Lines/Tubes/Devices

Case 49

Lines/Tubes/Devices / , , , ,

This radiograph demonstrates a transvenous phrenic nerve stimulator. The lead travels from the generator under the skin into the right subclavian vein, right brachiocephalic vein, left brachicephalic vein, and terminates in the left pericardiophrenic vein, which drains the superior diaphragm and pericardium. This allows the device to stimulate the left phrenic nerve, which courses alongside the left percardiophrenic vein (and artery). This device is approved for the treatment of central sleep apnea under the brand name Remedē.

This patient also has sternal wires from a prior, unrelated open sternotomy.

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Case 48

Lines/Tubes/Devices / , , , ,

This radiograph demonstrates an in situ wireless pH monitoring device, also called a Bravo device. It is placed by an endoscopist and continuously monitors the pH level in the esophagus, wirelessly transmitting the data to an external receiver worn around the patient’s waist for up to 96 hours. This allows for quantification of gastroesophageal reflux disease (GERD) over the recording interval. The device is designed to eventually detach, pass through the digestive tract, and be flushed down the toilet.

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Case 45

Lines/Tubes/Devices, Normal & Variants / , , ,

This radiograph demonstrates unusual but ultimately inconsequential pacemaker lead positioning. A dual chamber pacemaker generator pack projects over the left hemithorax. The right ventricular lead takes the expected course through the left brachiocephalic vein, superior vena cava, right atrium, and tricuspid valve and terminates in the expected position of the right ventricle. The right atrial lead, however, courses to the left of the aorta. There are no secondary signs to suggest an inadvertent extravascular course. The best explanation for this appearance is a persistent left superior vena cava. This is a normal variant and connects the left subclavian vein to the coronary sinus. Ultimately, the lead ends up in the right atrium. It is not clear in this case why this positioning was chosen rather than placing both leads in the right (normal) SVC.

The exam is otherwise unremarkable.

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Case 42

ICU/Surgery, Lines/Tubes/Devices, Malignancy / , , , , ,

This patient underwent bilateral mastectomies for breast cancer. Surgical clips from an axillary lymph node dissection are seen on the right side. The bilateral rounded metallic devices are tissue expanders. They are attached to a radiolucent inflatable bladder that can be progressively filled with saline to stretch the overlying soft tissues, creating redundant tissue that can later be used for reconstruction. The underlying lungs are clear.

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Case 36

ICU/Surgery, Infectious/Inflammatory, Lines/Tubes/Devices / , , , , , , , , ,

This radiograph demonstrates typical findings of septic emboli. There are multiple bilateral nodules, many with cavitation. Metastatic disease would be within the differential for this finding, though in practice the clinical history is typically quite useful to distinguish between these two entities; In this case, the patient is young with a history of drug abuse (suggesting endocarditis as a source) and presents with sepsis. In addition, this patient has medium bilateral pleural effusions. In the setting of septic emboli this is concerning for empyema. CT is usually confirmatory.

Support devices include a central venous catheter in the right internal jugular vein, an endotracheal tube in the mid trachea, and an enteric tube entering the stomach and terminating inferiorly beyond the border of the study.

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Case 30

ICU/Surgery, Lines/Tubes/Devices / , , , , , , , ,

This radiograph demonstrates a misplaced right IJ Swan-Ganz catheter. Not only is the catheter too deep in the right pulmonary artery, the course of the catheter extends all the way into the abdominal IVC before looping back into the right atrium and crossing the tricuspid valve. Other lines and devices include a left upper extremity PICC with the tip terminating in the SVC, and an intra-aortic balloon pump (IABP) with the distal marker appropriately located just inferior to the aortic knob.

The cardiac silhouette is prominent and there is mild interstitial edema, which makes sense in the context of an IABP indicating that the patient is in heart failure.

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Case 26

ICU/Surgery, Lines/Tubes/Devices / , , , ,

This radiograph demonstrates unilateral pulmonary edema in the right lung. The differential for this appearance is limited and includes severe mitral regurgitation (such as a papillary muscle rupture), unilateral pulmonary venous obstruction, and lymphangitic spread of malignancy mimicking edema. Those etiologies rarely present with as much uniformity as this case, which was due to prolonged decubitus positioning that rapidly resolved on subsequent radiographs.

Incidentally noted is the presence of a tracheostomy tube with an overlying tracheostomy mask supplying oxygen to the patient.

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Case 24

Lines/Tubes/Devices, Normal & Variants / , , ,

This radiograph demonstrates a left upper extremity peripherally inserted central catheter (PICC) with tip terminating in a persistent left SVC. The presence of a persistent left SVC was confirmed on review of prior cross sectional imaging. A PICC in the internal thoracic vein can have a similar appearance on AP/PA radiographs, however a lateral radiograph easily distinguishes the two as a persistent left SVC will course centrally and the internal thoracic vein will course anteriorly.

The radiograph is otherwise unremarkable.

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Case 21

Chronic & ILD, Lines/Tubes/Devices / , , , , , , ,

This radiograph demonstrates several findings:

First, this is a COPD patient with very few lung markings seen in the right upper lobe due to severe emphysema.

Second, this patient has undergone endobronchial valve placement leading to complete lobar atelectasis in the left upper lobe. The valves themselves are visible projecting over the left hilum. There is expected volume loss in the left hemithorax, with increased opacity in the left lung due to superimposition of the collapsed left upper lobe and aerated left lower lobe.

Third, a named sign is demonstrated: The luftsichel sign (German for “air crescent”), which is seen as a crescentic lucency in the paramedian left upper lung and indicates left upper lobe collapse. The lucency is created by a portion of the aerated left lower lobe that insinuates itself between the mediastinal wall and the collapsed upper lobe.

Fourth, there is an incidentally noted small hiatal hernia seen as a rounded opacity projecting just to the left of midline at the level of the diaphragm. Diaphragmatic eventration is also noted.

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Case 19

ICU/Surgery, Lines/Tubes/Devices / , , , , , , , , , ,

This radiograph is of a premature infant in the first week of life. The right lung demonstrates diffuse microatelectasis typical of Neonatal Respiratory Distress Syndrome (RDS), also known as Surfactant Deficiency Disorder, caused by insufficient surfactant production in the setting of prematurity (typically <35 weeks gestation). The left lung is hyperinflated relative to the right lung, with diffuse linear lucencies radiating from the hilum. This appearance is typical for Pulmonary Interstitial Emphysema (PIE), a condition secondary to barotrauma from ventilation seen in premature infants in the first weeks of life. An NG/OG tube terminates in the body of the stomach. A second tube, thicker and denser than the NG/OG, with multiple rounded lucencies along the distal aspect is also seen. This is a NAVA tube (Neurally Adjusted Ventilatory Assist), which detects electrical activity of the diaphragm to improve synchrony with the ventilator.

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