Ultrasound localization of central vein catheter tip by contrast-enhanced transthoracic ultrasonography: a comparison study with trans-esophageal echocardiography

Abstract

Background: To assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard.

Methods: A prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients.

Results: As per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p < 0.001) for CE-TTE via epigastric bicaval acoustic view.

Conclusions: The concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure.

Keywords: Bubble test; CVC misplacements; Cardiac surgery patients; Central venous catheterization; Chest radiography; Internal jugular vein cannulation.

Fig. 1

Heart ultrasounography. Apical four chamber view. RA right atrium, RV right ventricle, LA left atrium, LV left ventricle

Fig. 2

a Probe orientation in the epigastric bicaval acoustic window. b B-mode short-axis bicaval view, c CVC tip, d microbubbles solution injected as a bolus through the catheter directly showing the catheter tip and CE exit point. ICV inferior cava vein, SVC superior vena cava, RA right atrium, RV right ventricle, CVC tip central venous catheter tip

Fig. 3

TEE probe inserted at a mid-oesophageal position, turned clockwise and rotated to 123° to produce a mid-oesophageal SVC-RA junction visualization. Red arrow: central venous catheter tip at SCV-RA junction. SVC superior vena cava, RA right atrium, CVC tip central venous catheter tip

Fig. 4

ROC curves for subcostal bicaval transthoracic echocardiography (subcostal Bicaval TTE), apical four-chamber transthoracic echocardiography (apical four-chamber TTE) and chest-x-ray (CXR), with transesophageal echocardiography assumed as reference. AUC area under curve (95% confidence interval)