Perspective
Central Venous Catheter Tip Position: A Continuing Controversy

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There is continuing debate among physicians, nurses, and federal regulatory agencies regarding the correct position for the tip of a central venous catheter. The traditional approach has been to place the catheter tip within the superior vena cava. However, many interventionalists believe that the performance and durability of the catheter will be improved by positioning the catheter tip within the upper right atrium. Recently, this variability in clinical practice has become an increasingly divisive issue among physicians who insert these catheters and nurses who use them. This article is intended to elucidate the controversial issues and provide a brief review of the extensive literature on this important topic.

Section snippets

BACKGROUND

In 1989, the FDA published a precautionary statement regarding the positioning of central venous catheters that states that “the catheter tip should not be placed in or allowed to migrate into the heart” (1, 2). In 1996, the Oncology Nursing Society (3) published access device guidelines that restated the FDA recommendations that a catheter tip should not be positioned within the right atrium. In 1998, the National Association of Vascular Access Networks (4) published a position statement with

ANATOMY AND IMAGING

The tip of a central venous catheter is traditionally placed within the SVC. Subsequently, a standard anterior/posterior chest radiograph is often obtained to assess the location of the catheter tip. However, the radiographic borders of the SVC and SVC/atrial junction have not been well defined. Therefore, the determination of catheter tip position with chest radiography is often imprecise and subject to interobserver variability.

Various radiographic landmarks have been used to help identify

CATHETER TIP MOVEMENT

A critical concept to understand is that there are significant changes in the position of a catheter tip when the patient changes position. The direction and degree of catheter tip movement is dependent on several variables, including the type of catheter, insertion site, and body habitus of the patient.

The final position of the tip of a PICC is dependent on the specific insertion site and the position of the patient's arm. A PICC is often inserted with the arm abducted 90° from the patient's

CATHETER PERFORMANCE

The recommendations of the K/DOQI guidelines are based on the superior performance of a hemodialysis catheter when the tip is positioned into the upper right atrium (6). A hemodialysis catheter is the Ferrari of central venous catheters. A typical hemodialysis treatment requires a catheter blood flow rate of 450 mL/min and the ability to sustain this high flow for 3–4 hours. Positioning the tip of a hemodialysis catheter into the SVC or higher can limit its ability to achieve this high level of

Thrombosis

It is difficult to confidently ascertain the relationship between catheter tip position and thrombosis. Some physicians advocate the placement of a catheter tip into the right atrium to decrease thrombosis, whereas others are adamantly opposed to this position and believe that a catheter tip placed within the right atrium is predisposed to thrombosis.

A catheter inserted into a vein will be recognized as a foreign object and quickly covered with fibrin and plasma proteins (29). This is often

CONCLUSION

More than 800,000 central venous catheters were placed by physicians in 1999 and the majority of these catheters were inserted by surgeons and anesthesiologists without imaging guidance (60). Several studies have reported that 10%–30% of catheters placed without imaging guidance have a malpositioned catheter tip or a catheter tip in the right atrium (12, 15, 49). Therefore, it is likely that thousands of central venous catheters are malpositioned each year. However, the discrepancy between the

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    The author has identified no potential conflicts of interest.

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    Copyright © 2003 Society of Interventional Radiology. Published by Elsevier Inc. All rights reserved.