Cath placement are pneumothoraces, portal rotation or infection, catheter infection, embolism and migration, extravasation, partial or total obstruction of Port-A-Cath as well as rupture of the catheter. A Port-A-Cath is ideally placed into the cephalic vein, however, if the cephalic vein is not suitable than the subclavian vein can be used. Radiologically, the infection could sometimes be seen as a collection with air bubbles surrounding the port. A chest radiograph should always be obtained for the detection of pneumothorax and position of the tip of the catheter [Figure 20] and [Figure 21]. Risk of pneumothorax is much higher with the subclavian vein insertion rather than cephalic vein insertion. The pneumothorax rate has been reported between 1% and 5% for the Port-A-Cath insertion. Rupture of the catheter can be seen in the pinch off syndrome. [25] Pinch off syndrome is an unusual but a serious complication [Figure 22]. This can cause catheter fragmentation and embolization.  | Figure 20: Abnormal Placement of Right Port-A-Cath. A 54-year-old male with a history of metastatic pancreatic carcinoma. A right-sided Port-A-Cath placement was performed for the chemotherapy. The white arrows show the abnormal path taken by the Port-A-Cath. After traveling into the right subclavian vein, the catheter is heading into the right internal jugular vein instead of going inferiorly in the SVC and should be corrected.
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 | Figure 21: Twiddling of Port-A-Cath. A 61-year-old female with history of adenocarcinoma of unknown origin. A Port-A-Cath has been placed for long-term chemotherapy. a) PA view of the chest shows Port-A-Cath via right internal jugular vein going into the SVC. However there is a loop seen overlying the right upper chest just above the clavicle - white arrowheads. This is highly characteristic of a Twiddler like syndrome as seen in pacer and ICD boxes. b) The magnified image clearly show that tip of the Port-A-Cath is terminating high in the proximal SVC (black arrow) due to this looping. On close questioning, the patient admitted to unknowingly play and twist the Port-A-Cath hub.
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 | Figure 22: Catheter Pinch-off Syndrome. A 32-year-old male with malfunctioning left side Port-A-cath. The left subclavian port is pinched between clavicle and first rib marked with black and white arrows. The tip of port terminates in the cavoatrial junction.
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| Peripherally Inserted Central Catheters (PICCs) | | |
PICCs are being used increasingly in neonatal ICUs as well as in adults for long-term intravenous access. However, there are potential PICC complications, some of which falls into the radiology domain on chest imaging. Catheter malposition [Figure 23] is one of the most common complications detected radiologically. Extension of PICC within the right atrium [Figure 24]a can lead to perforation. The PICC can be looped in the axilla, coming from cephalic vein and after looping it can go into the axillary vein. The PICC can extend or loop into the internal jugular veins on either side [Figure 24]b. They can also cross the midline and go into the left-sided venous system. Clinically, occlusion is one of the most common postinsertion complications. [26] This may be due to a variety of factors including the formation of the thrombus at the tip of the catheter, wedging against the vessel wall or catheter may be kinked. The other complications associated with PICC insertion are bleeding, thrombosis, catheter failure, embolization, and infection. During insertion, there may be damage to the vessels and there may be arterial puncture. An X-ray can verify arterial or venous placement only if the catheter tip is located centrally. Catheter migration can happen after the insertion and this can also be evaluated with the help of chest radiographs. Catheters that migrate within the heart can cause dysrhythmia. | Figure 23: Four Different Cases of Misplaced PICC. a) The left PICC traversing path is shown into the SVC (white arrowheads) but has a loop at its distal end that may be in azygous vein. b) A right sided PICC has been advanced too far and terminates in the left main pulmonary artery (white arrow). c) A right PICC coming via cephalic vein into subclavian vein and then looping back within axillary vein and relooping within axillary vein with tip shown as white arrow. d) A left PICC is misplaced into the left jugular vein (white arrowheads) and a right jugular central catheter is crossing the midline and traversing into the left brachiocephalic vein (black arrowheads).
