Postprocedural Chest Radiograph Research Articles

Caudal fluoroscopic guidance for the insertion of transvenous pacing leads.

Pneumothorax is a well-recognized complication of cardiac implantable electronic device (CIED) insertion. While AP fluoroscopy alone is the most commonly imaging technique for subclavian or axillary access, caudal fluoroscopy (angle 40°) is routinely used at our institution. The caudal view provides additional separation of the first rib and clavicle and may reduce the risk of pneumothorax. We assessed outcomes at our institution of AP and caudal fluoroscopic guided pacing lead insertion. Retrospective cohort study of consecutive patients undergoing transvenous lead insertion for pacemakers, defibrillators, and cardiac resynchronization therapy devices between 2011 and 2023. Both de novo and lead replacement/upgrade procedures were included. Data were extracted from operative, radiology, and discharge reports. All patients underwent postprocedure chest radiography. Three thousand two hundred fifty-two patients underwent insertion of pacing leads between February 2011 and March 2023. Mean age was 71.1 years (range 16-102) and 66.7% were male. Most (n = 2536; 78.0%) procedures used caudal guidance to obtain venous access, while 716 (22.0%) procedures used AP guidance alone. Pneumothoraxes occurred in five (0.2%) patients in the caudal group and five (0.7%) patients in the AP group (p = .03). Subclavian contrast venography was performed less frequently in the caudal group (26.2% vs. 42.7%, p < .01). Caudal fluoroscopy for axillary/subclavian access is associated with a lower rate of pneumothorax and contrast venography compared with an AP approach.

Tip orientation under real-time point-of-care neck ultrasonic monitoring is advantageous in peripherally inserted central catheter procedures: a retrospective cohort study

Abstract Background We analyzed the success and catheter tip malposition rates of peripherally inserted central catheter (PICC) placement using ultrasonic monitoring. Methods A total of 564 patients were recruited and assigned to either the intervention or control group. In the intervention group, 282 patients underwent ultrasound-guided PICC insertion, which helped to identify the position and depth of the catheter tip. From a total of 9000 patients, 282 were selectively chosen to receive the traditional method using body surface measurements (control group). The primary endpoint was the success rate; the secondary endpoint was the catheter tip malposition rate as detected by postprocedure chest radiography. Results In the intervention group, a total of 94 catheters were in a suboptimal position; 26 were too deep, 68 were too shallow, and 1 was inserted into the subclavian vein, with success and malposition rates of 66.3% and 0.4%, respectively. In the control group, 139 catheters were in a suboptimal position; 88 were too deep, 51 were too shallow, 9 were inserted into the jugular vein, and 2 were inserted into the subclavian vein, with success and malposition rates of 46.8% (P &lt; 0.001) and 3.9% (P = 0.004), respectively. Significant differences were observed in success and malposition rates between the 2 groups. Conclusion Ultrasound-guided PICC procedures achieved higher success rates and lower malposition rates.

Use of point-of-care ultrasound and serial FAST as a monitoring tool for the removal of an ectopic chest tube in liver

Common complications of chest tube insertion are lung laceration, chest wall bleeding, improper tube positioning, and subcutaneous emphysema. However, a penetrating injury of the upper abdominal organs due to chest tube malposition is rare. A 33-year-old suffered multiple injuries in a road traffic accident. Due to the respiratory distress caused by right-sided hemothorax, an intercostal chest drain (ICD) was inserted, which drained 500 ml of venous blood, followed by hemodynamic instability. The post-procedural chest radiograph revealed a lower chest tube position within the liver shadow. As the patient was hemodynamically stable, it was decided to delay the removal of the ectopic ICD, and the patient was kept under close monitoring. After 7 days, ICD removal was done under ultrasound guidance, and a post-procedural serial-focused assessment with sonography for trauma (FAST) was done. Hepatic injury secondary to chest tube insertion is rare, and its management is not standardised. Point-of-care ultrasound has not been used before for the removal of an ectopic ICD. We managed the case conservatively because of the stable hemodynamic situation of the patient and to avoid invasive surgery as possible. Point-of-care ultrasound can be a valuable tool in these conditions where other imaging modalities such as CT are not available and help avoid surgery.

"Optimal" Central Venous Catheter Tip Position Does Not Increase Catheter Duration: A Retrospective Cohort Study.

