VoL. 120, No.

NORMAL AND ABNORMAL POSITION OF THE UM-

BILICAL ARTERY AND VENOUS CATHETER ON
THE ROENTGENOGRAM AND REVIEW
OF COMPLICATIONS*
By ALFRED L. WEBER, M.D., SALVATORE DELUCA, M.D.,
and DANIEL C. SHANNON, M.D.
BOSTON, MASSACHUSETTS

S INCE the introduction of intravascular of the Massachusetts General Hospital, we

catheters via the umbilical vein for ex- have a General Electric portable I 10 volt
change transfusion by Diamond in 1947,8 roentgenographic unit. For the AP view,
and measurement
by James
been employed
in 1959,”
with
of blood
these
increasing
gases
catheters
and pH

frequency,
have
the factors
exposure
additional
are io ma.,
time of 1/12
io kvp.
to
is added
6o kvp., with
seconds.
for the lateral
i/is
an
An

and recording of their exact position has projection. To reduce radiation exposure
become most important in order to prevent to the infant, paraspeed or highspeed films
American Journal of Roentgenology 1974.120:361-367.

complications and false measurements. are used. The gonads are shielded unless
Catheters are now used in acutely ill in- the pelvic area also needs to be demon-
fants for the above applications, as well as strated on the examination. Rapid evalua-
for hyperalimentation, and the measure- tion of the position of the catheter can also
ment of pressures, electrolytes and blood be obtained with the use of Polaroid film
sugar values. which is developed in a rapid processing
The purpose of this paper is to discuss unit.’
the methods and materials used, the nor- Umbilical catheterization usually can be
mal and abnormal position of catheters, performed in the first days of life. In
and the complications. hypoxic infants, the umbilical vessels may
remain open for a longer period of time, as
MATERIAL AND METHOD
occurred infant
in where
I catheterization
The catheters should be soft, small, and of the umbilical vessels was carried out ii
rigid enough to negotiate the vascular days after birth. The ideal location for the
channels. At the present time, nonwettable, tip of the umbilical artery catheter is at
polyvinyl chloride catheters are in use. We about the 3rd lumbar vertebra, between the
employ a 3.5 French catheter in infants up origin of the renal and superior mesenteric
to 1.5 kg. in weight, and a No. 5 for larger arteries and the bifurcation of the aorta.
infants. The catheter should be radiopaque Another desirable location is in the de-
with an acceptable dead space of less than scending aorta at the D6-7 level, where
0.5 ml. For prevention of clot formation, rapid flow gives good mixing and dilution
the catheter should have an end hole with of injected fluids. The catheter should be
no side holes, and the end should be repositioned to prevent air embolism to
rounded to prevent damage or perforation vital structures when placed in the left
of the vascular wall. common carotid artery, the innominate
Localization can be achieved by image artery, the external iliac artery, the femoral
intensification fluoroscopy or by antero- artery, or the pulmonary artery (reached
posterior (AP) and lateral roentgeno- via the ductus arteriosus).
graphic examination of the chest and abdo- The technique of umbilical venous cath-
men. In the Newborn Intensive Care Unit eterization is the same as that used for ar-

* From the Departments of Radiology and Pediatrics, Harvard Medical School and Massachusetts General Hospital, Boston,
Massachusetts.

361
 362 A. L. \Veber, S. DeLuca and D. C. Shannon FEBRUARY, 1974

A separate operation, such as withdrawing

and flushing of the catheters, can be handled
through these individual stopcocks. The
blood pressure can be monitored through a
third stopcock most distal to the infant by
connecting either a fluid-filled manometer
or, preferably, a calibrated strain gauge
(Fig. I). Restricting use of the proximal
FIG. . Photograph of stopcock system with arterial
catheter, millipore filter, and tubing to pump. stopcock for withdrawing blood samples
eliminates a potential source of injecting
terial catheterization. The tip should be contaminated old blood or air bubbles. A
inserted into the inferior vena cava near the millipore filter placed between the infusion
right atrium after passage through the pump and the last stopcock prevents con-
ductus venosus. Once the catheter is in- tamination or air injection during the infu-
serted, careful handling is important in sion of fluids. Thrombosis of the catheter
order to prevent accidental disconnection, when used for 5-7 days will be insignificant
contamination, air embolization, or clot if an intravenous maintenance solution
American Journal of Roentgenology 1974.120:361-367.

