American College of Radiology
ACR Appropriateness Criteria®

Radiologic Management of Central Venous Access

Variant 1: Device selection. Adult or child ≥13 years of age. Intravenous access for long-term total parenteral nutrition and intermittent intravenous antibiotics.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chest port Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Arm port May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Single lumen PICC Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Double lumen PICC May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Tunneled small bore central venous catheter single lumen May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Tunneled small bore central venous catheter double lumen Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Device selection. Adult or child ≥13 years of age. Sickle cell anemia requires intravenous access for the treatment of recurrent sickle cell crisis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chest port Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Arm port May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Single lumen PICC May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Double lumen PICC May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Tunneled central venous catheter May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Nontunneled central venous catheter May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Device selection. Adult or child ≥13 years of age. Stage 3 chronic kidney disease requires central venous access for 6 weeks of antibiotic treatment.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chest port Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Arm port Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Single lumen PICC Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Double lumen PICC Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Tunneled small bore central venous catheter single lumen Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Tunneled small bore central venous catheter double lumen May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Device selection. Adult or child ≥13 years of age. Intensive care unit (ICU) patient with sepsis and acute renal insufficiency requires intravenous access for approximately 7 to 10 days.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chest port Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
PICC May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Tunneled small bore central venous catheter Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Nontunneled central venous catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Site selection. Adult or child ≥13 years of age. Head and neck surgery. Central venous access required for adjuvant chemotherapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Arm port Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
PICC Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Chest port via internal jugular/subclavian vein Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Tunneled small bore catheter via internal jugular/subclavian vein May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Site selection. Adult or child ≥13 years of age. Sepsis in a patient with stage 4 chronic kidney disease, requires 7 to 10 days of intravenous antibiotic therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
PICC Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Nontunneled central venous catheter via the left internal jugular vein Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Nontunneled central venous catheter via the right internal jugular vein Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Nontunneled central venous catheter via the subclavian vein Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Site selection. Adult or child ≥13 years of age. ICU patient with sepsis. The patient receives hemodialysis via nontunneled catheter placed via the right internal jugular vein. Multilumen central venous access required.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Arm PICC Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Femoral vein nontunneled central venous catheter May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Right internal jugular vein nontunneled central venous catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Subclavian vein nontunneled central venous catheter May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Left internal jugular vein nontunneled central venous catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Variant 8: Site selection for permanent hemodialysis catheter. Adult or child ≥13 years of age. End stage renal disease has undergone creation of a left arm arteriovenous fistula. The fistula has not yet matured.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Right internal jugular vein Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
Right subclavian vein May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Left internal jugular vein May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Left subclavian vein Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Right or left femoral vein May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Variant 9: Immunocompromised patient. Adult or child ≥13 years of age. Has a tunneled small-bore catheter placed via right internal jugular vein. Patient is pancytopenic (ANC 300/µL, PLT 32,000/µL) and presents with fevers and malaise.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Immediate removal of the tunneled catheter, culture of the catheter tip and placement of a nontunneled central venous catheter via different site May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Retain the catheter and commence empiric antibiotics once peripheral and central blood cultures have been drawn May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Catheter should be removed if positive blood cultures are confirmed Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Catheter salvage may be considered even after positive blood cultures are acquired May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Variant 10: Thrombotic complications. Adult or child ≥13 years of age. Chest port placed via right internal jugular vein is being used for chemotherapy. The infusion nurse can infuse saline but is unable to aspirate blood from the catheter.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Continue to use the port for administering drugs but use peripheral access for blood draws May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Catheter removal and placement of alternative venous access May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Chest radiograph Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Interrogate the port with patient and/or patient arm in different positions Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Instill a thrombolytic agent into the port Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Contrast study of the catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Catheter exchange May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Catheter stripping May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Variant 11: Thrombotic complications. Adult or child ≥13 years of age. Permanent hemodialysis catheter placed via the right internal jugular vein. Poor flows are documented at hemodialysis via both lumens.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Catheter removal and placement of a new catheter from a different site Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Catheter exchange Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Contrast study of the catheter Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Fibrin sheath stripping Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Fibrin sheath disruption Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Attempt to perform dialysis with patient arm in a different position Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Variant 12: Thrombotic complications. Adult or child ≥13 years of age. Arm swelling secondary to extensive thrombus surrounding a triple lumen PICC placed via left Basilic vein. The catheter is being used for long-term parenteral nutrition and intermittent intravenous antibiotics. The catheter is functioning.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Immediate catheter removal May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Commence anticoagulation and continue to use the catheter Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Catheter-directed thrombolysis May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Systemic thrombolysis Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
SVC filter placement Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Catheter downsize for a single/double lumen PICC Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Variant 13: Infectious complications. Adult or child ≥13 years of age. Preventive measures to reduce catheter-related bloodstream infections when placing a nontunneled central venous catheter in ICU patient.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Antibiotic impregnated catheters May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Upper body insertion site Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Heparin-bonded catheter May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Prophylactic antibiotics prior to catheter placement May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Antimicrobial lock therapy (not ethanol lock) May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Routine guide-wire catheter exchanges Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Variant 14: Infectious complications. Adult or child ≥13 years of age. Therapeutic measures to manage catheter-related bloodstream infections.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Catheter should be removed immediately May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Catheter should be removed in the setting of Staphylococcus Aureus bacteremia Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Catheter should be preserved in clinically stable patients May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Catheter exchange in conjunction with systemic antibiotics can be considered in patients with coagulase-negative Staphylococcal bacteremia May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Exit site infections may be treated with antibiotics alone May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Catheter salvage and concomitant antibiotic therapy are appropriate in patients with limited venous access Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.