(Fig.1 and Fig. 2)

(Fig. 3 and Fig. 4)

Findings: The tip of the mediport catheter is directed cephalad, presumably terminating in the right internal jugular vein.

Diagnosis: Mediport catheter tip malpositioned in the jugular vein.

Discussion: A malpositioned central venous catheter is an uncommon incidental finding on non-routine chest radiography. While the abnormal position can occur at the time of initial placement, it may also be a spontaneous subsequent occurrence. That was the case in this patient. A chest radiograph one month previously was normal. Presumably due to some abrupt change in position and/or intrathoracic pressure, the catheter tip migrated into the right internal jugular vein. Once a malpositioned catheter is identified, angiographic study should be performed to verify the exact position of the catheter tip. Additionally, this will allow evaluation for the presence or absence of significant fibrin sheath or thrombus around the catheter that may alter therapeutic maneuvers. In this patient contrast venography (Fig. 1) demonstrates that the catheter is free within the right internal jugular vein and that there is no significant thrombus. There are many therapeutic options. Because of the risk of potential thrombosis, the catheter should be repositioned if at all possible. With accessible catheters, a guidewire can be passed through the catheter and this will often result in the catheter tip flipping in a caudal direction. Alternatively, a tip deflecting wire can be utilized from this approach to facilitate repositioning. In this case, the mediport catheter could not be accessed directly. Therefore, a transfemoral or contralateral upper extremity venous approach can be considered. While a right angled snare catheter would likely have worked nicely in this case, we elected to utilize a tip deflecting wire. This was advanced to and curved around the catheter (Fig. 2). The tip deflecting wire was gently pulled caudally (Fig. 3) and ultimately the catheter tip was pulled down into the superior vena cava (Fig. 4).

References:
Kidney DD, Nguyen DT, Deutsch S. Radiologic Evaluation in Management
of Malfunctioning Long Term Central Vein Catheters. AJR, 171:1251-1257.

Lois JF, Gomes AS, Pusey E. Nonsurgical Repositioning of Central Venous
Catheters, Radiology, 1987;165:329-333.

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