AJR 2003; 180:1147-1153
© American Roentgen Ray Society
Neonates and Umbilical Venous Catheters: Normal Appearance, Anomalous Positions, Complications, and Potential Aid to Diagnosis
Alan E. Schlesinger1,
Richard M. Braverman1 and
Michael A. DiPietro2
1 Edward B. Singleton Department of Diagnostic Imaging, Texas Children's
Hospital, Baylor College of Medicine, 6621 Fannin St., MC2-2521, Houston, TX
77030.
2 Department of Radiology, C. S. Mott Children's Hospital, University of
Michigan Medical Center, 1500 Medical Center Dr., Ann Arbor, MI
48109-0252.
Received July 12, 2002;
accepted after revision August 28, 2002.
Address correspondence to A. E. Schlesinger.
Presented at the annual meeting of the American Roentgen Ray Society,
Seattle, April–May 2001.
Introduction
Umbilical venous catheters are commonly used in the neonatal period for
vascular access. Despite their routine use, they are frequently malpositioned
and may occasionally be associated with complications. Furthermore, an unusual
course of an umbilical venous catheter may aid in the diagnosis of
cardiovascular or other anomalies. We review the normal vascular course and
radiographic appearance of umbilical venous catheters, several common and rare
anomalous positions of umbilical venous catheters, potential complications
associated with umbilical venous catheters, and unusual courses of these
catheters that may provide clues to the diagnosis of underlying anomalies. To
provide optimal patient care, the radiologist interpreting neonatal
radiographs should be familiar with these potential anomalous umbilical venous
catheter courses and complications.
Normal Vascular Course of Umbilical Venous Catheters and Normal
Radiographic Appearance
The single umbilical vein extends from the umbilicus to the left portal
vein and initially maintains an anterior, midline location in the anterior
abdominal wall until it courses posteriorly through the liver to the left
portal vein. There is a focal dilatation of the umbilical vein just before its
junction with the left portal vein: the umbilical recess
[1]. When blood from the
umbilical vein reaches the left portal vein, it is directed to the ductus
venosus, which originates from the left portal vein immediately opposite the
insertion site of the umbilical vein and courses cephalad to the inferior vena
cava (Fig. 1). In contrast, the
typically paired, bilateral umbilical arteries initially course posteriorly
and caudally to enter the right and left iliac arteries. Therefore, the
umbilical venous catheter and the umbilical artery catheter can be easily
distinguished on abdominal radiographs. The umbilical venous catheter
predominantly follows an anterior and cephalad course in the midline umbilical
vein until directed posteriorly in the liver, whereas the umbilical artery
catheter is initially directed caudally and posteriorly to enter either the
right or left iliac artery before coursing superiorly in the more posteriorly
positioned aorta (Fig. 2A,
2B).
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Fig. 1. —Postmortem venogram in 27-week premature neonate shows normal
anatomy. Umbilical vein enters left portal vein opposite origin of ductus
venosus. Focal dilatation of umbilical vein just inferior to its insertion
into left portal vein is umbilical recess. Ductus venosus begins at left
portal vein opposite site of insertion of umbilical vein and courses to
inferior vena cava, entering inferior vena cava at or near confluence of
inferior vena cava and hepatic veins. (Adapted with permission from
[1])
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Fig. 2A. —Normal radiographic appearance of umbilical venous catheter
and umbilical artery catheter. Frontal radiograph of abdomen shows that
umbilical venous catheter enters abdomen at umbilicus (small
arrowhead), travels in cephalad direction in umbilical vein (double
black arrows) (note that catheters cross just above umbilicus), courses
through left portal vein and ductus venosus, enters inferior vena cava, and
terminates in right atrium. Umbilical artery catheter also enters abdomen at
umbilicus (single black arrow) but extends inferiorly (white
arrow) and posteriorly into iliac artery before coursing superiorly in
aorta (large arrowheads).
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Fig. 2B. —Normal radiographic appearance of umbilical venous catheter
and umbilical artery catheter. Lateral radiograph shows anterior location of
umbilical venous catheter in abdomen until catheter reaches inferior vena cava
and right atrium. Umbilical artery catheter enters abdomen at umbilicus
(arrowhead) but courses posteriorly as it descends inferiorly in
abdomen to enter umbilical artery before ascending in posteriorly located
aorta (arrow).
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The preferred location of the tip of the umbilical venous catheter is
typically in the cephalad portion of the inferior vena cava or at the inferior
vena caval–right atrial junction. Air might be introduced inadvertently
into the intrahepatic portal venous system at the time of umbilical venous
catheter insertion. The air is usually transient and should not be
misinterpreted as evidence of necrotizing enterocolitis
(Fig. 3). Portal venous air
associated with necrotizing enterocolitis will typically be accompanied by
pneumatosis intestinalis, whereas air introduced into the portal venous system
at the time of umbilical venous catheter insertion is usually an isolated
finding.
