FIGURE 5-1. Left subclavian vein, central venous catheter placement. A: Posteroanterior (PA) chest radiograph shows the catheter entering the left subclavian vein under the left clavicle, crossing the midline as it courses to the right and descending, with the tip positioned over the expected area of the superior vena cava (SVC) (arrow). B: Lateral chest radiograph shows the catheter curving anteriorly (arrow), where it crosses from the left brachiocephalic vein to join the right brachiocephalic vein. This anterior curve makes it possible to determine on a lateral radiograph that a catheter has been placed from the left side.
FIGURE 5-2. Azygos vein placement of central venous catheter. A: PA chest radiograph shows that the catheter tip is positioned over the expected area of the SVC. The tip is seen on end (arrow), however, which is a clue to azygos vein placement. The SVC is joined by the azygos vein posteriorly. B: Lateral chest radiograph shows the catheter coursing posteriorly, along the expected course of the azygos vein (arrows). Note how the more proximal portion of the catheter curves anteriorly (arrowhead), confirming placement from the left.
FIGURE 5-3. Left superior vena cava placement of central venous catheter. PA chest radiograph shows that, instead of crossing the midline to enter the SVC on the right, the catheter courses inferiorly to the left of the aortic arch, which is typical of placement within a persistent left SVC. This placement should be confirmed on a lateral chest radiograph to exclude aberrant positioning of the catheter within another venous or arterial structure.
TABLE 5-1 COMPLICATIONS RESULTING FROM CENTRAL VENOUS CATHETER PLACEMENT
FIGURE 5-4. Malpositioned left peripherally inserted central venous catheter (PICC). AP chest radiograph shows a PICC (arrows) placed from the left side, crossing the midline, with the tip directed cephalad over the expected right jugular vein.
FIGURE 5-5. Intercostal vein placement of central venous catheter. Anteroposterior (AP) recumbent chest radiograph shows the left jugular central venous catheter crossing to the left and coursing horizontally, inferior to the left fifth posterior rib, typical of intercostal vein placement (straight arrows). The intercostal vessels and nerves are inferior to the rib; when performing thoracentesis, the needle should be inserted along the top of the rib to avoid puncturing these vessels. Note collapse of the right upper lobe, with superior displacement of the minor fissure (curved arrows).
FIGURE 5-6. Malpositioned catheter resulting in ectopic fluid administration. A: PA chest radiograph obtained prior to left catheter placement. The right subclavian central venous catheter tip is positioned over the expected junction of the SVC and right atrium (arrow). B: PA chest radiograph after placement of a new left subclavian central venous catheter shows acute widening of the mediastinum from extravascular placement of the catheter and ectopic infusion of fluid into the mediastinum. The extravascular location of the catheter is not obvious on the radiograph, but the change in mediastinal width should prompt further investigation to confirm catheter position.
FIGURE 5-7. Mediastinal hematoma from subclavian artery perforation. A: PA chest radiograph prior to catheter placement shows a normal upper mediastinal width. B: PA chest radiograph after placement of right subclavian central venous catheter shows acute widening of the mediastinum.
FIGURE 5-8. Hemothorax as a complication of central venous catheter placement. A: PA chest radiograph shows a normally positioned right jugular central venous catheter. B: PA chest radiograph after removal of the right catheter and placement of left subclavian central venous catheter shows a new large left pleural effusion. A chest tube was placed, which drained bright red blood.
FIGURE 5-9. Inflated pulmonary artery catheter balloon. AP recumbent intraoperative chest radiograph, taken during measurement of pulmonary capillary wedge pressure, shows the inflated radiolucent balloon at the tip of the catheter (arrows). Normally, the balloon should not be inflated during the time of radiographic exposure. The balloon should be inflated for only a short period while measurements are obtained and then immediately deflated; when left inflated for longer periods, blood flow distal to the balloon is interrupted, resulting in pulmonary infarction.
FIGURE 5-10. Looping of pulmonary artery catheter tubing. AP chest radiograph shows looping of the pulmonary artery catheter tubing (arrow) over the expected right atrium. This redundancy of catheter tubing can lead to dysrhythmias.
FIGURE 5-11. Pulmonary artery pseudoaneurysm as a complication of pulmonary artery catheter placement. A: AP recumbent chest radiograph in a 66-year-old woman with a history of chronic obstructive pulmonary disease and prior lung volume reduction surgery. The film was taken shortly after right heart catheterization, during which time a pulmonary artery catheter was placed into the right pulmonary artery to measure pulmonary capillary wedge pressure. The radiograph shows diffuse airspace disease in the right lung, consistent with acute pulmonary hemorrhage, which was new compared with a precatheterization radiograph. B: CT scan obtained after administration of intravenous contrast material, performed the same day as the chest radiograph in (A), shows an enhancing peripheral pulmonary artery pseudoaneurysm (arrows), with surrounding pulmonary hemorrhage (arrowheads). The pseudoaneurysm was embolized with coils by interventional radiologists, and the bleeding stopped.
FIGURE 5-12. Pulmonary artery pseudoaneurysm as a complication of pulmonary artery catheter placement. A: AP chest radiograph shows pulmonary edema and the tip of a pulmonary artery catheter projected over an expected left lower lobe segmental pulmonary artery branch (arrow). B: The distal placement of the catheter tip resulted in perforation of a subsegmental pulmonary artery and development of a pulmonary artery pseudoaneurysm, shown as an enhancing mass in the left lower lobe on CT (arrow).
TABLE 5-2 COMPLICATIONS RELATED TO PULMONARY ARTERY CATHETER PLACEMENT
FIGURE 5-13. Hemothorax as a complication of pulmonary artery catheter placement. AP chest radiograph shows appropriate placement of a right jugular pulmonary artery catheter. However, there is complete opacification of the right hemithorax, representing acute and massive hemothorax.