formation. A useful method is the applica- containing i unit of heparin per ml. is
tion of three-way separate disposable stop- flushed continuously.
cocks locked to each other with metal clips. If the infant’s condition requires con-

FIG. 2. (A) Anteroposterior and (B) lateral roentgenograms of the chest and abdomen
demonstrating normal course and position of umbilical venous catheter.
 VOL. 120, No. 2 Normal and Abnormal Position of the Umbilical Artery 363

tinued monitoring, a catheter can be used the liver through the ductus venosus into
safely for as long as I week. If an alternate the inferior vena cava. The umbilical artery
site for monitoring arterial blood pressures, catheter passes medially, inferiorly, and
gases, and electrolytes becomes necessary, forms a ioop before entering the hypogas-
a 20-22 gauge teflon-covered cannula can tric arteries, and then ascends within the
be placed in a radial, dorsalis pedis, or tem- aorta to the left and anterior of the lumbar
poral artery. spine (Fig. 3, 4 and B).
In view of the relatively slow flow in a
COMPLICATIONS FOLLOWING PASSAGE OF
peripheral artery, no medications, hyper-
UMBILICAL ARTERY OR
tonic solutions, or albumin should be in-
VENOUS CATHETERS
jected. The same sampling, pressure moni-
toring, and flushing procedures can be em- In order to prevent complications or
ployed as described above. With careful false measurements, accurate position of
handling, the peripheral artery can be ex- the catheter, sterile technique, gentle ma-
pected to remain serviceable for 5 to 7 days. neuvering of the catheter, and flushing of
As soon as the umbilical artery or venous the catheter should be strictly adhered to.
catheter is in place, AP and lateral roent- A catheter positioned in the inferior vena
cava can measure central venous pressure
American Journal of Roentgenology 1974.120:361-367.

genograms of the abdomen and chest

should be obtained for accurate localiza- which is a reflection of the vascular volume.
tion.3”6 In the
view AP
the venous Measurement of portal venous pressure,
catheter ascends slightly
to the right at the however, is always higher than central
level of the ductus (Fig. 2, A’ and B). In venous pressure, and therefore cannot be
the lateral view, the catheter ascends be- used for evaluating the general cardiovas-
neath the rectus muscle posteriorly within cular status.2

FiG. 3. (A) Anteroposterior and (B) lateral roentgenograms of the chest and abdomen
demonstrating normal course and position of arterial catheter.
 364 A. L. \Veber, S. DeLuca and D. C. Shannon FEBRUARY, 1974

tem (Fig. 6, A’ and B). Also, the catheter

tip should not be located in arteries supply-
ing the head, neck, and extremities (Fig.
7, 1 and B; and 8), or in the mid-abdom-
inal aorta at the level of the superior mesen-
teric or renal arteries. Intracardiac cath-
eters may produce cardiac arrhythmias,
damage to cardiac valves, and perforation
of the myocardium’2 (Fig. 9).
Catheters in the umbilical vein or portal
system have caused hemorrhage in the yes-
Sel wall with or without thrombus forma-
tion with the degree and frequency of
thrombus formation often related to the
duration of the indwelling catheter. Scott,’7
in a review of 92 autopsies among 200 cases
suffering from respiratory stress syndrome,
American Journal of Roentgenology 1974.120:361-367.