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Fig. 3. —Radiograph of abdomen shows air in portal venous branches
associated with umbilical venous catheter insertion. Inconsequential transient
portal venous air can be seen immediately after umbilical venous catheter
insertion and should not necessarily be attributed to necrotizing
enterocolitis.
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Anomalous Positioning of the Umbilical Venous Catheter
Anomalous positioning of the umbilical venous catheter occurs frequently
because the catheter is inserted by the pediatrician without imaging guidance.
If the umbilical venous catheter follows the normal course to the inferior
vena cava or right atrium but is advanced too far, the umbilical venous
catheter may extend through a patent foramen ovale or an atrial septal defect
into the left atrium (Fig. 4)
or, if advanced farther, into a pulmonary vein, most commonly the pulmonary
vein of the left upper lobe (Figs.
5 and
6). Alternatively, the catheter
may continue through the right atrium and into the superior vena cava
(Fig. 7) or may cross the
tricuspid valve and enter the right ventricle. If advanced, the umbilical
venous catheter may continue into the main, right, or left pulmonary
artery.
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Fig. 4. —Umbilical venous catheter in left atrium. Radiograph of chest
and abdomen shows that umbilical venous catheter crosses atrial septum through
patent foramen ovale, and tip terminates in left atrium.
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Fig. 5. —Umbilical venous catheter with tip in pulmonary vein of left
upper lobe. Chest radiograph reveals that umbilical venous catheter enters
right atrium, crosses patent foramen ovale into left atrium, and ends in
pulmonary vein of left upper lobe.
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Fig. 6. —Umbilical venous catheter with tip in pulmonary vein of right
upper lobe. Radiograph of chest and abdomen shows that umbilical venous
catheter crosses foramen ovale, coils in left atrium, and enters pulmonary
vein of right upper lobe.
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Fig. 7. —Full-term neonate with transient tachypnea of newborn and
umbilical venous catheter in superior vena cava. Chest radiograph reveals that
umbilical venous catheter has been advanced into inferior vena cava, through
right atrium, and into superior vena cava.
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The umbilical venous catheter can be misdirected before reaching the
expected location of the inferior vena cava or right atrium. The tip of the
umbilical venous catheter can coil in the umbilical recess before entering the
left portal vein (Fig. 8). If
after coiling in the umbilical recess, the umbilical venous catheter is
advanced farther, it may travel in a retrograde direction in the umbilical
vein toward the umbilicus (Fig.
9). Rarely, the umbilical venous catheter may reach the inferior
vena cava but may progress caudally rather than cranially in the inferior vena
cava (Fig. 10). If the
umbilical venous catheter reaches the left portal vein but does not continue
into the ductus venosus, the catheter can travel left into the more peripheral
left portal vein (Fig. 11) or
right, where it can eventually course into the right portal vein
(Fig. 12) or hepatofugally
into the main portal vein (or potentially farther into the vessels that merge
to form the portal vein: the superior mesenteric and splenic veins)
(Fig. 13).
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Fig. 8. —Umbilical venous catheter coiled in umbilical recess.
Portable radiograph of abdomen in neonate after umbilical venous catheter
placement shows catheter tip coiled in umbilical recess.
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Fig. 10. —Umbilical venous catheter with distal tip in right
hemipelvis. Abdominal radiograph shows that catheter enters umbilicus
(arrowheads), which projects to left of midline because of patient
rotation, and follows expected course through umbilical vein (white
arrows) until it reaches inferior vena cava and is directed inferiorly
into inferior vena cava (black arrows), through right common iliac
vein, and finally into right femoral vein.
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Fig. 11. —Umbilical venous catheter in peripheral left portal vein.
Radiograph of abdomen shows that umbilical venous catheter enters left portal
vein but, rather than entering ductus venosus, continues in leftward direction
into more peripheral portion of left portal vein. Note normal prominent left
hepatic lobe in neonate.
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Fig. 12. —Umbilical venous catheter in right portal vein. Radiograph of
chest and abdomen shows that umbilical venous catheter reaches left portal
vein via umbilical vein but enters right portal vein instead of crossing
ductus venosus into inferior vena cava.
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Fig. 13. —Umbilical venous catheter in splenic vein. Abdominal
radiograph reveals that umbilical venous catheter courses through umbilical
vein into left portal vein but then travels into main portal vein
(arrow) and eventually into splenic vein (arrowhead).
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Complications Associated with Umbilical Venous Catheters
If the umbilical venous catheter perforates an intrahepatic vascular wall,
a hepatic hematoma may result
[2]. These hematomas may
eventually calcify. A hepatic hematoma is typically identified on sonography,
usually requested for poor blood return from the umbilical venous catheter or
because fluids cannot be easily administered though the catheter (Fig.
