Comparison of radiographic landmarks and the echocardiographic SVC/RA junction in the positioning of long-term central venous catheters

Background: When implanting a permanent central venous catheter, the usual aim is to place the tip at the superior vena cava/right atrial (SVC/RA) junction. However, data validating radiographic landmarks of the SVC/RA junction are limited. This investigation was undertaken to compare the radiographic landmarks with the SVC/RA junction as determined by transesophageal echocardiography (TEE). Methods: In 20 adult oncologic patients undergoing implantation of a permanent subcutaneous central venous catheter, the catheter tip was placed in the SVC/RA junction under TEE guidance. The position of the catheter tip on chest X‐ray, which represented the echocardiographic SVC/RA junction, was then compared with a standard radiographic landmark of the SVC/RA junction and with thoracic vertebral levels. Results: In all but two patients radiographic SVC/RA junctions were identified. The echocardiographic SVC/RA junction ranged from 0.6 cm above to 2.8 cm below the radiographic SVC/RA junction. There was a significant difference between the distance from the carina to the radiographic SVC/RA junction and the distance from the carina to the echocardiographic SVC/RA junction. The thoracic vertebral body correlating with the echocardiographic SVC/RA junction ranged from the sixth to the ninth level. Conclusion: Both the radiographic SVC/RA junction and the thoracic vertebral bodies are not reliable landmarks for the SVC/RA junction defined by TEE. Physicians should be aware that using the radiographic SVC/RA junction to confirm proper positioning of permanent central venous catheters risks placing the catheter tip in the upper SVC, with subsequent potential long‐term complications. More reliable radiographic landmarks for the SVC/RA junction should be investigated.