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 | Figure 24: A Deep PICC and a Looped PICC. a) A 49-year-old male with a history of left PICC placement. The left-sided PICC placement is suboptimal as its tip (white arrow) terminates within right atrium therefore increasing the chances of right atrial myocardial wall injury. b) In another patient, the right-sided PICC is forming a loop (white arrows) within the right internal jugular vein and then proceeding to the proximal SVC. Any kind of loop in the central line increase the risk for the thrombosis as well as malfunctioning and therefore should be manipulated and corrected.
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| Pulmonary Arterial Catheters (PAC) | | |
PAC (also known as Swan-Ganz catheters) are used for monitoring circulatory hemodynamics, measuring pulmonary capillary wedge pressure and thus differentiating between cardiogenic and noncardiogenic edema. Insertion is usually via the subclavian vein or internal jugular vein. The preferred position of the tip of the catheter is in the left or right main pulmonary artery. To avoid complications, avoid malpositioning [Figure 25] and the tip should not extend beyond 2 cm of the hilum. [6] If the Swan-Ganz catheter placement is too distal, a pulmonary artery branch may be occluded and may result in pulmonary infarction that can present as wedge shaped opacity abutting the pleura. [11] The other complications inherent to CVC placement are also applicable to the PAC placement, including misplacement, looping, coiling, knotting, pneumothorax, fracture, and vascular injury. Rarely pulmonary arterial rupture, pulmonary arterial dissection, and pseudo-aneurysm formation can happen. The pseudoaneurysm can present as a new lung nodule on the chest radiograph. [10] Bronchial pulmonary artery fistula has been rarely described with the placement of PAC. | Figure 25: Three Cases of Malpositioned Pulmonary Arterial Catheters (PAC). a) The day zero postoperative portable chest radiograph showed the coiled PAC in the left main pulmonary artery (white arrow). There are normally placed anterior mediastinal surgical drain (short white arrows), a pericardial drain (white arrowheads) and left chest tube not marked. b) The PAC is coiled (arrowheads) in the right atrium. c) The PAC tip is too far in the left upper lobe pulmonary artery. The PAC course through right ventricle and pulmonary outflow tract is marked with arrowheads.
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| Umblical Venous And Arterial Catheters | | |
Umbilical arterial catheters (UACs) are placed for blood gas or laboratory sample analysis, arterial oxygen tension or contiguous blood pressure monitoring, cardiac catheterization, exchange transfusions and infusion of medications. Umbilical arterial circulation is from umbilical arteries to the internal iliac arteries that lead into the common iliac artery and then into the aorta. The UAC catheter can be placed at a high level or low level, at the high level of T6-T9 or low at the level of L3/L4 above the aortic bifurcation. [27] Complications from umbilical arterial catheters range between 1.5% and 30%. [28] Hemorrhage, perfusion, thrombosis, mechanical, and infectious complications have been described with the placement of umbilical arterial catheters. The placement of UAC is usually checked with a babygram [Figure 26]a, which includes chest, abdomen, and pelvis. Most of these cases also have placement of a umbilical venous catheter (UVC), which can be simultaneously checked on these radiographs. | Figure 26: Three Cases of Misplaced Umbilical Venous Catheter (UVC). a) Malpositioned UVC and umbilical arterial catheter (UVA) with their tips respectively in the superior vena cava (white arrow) and aorta at level of L1 vertebra (black arrow). Endotracheal tube is satisfactory. b) The UVC tip terminates in the left portal vein (white arrow). The ideal position for the UVC is marked. c) The UVC catheter terminates in the right portal vein (black arrow). There is associated portal venous gas (white arrowheads).