Background Central venous cannulation provides venous access in different settings. Multiple guidelines and checklists still recommend confirmation of central venous catheter (CVC) tip position using a chest radiograph. The rationale is to detect and prevent complications thus optimizing CVC placement. Our primary hypothesis is that confirmation of catheter tip position by chest radiograph is not associated with increased catheter duration. Methods A retrospective cohort study was conducted with 921 patients included. Demographic, procedure and catheter data was obtained from adult patients that placed a CVC in the operating room. The catheter tip was independently classified as "optimal" or "malpositioned" independently by two researchers. Results Data from 921 CVC placements was collected. Patients who had a post-procedure chest radiograph(n=682, 74.0%) differed from those who did not in terms of co-morbidities (p=0.030), indication for CVC (p=0.023), duration of placement (p<0.001), number of punctured veins (p=0.036) and use of ultrasound (p<0.001). There was substantial agreement between researchers when classifying CVC tip as "optimal" or "malpositioned" (κ=0.632,p<0.001). No statistically significant difference was found between duration or complications of "optimal" CVCs compared to unknown tip/"malpositioned" CVCs. This study showed a 99% rate of clinically redundant chest radiographs according to Pikwer's criteria for radiographic examination. Conclusion No difference was found regarding catheter duration or complications when comparing "optimal" and unknown/"malpositioned" tip. This study illustrates some consequences of post-procedure radiographs and reinforces that the risks/benefits should be weighed and that chest radiograph should not be done by routine.

PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION DIAGNOSED AFTER CENTRAL VENOUS CATHETER PLACEMENT

PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION DIAGNOSED AFTER CENTRAL VENOUS CATHETER PLACEMENT

Elderly man with abnormal chest radiograph after central venous catheter insertion.

A 78-year-old male presented to the emergency department with septic shock. A left-sided internal jugular central venous catheter (CVC) was inserted using ultrasound guidance. A routine post-procedure chest radiograph was obtained to confirm CVC placement (Figure 1). The chest radiograph findings raised concerns for the possibility of an unanticipated carotid artery placement as the intraluminal catheter did not appear to cross the midline and terminated in an abnormal left paramediastinal location. A follow-up computed tomography (CT) scan of the chest was performed to further evaluate line positioning (Figure 2 and 3). The prevalence of left-sided SVC is unknown as it is often silent and detected incidentally on imaging, though estimates range from 0.3% to 3%.1 Paired transient anterior cardinal veins are present during routine fetal development. The left anterior cardinal vein typically involutes and the right anterior cardinal vein enlarges to form the SVC. A left-sided SVC is a congenital anomaly resulting from the failure of the left anterior cardinal vein to obliterate.2 A left-sided SVC typically drains into the right atrium via the coronarysinus, though the precise vascular anatomy may be challenging to delineate in the absence of intravenous contrast.3 Infrequently, it drains into the left atrium causing a right-to-left shunt most frequently without significant cyanosis.3 Inadvertent arterial placement is the principal consideration that should be excluded when a left-sided CVC fails to cross the midline as anticipated. Occasional anatomic variants may exist that can be more readily delineated with the use of cross-sectional imaging if needed. In this case, after confirmation of the anatomical variation and adequate venous placement by CT imaging, the catheter was used without issue or complication.

Necessity of performing a routine chest radiograph following the insertion of tunnelled Hickman catheter under imaging guidance: A single centre experience.

A chest radiograph has traditionally been performed following the insertion of a tunnelled Hickman catheter to immediately exclude rare but potentially serious complications such as pneumothorax and haemothorax and confirm appropriate positioning of the catheter tip. The value of completing the routine chest radiograph has been questioned when fluoroscopic image may be easily obtained in the angiography suite for the same purpose, and the rate of iatrogenic pneumothorax remains extremely low in the Medical literature. We describe our experience of performing Hickman catheter insertion under ultrasound and fluoroscopic guidance and whether routinely performing the chest radiograph is justifiable. A single centre retrospective review was performed of patients who received a tunnelled Hickman catheter and underwent postprocedural chest radiograph in the Interventional Radiology Department during a fifteen-year period from August 2007 to April 2021. Patient demographics and complications were documented. Delayed iatrogenic pneumothorax was diagnosed in one asymptomatic patient (0.06%) on a chest radiograph out of 1735 patients, and they required chest tube insertion. Other complications included two cases of right common carotid artery puncture, one case of right internal jugular vein dissection and one case of left internal jugular perforation. Two patients required a repeat procedure within 24 h due to superior migration of the Hickman catheter on chest radiograph. Given the extremely low rate of iatrogenic pneumothorax, chest radiograph following the insertion of a tunnelled Hickman catheter under ultrasound and fluoroscopic guidance may be an unnecessary investigation unless the patient is symptomatic, or there is sufficient clinical concern.

