CVC: CXR landmarks

It is considered standard of care to obtain a chest x-ray after placing a central line in order to exclude complications such as pneumothorax and also to confirm proper placement. There has been controversy as to whether the placement of the CVC tip should lie above the pericardial reflection or not. Most guidelines suggest that the tip should lie outside of the pericardial sac, as this limits the risk of cardiac tamponade. It is generally accepted that the upper limit of the pericardial sac is below the carina on a plain chest x-ray, thus the tip of the catheter in right-sided CVCs should be seen above the carina. Given the steep angle the left brachiocephalic angle makes with the SVC, left-sided CVCs are more likely to perforate the SVC than right-sided SVCs. This means that often the tip of these catheters will require placement in the distal SVC or below the carina in the upper right atrium.