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UVC are usually used for infusion of hypertonic solutions, for total parentral nutrition (TPN) and emergency access for blood and fluids. The UVC catheter traverses umbilical vein into the left portal vein, ductus venosus, and then to IVC. Malpositioned UVC can be seen in the left portal vein, right portal vein, right atrium, left ventricle, pulmonary vein, and jugular vein. Optimal position is considered to be at the level of the inferior cavo-atrial junction, which usually corresponds to T8-T9. However, there are variations of inferior cavo-atrial junction. [29] If the UVC catheter terminates above T7, it is high. If the UVC catheter is inferior to T11, it is considered beneath the ductus venosus. [30] Catheter can sometimes enter into the SVC. The catheter may also go into the left atrium and then into the pulmonary venous system via a patent foramen ovale. Another possible abnormal positioning of the UVC is through the tricuspid valve into the right ventricle and beyond. UVC placement, which is low in position, can be within the portal venous system [Figure 26]b and c, any of the hepatic veins, ductus venosus or within the umbilical vein. Majority of the complications of UVC are associated with the low position of the catheter within the liver including thrombosis of the portal vein with development of portal hypertension and cirrhosis. This can present on the radiographs as calcification of the portal vein, umbilical vein or ductus venosus or by direct identification of thrombus with ultrasound imaging. The portal veins are at increased risk of thrombosis because of the slow flow.
| Pacers and Automatic Implantable Cardioverter Defibrillator | | |
Temporary and permanent cardiac pacers are often utilized to treat a host of conduction abnormalities. Transvenous temporary pacing is done via internal jugular, subclavian or less commonly via femoral vein. Nonvenous routes can be epicardial, thoracic, per-cutaneous, or transesophageal. Permanent pacer/automatic implantable cardioverter defibrillator (AICD) usually included pulse generator, and majority of these are implanted in the anterior chest wall and the leads reach to endocardium or myocardium via transvenous route [Figure 27]. The pacers and ICDs may have single wire or multiple wires including multiple atrial and multiple ventricular leads. [19]  | Figure 27: Normal Automatic Implantable Cardiovert Defibrillator (AICD) Laxity Loop in Right Atrium. There is a normal minor looping of AICD (arrow) in the right atrium and this does not need to be called to the cardiac electrophysiology team. This is usually left this way to avoid tension on the lead during cardiac pulsations.
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During transvenous insertion of the pacer, ICD and a combination of these, pneumothorax is the most common complication and therefore a CXR is mandatory after insertion. A CXR not only confirms or excludes pneumothorax but is also helpful in assessment of the position of the wires in patients with malfunctioning hardware [Figure 28]. On a lateral view, the orientation of pacer wires should be anterior to the line of descent. If it is not, then then it is indicative of congenital or acquired heart disease [Figure 29] and [Figure 30] or malpositioning. Vascular injuries, myocardial perforation though uncommon are recognized complication of pacer/AICD insertion. On the chest radiograph, projection of lead beyond the myocardial confinements should be suggestive of perforation [Figure 31]. The majority of these case may not be clinically significant but may result in pericardial effusion and cardiac tamponade. [6] Fracture of the leads as well as migration of the leads are also known complications and seen in approximately 1-4% of cases. [31] Similar to pinch off syndrome of vascular catheters, one can have fracture of the pacer/AICD lead(s). Migration and fracture of the leads may also happen in Twiddler syndrome. [32]  | Figure 28: Malfunctioning AICD. A 57-year-old male with sudden malfunctioning and inappropriate firing of AICD. At presentation PA and lateral chest views show abnormal positioning of the right atrial lead which has flipped back into superior vena cava (RA lead) (a, b). In comparison the normal lead positioning are shown on the previous set of chest radiographs (c, d).
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 | Figure 29: Malpositioned Pacer Leads. The pacer leads terminate posterior to the line of descent of pacer wires. Normally the termination of leads should be anterior to the line of descent in the region of right ventricle (RV). This patient had unknown ASD. The black arrow show the lead into left atrium (LA) and white arrow show termination of lead into left ventricle (LV) after traversing through ASD.
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 | Figure 30: Normal Pathway of AICD Leads in Baffle Repaired Transposition of Great Vessels (TOGV). a, b) The AICD leads take abnormal appearing pathway on frontal and lateral chest radiographs. On frontal radiograph the leads cross the midline higher than usual normal course of leads. One of the leads terminates in the region of pulmonary artery (white arrow). On lateral view, the distal portion of leads taking a posterior course to the line of descent. c) The oblique coronal CT reconstruction showed that leads are crossing from the superior vena cava into the right ventricle through the baffle repair for TOGV.
