Why doesn't a peripherally inserted central catheter (Permacath) placed under Interventional Radiology (IR) require a chest X-ray (CXR) to verify placement?

From the Guidelines

A peripherally inserted central catheter (Permacath) placed under Interventional Radiology (IR) guidance does not require a post-procedure chest X-ray (CXR) to verify placement because real-time imaging is used throughout the insertion process. During IR-guided placement, fluoroscopy provides continuous visualization of the catheter as it is threaded through the venous system and positioned in the superior vena cava or right atrium, as noted in studies on central venous catheter placement 1. This dynamic imaging allows the interventional radiologist to confirm proper positioning immediately, detect any potential complications such as pneumothorax or catheter malposition, and make adjustments as needed during the procedure itself.

Some key points to consider in this context include:

• The use of real-time imaging during IR-guided placement reduces the risk of complications and the need for additional imaging studies.
• Contrast may be injected to verify blood flow and proper function of the catheter before completing the procedure, further ensuring accurate placement.
• The comprehensive imaging during placement eliminates the need for a subsequent CXR, which would only provide static, after-the-fact confirmation of what was already directly observed during the procedure.
• Studies have shown that routine chest radiographs after US-guided central line placement have a low yield for detecting clinically significant complications, supporting the idea that real-time imaging during IR-guided placement is sufficient for verifying catheter position 1.

Overall, the real-time visualization capability of IR makes the process more efficient and reduces radiation exposure by avoiding an additional imaging study, thereby improving patient outcomes in terms of morbidity, mortality, and quality of life. The current evidence supports the omission of a routine post-procedure CXR for Permacath placements under IR guidance, prioritizing a more streamlined and safer approach to patient care 1.

From the Research

Peripherally Inserted Central Catheter Placement

• A peripherally inserted central catheter (Permacath) placed under Interventional Radiology (IR) may not require a chest X-ray (CXR) to verify placement due to the use of fluoroscopic guidance during the procedure 2, 3.
• Studies have shown that the incidence of complications such as pneumothorax (PNX) and catheter malposition is low, and these complications are often not detected by routine postprocedure CXR 2, 3.
• In fact, one study found that postprocedure clinical symptoms, rather than routine CXR, prompted the identification of PNX in patients who underwent subclavian central venous port placement 2.

Fluoroscopic Guidance

• The use of fluoroscopic guidance during IR procedures allows for real-time visualization of the catheter placement, reducing the need for postprocedure CXR to confirm placement 3, 4.
• Fluoroscopy enables the operator to adjust the catheter position immediately, minimizing the risk of malposition and complications 3.

Clinical Judgment

• While clinical judgment is important in evaluating patients after central line placement, it may not reliably predict malpositioning or complications, and CXR may still be necessary in certain cases 4.
• However, other studies suggest that conscientious physical examination and good clinical acumen can obviate the need for routine postprocedure CXR in patients who undergo uncomplicated guidewire replacement of a central line 3.

Specific Procedures

• The evidence provided does not specifically address the placement of Permacaths under IR, but rather central venous catheterization and port placement 2, 3, 4.
• However, the principles of fluoroscopic guidance and clinical judgment may still apply to Permacath placement, suggesting that CXR may not always be necessary to verify placement 2, 3.