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Minimising Risk

Misplacement and Malposition of Central Venous Access Devices

The main risks of central venous access devices misplacement include infections, bleeding, perforation of the vessel or organ, and difficulty in removing the device. Misplacement can also lead to catheter-related bloodstream infections and thrombosis, which can result in serious complications such as sepsis and pulmonary embolism. Prompt recognition and correction of misplacement are crucial to reduce these risks and improve patient outcomes.

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Central venous access devices

Central venous access devices (CVADs) are used for short or long-term infusion of fluids, medications and monitoring, or when establishing a peripheral venous access is not possible or difficult CVADs can be inserted into the subclavian or jugular vein as centrally inserted central venous catheters (CICCs or conventionally called CVCs), totally implanted venous access devices (TIVAD conventionally called access ports AP), or can be inserted into one of the peripheral veins of the upper extremities, called peripherally inserted central catheters (PICCs).1

 

Misplacement and Malposition of CVAD 

The misplacement or malposition of centrally and peripherally inserted central venous catheters describes the improper location of the catheter tip.2,3

Where is the “ideal” catheter tip location and how do you place the catheter tip correctly? 

“The tip of the catheter should be in a central vein (Superior Vena Cava, SVC, or Inferior Vena Cava, IVC), close to the cavoatrial junction.”1

  • Ideally outside of the pericardial sac.
  • Parallel with the long axis of the vein.
  • The tip does not abut the vein or heart wall at an acute angle or end on.3,4 
  • The ideal catheter position is the area between the lower third of vena cava superior and upper the third of right atrium.5

Correct catheter tip positioning6

Conclusion:

„ [...] correct position of the catheter has to be ensured during placement"

scheme of catheter tip position Caers J, Fontaine C,Vinh-Hung V et al (2005) Catheter tip position as a risk factor for thrombosis associated with the use of subcutaneous infusion ports. Support Care Cancer 13:325-331​

Relation between catheter tip position and complication rate1-6

 

Location of catheter tip positionNumber of patientsVenous thrombosisFunctional problems
Brachocephalic vein3245.2%6.5%
SVC cranial 1/34219%16.7%
SVC mid 1/31424.2%1.4%
SVC caudal 1/3661.5%0%
RA or inferior Vena Cava185.5%5.6%

Why is it important to achieve an "ideal" catheter tip location for CVC, TIVAD and PICC?

  • Infusion of vasopressors, irritant drugs, or parenteral nutrition requires maximal dilution, avoiding mixing of multiple drugs such as chemo- and antibiotic therapy and blood sampling  
  • Extracorporeal circuits, e.g. dialysis requires a very high blood flow rate passing by the catheters, and separation of inflow and outflow of catheters to avoid blood recirculation
  • Measurement of ScvO2 requires catheter tip placement in or as close to the right atrium as possible

Misplacement/Malposition is one of the most common complications related to CVADs7-10

Misplacement/Malposition could occur in different CVAD applications

graphic-misplacement-one-of-the-mot-common-complications

Catheter tip positions are shown in percent of the total number of cannulations at each puncture site. 

1. Right atrium

2. Caudal third of superior vena cava (SVC)

3. Cranial two-thirds of SVC or brachiocephalic veins

4. Intrathoracic part of the right subclavian vein

5. Intrathoracic part of the left subclavian vein

6. Right internal jugular vein

7. Left internal jugular vein

Graphic adapted from Pikwer, A., Bååth, L., Davidson, B., Perstoft, I., & Åkeson, J. (2008). The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients. Anaesthesia and Intensive Care, 36(1), 30-37.

Jugular vein right

Cannulation by the right internal vein n=1023 (63.2%)

/

Jugular vein left

Cannulation by the left internal jugular vein n= 104 (6.4%)

/

Subclavian vein right

Cannulation by the right subclavian vein n=287 (17.7%)

/

Subclavian vein left

Cannulation by the left subclavian vein n= 37 (2.3%)

/

Clinical needs:
​

  • Access Port catheters might remain in situ for several years!​
  • Therefore, correct and accurate positioning of the catheter is important
  • Incorrect positioning can lead to a higher rate of long term complications (e.g. thrombosis)*
     

*Superior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted ports.

*Puel, V., Caudry, M., Le Métayer, P., Baste, J. C., Midy, D., Marsault, C., Demeaux, H., & Maire, J. P. (1993). Superior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted ports. Cancer, 72(7), 2248-2252.

  • 379 patients from December 1985 to December 1990
  • 4 groups
GroupThrombosis Rate
Catheter tip in upper SVC Left sided port8/28 (28.6%)
Catheter tip in upper SVC Right sided port1/33 (3%)
Catheter tip in lover SVC Left sided port0/250
Catheter tip in lover SVC Right sided port1/68 (1.5%)

Conclusion:​

„ […] patients with left-sided port and catheter tips lying in the upper part of the vena cava are at high risks for severe thrombotic complications.“

Molassiotis, A., Saunders, M. P., Valle, J., Wilson, G., Lorigan, P., Wardley, A., Levine, E., Cowan, R., Loncaster, J., & Rittenberg, C. (2005). The impact of chemotherapy-induced nausea and vomiting on health-related quality of life. Supportive Care in Cancer, 13(5), 325-331.