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 | Figure 31: Perforated Right Ventricle (RV) from the Pacer Lead. A 64-year-old male complained left sided chest pain after placement of pacer. a) The upturned lead (arrow) on frontal chest radiograph is suggestive but not confirmatory of RV perforation. b, c) Axial and sagittal reconstruction confirm the RV perforation by the lead (arrows). d) The lead was removed and normal appearing pacer was placed with the tip shown by arrow.
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| Circulatory Assist Devices | | |
Intraaortic balloon pump (IABP)
IABP is usually employed in patients with cardiogenic shock and works on the principle of counter-pulsation. The IABP is inflated during diastole to increase the coronary artery perfusion and deflates during systole to increase the forward flow within the aorta by decreasing the ventricular afterload. IABP has a central catheter surrounded by an inflatable balloon approximately 25 cm in length and it is distally terminated into an opaque marker. This opaque marker is used for optimal positioning of the IABP. The IABP is deployed via the femoral artery and its ideal distal tip location should be 2-2.5 cm below the aortic arch, distal to the origin of the left subclavian artery. [12],[19] On the chest radiograph, the tip should lie approximately 2-2.5 cm below the aortic arch so that during balloon inflation, there is no obstruction to the subclavian arterial flow to avoid compromise of blood flow to the left arm. High placement [Figure 32]a may also include vertebral artery as well as left common carotid artery occlusion resulting in cerebral ischemia. Similarly low positioning of the IABP [Figure 32]b is also not desired as it may compromise blood flow to the upper abdominal systemic arteries causing complications as a result of occlusion of the renal or mesenteric arteries. [12],[33] Complication rate of approximately 8-36% has been described in the literature with the IABP placement. [33],[34]  | Figure 32: Low and High Termination of Intra-aortic Balloon Pump (IABP). a) The tip of the IABP is low as marked by black arrow. One clue is that the tip should be always above the curve of the pulmonary artery catheter and if it is below, it means low positioning of IABP. b) This IABP is high in position at the level of aortic arch. The normal position of radio-opaque tip of the IABP should be approximately 2.5 cm below the aortic arch.
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Some of other complications of IABP include aortic dissection, reported in 1-4% of placement and can be suspected on the chest radiograph showing loss of definition of the descending thoracic aorta and lateral positioning of the catheter along the aorta. Rupture of the balloon with gas embolization to various organs is an extremely rare but catastrophic complication. [34]
Ventricular assist devices (VAD)
VADs are used to replace the function of the left or right ventricle or both ventricles simultaneously. [35] The indications of their use include bridge to heart transplant, as a destination therapy or means to myocardial recovery. [36] A variety of VADs are currently available in the market. Majority of these have a pump to propel blood from the left or right ventricle to ascending aorta or main pulmonary artery, respectively. Part of the inflow and outflow tubes are not radiopaque and cannot be visualized on the chest radiograph but can be seen on the CT scans. In Heart Mate II VAD [Figure 33]a and b, the pump is placed outside the heart, while Jarvik 2000 [Figure 33]c has the pump placed within the left ventricular cavity. A small VAD called Impella device from biomed is less invasive in placement and can be used as short-term cardiac assist device. This is inserted via catheterization of the femoral artery or IVC and placed within the left ventricle, straddling the aortic valve, and terminating in the proximal ascending aorta [Figure 34]. Its placement helps in reducing the myocardial workload and increasing the cardiac output. [37] Complications associated with the VADs include pneumothorax, hemothorax, postoperative hemorrhage due to anticoagulation either within the pericardium or mediastinum [Figure 35] or may be systemic hemorrhage. Pericardial hemorrhage can cause cardiac tamponade. Inadequate anticoagulation can cause thrombosis and thromboembolism. Arrhythmias, infections, pneumoperitoneum, bowel obstruction, and pump/mechanical failure are other known complications. [23],[35],[38]  | Figure 33: Two Different Left Ventricular Assist Devices (LVAD). a, b) Heartmate II LVAD showing inflow cannula (black arrow) draining blood from LV and opaque portion of outflow cannula (white arrow). c) Jarvik 2000 LVAD is shown in the left ventricle and the tract to aorta is not seen as it is not radiopaque.
