Five-Step Guide to Central Venous

Catheter Placement with 3D

Anatomic References
Khushboo Jhala, MD MBA; Anji Tang, MD; Mark M. Hammer, MD
Khushboo Jhala, MD, MBA
[email protected]

Brigham and Women’s

Hospital
Harvard Medical School
Disclosures of Conflicts of Interest.—M.M.H. Activities related to the present article:
editorial board member of RadioGraphics (not involved in the handling of this article).
Activities not related to the present article: disclosed no relevant relationships. Other
activities: disclosed no relevant relationships.
 Learning Objectives
Learning Objectives

To develop an To understand the chest To learn common

algorithmic approach to radiograph landmarks of central vascular
line placement vascular structures. anatomic variants.
evaluation.
 LearningCentral
Objectives
venous catheter placement is a
common procedure used in both inpatient and
outpatient settings.

Incorrect insertion can result in many

complications, including arterial injury,
hemorrhage, pneumothorax, pericardial
effusion, or thrombosis.
Confirming appropriate catheter positioning
after placement at imaging is essential for
Introduction patient safety, for which radiologists play a
critical role.

Because of its speed and accessibility in

patients who are immobile, chest radiography is
the preferred initial modality in assessing
catheter tip position.
 Learning Objectives
AML = acute myeloid leukemia
AO = aorta
CR = cinematic rendering
CVC = central venous catheter
CXR = chest radiography
ESRD = end-stage renal disease
IJ = internal jugular
LMB = left mainstem bronchus

Abbreviatio PA = pulmonary artery

PAPVR = partial anomalous pulmonary venous return

ns PE = pulmonary embolism
PICC = peripherally inserted central catheter
RA = right atrium
RMB = right mainstem bronchus
STEMI = ST-elevation myocardial infarction
SVC = superior vena cava
3D = three-dimensional
 Learning Objectives
The target area for a CVC tip is within the lower one-third of the SVC, superior cavoatrial
junction, or the RA. The SVC is posterolateral to the aorta.

R subclavian artery L subclavian artery L subclavian artery

R brachiocephalic L subclavian vein

L subclavian vein R brachiocephalic L subclavian vein R brachiocephalic
L brachiocephalic
L brachiocephalic L brachiocephalic

C
ta

rta
A or

SV
SVC
Aorta

Ao
RA
Target PA
PA

RA
P A R L A P
 Learning Objectives
R subclavian artery
Review of anatomy
R subclavian vein

L subclavian artery The brachiocephalic

veins project directly
SVC superior to the
AO anterior first rib.

The subclavian
arteries are higher
than the
brachiocephalic veins.
 Learning Objectives
R subclavian artery
Review of anatomy
R subclavian vein

L subclavian artery

The left brachiocephalic

SVC
vein (not pictured)
AO crosses the midline just
below the
sternoclavicular joint.
 Learning Objectives
R subclavian artery
Review of anatomy
R subclavian vein

L subclavian artery

The SVC is a right-

SVC
sided structure, for
AO
which the carina and
the sternum may be
used as landmarks.
 Review of anatomy: CXR Correlations
Learning Objectives
R subclavian artery

R subclavian vein

Fir Sternoclavicular
st joint
r ib
L subclavian artery

Sternum
SVC
AO

Frontal radiograph
Learning Objectives
Review of anatomy

The SVC (green

bracket) spans the
segment from the
tracheobronchial
angle (blue dotted
line) to two
vertebral bodies
(yellow rectangles)
below the carina.
 Where Do You Draw the Line?:
The Five-Step Guide to Line Placements

1 Be suspicious of lines that do not cross when they should.

2 Be suspicious of lines that cross when they should not.

3 After suspicion is raised, consider alternative or variant anatomy.

4 Some variant placement is intentional.

5 If there is doubt, check a waveform or perform CT.

 Where Do You Draw the Line?:
The Five-Step Guide to Line Placements

1 Be suspicious of lines that do not cross when they should.

2 Be suspicious of lines that cross when they should not.

3 After suspicion is raised, consider alternative or variant anatomy.

4 Some variant placement is intentional.

5 If there is doubt, check a waveform or perform CT.

Case 1. 58-year-old man with bilateral massive PEs.
Learning Objectives (1A) Frontal CXR obtained after CVC
placement shows the tip along the left mediastinum below the left sternoclavicular joint ( ).
(1B) Repeat frontal CXR for increasing shortness of breath shows new mediastinal widening.
(1C) Coronal CT image shows the tip outside the brachiocephalic vein ( ), with fluid in the
mediastinum from direct infusion of thrombolytics ( ).

