Characteristic CT angiography findings and clinical value of catheter-related central venous thrombosis in hemodialysis patients with end-stage renal disease

BACKGROUND

Central catheter-related thrombosis (CRT) is the most common catheter-related complication in patients with end-stage renal disease (ESRD) but is often underappreciated and misdiagnosed by radiologist.

PURPOSE

To find the computed tomography angiography (CTA) characteristics of central CRT, then raise the diagnosis of this disorder.

MATERIAL AND METHODS

A total of 301 eligible patients with ESRD who experienced both chest multi-phase multidetector CTA (MDCTA) and digital subtraction angiography were enrolled in the final analysis. The location, shape, and related signs of the central CRT in MDCTA images were evaluated. Independent-samples T test, chi-square test, and binary logistic regression were analyzed using SPSS software.

RESULTS

In total, 166 patients were found to have CRT using MDCTA, and this was verified by DSA. Central CRT was usually irregular in the superior vena cava segment, and the angle of the contact area between central CRT and catheter was <180° (all P < 0.05). Age, collateral circulation, and venous stenosis were shown to have significant differences when compared to patients without CRT (all P < 0.05), but there were no significant differences about the sex or catheter insertion site. In addition, age and collateral circulation were the factors found to be significantly associated with thrombosis (P < 0.05). In particular, the thrombosis was 2.213 times more likely to be found in those patients with collateral circulation (odds ratio = 2.213, 95% confidence interval = 1.236-3.961).

CONCLUSION

Chest multi-phase MDCTA can effectively reduce the missed diagnosis and misdiagnosis of central CRT. It is worth paying more attention to the central CRT especially when the collateral circulation is observed.

The undulating line sign and other more common pediatric central catheter malpositions

Central venous and arterial catheters are among the most commonly assessed support devices by radiologists. The position of these catheters must be carefully assessed to ensure proper placement, as malpositioning may lead to life-threatening consequences. Therefore, it is important for radiologists to understand the anatomy of the central vessels and the expected location of catheters. While this can be difficult in small children and especially in neonates, knowledge of the expected course and ideal termination of catheters allows for recognition of a malpositioned line, which may be unsuspected clinically. The purpose of this article is to discuss appropriate positioning of central catheters in pediatric patients, focusing primarily on venous catheters. We also propose a new radiographic sign to recognize, the undulating line sign, as an indication of an inappropriate course of a newly placed venous catheter.

The Incidence of Totally Implantable Venous Access Devices Insertion and the Associated Abnormalities in Patients With Cancer Revealed in 18F-FDG PET-CT Imaging

RATIONALE AND OBJECTIVES

The purpose of this retrospective study was to evaluate the incidence of totally implantable venous access devices, also called ports, implantation and the associated abnormalities in 2-[¹⁸F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) images for patients with cancer, and to determine the percentage of abnormalities identified in the original reports.

MATERIALS AND METHODS

The study aimed to perform a retrospective review of all FDG PET-CT imaging in a 3-year period. Cases of port-associated abnormalities found on the FDG PET-CT images were identified and then correlated with X-ray reports and clinical treatment or follow-up.

RESULTS

In total, 2442 FDG PET-CT scans were retrospectively reviewed. Among them, 897 (897 of 2442, 36.7%) demonstrated port implantation. Abnormalities, including 22 port fractures (22 of 897, 2.45%), 14 malposition (1.56%), one infection (0.11%), and one embraced by a fibrin sheath or tumor (0.11%) were found. Only the infectious one had clinical symptoms. Among the 22 fractured ports, eight fractured catheters migrated and became dislodged. All of the malpositioned ports, except two in the contralateral subclavian vein, were found in the ipsilateral jugular vein. Both the port infection and the port embraced by a fibrin sheath or tumor occurred at the tips of the devices, which demonstrated FDG uptake in the mediastinal region. Only seven of the 38 (18.42%) images of port abnormalities had been identified in the original reports.

