Central venous catheters tip positioning: Insights from a retrospective analysis

Background: Tunneled central venous catheters (tCVCs) are essential in hemodialysis when arteriovenous access is not feasible. Their correct positioning is crucial to ensure efficient dialysis and prevent complications such as stenosis and thrombosis. Methods: This retrospective, non-randomized study reviewed all tCVC placements performed from January 2017 to December 2024 at the Nephrology Department of St. Eugenio Hospital (Rome, Italy). Data collection focused on catheter tip positioning under fluoroscopy and associated complications. Results: A total of 1238 tCVCs were placed in 1187 patients. Most catheters (83%) were positioned in the right internal jugular vein. Tip placement under fluoroscopic guidance showed 9.8% above the right atrium (RA), 44.5% within, and 45.5% below. Central venous stenosis was diagnosed in 18.8% of patients, with 2.4% requiring stent placement following failed angioplasty. Discussion: Precise tip positioning is critical for maintaining patency and minimizing complications. Fluoroscopy, while commonly used, may underestimate the anatomical boundaries of the RA, as evidenced by discrepancies with CT-based evaluations. Individual patient factors and catheter design can influence final tip position and should be considered during placement. Emerging technologies such as AI and immersive reality show promise in improving procedural accuracy and reducing risks. Conclusions: Optimal tCVC tip positioning remains a clinical challenge with significant implications for patient outcomes. Integration of advanced imaging techniques and AI could enhance accuracy and safety, while further data are needed to clarify the role of malposition in central venous stenosis.