Radiologist said that it was because of the angle/rotation of the patient/film that makes this misleading (attending MD with a lot of experience, although I also have multiple first hand experiences disagreeing with senior rads and being correct).
Internal thoracic? 3CG and Sherlock used.
Thanks,
Mari Cordes, RN VA-BC
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I'll be anxious to hear what the experts say. It looks azygos to me.
The film is a little rotated so it would naturally appear to be midline. I believe from the left if it were internal thoracic that it would have to go more contralateral first. It doesn't look like any azygos I have seen but the rotation may be skewing it. That sharp turn down is the odd part. I would get a lateral just to be sure. We have had several azygos placements with ECG/Sherlock.
Darliyn
I am unsure about that sharp turn also. Or is that part that appears to be a continuation of the downward catheter actually some type of artifact on the film? The arch in the subclavian area is high but it does not extend above the clavicle which could indicate arterial placement. May also be the thymic vein but it appears to be located in the center of the SVC and the thymic vein would be more to the left. Please satisfy our curiosity and tell use where it actually was. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Well....the attending, long time practising, chest radiologist called it CAJ, and said not to worry about the appearance of the sharp bend. He said it was because of the rotation of the patient.
Still makes me nervous.
Mari
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
It barely looks midline to me.
Emily - You have to follow the PICC down a little further - if it was truly in the SVC, it would be CAJ as the radiologist thought (it courses deeper than where it first appears). We of course could ask for further imaging - I don't think contrast is necessary, but a lateral view would help.
What I'm really looking for is help from folks who regularly read films for tip location to confirm my concerns that this is not in the SVC.
Thanks, all -
Mari
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
I see the tip very clearly. Please refer to my previous post as why I think contrast may be needed. But only if the lateral view doesn't prove anything.
Can you use some contrast to find out if it is in the SVC at all? It could be a collateral vein along with SVC and the PICC is then not central.
I'm betting azygos but the rotation of the patient skews the the bend.
Please see if they can contrast the line, I am very curious.
I agree with Mari that a lateral view may be indicated but would seriously hesitate to use contrast. Remember this was placed using ECG guidance also. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree with lateral view. I am continually reminded about how little we can see with a/p view.
Rose Galyan RN, BSN, CRNI
Speciality Practice Nurse
Vascular Access Team
Indiana University Hospital Bloomington
[email protected]
A lateral view may not rule out colateral placement 100%. If the vein like an azygos is suspected, a lateral view helps. But if the vein goes along parallel with SVC, a lateral view doesn't help. Haven't there reported PICC placement with ECG tip confirming ended up in Azygos? I have seen cases like this been proved to be in the colateral veins. Your call.
Bilateral SVCs are present in 0.3% of the population. The left-sided SVC most commonly
drains into an enlarged coronary sinus, and the left brachiocephalic vein is absent
in 65% of cases (D¨ahnert 1999). A CVC placed via a left subclavian or jugular venous
approach would therefore have an unusual mediastinal course on a plain radiograph
I have a pix but it will not allow me to copy it. email me.
Would like to see what you all are talking about. Can you email me the pix?
I found it online. A little dated 2006 but much good information and CVC pictures on many topics I have not found anywhere else.
http://xa.yimg.com/kq/groups/16749867/1028761575/name/Central+Venous+Catheters.pdf
Right click and download for easy searching .... Slide 159 of the document pt 144 of the text.
I have seen some odd courses esp in the elderly. Perhaps that steep turn is normal anatomy for that person? I see a shoulder replacement,not to stereotype ,but could be elderly?
Definitely not LSVC - we ruled that out last week by CT. Repeat lateral film showed it was in SVC, not another vein which is what I was primarily worried about.
Go figure.
To the person wanting to see the pic - look under my post at the top of the page - there is a hyperlink to the image.
Great discussion - thanks, all!
Mari
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center