CONCLUSIONS

Based on this study, we recommend that the interpretation of FDG PET-CT scans should include a checklist to record all metallic device implantations and to interpret the whole-body X-ray topography as a standard part of PET-CT image report.

Thrombotic complications and tip position of transjugular chronic dialysis catheter scheduled into superior vena cava: Findings on HR-MRCP and HR-T2WI

BACKGROUND

Catheter-related thrombotic complications(TCs) can occur during the long term use of a chronic dialysis catheter (CDC), including fibrin sheath (FS), mural thrombosis (MT), venous thrombosis (VT), and intraluminal clots (IC), which has not been reported with MRI. The aim of our study was to evaluate the determination of catheter tip position (TP) and resolution of TCs in patients with transjugular CDC scheduled into the superior vena cava using high resolution magnetic resonance cholangiopancreatography (HR-MRCP) and T2-weighted imaging (HR-T2WI).

METHODS

The study protocol was approved by the local Research Ethics Committee. Informed consent was obtained from all patients. In total, 41 consecutively enrolled transjugular CDC patients with suspected catheter dysfunction were scanned with HRMRCP and HR-T2WI. The distance from the top to the tip of the catheter and the presence and nature of catheter TCs were assessed by 2 experienced radiologists. Chest x-ray was taken within 1 to 2 days and CDC was withdrawn within 3 to 10 days from those patients with TCs identified by HR-MRI.

RESULTS

A total of 38 subjects successfully underwent HR-MRI, including 13 normal and 25 with TCs (fibrin sheath [FS]: n = 21, mural thrombosis [MT]: n = 7, venous thrombosis [VT]: n = 3, intraluminal clots [IC]: n = 4). There was no significant difference between HR-MRCP and chest x-ray in catheter TP determination (P = .124). Normal catheter appeared as "double eyes" on HR-T2WI and "double tracks" on HR-MRCP. TCs appeared as follows: FS displayed as a "thin ring" (<1mm) around the catheter, MT as patchy hyperintensity and VT as a "thick ring" (>5mm) on HR-T2WI. Unilateral IC appeared as a "single eye" on HR-T2WI and a "single track" on HR-MRCP (n = 3). Bilateral IC appeared as neither "eye" nor "track" (n = 1). Catheter withdrawal confirmed FS (n = 16), MT (n = 6), VT (n = 1), and IC (n = 4).

CONCLUSION

HR-MRCP and HR-T2WI are promising methods for visualizing TP and TCs in CDC patients, and are helpful in adjusting the treatment plan and avoiding the risk of pulmonary embolism.

Chest radiography in the ICU: Part 2, Evaluation of cardiovascular lines and other devices

OBJECTIVE

In this pictorial essay, we discuss and illustrate normal and aberrant positioning of the cardiovascular support and monitoring devices frequently used in critically ill patients, including central venous catheters, pulmonary artery catheters, left atrial catheters, transvenous pacemakers, automatic implantable cardioverter defibrillators, intraaortic counterpulsation balloon pump, and ventricular assist devices, as well as their inherent complications.

CONCLUSION

The radiographic evaluation of the support and monitoring devices used in patients in the ICU is important, because the potentially serious complications arising from their introduction and use are often not clinically apparent. Familiarity with normal and abnormal radiographic findings is critical for the detection of these complications.

Thrombosis and cancer: spectrum of multidetector CT findings in oncologic patients with thromboembolic disease. A pictorial review

This article is a reasoned pictorial review illustrating the many faces of thrombotic and embolic disease developing in the cancer patient. From a clinical point of view, we particularly point out the importance of properly identifying this occurrence in its various presentations. From a radiological point of view, special emphasis is given to the wide spectrum of multidetector CT findings, to the clues of benign and malignant thrombus diagnosis, and to the potential interpretative pitfalls.