FIGURE 5-14. Inflated balloon of intra-aortic balloon pump. AP chest radiograph shows the radiopaque tip of an intra-aortic balloon pump (dashed arrow) and its radiolucent air-filled balloon (solid arrows). The balloon is inflated during diastole and deflated during systole. The tip is slightly low, with the desired location at the level of the aortic arch.
FIGURE 5-15. Malpositioned intra-aortic balloon pump. AP chest radiograph shows the radiopaque tip of an intra-aortic balloon pump projected over the expected left subclavian artery (arrow). This positioning can result in cerebral embolism and partial occlusion of blood flow to the left upper extremity.
FIGURE 5-16. Malpositioned intra-aortic balloon pump. AP chest radiograph shows that the tip of the intra-aortic balloon pump (arrow) is below the desired level of the aortic arch.
TABLE 5-3 COMPLICATIONS RELATED TO INTRA-AORTIC BALLOON PUMP PLACEMENT
FIGURE 5-17. Left ventricular assist device. AP recumbent chest radiograph shows the inflow cannula (small arrows) within the left ventricle and directed toward the mitral valve, the pump (P), and the radiopaque portion of the outflow cannula (large arrows). The outflow cannula carries blood from the pump to the ascending aorta (the distal portion of the outflow cannula is nonradiopaque). The cardiac silhouette is markedly enlarged in this patient with end-stage heart disease.
FIGURE 5-18. Biventricular pacer. PA (A) and lateral (B) chest radiographs show normal positioning of lead tips in the right atrium (solid white arrow), right ventricle (dashed white arrow), and coronary sinus (solid black arrow).
FIGURE 5-19. Fractured insulation covering pacer lead. PA chest radiograph shows a short segment of pacer lead that is less opaque (arrow). Note that the lead is not completely fractured. Even so, disruption of the insulation can result in pacer malfunction.
FIGURE 5-20. Fractured pacer lead. PA chest radiograph shows complete separation of lead fragments at the site of pacer lead fracture (arrow).
FIGURE 5-21. Fractured pacer lead. PA chest radiograph shows a fractured lead (arrow) and minimal distraction of the fracture fragments.
FIGURE 5-22. Looped pacer lead. PA (A) and lateral (B) chest radiographs show looping of the pacer lead over the area of the expected tricuspid valve (arrow). This positioning can result in dysrhythmia, lead fracture, or myocardial perforation.
FIGURE 5-23. Displacement of pacer lead. A: PA chest radiograph shows that the tip of the pacer lead (arrow) is beyond the expected right ventricular wall. B: CT shows the lead outside of the myocardium (arrow). A more inferior image (not shown) showed that the lead tip was within the anterior chest wall.
FIGURE 5-24. Overdistended endotracheal tube cuff. AP chest radiograph, coned to the neck and upper chest, shows that the tip of the ETT (dashed arrow) is above the thoracic inlet. The ETT balloon is overdistended (solid arrows). If left in this position long enough, the cuff could cause permanent damage to the vocal cords.
TABLE 5-4 COMPLICATIONS RELATED TO ENDOTRACHEAL OR TRACHEOSTOMY TUBE PLACEMENT
FIGURE 5-25. Endotracheal tube within right main bronchus. The left lung is radiopaque, and there is a shift of the mediastinum to the left because of malpositioning of the ETT within the right main bronchus (arrow); atelectasis of the left lung has resulted.
FIGURE 5-26. Endotracheal tube within bronchus intermedius. AP recumbent chest radiograph of a 29-year-old woman after a motor vehicle accident. The patient was intubated emergently outside the hospital. Malpositioning of the ETT within the bronchus intermedius (arrow) resulted in aeration of the right middle and lower lobes, with associated collapse of the right upper lobe and the entire left lung.
FIGURE 5-27. Malpositioned chest tube. AP chest radiograph shows that the side hole of the right chest tube (arrow) is outside of the pleural space. Note bilateral subcutaneous emphysema, seen as mottled lucencies within the soft tissues of the chest wall.
FIGURE 5-28. Chest tube track mimicking pneumothorax. A: PA chest radiograph, coned to the left upper hemithorax, shows a thin curvilinear opacity paralleling the chest wall (arrows). B: AP chest radiograph obtained 1 day earlier shows a chest tube following the course of the opacity seen in (A).
FIGURE 5-29. Malpositioned nasogastric tube. AP chest radiograph shows that the tip of the nasogastric tube (arrow) is well above the gastroesophageal junction. Note the distinctive morphology of the tip, which assists in recognizing its placement.
FIGURE 5-30. Looped nasogastric tube. AP chest radiograph shows the nasogastric tube (arrows) looped over the expected location of the esophagus.
FIGURE 5-31. Malpositioned feeding tube. AP chest radiograph shows that the radiopaque tip of the feeding tube (arrow) is well above the gastroesophageal junction. The distinctive morphology of the tip aids in recognizing its placement.
FIGURE 5-32. Nasogastric tube placement in the lung. AP chest radiograph shows the course of the nasogastric tube following the expected course of the right main bronchus and out into the lung.
FIGURE 5-33. Malpositioned feeding tube in the lung. AP chest radiograph shows a feeding tube outside the expected course of the esophagus, with the tip projected over the right lung apex (arrow).
FIGURE 5-34. Malpositioned feeding tube in the lung. AP chest radiograph shows a feeding tube projected over the right lung base. If not recognized before feeding the patient, such a placement can result in chemical pneumonitis.
FIGURE 5-35. Malpositioned feeding tube. A: AP chest radiograph shows the feeding tube outside the expected course of the esophagus. B: After removal of the tube, the patient developed a large right pneumothorax as a result of the tube having penetrated the pleural space.