 

Catheter tip position as a risk factor for thrombosis associated with the use of subcutaneous infusion ports.

Caers J1, Fontaine C, Vinh-Hung V, De Mey J, Ponnet G, Oost C, Lamote J, De Greve J, Van Camp B, Lacor P

 

  • 2005
  • 437 patients
  • 370 patients with solid tumors and 58 patients with hematological disease

 

Location of catheter tipNumber of patientsVenous thrombosisFunctional problems
Brachiocephalic vein3145.2%6.5%
SVC cranial 1/34219%16.7%
SVC mid 1/31424.2%1.4%
SVC caudal 1/3661.5%0%
RA or inferior Vena Cava185.5%5.6%

Results:

  • Complications at 91 patients  (20.83 %) were detected​
  • Most common complications after implantation​
  • Thrombosis 8.5 %​
  • Catheter dysfunction 4.8 %​
  • Infection 4.4 %

Potential Causes of Catheter Misplacement

Patient factors

  • Complex or abnormal anatomy (e.g. dilated azygos vein, high CVP, blocked SVC, IVC, persistent left superior vena cava)

 

Physician/Hospital factors

  • Pinch off Syndrome 
  • Catheter dislocation (not correctly secured) 

 

Product factors

  • No navigation technique available (Ultrasound, ECG)
  • Inappropriate catheter size or length

Type and Position of Catheter Misplacement 12

 

Intravascular MisplacementExtravascular Misplacement
Carotid arteryExtradural space
Azygos veinPericardium
Paersistent left sided superior vena cavaPleural space
Internal thoracic (mammarx) veinMediastinum
Vertebral veinThoracic duct

Intravascular Misplacement

Extravascular Misplacement

Consequences related to CVC application12

  • Catheter dysfunction
  • Delay of critical therapy (e.g. vasopressors, chemotherapy)

 

Consequences related to Access Ports application12  

  • Pinch off Syndrome
  • Pneumothorax 
  • Haemothorax 
  • Air embolism 
  • Accidential arterial puncture 

 

Complications related to PICC application12 

  • Accidental arterial puncture 
  • Haematoma 
  • Difficulties in finding the vein 

 

Complications related to the misplaced location12

  • Carotid Artery: Hypotension, haemorrhagic shock
  • Azygos Vein: Pleural diffusion pulmonary oedema, dyspnea, chest pain, back pain
  • Pericardium: Fatal ventricular fibrillation
  • Drug extravasation into surrounding -> tissue necrosis, organ dysfunction

Estimated level of costs (time, material, and personnel) related to diagnostic procedures, delay of therapy and required management for misplaced CVADs. 12

 

 

Clinical Consequences

Clinical Examination and Treatment

Level of additional length of stay and cost

Complications related to CVAD application

  1. Catheter dysfunction

    Delay of therapy

Medica Image to detect misplaced catheter, chest X-ray, alternatively CT or MRI

+ ∼ +++
 

Removal of catheter, according to the sereneness (bedside, via Interventional radiology or via surgery
Insertion of new catheter.

+ ∼ ++++
 

Catheter removal via Interventional Radiology

+++

Complications related to the misplaced location 

  • Carotid artery: hypotension, hemorrhagig shock

    Azygos vein; pleural diffusion pulmonary edema, dyspnea, chest pain, back pack pain

    Pericardium: fatal ventricular fibrillation

 

Individual surgical or non-surgicak treatment according to the impaired organ or tissue

++ ∼ ++++

Drug extravasation into surrounding

Non-surgical or surgical treatment fot extravasation

++ ∼ ++++

Selecting the proper vessel  

  • Incidence of malpositioning is higher in the left thoracic venous system than in the right side  
  • The right side of the circulation should be considered of first preference for CVC insertion unless those insertion sites are contraindicated
  • Use ultrasound for selecting the proper vessel for insertion

Select/trim the correct catheter length according to the insertion site and patient’s condition 

  • Use the different technique correctly to implant TIVADs and PICCs (Seldinger, OTW, surgical cutdown).16  
  • Use of Valve Needles to access the vein for central venous catheters:
    Save time/no disconnection needed.
  • Secure the CVADs sufficiently.  

 

Select a proper device to guide insertion and confirm tip position 

  • Ultrasound guidance 
  • Intraatrial ECG  
  • Chest X-Ray17 
  • Other supporting methods/techniques: electromagnetic, manometry (needle and catheter, pressure waveform analysis, blood gas analysis.8-12

Use of Valve Needle for venous access: save time/no disconnection needed

 

Verification of Catheter Position with Medical Imaging

X-Ray

  • Plain Chest X-Ray is most commonly used to confirm catheter position within the chest and to detect pneumothorax, haemothorax or effusions after CVC placement.

