KDIGO Clinical Practice Guideline for Acute Kidney Injury
Obtaining a chest radiograph promptly after placement and before first use of an internal jugular or subclavian dialysis catheter: Recommendations and Rationale

• 5.4.4: We recommend obtaining a chest radiograph promptly after placement and before first use of an internal jugular or subclavian dialysis catheter. (1B):

Rationale

Uncuffed, nontunneled dialysis catheters are semirigid. Their tip should not be in the heart, because of the risk of atrial perforation and pericardial tamponade. On the other hand, a position too high in the brachiocephalic vein, especially with subclavian and left-sided catheters, should also be avoided, because it allows a narrow contact between the catheter tip and the vessel wall, which may result in improper catheter function and vessel thrombosis.^655,679,680 The correct position of the tip of a semirigid dialysis catheter is at the junction of the superior vena cava and the right atrium, allowing the catheter to run in parallel with the long axis of the superior vena cava.⁶⁷⁹ Tunneled catheters are usually softer and can be positioned into the right atrium, thus allowing a higher blood flow.⁶⁸⁰

To confirm the correct position and to assess for potential complications, a postprocedural chest radiograph is conventionally performed. Although this procedure has been debated after uneventful placement of a CVC, the high blood flows used during RRT and the administration of anticoagulants necessitate confirming the correct position before initiating dialysis therapy.⁶⁴⁰ It should, however, be remembered that none of the radiographic landmarks (carina, right tracheobronchial angle, etc) that are used to exclude intra-atrial tip position are 100% reliable.^679,680 Echocardiography might be another tool to confirm the correct position of the catheter.⁶⁸¹