The role of routine chest radiography after implantable venous access port catheter insertion under the guide of ultrasonography and fluoroscopy

BackgroundThe objective of this study is the evaluation of routine chest radiography following the placement of Implantable venous access port catheter (IVAPC) central lines using combined ultrasound and fluoroscopic guidance by a vascular surgeon in the operating room.Material and methodA prospective study of 189 consecutive patients who underwent IVAPC central line insertion in the vascular surgery operating room from 2016 to 2019. Venipuncture was performed with an 18-gauge needle under the guidance of sonography in each case, and the access site was noted. The line position was confirmed by fluoroscopy following the procedure. Multiple tries for puncture and patients under 18 were excluded from our study. Routine radiography of chest was performed for all patients and pneumothorax, hemothorax, and catheter malposition were evaluated in each case.ResultsThere were 2 cases of asymptomatic pneumothorax, no cases of hemothorax, and all catheter tip positions were optimal or acceptable. The annual cost of chest radiography was 33,000,000IRR, 220 h of hospital and staff time, and 1.1 mSv radiation.ConclusionIn conclusion, when imaging guidance is used for IVAPC insertion by an experienced surgeon in a high-volume center, performing post-procedure routine chest radiography shows little benefit.

Mediastinal Haematoma: A Rare Complication Following Insertion of Central Venous Catheter

Mediastinal haematoma is a rare complication following insertion of central venous catheter, with few cases reported in the literature. We report a case of mediastinal haematoma in a 33-year-old male patient with end-stage renal disease. In this patient central venous catheter insertion through the right subclavian vein was attempted on the operation table for renal transplantation but the procedure was abandoned as the attempt was unsuccessful. Post-procedure chest radiograph showed a large mediastinal haematoma occupying right hemithorax that developed as a result of injury to the subclavian vein. Patient was managed conservatively and haematoma completely resolved in four weeks time. This case is being reported to signify the importance of routine obtaining a post-procedure chest radiograph and to state that even large mediastinal haematoma can be managed conservatively in asymptomatic patients.

Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest

Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest

A retrospective comparison for prediction of optimal length of right subclavian vein catheterization in infants: landmark-based estimation vs. linear regression model.

BackgroundThe optimal insertion length for right subclavian vein catheterization in infants has not been determined. This study retrospectively compared landmark-based and linear regression model-based estimation of optimal insertion length for right subclavian vein catheterization in pediatric patients of corrected age < 1 year.MethodsFifty catheterizations of the right subclavian vein were analyzed. The landmark related distances were: from the needle insertion point (I) to the tip of the sternal head of the right clavicle (A) and from A to the midpoint (B) of the perpendicular line drawn from the sternal head of the right clavicle to the line connecting the nipples. The optimal length of insertion was retrospectively determined by reviewing post-procedural chest radiographs. Estimates using a landmark-based equation (IA + AB – intercept) and a linear regression model were compared with the optimal length of insertion.ResultsA landmark-based equation was determined as IA + AB – 5. The mean difference between the landmark-based estimate and the optimal insertion length was 1.0 mm (95% limits of agreement –18.2 to 20.3 mm). The mean difference between the linear regression model (26.681 – 4.014 × weight + 0.576 × IA + 0.537 × AB – 0.482 × postmenstrual age) and the optimal insertion length was 0 mm (95% limits of agreement –16.7 to 16.7 mm). The difference between the estimates using these two methods was not significant.ConclusionsA simple landmark-based equation may be useful for estimating optimal insertion length in pediatric patients of corrected age < 1 year undergoing right subclavian vein catheterization.

