title: Radiographic signs of non-venous placement of intended central venous catheters in children.
abstract: BACKGROUND
  Central venous catheters (CVCs) are commonly used in children, and inadvertent arterial or extravascular cannulation is rare but has potentially serious complications.
  
  
  OBJECTIVE
  To identify the radiographic signs of arterial placement of CVCs.
  
  
  METHODS
  We retrospectively reviewed seven cases of arterially malpositioned CVCs on chest radiograph. These cases were identified through departmental quality-assurance mechanisms and external consultation. Comparison of arterial cases was made with 127 age-matched chest radiographs with CVCs in normal, expected venous location. On each anteroposterior (AP) radiograph we measured the distance of the catheter tip from the right lateral border of the thoracic spine, and the angle of the vertical portion of the catheter relative to the midline. On each lateral radiograph we measured the angle of the vertical portion of each catheter relative to the anterior border of the thoracic spine. When bilateral subclavian catheters were present, the catheter tips were described as crossed, overlapping or uncrossed.
  
  
  RESULTS
  On AP radiographs, arterially placed CVCs were more curved to the left, with catheter tip positions located farther to the left of midline than normal venous CVCs. When bilateral, properly placed venous catheters were present, all catheters crossed at the level of the superior vena cava (SVC). When one of the bilateral catheters was in arterial position, neither of the catheters crossed or the inter-catheter crossover distance was exaggerated. On lateral radiographs, there was a marked anterior angulation of the vertical portion of the catheter (mean angle 37 ± 15° standard deviation [SD] in arterial catheters versus 5.9 ± 8.3° SD in normally placed venous catheters).
  
  
  CONCLUSIONS
  Useful radiographic signs suggestive of unintentional arterial misplacement of vascular catheters include leftward curvature of the vertical portion of the catheter, left-side catheter tip position, lack of catheter crossover on the frontal radiograph, as well as exaggerated anterior angulation of the catheter on the lateral chest radiograph.
authors.affiliation: Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.
authors.forename: Erin C
authors.initials: EC
authors.lastname: Taylor
authors.affiliation: Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA. george.taylor@childrens.harvard.edu.|Department of Radiology, Harvard Medical School, Boston, MA, USA. george.taylor@childrens.harvard.edu.
authors.forename: George A
authors.initials: GA
authors.lastname: Taylor
mesh_terms: D000328:Adult; D002405:Catheterization, Central Venous / Q000009:adverse effects; D062905:Central Venous Catheters / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D005260:Female; D005548:Foreign-Body Migration / Q000000981:diagnostic imaging* / Q000209:etiology*; D006801:Humans; D007223:Infant; D008297:Male; D011856:Radiographic Image Enhancement / Q000379:methods; D013902:Radiography, Thoracic / Q000379:methods; D057772:Vascular System Injuries / Q000000981:diagnostic imaging* / Q000209:etiology*; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging* / Q000209:etiology
keywords: Arterial cannulation; Central venous catheter; Chest; Children; Complication; Radiography