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 | Figure 34: Impella Device. This device is placed either via arterial route or venous route. The inlet area is marked by the lower white arrowhead and is located in the left ventricle. The output area is marked with upper arrowhead and located in the proximal ascending aorta. The motor housing is marked with upper arrow.
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 | Figure 35: Hematoma as Complication of Left Ventricular Assist Device. A 63 year male with history of ventricular assist device placement for bridge to cardiac transplant. The chest radiograph that showed a right cardiac bulge is not shown. a) Coronal reconstruction from a contrast-enhanced CT show outflow cannula (OF) with an associated right-sided mediastinal hematoma (H). The distal portion of outflow cannula is inserted into the ascending aorta before the takeoff of the right innominate artery not shown). The left ventricular assist device is partially visualized at the left lower edge of the coronal reconstruction. b) On sagittal reconstruction the right-sided mediastinal hematoma extending retrosternally (H) is clearly identified. The outflow cannula is also called efferent cannula (Eff).
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| Foreign Bodies | | |
In elderly patients after an accidental trauma or iatrogenic trauma like endotracheal intubation, the loose teeth can be aspirated. Chest radiograph, in these setting, is a valuable tool [Figure 36].  | Figure 36: Missing Tooth as a Foreign Body. A 86-year-old female with a missing tooth after a fall. Frontal radiograph (a) Hard to see aspirated tooth (white arrow) in the right lower lobe bronchus. Reconstructed CT images clearly show the aspirated tooth clearly marked by the white arrow (b and c) This was removed bronchoscopically.
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The occurrence of surgical sponges left in the body following operations is not as rare as one would suspect, however, the actual incidence is difficult to estimate. There have been only a few papers in the literature exploring foreign bodies left in place after cardiac surgical procedures. Two cases of gauze swabs left intrapericardially following cardiac surgery are presented in this paper. [39] A swab or pack left in a patient may not be recognized on a radiograph. This will usually be due to poor observation, but errors may result from unfamiliarity with the pattern of the markers. In addition, some markers may be difficult to detect, though this usually applies only to swabs that are very small. Sometimes the packing swabs are left deliberately [Figure 37] to combat the bleeding and these are removed at a later time. De Lacey has an excellent publication for assisting swab recognition. [40] Chest radiograph can be helpful [Figure 38] before closing where there is a missing needle count or discrepant instrument count. | Figure 37: Foreign Body (Sponge Marker). A 48-year-old male with the nonischemic dilated cardiomyopathy. a) For the dilated non-ischemic cardiomyopathy and poor ejection fraction, this patient had undergone biventricular assist devices placement. However, patient continued to bleed from the mediastinal wound. b) Ribbon like opacities over the left cardiac apex and mediastinum are seen (white arrows) consistent with packing material after patient underwent redo sternotomy (black arrowheads). The black arrow mark part of right ventricular assist device.
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 | Figure 38: Missing Needle in a Patient with Cardiothoracic Surgery. a) The radiopaque needle (black arrow) was identified on the immediate postoperative chest radiograph when there was a discrepant surgical instruments count. A repeat lateral view (b) Also showed the needle (white arrowheads). In view of these findings, the patient was reopened however needle was not found and sternotomy was reclosed. A CT chest (c) Afterwards showed the curved needle (white arrow) in the left lower lobe medial lung.
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| Conclusion | | |
Despite carrying inherent handicaps, portable chest radiographs are still a most valuable ally in the ICU ecosystem. They play an extremely significant role in the detection of complications associated with multitude of hardware devices employed in critically ill patients. These include technology used to monitor, administer treatment or provide circulatory support. Complications can occur both when such hardware is introduced into a person or it is subsequently being used. Radiologists and nonradiologists must be aware and cognizant of the radiological findings which can have a major impact on the management and outcome of these patients.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31], [Figure 32], [Figure 33], [Figure 34], [Figure 35], [Figure 36], [Figure 37], [Figure 38]
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