Limited Clinical Utility of Chest Radiography in Asymptomatic Patients after Interventional Radiology-Performed Ultrasound-Guided Thoracentesis: Analysis of 3,022 Consecutive Patients

Abstract Purpose The aim of this study was to report the utility of chest radiography following interventional radiology-performed ultrasound-guided thoracentesis. Materials and Methods A total of 3,998 patients underwent thoracentesis between 2003 and 2018 at two institutions. A total of 3,022 (75.6%) patients were older than 18 years old, underwent interventional radiology-performed ultrasound-guided thoracentesis, and had same-day post-procedure chest radiograph evaluation. Patient age (years), laterality of thoracentesis, procedural technical success, volume of fluid removed (mL), method of post-procedure chest imaging, absence or presence of pneumothorax, pneumothorax size (mm), pneumothorax management measures, and clinical outcomes were recorded. Technical success was defined as successful aspiration of pleural fluid. Post-procedure clinical outcomes included new patient-perceived dyspnea and hypoxia (oxygen saturations &lt; 90% on room air). Costs associated with radiographs were estimated using Medicare and Medicaid fee schedules. Results Mean age was 56.7 ± 15.5 years. Interventional radiology-performed ultrasound-guided thoracentesis was performed on the left (n = 1,531; 50.7%), right (n = 1,477; 48.9%), and bilaterally (n = 14; 0.5%) using 5-French catheters. Technical success was 100% (n = 3,022). Mean volume of 940 ± 550 mL of fluid was removed. Post-procedure imaging was performed in the form of posteroanterior (PA) (2.6%; 78/3,022), anteroposterior (AP) (17.0%; 513/3,022), PA and lateral (77.9%; 2,355/3,022), or PA, lateral, and left lateral decubitus (2.5%; 76/3,022) chest radiographs. Post-procedural pneumothorax was identified in 21 (0.69%) patients. Mean pneumothorax size, measured on chest radiograph as the longest distance from the chest wall to the lung, was 18.8 ± 10.2 mm (range: 5.0–35.0 mm). Of the 21 pneumothoraces, 7 (33.3%) were asymptomatic, resolved spontaneously, and had a mean size of 6.4 ± 2.4 mm. Fourteen pneumothoraces, of mean size 25.0 ± 5.8 mm, required management with a pleural drainage catheter (66.6%). The overall incidence of pneumothorax requiring pleural drainage catheter placement following interventional radiology-performed ultrasound-guided thoracentesis was 0.46% (14/3,022). Of the patients requiring drainage catheter placement, 12/14 (85.7%) and 13/14 (92.9%) had dyspnea and hypoxia, respectively. Potential costs to Medicare and Medicaid, for chest radiographs, in this study, were $27,547 and $10,581, respectively. Conclusion The incidence of clinically significant pneumothorax requiring catheter drainage following interventional radiology-operated ultrasound-guided thoracentesis is exceedingly low (0.46%), and routine post-procedure chest radiographs in asymptomatic patients provide little value. Reserving post-procedure chest radiographs for patients with post-procedure dyspnea or hypoxia will result in more efficient resource utilization and health care cost savings.

Bedside ultrasound as an alternative to chest radiograph in detecting complications associated with central venous catheter placement: a retrospective cohort study

Background: Current practice in most institutions includes a routine post-procedural chest radiograph after central venous catheter (CVC) placement. After the introduction of ultrasonography guidance, the utility of obtaining such imaging was called into question. The goal of this study was to determine whether the use of bedside ultrasound is inferior to chest radiograph in detecting post-procedural complications and to assess the cost-effectiveness of these studies.

Chest radiography of contemporary trans-catheter cardiovascular devices: a pictorial essay.

There is a plethora of cardiovascular devices used for therapy and monitoring, and newer devices are being introduced constantly. As a result of advancement of medical technology and rapid development of such technology to address unmet needs across cardiovascular care, multiple conditions which were previously treated surgically or with medications now benefit from trans-catheter device-based evaluation and management. Moreover, innovation to existing technology has transformed the structural design of many traditional cardiovascular devices, making them safer and enabling easier deployment within the chest (catheter-based versus surgical). A post-procedure chest radiography (CXR) is often the first routine imaging test ordered in these patients. A CXR is a relatively inexpensive and noninvasive imaging tool, which can be obtained at the patient's bedside if needed. Commonly implanted cardiovascular devices can be quite easily checked for appropriate positioning on routine CXRs. Potential complications associated with mal-positioning of such devices may be life-threatening. Such complications often manifest early on CXRs and may not be readily apparent on clinical examination. Prompt recognition of such abnormal radiographic appearances is critical for timely diagnosis and effective management. Clinicians need to be familiar with new devices in order to assess proper placement and identify complications related to mal-positioning. This pictorial essay aims to describe the radiologic appearances of contemporary cardiovascular devices, review indications for their usage and potential complications, and discuss magnetic resonance imaging (MRI) compatibility.

Case Report of a Left-sided Superior Vena Cava Causing Unique Positioning of Central Line.