Sternoclavicular joint

c vein
hali
i o cep
ac h
L br

1A 1B 1C
 Learning Objectives
Teaching Point 1

a li
c Left CVCs should follow the
ph
hio
ce course of the left
c
ra
Lb brachiocephalic vein, which
rta
Ao crosses the midline just
SVC

below the sternoclavicular

joint (yellow box) to join the
confluence.

Raise your suspicion at this

level if a left CVC is not
directed toward the right
mediastinum.
 Learning ObjectivesComparison
Sternoclavicular joint Sternoclavicular joint

Left CVCs should

follow the course of
the left
brachiocephalic vein,
which crosses the
midline just below the
sternoclavicular joint
to join the confluence.

Raise your suspicion

at this level if a left
CVC is not directed
A. Frontal CXR shows the tip (blue B. Frontal CXR shows the tip toward the right
arrow) malpositioned in the (green arrow) in the left mediastinum.
mediastinum. brachiocephalic vein.
Case 2. Companion case: Left IJ CVC tip in the left internal mammary vein. (2A) Frontal CXR
Learning Objectives
depicts the line projecting over the left mediastinum ( ), without directing medially at the
level of the sternoclavicular joint.
(2B) Sagittal CT image shows how the line anteriorly abuts the sternum ( ). (2C) Sagittal CT
image in a different patient demonstrates the CVC course into the SVC posteriorly for
comparison.

Sternoclavicular joint

SVC
Internal mammary

RA
2A 2B 2C
Case 3. 56-year-old woman with nephrotic syndrome presenting with respiratory failure.

level of the carina (

Learning Objectives
(3A) Frontal CXR obtained after placement shows the tip projecting along the midline at the
). Because of an inability to receive appropriate blood return and
continued respiratory decompensation, a noncontrast CT image (3B) was obtained and shows
line placement in the aorta.

Key:

SVC
Right mainstem bronchus (RMB)

ta
LM Left mainstem bronchus (LMB)

Aor
B
B

Right mediastinum ( )
RM

Carina
1A

3A 3B
 Learning Objectives
Teaching Point 2

ali
c The carina ( ) serves as a landmark
i
lp c h
p
i hcae
o for the SVC. Just above this level, the
i
r a
o cceh
raLc
hb SVC should be in the right
Lb
mediastinum.

ta
SVC

or
rtAa
Ao
SVC

Raise suspicion at this level if a line

does not reach the right mediastinum
( ) by the level of the carina.

Note: projectional differences may impact position,

and rotation is important to keep in mind for CXR.
 Learning ObjectivesComparison

The carina ( ) serves as a

landmark for the SVC. Just
above this level, the SVC
should be in the right
Carina mediastinum.
Carina
Raise suspicion at this level
if a line does not reach the
1A right mediastinum ( ) by
the level of the carina.
3A. B.
A. Frontal CXR shows the tip B. Frontal CXR shows the tip
(blue arrow) malpositioned in (yellow arrow) in the RA.
the aorta.
 Where Do You Draw the Line?:
The Five-Step Guide to Line Placements

1 Be suspicious of lines that do not cross when they should.

2 Be suspicious of lines that cross when they should not.

3 After suspicion is raised, consider alternative or variant anatomy.

4 Some variant placement is intentional.

5 If there is doubt, check a waveform or perform CT.

Case 4. 68-year-old man in septic shock requiring pressors after orthotopic heart transplant. A
Learning Objectives
right subclavian–approach line was attempted, without appropriate blood return. (4A) Frontal
CXR shows the tip projecting superior to the first rib ( ). (4B) Coronal noncontrast CT image
shows the line ( ) in the right subclavian artery.

