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Tunneled hemodialysis catheter insertion: Above, within, or below the right atrium-Where is the tip?
Jonas Auer1, Joachim Braun1, Julian Lenk1
1Department of Radiology, Charité - University Medicine, Berlin, Germany.
Insights
Assessing central venous catheter (CVC) tip placement using landmark technique approximation (LTA) for hemodialysis may underestimate right atrial (RA) position. Post-CT scans revealed lower tip placement than LTA suggested, indicating potential inaccuracies.
Area of Science:
- Nephrology
- Interventional Radiology
- Medical Imaging
Background:
- Accurate central venous catheter (CVC) tip placement is crucial for hemodialysis.
- Fluoroscopic assessment relative to the cardiac silhouette (approximating the right atrium [RA]) is challenging.
Purpose of the Study:
- To evaluate the utility of a weighted mean from published two-dimensional landmark reference distances.
- To assess CVC tip positions in relation to the RA using this landmark technique approximation (LTA).
Main Methods:
- Retrospective analysis of fluoroscopically placed CVC tips using two reference distances (carina to RA border, RA extent).
- Categorization of tip locations: above, within, or below the RA via LTA.
- Validation of LTA by correlating with postinterventional computed tomography (CT) datasets.
Main Results:
- LTA categorized 47.2% of tips below the RA, 42.2% within, and 10.6% above.
- Post-CT (n=57) showed 66.7% of tips within the RA, 26.3% above, and 7.0% below.
- Significant discrepancies observed between LTA and CT findings.
Conclusions:
- The LTA method appears to categorize CVC tips lower than their actual position.
- Postinterventional CT indicates LTA may underestimate RA visualization.
- Specific patient characteristics associated with higher risk of LTA misestimation were identified.
Background:
One major challenge when inserting a tunneled, cuffed central venous catheter (CVC) for hemodialysis under fluoroscopy is to accurately place the catheter tip by assessing its position in relation to the cardiac silhouette to approximate the right atrium (RA).
Purpose:
To investigate whether a weighted mean calculated from published results for two two-dimensional landmark reference distances may be useful in assessing CVC tip positions in relation to the RA.
Material And Methods:
Central venous catheter tip positions attained under fluoroscopic imaging during insertion using the cardiac silhouette as approximation were retrospectively related to two reference distances (carina to cranial RA border and craniocaudal RA extent), which were used to group catheter tip locations above (1), within (2), or below (3) the RA (henceforth referred to as landmark technique approximation, LTA). The LTA-derived catheter tip locations were validated by correlation with postinterventional computed tomography (CT) datasets acquired shortly after implantation (if available).
Results:
Based on LTA, 45 catheter tips (10.6%) were above, 179 (42.2%) within, and 200 (47.2%) below the RA. Postinterventional CT (n = 57; 13.4%) visualized 26.3% above, 66.7% within, and 7.0% below the RA.
Conclusion:
The LTA reference distances appear to lead to a rather low categorization of the CVC tips, or the tips have been placed rather low in the study population. Validation using postinterventional CT indicated an underestimation of the RA in the LTA. Patient characteristics with a higher risk of false estimation through LTA have been defined.
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