IntroductionPersistent left-sided superior vena cava is a rare congenital venous malformation. While often clinically asymptomatic, these variations in normal anatomy may give rise to complications with central venous catheter placement.Case ReportWe present a case of a 71-year-old male who presented to the emergency department with sepsis of unknown etiology. A right-sided central venous catheter was placed, and due to a persistent left-sided superior vena cava the post-procedure chest radiograph showed a uniquely positioned catheter tip within the left atrium.ConclusionA persistent left-sided superior vena cava may lead to uniquely positioned catheter tip placement on post-procedural imaging. This case demonstrates the need to consider variants in normal venous anatomy, such as persistent left-sided superior vena cava, to aid with correct interpretation of post-procedure imaging findings.

Unusual Dialysis Catheter Location in a Transplant Patient.

A 56-year-old woman, the recipient of a kidney transplant 8 years ago, was admitted to the nephrology intensive care unit with septic shock secondary to disseminated shingles after immunosuppressive therapy for acute cellular rejection. The patient developed AKI requiring RRT. Due to history of right internal jugular vein thrombosis related to previous vascular access, the left internal jugular vein was catheterized with a nontunneled double lumen hemodialysis catheter (12 French, 20 cm) without any complications. Routine postprocedure chest radiograph (Figure 1A) showed that the catheter was descending straight into the left border of the mediastinum. A transthoracic echocardiogram then showed enlarged coronary sinus with normal size cardiac chambers and no septal defects. Figure 1. Imaging studies exposing the persistent left superior vena cava. (A) Chest radiograph showing dialysis catheter descending straight to the left border of the mediastinum. (B) Anteroposterior three-dimensional computed tomography angiography (CTA) reconstruction revealing …

(F)utility of "routine" postprocedural chest radiograph after hemodialysis catheter (central venous catheter) insertion.

A routine postprocedural chest radiograph had been a safe, checklist-based final step of the procedure, since the start of central venous catheter insertion for hemodialysis to check the position of the catheter tip and to rule out complications. However, the chest radiograph is a suboptimal method to rule out complications like pneumothorax and is not a reliable test to confirm its position. Although it is relatively inexpensive, it is labor-intensive and exposes patient to unnecessary radiation exposure, cost, and often results in delayed use of the catheter. Various studies question the value of a routine chest radiograph as a screening test to rule out the mechanical complications of catheter insertion. We, in this brief viewpoint, present evidence to support the futility of a routine postprocedural chest radiograph in majority of asymptomatic patients and support Choosing Wisely Initiative to avoid low-value studies. However, it should be considered under specific indications, as discussed.

Abstract No. 577 Limited clinical utility of chest radiography in asymptomatic patients after interventional radiology-performed ultrasound-guided thoracentesis: analysis of 3022 consecutive patients

To report the utility of chest radiography following interventional radiology (IR)–performed ultrasound-guided thoracentesis. A total of 3998 patients underwent thoracentesis between 2003-2018 at two institutions. A total of 3022 (75.6%) patients were >18 years old, underwent IR-performed ultrasound-guided thoracentesis, and had same-day post procedure chest radiograph evaluation. Patient age (years), laterality of thoracentesis, procedural technical success, volume of fluid removed (mL), method of post procedure chest imaging, absence or presence of pneumothorax, pneumothorax size (mm), pneumothorax management measures, and clinical outcomes were recorded. IR-performed ultrasound-guided thoracentesis was performed on the left (n = 1531; 50.7%), right (n = 1477; 48.9%), and bilaterally (n = 14; 0.5%) using 5-French catheters. Technical success was 100% (n = 3022). Mean volume of 940 ± 550 mL of fluid was removed. Postprocedural pneumothorax was identified in 21 (0.69%) patients. Mean pneumothorax size, measured on chest radiograph as the longest distance from the chest wall to the lung pleural reflection, was 18.8 ± 10.2 mm (range, 5.0-35.0 mm). Of the 21 pneumothoraces, 7 (33.3%) resolved spontaneously and had a mean size of 6.4 ± 2.4 mm. Fourteen pneumothoraces, of mean size 25.0 ± 5.8 mm, required management with a pleural drainage catheter (66.6%). The overall incidence of pneumothorax requiring pleural drainage catheter placement following IR-performed ultrasound-guided thoracentesis was 0.46% (14/3022). Of the patients requiring drainage catheter placement, 12/14 (85.7%) and 13/14 (92.9%) had dyspnea and hypoxia, respectively. Potential costs to Medicare and Medicaid, for chest radiographs, in this study, were $27,547 and $10,581, respectively. The incidence of clinically significant pneumothorax requiring catheter drainage is exceedingly low (0.46%), and routine post procedure chest radiographs in asymptomatic patients provide little value. Reserving post procedure chest radiographs for patients with post procedure dyspnea or hypoxia will result in more efficient resource utilization and health care cost savings.Table 1Thoracenteses and Post-Procedural Chest Radiograph ResultsVariableOutcomeLaterality of EffusionLeft1,531 (50.7%)Right1,477 (48.9%)Bilateral14 (0.5%)Mean Volume Removed940 mL (550 mL)Chest Radiograph Technique Portable78 (2.6%)One View513 (17.0%)Two Views2,355 (77.9%)Three Views76 (2.5%)Post-Procedural Pneumothorax21 (0.69%)Mean Pneumothorax Size18.8 (10.2 mm) Open table in a new tab

