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Case report: Venobronchial fistula — An unusual chest radiograph presentation of a central venous line complication
ClinicalRadiology (1991) 44, 283-284
Case Report: Venobronchial FistulaAn Unusual Chest Radiograph Presentation of a Central Venous Line Complication M. E. L I P T O N
Department of Radiology, Whiston Hospital, St Helens, Merseyside A fistula between the superior vena cava and right main bronchus due to a malpositioned central venous line is described. The diagnosis was suggested by the signs on a chest radiograph and confirmed at bronchoscopy. L i p t o n , M . E . (1991). Clinical Radiology 44, 2 8 3 - 2 8 4 . C a s e Report: Venobronchial Fistula - An Unusual Chest Radiograph Presentation of a Central Venous Line Complication
graphs demonstrated progressive bilateral alveolar shadowing most marked on the right and attributed to heart failure (Fig. 1). One of the chest radiographs also demonstrated a lucency around the tip of the left central venous line adjacent to the right main bronchus (Fig. 2). Bronchoscopy demonstrated parenteral fluid trickling down the lateral wall of the right main bronchus and filling all segmental bronchi in the right lung. Following removal of the left central line the patient's condition improved rapidly. DISCUSSION A number of complications following central venous line p l a c e m e n t are r e a d i l y seen o n t h e c h e s t r a d i o g r a p h
Fig. 1 Bilateral alveolar shadowing more prominent on the right with two central lines in silu.
C e n t r a l v e n o u s lines are u s e d f o r v a s c u l a r p r e s s u r e m e a s u r e m e n t s a n d fluid a d m i n i s t r a t i o n . T h e i r p l a c e m e n t has a c o m p l i c a t i o n r a t e o f 0 . 4 - 9 % (Borja, 1972). T h e r a d i o l o g i s t is o f t e n the first to s u s p e c t these c o m p l i c a t i o n s f r o m i n s p e c t i o n o f the c h e s t r a d i o g r a p h .
CASE R E P O R T A 59-year-old female was admitted to hospital with severe asthma requiring ventilation, Initially a right infraclavicular subclavian line was sited for venous access. Subsequently a left infraclavicular subclavian line was sited for total parenteral nutrition. Subsequent chest radio-
Correspondence to: Dr M. E. Lipton, Department of Radiology, Alder Hey Hospital, Eaton Road, Liverpool L12 2AP.
Fig. 2 - A small lucency is demonstrated around the tip of the left central venous line adjacent to the right main bronchus (arrow). Also demonstrated is right perihitar alveolar shadowing. A right central venous line and ECG lead are alsd present.
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CLINICAL RADIOLOGY
(Mitchell and Clarke, 1979). They are pneumothoraces, which m a y be unilateral or bilateral; catheter malposition, which in m o r e serious cases m a y lie in the internal jugular vein or arterial system; and catheter perforation into the pleura, mediastinum or bronchial tree, as in this case. The venobronchial fistula in the case presented was between the superior vena cava and right main bronchus. These structures are closely related and the central venous line was p r o b a b l y within the wall and not the lumen o f the right main bronchus as only parenteral fluid was seen at bronchoscopy. Air a r o u n d the catheter tip produced the unusual radiological appearance o f a small lucency. A previous case o f venobronchial fistula due to a central venous line has been reported (Brennan et al., 1972). The fistula was between the azygous vein and right
main bronchus during long term parenteral nutrition. The diagnosis was made by a contrast study t h r o u g h the catheter after a chest radiograph demonstrated right upper lobe shadowing. As in our case, the a b n o r m a l lung shadowing was initially misinterpreted as pneumonia.
REFERENCES
Borja, AR (1972). Current status of infraclavicular subclavian vein catheterisation. Annals of Thoracic Surgery, 13, 615-624. Brennan, MF, Sugarbaker, PH & Moore, FD (1972). Venobronchial fistula a rare complication of central venous catheterisation for parenteral hyperalimentation. Archives of Surgery, 106, 871-872. Mitchell, SE & Clark, RA (1979). Complications of central venous catheterisation. American Journal of Roentgenology, 133, 467-476.