R subclavian artery

I nn
om
ina
te
ar t
1st rib

er y
ta
Aor
SVC
4A. 4B.
Learning Objectives
Teaching Point 3

The subclavian veins (red)

are located at the level at
or directly above the first
rib anteriorly, whereas the
subclavian arteries (tan)
are located more superiorly.

Be suspicious of lines that

sit high on the first rib.
 Learning Objectives
Teaching Point 3

The scalene tubercle (dotted

line and arrow) is a small
bony projection on the
medial border of the first rib
and runs between the
subclavian artery and vein
grooves, making it a good
CXR landmark.

The subclavian vein groove

is closer to the tubercle
Frontal radiograph compared to the artery,
which is more superior.
 Learning Objectives
Teaching Point 3
Subclavian arterial line

The scalene tubercle is a

small bony projection on the
medial border of the first rib
and runs between the
subclavian artery and vein
grooves, making it a good
Expected location of
CXR landmark.
subclavian venous line

The subclavian vein groove

is closer to the tubercle
compared to the artery,
which is more superior.
 Learning Objectives
Case 5. Companion case: Cardiac arrest requiring multiple
access sites in a 29-year-old industrial worker who was struck
by an overhead concrete slab.

Frontal CXR (A) and 3D CR

correlate (B) show a right
subclavian arterial line (
) crossing superiorly to the
first rib on the CXR.
1st rib

vein
R subclavian
CXR shows a right
subclavian vein CVC
( ), obscured by

rta
contrast material on the 3D

SVC
Ao
CR.

Note that the subclavian

arterial line is above the
A B venous line.

A right IJ CVC is also seen (

).
Learning Objectives
Case 5. Companion case: Cardiac arrest requiring multiple
access sites in a 29-year-old industrial worker who was struck
by an overhead concrete slab.

Note the proximity

of the subclavian
R subclavian vein vein CVC ( ) to
the scalene tubercle
(dotted yellow line),

rta
SVC
and the more

Ao
superior location of
the arterial line
( ).
Case 6. 65-year-old woman presenting with a STEMI. (6A) Postplacement CXR shows a right
Learning Objectives
subclavian– approach CVC tip crossing the midline and projecting over the left mediastinum (
). The patient was taken to the cath lab, and injection into the CVC confirmed innominate artery
placement of the line (6B). The line was then removed.

6 2 1: Innominate artery
4
2. Common carotid
3
artery

5 1 3: Subclavian artery

4: Thyrocervical trunk

5: Internal thoracic

artery
6B
6A 6: Dorsal scapular

artery

Scalene tubercle
Learning Objectives
Teaching Point 4

Never remove an arterial line

until knowing its location.

If peripheral, it can be
removed at bedside, while
holding pressure.

If central, it needs to be
removed with the help of
angiography.
 Learning Objectives
Case 7. 50-year-old man with necrotizing fasciitis of the right foot. A central line was placed. Frontal CXR
shows left PICC, which crosses the midline at the manubrium, although after reaching the right mediastinum, it
abruptly curves medially ( ), found to be in the azygos vein.

R brachiocephalic L brachiocephalic L brachiocephalic

R brachiocephalic

gos
Azy

SVC

SVC
Azygos

Right Left Posterior Anterior

Frontal CXR
 Learning Objectives
Teaching Point 5

A curve in a central line at

this exact location, the
tracheobronchial angle ( ),
is essentially diagnostic of
azygos placement.

Cannulations are more

common in patients with
heart failure in which the
Frontal radiograph
vein is dilated.
 Learning Objectives
Teaching Point 6

Complications of azygos vein

SVC

cannulation include potential

Azygos rupture of the vein, poor blood
return, and thrombosis.

A rapid saline flush may help

pop out the catheter into the
SVC.
 Teaching Point 7
Learning Objectives
The target for the SVC is along the inferior portion of the right mediastinum. Be on the
lookout for lines that curl or project superiorly.