(Mis)placed central venous catheter in the left superior intercostal vein

Background

Chest X-ray is routinely performed to check the position of the central venous catheter (CVC) inserted through the internal jugular or subclavian vein, while the further evaluation of CVC malfunction is usually performed by contrast venography. In patients with superior vena cava obstruction, the tip of the catheter is often seen in collateral mediastinal venous pathways, rather than in the superior vena cava. In such cases detailed knowledge of thoracic vessel anatomy is necessary to identify the exact location of the catheter.

Case report.

We report a case of 32-year-old female patient with relapsing mediastinal lymphoma and previous superior vena cava obstruction with collateral azygos-hemiazygos venous pathways. The patient had CVC inserted through the left subclavian vein and its position was detected by CT to be in the dilated left superior intercostal vein and accessory hemiazygos vein. Considering that dilated accessory hemiazygos vein can tolerate infusion, the CVC was left in place and the patient had no complaints related to CVC (mal)position. Furthermore, we present anatomical and radiological observations on the azygos-hemiazygos venous system with the special emphasis on the left superior intercostal vein.

Conclusions

Non-contrast CT scans can be a valuable imaging tool in the detection of the CVC position, especially in patients with renal insufficiency and contrast media hypersensitivity.

Central venous device-related thrombosis as imaged with MDCT in oncologic patients: prevalence and findings

BACKGROUND

Venous thrombosis is a common occurrence in cancer patients, developing spontaneously or in combination with indwelling central venous devices (CVD).

PURPOSE

To analyze the multidetector CT (MDCT) prevalence, appearance, and significance of catheter-related thoracic venous thrombosis in oncologic patients and to determine the percentage of thrombi identified in the original reports.

MATERIAL AND METHODS

Five hundred consecutive patients were considered. Inclusion criteria were: presence of a CVD; availability of a contrast-enhanced MDCT; and cancer history. Exclusion criteria were: direct tumor compression/infiltration of the veins; poor image quality; device tip not in the scanned volume; and missing clinical data. Seventeen (3.5%) out of the final 481 patients had a diagnosis of venous thrombosis.

RESULTS

Factors showing the highest correlation with thrombosis included peripherally-inserted CVD, right brachiocephalic vein tip location, patient performance status 3, metastatic stage disease, ongoing chemotherapy, and longstanding CVD. The highest prevalence was in patients with lymphoma, lung carcinoma, melanoma, and gynecologic malignancies. Eleven out of 17 cases had not been identified in the original report.

CONCLUSION

CVD-related thrombosis is not uncommon in cancer patients and can also be observed in outpatients with a good performance status and a non-metastatic disease. Thrombi can be very tiny. Radiologists should be aware of the possibility to identify (or overlook) small thrombi.

Multidetector computed tomography findings of dense pulmonary emboli in oncologic patients

Pulmonary embolism is a frequent condition for which multidetector computed tomography (MDCT) plays an important role in its detection. Occasionally, on MDCT studies, dense linear branching opacities may be found within the pulmonary vessels. They represent dense emboli within the pulmonary arteries (DEPA). These may occur in oncologic patients that undergo specific treatments or interventional procedures, such as cement embolus from vertebroplasty, catheter or coil migration after embolization procedures, radioactive seed embolus in patients treated with local brachytherapy for prostate, lung, or liver cancer, and also in chronic pulmonary embolism. Usually DEPA does not have any clinical significance but may be fatal when massive or when in patients with impaired cardiopulmonary function. Being familiar with their radiologic appearance and knowing about the good clinical outcome of these patients will avoid unnecessary imaging testing. In this article, we describe some examples of DEPA. Based on the MDCT imaging findings, these emboli have very few or no side effects on the underlying lung parenchyma. We would like to stress the need for using bone window values for identifying these emboli. We provide examples of dense linear nonvascular images (pulmonary calcification secondary to tuberculosis (TBC) or radiotherapy, calcified mucous plugs, lung sutures, etc) that may mimic DEPA.