Abstract No. 530 The role of chest radiographs post computed tomography–guided lung biopsy with gelatinous foam slurry: is it necessary?

To explore whether it is necessary to obtain chest radiographs post CT-guided lung biopsy with gelatinous foam slurry needle track embolization This is an IRB-approved prospective study of 47 patients with lung masses visualized on CT who came to our institution for lung biopsy. At our institution, gelatinous foam with 0.9% sodium chloride is mixed together to create a slurry and administered through a coaxial needle post biopsy. Post biopsy CT is obtained as well as chest radiographs are obtained at 1 and 2 hours post procedure. If a pneumothorax is visualized, the patient is examined clinically and a determination is made whether further intervention with a chest tube is necessary. Of the 47 patients in our study, only one patient had a pneumothorax not visualized on CT (2.1%). 11 patients in our study developed pneumothorax, 10 of which were visualized on CT prior to the patient leaving the CT table and subsequently viewed on the 1 hour and 2 hour post procedure chest radiograph with no significant interval change in size of pneumothorax. One of the known risks of a lung biopsy is pneumothorax. Our study demonstrates a low rate of delayed/developing pneumothorax; one patient of 47 (2.1%). Upon reviewing the images of the one delayed pneumothorax, the lung mass was in the right perihilar region and the final CT image did not extend to the apex and inferior parts of the lung. It is possible that the pneumothorax was there immediately however it may not have been imaged. The trend shown in our study demonstrates that although there is always concern for delayed/developing pneumothorax after lung biopsy with gelatinous foam slurry, the risk is very low. As we continue to add patients to the study, we hope to achieve a large enough sample size to further demonstrate that it may not be necessary to obtain chest radiographs post lung biopsy if the final CT shows no pneumothorax.

A Novel Objective Approach Towards Physicians' Knowledge and Practice Patterns to Optimize Central Venous Catheter Placement: A Cross-sectional Study

Study objective: Central venous catheterization is an essential component of intensive care of critically ill patients, and proper positioning of the catheter is essential to prevent position-related complications. This study was conducted by using digital tape measurement to objectively assess clinician preferences for central venous catheter positioning based on specific position levels and landmarks on post-procedural chest radiographs. Design: A cross-sectional study using electronic questionnaire survey. Setting: Single academic teaching hospital participated in this study. Participants: The study enrolled 276 physicians from multiple clinical disciplines. Interventions: None. Measurements: A seven-level reference system labeled on a sample chest radiograph was used to identify the acceptable lower and upper limits and landmarks used to determine the optimal central venous catheter tip position as well as the pattern of clinical practices based on the specialty and level of experience of participants. Main results: Among the 276 respondents, the ratio of cumulative acceptance for the lower and upper catheter tip limit was 62% and 66.3% within a 4-cm range below or above the carina, respectively. Intensive care unit (ICU) physicians showed a greater tendency to choose a catheter tip 4 cm below and 6 cm above the carina (p = 0.004 and 0.002, respectively) as did experienced physicians (p = 0.007 and &lt; 0.001, respectively). The commonest reason for catheter tip withdrawal was arrhythmia (50% of cases). Physicians in the ICU and experienced physicians were more concerned about the risk of cardiac perforation than other respondents (p &lt; 0.001 and &lt; 0.001, respectively). The carina was the most commonly used landmark in 71.7% of all physicians, although 50% of radiologists also used other landmarks. Conclusions: The acceptable limit of the catheter tip is 4 cm above and below the carina (-4 to +4), as determined on chest radiography, without a need for tip adjustment.