reported an incidence of 20 per cent compli-

cations from catheters in the venous sys-
tem. The complications consisted of peri_
venous hemorrhage ( cases), thrombosis
FIG. 4. Anteroposterior roentgenogram of the chest
including the upper abdomen showing coiling of (6 cases), pulmonary emboli (6 cases), and
umbilical vein catheter in portal vein. infection ( cases). Phlebitis with subse-
quent thrombosis of the portal system may
The tip of the catheter should not be ensue if strict sterile technique is not used
located in the umbilical vein, in the intra- or if an infusion of hypertonic solutions or
or extrahepatic portal systems (Fig. ; and bicarbonate is given. A delayed complica-
5, ii and B), or the cardiopulmonary sys- tion is occlusion of the portal venous sys-

FIG. 5. (A) Anteroposterior and (B) lateral roentgenograms of the abdomen showing
umbilical vein catheter coiled at the level of ductus venosus.
 VOL. 120, No. 2 Normal and Abnormal Position of the Umbilical Artery 365

IiG. 6. (A) Anteroposterior and (B) lateral roentgenograms of the chest revealing the tip of umbilical vein
American Journal of Roentgenology 1974.120:361-367.

catheter in the left atrium after passage through patent foramen ovale.

tern with ensuing portal hypertension.’4 change transfusion through a catheter in

Clot formation in the portal vein or its the portal venous system, perforation of
intrahepatic branches can lead to liver the bowel, most often of the colon, from
necrosis.’9 Pulmonary emboli have fol- underlying infarction has been reported.6’#{176}”
lowed thrombus formation in the portal The underlying mechanism is not known,
system and hepatic veins.’7 Following ex- but increased pressure in the portal circu-

FIG. 7. (A) Anteroposterior and (B) lateral roentgenograms of the chest including neck show-
ing the umbilical vein catheter in the left lugular vein after crossing the right atrium.
 366 A. L. Weber, S. DeLuca and D. C. Shannon FEBRUARY, 1974

blanching of the lower extremities occurs

during the introduction of an umbilical
artery catheter, partial or complete with-
drawal is indicated. Correction of either
metabolic acidosis or hypovolemia, how-
ever, may relieve the blanching.

DISCUSSION

Umbilical artery and venous catheteriza-

tion has proved of great benefit in the man-
agement of newborn infants with low birth
weight, respiratory distress syndrome, and
a variety of other diseases. It is hoped that
future developments in noninvasive moni-
American Journal of Roentgenology 1974.120:361-367.

FIG. 8. Anteroposterior roentgenogram of the chest

showing the umbilical artery catheter in the left
axillary artery. Note nasogastric tube and severe
hyaline membrane disease.

lation secondary to obstruction by the

catheter or retrograde microemboli is
thought to be responsible.
Complications following umbilical artery
catheterization have occurred at a rate of
4.6 to 10.4 per cent. Among 387 infants
investigated by Cochran et al.,7 the compli-
cations related to umbilical artery cath-
eters were vasospasm and temporary
blanching in 13 infants and thrombosis,
arteritis, or other inflammation noted at
postmortem examination in i8 infants.
Thrombosis has also been reported in the
aorta, iliac, renal, celiac, splenic, and pul-
monary arteries. Severe complications have
resulted from the infusion of THAM (tris-
hydroxymeth ylami nomethan) and 40 per
cent glucose solution into the umbilical
artery, with the result of a large recto-
vaginal-bladder fistula, right pyonephro-
sis, hemiparesis of the right leg, right labial
FIG. 9. Anteroposterior roentgenogram of the chest
edema, and gluteal muscle necrosis.4 If the
and abdomen demonstrating the umbilical vein
catheter is forcefully manipulated through
catheter perforating through the right atrium fol-
the umbilical artery, perforation into the lowing passage through the right atrium, left
peritoneal cavity may occur.’8 When atrium, left ventricle, and right ventricle.
 VOL. 120, No. 2 Normal and Abnormal Position of the Umbilical Artery 367

