Is a chest X-ray (CXR) necessary after Peripherally Inserted Central Catheter (PICC) line placement?

Chest X-ray After PICC Line Placement

Chest X-ray is usually appropriate and recommended following PICC line placement to confirm proper positioning and rule out complications. 1

Rationale for Post-PICC Line CXR

• Chest radiographs following central venous catheter insertion are useful, with approximately 10% of chest radiographs demonstrating malpositioned catheters 1
• The American College of Radiology recommends that radiography chest portable is usually appropriate for the initial imaging of patients in ICU following support device placement 1
• Proper positioning of the catheter tip is critical - high osmolarity parenteral nutrition requires central venous access and should be delivered through a catheter whose tip is in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium 1

Complications Detected by CXR

• Malpositioned catheters (approximately 10% of cases) 1
• Pneumothorax (present in a small percentage of patients) 1
• Catheter tip position verification (critical for proper function and to avoid complications) 1

Considerations Based on Insertion Site

• Complications are twice as common with subclavian catheters (17%) compared to jugular catheters (8%), although unsuspected complications are infrequent 1
• The femoral vein is relatively contraindicated for parenteral nutrition due to high risk of contamination and venous thrombosis 1

Emerging Alternatives to CXR

• Ultrasound has shown promise but is not yet a complete replacement for CXR in PICC line verification 1
• Bedside ultrasound is faster than radiography at identifying pneumothorax after CVC insertion and can identify 4 out of 5 CVC malpositions earlier than chest radiography 1
• Tracking and tip confirmation systems (e.g., Sherlock 3CG) have shown promise in improving placement accuracy and potentially reducing the need for confirmatory X-rays 2

Special Circumstances

• For guidewire exchanges of existing central lines, the necessity of routine post-procedure CXR is more controversial, with some evidence suggesting it may not be necessary in uncomplicated cases 3
• For fluoroscopically-guided subclavian central venous port placements, routine post-procedure CXR may not be necessary as complications are typically identified during the procedure or through clinical symptoms 4

Optimizing CXR Technique

• Right posterior oblique chest radiographs may provide better visualization of catheter tip position (80% agreement between readers) compared to standard anteroposterior projections (55% agreement) 5
• Postoperative X-ray is mandatory when the position of the tip has not been checked during the procedure, and/or when the device has been placed using blind subclavian approach 1

Common Pitfalls

• Relying solely on physical examination to determine catheter position is inadequate, as it is not possible to determine CVC tip position clinically 5
• Delaying treatment while waiting for CXR confirmation - consider using bedside ultrasound as a preliminary confirmation method in emergency situations 1
• Misinterpreting radiographs - between 2005 and 2010,45% of all cases of harm caused by misplaced nasogastric tubes reported by the National Patient Safety Agency were due to misinterpreted radiographs 1

While newer technologies like ultrasound and tracking systems show promise, the current standard of care supported by the American College of Radiology guidelines still recommends chest radiography following PICC line placement to ensure proper positioning and patient safety.