Case 8. Frontal radiograph shows right Case 9. Frontal radiograph shows the left IJ Case 10. Frontal radiograph shows
(arrows) curling superiorly into the right left PICC (arrow) curling superiorly
PICC (arrow) entering right IJ in brachiocephalic vein. into the left IJ.
the neck.
 Where Do You Draw the Line?:
The Five-Step Guide to Line Placements

1 Be suspicious of lines that do not cross when they should..

2 Be suspicious of lines that cross when they should not.

3 After suspicion is raised, consider alternative or variant anatomy.

4 Some variant placement is intentional.

5 If there is doubt, check a waveform or perform CT.

Case 11. (A) Frontal CXR shows a left IJ line appearing to course into the lung (
Learning*Objectives ). (B, C) Coronal CT image (B) and
3D CR correlation (C) show left upper lobe PAPVR ( ). This is the most common type of PAPVR.

L brachiocephalic vein L brachiocephalic vein

* *

SVC
PA AO
AO PA

A. B. C.
 Learning Objectives
Teaching Point 8
L brachiocephalic vein

*
The left upper lobe PAPVR ( )
* courses into the lung, and blood
return is oxygenated.
AO
SVC

PA
A CT or waveform analysis can
help confirm.
 Where Do You Draw the Line?:
The Five-Step Guide to Line Placements

1 Be suspicious of lines that do not cross when they should.

2 Be suspicious of lines that cross when they should not.

3 After suspicion is raised, consider alternative or variant anatomy.

4 Some variant placement is intentional.

5 If there is doubt, check a waveform or perform CT.

Case 12. 69-year-old man with relapsed AML after stem cell transplant. (1A) Frontal CXR obtained after admission
Learning Objectives
shows a right IJ CVC coursing to the left across the midline, with the tip projecting just superior to the aortic arch
( ). While this appears suggestive of arterial placement, images from prior fluoroscopic line placement revealed a
left-sided SVC draining into the coronary sinus (1B), which was confirmed at noncontrast CT (not pictured). (1C) 3D CR
in another patient depicts a duplicate SVC.

R SVC Duplicate L SVC

L SVC
*
PA
AO

Coronary
1A 1A 1B Sinus 1C
 Learning Objectives
Teaching Point 9

L SVC

Left-sided SVCs
typically drain into the
coronary sinus.

Coronary
1B Sinus

1A
 Learning Objectives
Case 13. Companion case: Left subclavian defibrillator lead tip (
*
) traverses a left persistent SVC ( ) to
reach the right ventricle. Right paratracheal opacity ( ) corresponds to right-sided aortic arch ( ). LPA = left
pulmonary artery.

LP
A
Frontal radiograph Sagittal radiograph Axial CT image
Case 14. Frontal CXR shows a left IJ CVC tip just below the aortic arch ( ), which is found in the
Learning Objectives
left superior intercostal vein on the 3D CR.

L brachiocephalic L brachiocephalic L superior

intercostal
vein coursing
posteriorly to
join the
L superior hemiazygos
intercostal
vein
Aortic

SVC
nipple

A. Right Anterior Posterior

Left
Frontal radiograph
L brachiocephalic
Learning Objectives
Teaching Point 10
vein

The left superior intercostal

L superior
intercostal vein forms the aortic nipple
vein
and communicates with the
SVC

accessory hemiazygos vein.

VC
ASO

It can be enlarged because of

SVC obstruction. Placement in
A this vein can be intentional to
.
bypass the obstruction.
 Case 15. Companion case: 43-year-old woman with cystic fibrosis who
Learning Objectives
underwent port placement.

A. Frontal radiograph shows a

left IJ approach CVC tip coursing
* along the aortic nipple ( ) with
*
* the tip ( )
inferior to the aortic knob.

B. Preplacement venogram
maps the tip location in the
hemiazygos vein ( ), which is
A B in continuity with the left
*
superior intercostal vein at the
aortic nipple ( ).
 Where Do You Draw the Line?:
The Five-Step Guide to Line Placements

1 Be suspicious of lines that do not cross when they should.

2 Be suspicious of lines that cross when they should not.

3 After suspicion is raised, consider alternative or variant anatomy.

4 Some variant placement is intentional.

5 If there is doubt, check a waveform or perform CT.

 Case 16. 71-year-old man with ESRD who recently started
Learning Objectives
undergoing hemodialysis.