Case Report: Venobronchial FistulaAn Unusual Chest Radiograph Presentation of a Central Venous Line Complication M. E. L I P T O N
Department of Radiology, Whiston Hospital, St Helens, Merseyside A fistula between the superior vena cava and right main bronchus due to a malpositioned central venous line is described. The diagnosis was suggested by the signs on a chest radiograph and confirmed at bronchoscopy. L i p t o n , M . E . (1991). Clinical Radiology 44, 2 8 3 - 2 8 4 . C a s e Report: Venobronchial Fistula - An Unusual Chest Radiograph Presentation of a Central Venous Line Complication
graphs demonstrated progressive bilateral alveolar shadowing most marked on the right and attributed to heart failure (Fig. 1). One of the chest radiographs also demonstrated a lucency around the tip of the left central venous line adjacent to the right main bronchus (Fig. 2). Bronchoscopy demonstrated parenteral fluid trickling down the lateral wall of the right main bronchus and filling all segmental bronchi in the right lung. Following removal of the left central line the patient's condition improved rapidly. DISCUSSION A number of complications following central venous line p l a c e m e n t are r e a d i l y seen o n t h e c h e s t r a d i o g r a p h
Fig. 1 Bilateral alveolar shadowing more prominent on the right with two central lines in silu.
C e n t r a l v e n o u s lines are u s e d f o r v a s c u l a r p r e s s u r e m e a s u r e m e n t s a n d fluid a d m i n i s t r a t i o n . T h e i r p l a c e m e n t has a c o m p l i c a t i o n r a t e o f 0 . 4 - 9 % (Borja, 1972). T h e r a d i o l o g i s t is o f t e n the first to s u s p e c t these c o m p l i c a t i o n s f r o m i n s p e c t i o n o f the c h e s t r a d i o g r a p h .
CASE R E P O R T A 59-year-old female was admitted to hospital with severe asthma requiring ventilation, Initially a right infraclavicular subclavian line was sited for venous access. Subsequently a left infraclavicular subclavian line was sited for total parenteral nutrition. Subsequent chest radio-
Correspondence to: Dr M. E. Lipton, Department of Radiology, Alder Hey Hospital, Eaton Road, Liverpool L12 2AP.
Fig. 2 - A small lucency is demonstrated around the tip of the left central venous line adjacent to the right main bronchus (arrow). Also demonstrated is right perihitar alveolar shadowing. A right central venous line and ECG lead are alsd present.
284
CLINICAL RADIOLOGY
(Mitchell and Clarke, 1979). They are pneumothoraces, which m a y be unilateral or bilateral; catheter malposition, which in m o r e serious cases m a y lie in the internal jugular vein or arterial system; and catheter perforation into the pleura, mediastinum or bronchial tree, as in this case. The venobronchial fistula in the case presented was between the superior vena cava and right main bronchus. These structures are closely related and the central venous line was p r o b a b l y within the wall and not the lumen o f the right main bronchus as only parenteral fluid was seen at bronchoscopy. Air a r o u n d the catheter tip produced the unusual radiological appearance o f a small lucency. A previous case o f venobronchial fistula due to a central venous line has been reported (Brennan et al., 1972). The fistula was between the azygous vein and right
main bronchus during long term parenteral nutrition. The diagnosis was made by a contrast study t h r o u g h the catheter after a chest radiograph demonstrated right upper lobe shadowing. As in our case, the a b n o r m a l lung shadowing was initially misinterpreted as pneumonia.
REFERENCES
Borja, AR (1972). Current status of infraclavicular subclavian vein catheterisation. Annals of Thoracic Surgery, 13, 615-624. Brennan, MF, Sugarbaker, PH & Moore, FD (1972). Venobronchial fistula a rare complication of central venous catheterisation for parenteral hyperalimentation. Archives of Surgery, 106, 871-872. Mitchell, SE & Clark, RA (1979). Complications of central venous catheterisation. American Journal of Roentgenology, 133, 467-476.