 

Intraatrial (Intravascular) ECG

  • The intraatrial (intravascular) ECG technique can be used to confirm CVAD tip position during or after CVAD placement. 9,10,18
  • Intracavity (Intravascular or intraatrial) ECG tip positioning method with Certodyn  is accurate and feasible in all adult and paediatric patient.s9,18

 

ECG Method: Accuracy and Feasibility compared with Radiography9,18

 AdultsChildren
Accuracy94.5%95.8%
Feasibility98.5%99.3%

 

Ultrasound

  • Ultrasound can be used to assess the jugular, femoral, axillary, and arm veins to aid insertion of a CVC, but is of limited value in confirming tip position in the SVC.
  • Transesophageal ultrasound (TEE) can be used if available to directly image the SVC, but this has practical limitations due to availability and operator training.
  • Transthoracic echo (TTE) can identify catheters in the RA, particularly with the injection of bubble contrast, but is not used in routine practice.8-11

Devices and Accessories for CVC Placement

Piczure of product

Certodyn® Universal Adapter

Universal Adapter for recording alternately an intra-vascular and surface ECG for positioning of central venous catheters

Central Venous Catheters (CVC) Devices

Central Venous Catheters

Product Picture Enlargement CW

Celsite® Epoxy

Premium venous access ports with special compact port design

[1]   Ho, Chuong, and Carolyn Spry. "Central venous access devices (CVADs) and peripherally inserted central catheters (PICCs) for adult and pediatric patients: a review of clinical effectiveness and safety." 2018.

[2]  Pittiruti, Mauro, Antonio La Greca, and Giancarlo Scoppettuolo. "The electrocardiographic method for positioning the tip of central venous catheters." The journal of vascular access 12.4: 280-291. 2011.

[3]   Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DAV. Videos in clinical medicine. Central venous catheterization. N Engl J Med 2007; 356: e21. https://doi.org/10.1056/NEJMvcm055053. 

[4]   Gibson F, Bodenham A. Misplaced central venous catheters: applied anatomy and practical management. British journal of anaesthesia 2013; 110: 333–46. https://doi.org/10.1093/bja/aes497. 

[5]   Schutz JCL, Patel AA, Clark TWI, et al. Relationship between chest port catheter tip position and port malfunction after interventional radiologic placement. Journal of vascular and interventional radiology: JVIR 2004; 15: 581–87. https://doi.org/10.1097/01.rvi.0000127890.47187.91. 

[6]   Caers J, Fontaine C, Vinh-Hung V, et al. Catheter tip position as a risk factor for thrombosis associated with the use of subcutaneous infusion ports. Supportive care in cancer: official journal of the Multinational Association of Supportive Care in Cancer 2005; 13: 325–31. https://doi.org/10.1007/s00520-004-0723-1. 

[7]   Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. International Journal of Critical Illness and Injury Science 2015; 5: 170–78. https://doi.org/10.4103/2229-5151.164940. 

[8]   McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348: 1123–33. https://doi.org/10.1056/NEJMra011883. 

[9]   Rossetti F, Pittiruti M, Lamperti M, Graziano U, Celentano D, Capozzoli G. The intracavitary ECG method for positioning the tip of central venous access devices in pediatric patients: results of an Italian multicenter study. The journal of vascular access 2015; 16: 137–43. https://doi.org/10.5301/jva.5000281. 

[10]   Pelagatti C, Villa G, Casini A, Chelazzi C, Gaudio AR de. Endovascular electrocardiography to guide placement of totally implantable central venous catheters in oncologic patients. The journal of vascular access 2011; 12: 348–53. https://doi.org/10.5301/JVA.2011.8380. 

[11]   Parienti J-J, Mongardon N, Mégarbane B, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med 2015; 373: 1220–29. https://doi.org/10.1056/NEJMoa1500964. 

[12]   Wang L, Liu Z-S, Wang C-A. Malposition of Central Venous Catheter: Presentation and Management. Chin Med J (Engl) 2016; 129: 227–34. https://doi.org/10.4103/0366-6999.173525. 

[13]   Smit JM, Raadsen R, Blans MJ, Petjak M, van de Ven PM, Tuinman PR. Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis. Critical care (London, England) 2018; 22: 65. https://doi.org/10.1186/s13054-018-1989-x. 

[14]   Roldan CJ, Paniagua L. Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction. West J Emerg Med 2015; 16: 658–64. https://doi.org/10.5811/westjem.2015.7.26248. 

[15]   Fletcher SJ, Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? British journal of anaesthesia 2000; 85: 188–91. https://doi.org/10.1093/bja/85.2.188. 

[16]   Stas M, Mulier S, Pattyn P, Vijgen J, Wever I de. Peroperative intravasal electrographic control of catheter tip position in access ports placed by venous cut-down technique. European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 2001; 27: 316–20. https://doi.org/10.1053/ejso.2000.1047. 

[17]   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. Journal of anaesthesiology, clinical pharmacology 2013; 29: 397–400. https://doi.org/10.4103/0970-9185.117114. 

[18]   Pittiruti M, Bertollo D, Briglia E, et al. The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study. The journal of vascular access 2012; 13: 357–65. https://doi.org/10.5301/JVA.2012.9020. 

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