It was noted that the catheter

was not functioning properly
on the third hemodialysis
treatment. The catheter was
removed, and a new left IJ line
was placed on the same day.
This second IJ line was also
not functioning.

Frontal radiograph
 Case 16. 71-year-old man with ESRD who recently started
Learning Objectives
undergoing hemodialysis.

Left IJ line crosses the

midline at the
manubrium.

Accounting for
differences in rotation,
projects along the right
mediastinum at the level
of the carina ( ).

Tip ( ) appears to
project over the RA.
 Case 16. 71-year-old man with ESRD who recently started
Learning Objectives
undergoing hemodialysis.

Left IJ line crosses the

midline at the
manubrium.

Accounting for
differences in rotation,
projects along the right
mediastinum at the level
of the carina ( ).

Tip ( ) appears to
Given continued poor function,
project over the RA. CT was performed.
 Case 16. 71-year-old man with ESRD who recently started
Learning Objectives
undergoing hemodialysis.

Coronal CT images show that the line punctured through the SVC ( ), terminating in the
pericardial space adjacent to the RA, with contrast material filling the pericardial sac.
 Case 17. 57-year-old patient with pneumococcal
Learning Objectives
meningoencephalitis.

Left PICC crosses the

midline at the manubrium.

Accounting for differences in

rotation, the line ( )
projects along the right
mediastinum at the level of
the carina ( ).

The line dives more acutely

than expected for the
course of the left
Frontal radiograph
brachiocephalic vein, and it
is straight rather than
curved.
 Learning Objectives
Teaching Point 11

L brachiocephalic L subclavian
artery The left brachiocephalic vein
forms a slightly more obtuse
angle with the SVC and bends at
SVC the confluence ( ), as
AO
opposed to the left subclavian
artery, for which the angle is
straight, without a bend ( ).
 Case 17. 57-year-old patient with pneumococcal
Learning Objectives
meningoencephalitis.

L subclavian artery

Innominate
AO artery
SVC
PA PA
AO

LV LV

Coronal CT images show the left PICC in the left subclavian artery, terminating in the aortic
arch ( ).
 Case 17. 57-year-old patient with pneumococcal
Learning Objectives
meningoencephalitis.

L subclavian artery

AO
SVC
PA PA

LV

Coronal CT image (left) and frontal CXR correlation (right). A left

PICC tip terminates in the aortic arch ( ).
 Where Do You Draw the Line?:
The Five-Step Guide to Line Placements

1 Be suspicious of lines that do not cross when they should.

2 Be suspicious of lines that cross when they should not.

3 After suspicion is raised, consider alternative or variant anatomy.

4 Some variant placement is intentional.

5 If there is doubt, check a waveform or perform CT.

 Learning
• Demos TC,Objectives
Posniak HV, Pierce KL et al. Venous anomalies of the
thorax. AJR Am J Roentgenol 2004;182(5):1139–1150.

• Melarkode K, Latoo MY. Pictorial essay: central venous catheters on

chest radiographs. BJMP 2009;2(2):55–56.

• Stonelake PA, Bodenham AR. The carina as a radiological landmark

Suggested for central venous catheter tip position. Br J Anaesth

Readings 2006;96(3):335–340.

• Venugopal AN, Koshy RC, Koshy SM. Role of chest X-ray in citing
central venous catheter tip: A few case reports with a brief review of
the literature. J Anaesthesiol Clin Pharmacol 2013;29(3):397–400.
 L superior
halic
iocep
ra c h intercostal vein
A visually interesting Lb
(full course not
case of SVC obstruction

ta
shown)

A or
after SVC stent
placement ( ), with PA
central line placement
within the SVC
stent ( ). PA

3D CR shows collateral
venous mapping. 1B

Thank you!
Contact:
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