14A,
14B). If fluids are
administered through an umbilical venous catheter with its tip in an
extravascular location, fluid collections may be seen on sonography. These
collections may be anechoic, heterogeneous, or echogenic, depending on the
type of fluid and the elapsed time. Intravascular thrombi may form along the
course of the umbilical venous catheter, likely related to intimal injury
[3], and may be identified on
radiography, sonography (Fig.
15), or CT (Fig.
16A,
16B,
16C). The umbilical venous
catheter can also perforate the right or left atrial wall and enter the
pericardial space (Fig. 17A,
17B,
17C).
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Fig. 14A. —Hepatic hematoma caused by extravascular intraparenchymal
positioning of umbilical venous catheter tip. Sonogram of abdomen, obtained
because umbilical venous catheter could not be easily flushed, reveals
catheter tip (arrow) adjacent to echogenic focus in liver
parenchyma.
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Fig. 14B. —Hepatic hematoma caused by extravascular intraparenchymal
positioning of umbilical venous catheter tip. Follow-up sonogram reveals
decreased size of hematoma with increased echogenicity (arrow) and
acoustic shadowing consistent with calcification.
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Fig. 15. —Calcification in ductus venosus and left portal vein.
Sonogram shows echogenic calcified thrombus (arrows) in ductus
venosus and left portal vein in neonate with prior umbilical venous
catheter.
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Fig. 17A. —Perforation of left atrial appendage. (Courtesy of
Yousefzadeh D, Chicago, IL) Frontal radiograph of chest after catheter
placement shows coiled catheter superimposed over cardiac silhouette.
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Fig. 17C. —Perforation of left atrial appendage. (Courtesy of
Yousefzadeh D, Chicago, IL) Frontal radiograph after contrast injection
confirms that umbilical venous catheter tip is in pericardial space. Catheter
has crossed atrial septum through patent foramen ovale and perforated left
atrial appendage to enter pericardial space (arrowhead denotes
presumed region of wall of left atrial appendage).
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Umbilical Venous Catheter as an Aid to Diagnosis
Although the umbilical venous catheter is not placed for this purpose, its
course may aid in the diagnosis of congenital abnormalities causing
displacement of the liver, such as anomalous positioning of the liver into the
chest in neonates with congenital diaphragmatic hernia
(Fig. 18).
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Fig. 18. —Umbilical venous catheter position confirming intrathoracic
displacement of liver in patient with congenital diaphragmatic hernia.
Umbilicus and proximal umbilical venous catheter (arrowheads) project
to left of midline because of patient rotation on this chest and abdominal
radiograph in neonate with congenital diaphragmatic hernia. Position of distal
umbilical venous catheter (arrow) confirms intrathoracic location of
liver.
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Congenital cardiovascular lesions may be deduced from an anomalous course
of an umbilical venous catheter. An umbilical venous catheter can cross the
interatrial septum from the right atrium to the left atrium (and ultimately
into a pulmonary vein if advanced farther) via a true atrial septal defect or,
more likely, via a patent foramen ovale, which will likely eventually close
spontaneously (Fig. 4). In
infants with a persistent left superior vena cava, the anomalous vessel
terminates in the coronary sinus of the right atrium. An umbilical venous
catheter entering the coronary sinus and extending cephalad into a left
superior vena cava can be misinterpreted on imaging as crossing a patent
foramen ovale into the left atrium and eventually into the pulmonary vein of
the left upper lobe. However, if the catheter has been advanced far enough
into the left superior vena cava to reach the periphery of the left hemithorax
or into the left jugular vein in the neck, the diagnosis of persistent left
superior vena cava is likely (Fig.
19).
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Fig. 19. —Neonate with trisomy 21 syndrome and complete
atrioventricular canal with persistent left superior vena cava. Umbilical
venous catheter enters right atrium and then follows course suggesting it has
crossed patent foramen ovale into left atrium and eventually into pulmonary
vein of left upper lobe on this portable chest and abdominal radiograph.
However, catheter extends beyond lung, indicating that it cannot be within
pulmonary vein or artery. Therefore, we deduced that umbilical venous catheter
had exited right atrium via coronary sinus, been advanced through persistent
left superior vena cava, and eventually entered left jugular vein (confirmed
on echocardiography [not shown]). Persistent left superior vena cava had not
been identified on initial echocardiogram (not shown), and knowledge of this
congenital vascular anomaly was important when treating patient with cardiac
bypass during surgery for congenital heart disease.
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References
- Richter E, Lierse W. Imaging anatomy of the
newborn. Baltimore: Urban & Schwarzenberg,
1991: 151–171
- Singleton EB. Radiologic considerations of intensive care in the
premature infant. Radiology
1981;140:291
–300[Abstract/Free Full Text]
- Friedman AP, Haller JO, Boyer B, et al. Calcified portal vein
thromboemboli in infants. Radiology
1981;140:381
–382[Abstract/Free Full Text]
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Introduction
Normal Vascular Course of...
