Re: PICC in SVC with curl

[Ryder1234]

Lieve,

>From what you describe, the catheter tip may be in the azygos vein.  This malposition appears classically on xray with a J-shape appearance within the SVC.  The fact that the catheter position remains after flushing adds to the suggestion of azygos tip position.  The catheter should be repositioned as thrombosis is a definite and dangerous risk.  The azygos vein provides venous return from the thorax that is not drained by the discontinuous superior and inferior vena cava and thus would not be a desirable vein to occlude. 

This has been described in the literature......here is one article

Bankier AA, Mallek R, Wiesmayr MN, Fleischmann D, Kranz A, Kontrus M, Knapp S,
Winkelbauer FW. J Thorac Imaging. 1997 Jan;12(1):64-9.

Azygos arch cannulation by central venous catheters: radiographic detection of
malposition and subsequent complications.

The aim of this study was to determine the frequency of radiographically evident
central venous catheter misplacement in the azygos arch and to analyze whether
the frequency of azygos arch cannulation is dependent on the anatomical site of
catheter insertion. We reviewed 1,287 postprocedural examinations and 3,441
follow-up examinations. Catheters had been inserted through the left (6%) or
right (15%) internal jugular veins and through the left (32%) or right (46%)
subclavin veins. Radiographs were analyzed for possible catheter malposition in
the azygos arch and for complications related to this malposition. Catheter
malposition in the azygos arch was seen on 16/1,287 (1.2%) postprocedural
radiographic examinations. Of the 16 malpositioned catheters, 11 (69%) had been
inserted in the left subclavian vein, three (19%) in the left jugular vein, two
(12%) in the right subclavian vein, and none (0%) in the right jugular vein.
There was a statistically significant difference in the frequency of azygos arch
cannulation between left- and right-sided catheters (p = 0.001). All
complications consisted of venous perforations and were seen in three of 16
cases (19%). Azygos arch cannulation is a rare but hazardous central venous
catheter malposition that occurs early after catheter insertion and carries a
substantial risk for complication. The risk for azygos arch cannulation is
substantially increased if catheters are inserted in left-sided veins. Because
of the severity of subsequent complications, radiologists should be vigilant in
the detection of this rare malposition.

Marcia Ryder