toring techniques will permit the physician Proper localization umbilical

of arterial and
venous catheters by lateral roentgenograms.
to manage these infants with less risk. Ac-
Pediatrics, 1969, 43, 34-39.
curate placement of the catheters is of ut- 4. BRAUNE, M., and HEIMING, E. Report IXth
most importance to prevent complications Annual Meeting of the European Society of
and obtain accurate blood measurements. Pediatric Radiology, Paris, 1972, pp. 10-13.
We recommend AP and lateral roentgeno- 5. CAMPBELL, R. E. Roentgenologic features of
umbilical vascular catheterization in newborn.
grams of the chest and abdomen to assure
AM. J. ROENTGENOL., THERAPY RAD.&
correct localization of the arterial or venous NUCLEAR MED., 68-76.
1971, 112,
catheter. A portable x-ray machine in the 6. CASTOR, W. R. Spontaneous perforation of bowel
intensive care unit is adequate, but a built- in newborn following exchange transfusion.
in unit is preferable. The latter unit allows Canad. M. A. 7., 1968, 99, 934-939.
conventional roentgenographic technique, 7. COCHRAN, W. D., DAVIS, H. T., and SMITH,
C. A. Advantages and complications of urn-
magnification studies of the lung, and cath-
bilical artery catheterization in newborn.
eterization of the umbilical artery and vein Pediatrics, 1968, 42, 769-777.
on the roentgenographic table. For rapid 8. DIAMOND, L. K. Erythroblastosis foetalis or
localization of the catheter alone, Polaroid haemolytic disease ofnewborn. Proc. Roy. Soc.

film can also be used. Med., ‘947, 40, 546-550.

9. DIAMOND, L. K., ALLEN, F. H., JR., and THOMAS,
American Journal of Roentgenology 1974.120:361-367.

In addition to localization of vascular

W. 0., JR. Erythroblastosis fetalis treatment
catheters, positions of thermocouples, naso-
with exchange transfusion. New England 7.
tracheal tubes, and electrocardiographic Med., 1951, 224, 39-49.
leads can be determined. The catheters can 10. FRIEDMAN, A. B., ABELLERA, R. M., LIDSKY, I.,
be used to inject contrast material into the and LUBERT, M. Perforation of colon after
vascular structures for evaluation of the exchange transfusion in newborn. New En-
gland 7. Med., 1970, 282, 796-797.
heart, aorta and branches, vessels in the
I I . JAMES, L. S. Biochemicalaspects of asphyxia at
lungs, head and neck.
birth. In: Adaptation of Extra-Uterine Life.
Report of the 31st Ross Conference of Pedi-
SUMMARY
atric Research, Vancouver, B. C., 1959.
Proper placement of umbilical venous 12. JOHNSON, C. E. Perforation ofright atrium with
polyethylene catheters. 7.A.M.A., 1966, 195,
and arterial catheters is important for mea-
584-586.
suring blood gases, pH, blood pressure, and
13. ORME, R. L’E., and EADES, S. M. Perforation
infusion of blood and alkalizing solutions. of bowel in newborn as complication of cx-
AP and often lateral roentgenograms of change transfusion. Brit. M. 7., 1968, 4, 349-
the chest and abdomen are mandatory for 35 I.

accurate localization of the catheters. 14. O5KI, F. R., ALLEN, D. M., and DIAMOND, L. K.
Portal hypertension-complication of umbilical
Improper placement and handling leads
vein catheterization. Pediatrics, 1963, 3!,
to false measurements and complications, 297-302.
such as thrombosis with resultant infarcts Is. PECK, D. R., and LOWMAN, R. M. Roentgen
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in newborn. Radiology, 3967, 89, 874-877.
Alfred L. Weber, M.D. i6. ROSEN, M. S., and REICH, S. B. Umbilical ven-
Department of Radiology ous catheterization in newborn: identification
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17. SCOTT, J. M. latrogenic lesions in babies follow-
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American Journal of Roentgenology 1974.120:361-367.