Imaging description

Figures 34.1a and b are chest radiographs obtained following placement of a peripherally inserted central catheter (PICC) by a nurse at the bedside. On the basis of this radiograph, the nurse withdrew the PICC to position its tip at the junction of the superior vena cava and right atrium. Figure 34.1c is a portable abdominal radiograph for nasogastric tube placement obtained 8 days after PICC insertion. Figure 34.1d is an AP portable chest radiograph obtained 9 days after PICC insertion. When this was compared to the earlier chest radiographs, the vertical linear metallic density projecting over the heart was noted. In retrospect, the bottom of this density could be seen at the same location on the abdominal radiograph (Fig. 34.1c). This triggered the AP and cross-table lateral chest radiographs depicted in Figures 34.1e and f, which confirmed the presence of an intrapulmonary foreign body. A CT scan showed that the foreign body was located in a branch of the left pulmonary artery rather than in the left lower lobe bronchus or lung (Fig. 34.1g.) Unbeknownst to the nurse doing the procedure, the guidewire had broken off at the time of PICC insertion and the central guidewire fragment remained in the catheter when the rest of the guidewire was removed, which is noted in retrospect only on close examination of Figures 34.1a and b. At some point between the chest radiograph in Figure 34.1a and the abdominal radiograph 8 days later, the guidewire fragment embolized out of the catheter, through the heart, and into the left lower pulmonary artery branch.