Study Design

• Retrospective review of twenty-four patients (2019–2023) at a single secondary care hospital’s ICU.
• Inclusion criteria: clinically or radiologically confirmed device-related complications.
• Imaging modalities: Portable CXR, US, and CT scans.

1. Airway Complications

• Tracheal Rupture / Tear
• Mechanism: Overinflation of the endotracheal tube balloon or traumatic intubation.
• Imaging Findings: Pneumomediastinum, subcutaneous emphysema, and focal discontinuity of the tracheal wall on CT. CT is the non-invasive investigation of choice for detecting tracheobronchial injuries; however, it can miss or underestimate the true extent of these ruptures in an alarming 25% to 68% of cases, which does not exclude the possibility of a tear. In such circumstances, flexible bronchoscopy remains the gold standard, offering direct visualization of the lesion and a more precise assessment of its severity.
• Illustrative Case: Several patients (Cases 1, 2, and 12) presented with massive subcutaneous emphysema and/or pneumomediastinum; CT revealed a tracheal defect just below the balloon placement site, confirming iatrogenic rupture.
• Bronchial Intubation
• Mechanism: ETT advanced too far, entering a main bronchus (frequently the right).
• Imaging Findings: CXR shows ETT tip beyond the carina in a main bronchus; atelectasis or consolidation of the contralateral lung.
• Illustrative Cases: Cases 6 and 7 showed the ETT tip in a main bronchus, leading to partial left lung collapse or contralateral overdistension.

1. Pleural and Parenchymal Injuries

• Chest Drain Malposition / Malfunction / Lung Laceration
• Mechanism: Excessive force or inaccurate trajectory during tube thoracostomy. Also, chest drain malfunction due to obstruction (e.g., clot formation) or migration toward the thoracic wall. If the drain is well-positioned but does not function in the context of significant trauma, a possible bronchial tear should be considered.
• Imaging Findings: CT demonstrating the drain traversing lung parenchyma, or intrafissural positioning sometimes with adjacent hematoma.
• Illustrative Cases: Cases 3, 4 show intraparenchymal trajectory of the chest drain, causing lacerations and/or hematomas in the adjacent lung parenchyma.

1. Gastrointestinal Perforations

• Nasogastric Tube (NGT) Malposition
• Mechanism: Inadverted advancement into the tracheobronchial tree or failure to confirm intragastric position.
• Imaging Findings: CXR/CT showing the NGT radiopaque line within bronchus or lung parenchyma, sometimes with associated pneumothorax or pulmonary consolidations.
• Illustrative Cases:
• Case 10, 11 and 14: NGT advanced through the right main bronchus, causing parenchymal opacities likely due to aspiration.
• Case 13: NGT passing through the bronchi to the costophrenic recess with resulting pneumothorax.
• Gastric Perforation
• Mechanism: Overdistension of the stomach or direct mechanical trauma (inadvertent intubation of the esophagus with high pressure).
• Imaging Findings: Free air under the diaphragm (CXR) or large pneumoperitoneum (CT) with direct visualization of a gastric wall defect.
• Illustrative Case: Case 5 showed a large perforation at the greater curvature from iatrogenic injury, requiring partial gastrectomy.

1. Vascular Complications

• Central Venous Catheter (CVC) Malposition

• Mechanism: Misplacement in an unintended vessel (e.g., artery, ventricle) or perforation of venous structures.
• Imaging Findings: Catheter course deviates from expected path, sometimes crossing midline or descending abnormally (CXR). Definitive identification of intravascular or extravascular path, associated complications (e.g., mediastinal hematoma) (CT/Angiography).
• Illustrative Cases:

• Case 8: Catheter passing through the aorta into the left ventricle.
• Case 17: hemothorax due to subclavian vein injury after pacemaker placement.
• Cardiac Perforation and Pericardial Effusion
• Mechanism: Rigid or malpositioned pacemaker leads, especially if advanced forcefully, leading to hemopericardium and/or pericardial effusion.

• Imaging Findings: Electrode tip outside the cardiac lumen, possibly in pericardial or mediastinal space. Pericardial effusion or hemopericardium may occur (CT).

• Illustrative Cases:

• Case 15: The lead was identified in the epicardial fat near the cardio-phrenic angle.
• Case 16: The electrode crossed the superior vena cava wall into the mediastinal fat.
• Case 19: CT confirmed one pacemaker lead perforating the anterolateral right atrial wall and associated hemopericardium.

• Arterial Injury and Pseudoaneurysm Formation

• Mechanism: Iatrogenic arterial wall damage during venous puncture, leading to pseudoaneurysm formation.

• Imaging Findings: Turbulent flow within a collection communicating with the injured artery, with to-and-fro flow pattern (Doppler-US).

• Illustrative Cases:

• Case 18: A patient developed a pseudoaneurysm of the distal humeral artery after venous puncture, leading to localized hematoma and hemodynamic instability. Arterial Doppler ultrasound confirmed a pseudoaneurysm.
• Case 20: A patient with a temporary pacemaker developed a left-sided hemothorax. CT revealed a multiloculated pleural collection, and a pseudoaneurysm in the extrapleural fat of the left vertex.
• Hemothorax

• Mechanism: Vascular injury leading to blood accumulation in the pleural cavity or pseudoaneurysm formation.

• Imaging Findings: Increased opacity in the pleural cavity with sharp borders, pleural thickening (CXR), contrast extravasation in pseudoaneurysm cases (CT/Angiography).

• Illustrative Cases:
• Case 20: A patient with a temporary pacemaker developed a left-sided hemothorax. CT revealed a multiloculated pleural collection and a pseudoaneurysm in the extrapleural fat of the left vertex, anterior to the subclavian artery and posterior to the subclavian vein.
• Case 21: A patient with pleuritic rib pain and anemia after pacemaker placement. CXR initially showed left pneumothorax. CT angiography confirmed hemopneumothorax with complete pulmonary collapse but no active bleeding.
• Hydrothorax due to extravasation of intravenous contrast

• Mechanism: Vessel perforation during defibrillator or pacemaker lead placement, leading to extravasation of contrast into the pleural cavity.

• Imaging Findings: High-density pleural effusion with iodinated contrast content, pneumothorax (CT).

• Illustrative Case: A patient with difficult venous access for implantable cardioverter-defibrillator placement. CT showed iodinated contrast extravasation into the right pleural space and bilateral pneumothorax, indicating vessel perforation (Case 22).
• Mediastinal Hematoma

• Mechanism: Accidental arterial puncture during pacemaker lead placement, leading to mediastinal hematoma and possible active bleeding.

• Imaging Findings: Paratracheal mediastinal widening, tracheal deviation (CXR). Denser regions during late phases (CT/Angiography).

• Illustrative Case: A patient with suspected subclavian artery puncture during pacemaker implantation. CXR showed left mediastinal widening and tracheal displacement. CT angiography confirmed a large left mediastinal hematoma, with active bleeding from a mediastinal vein, possibly a branch of the left internal mammary vein (Case 23).

• Pacemaker Lead Malposition and Repositioning

• Mechanism: Incorrect positioning of pacemaker leads at the time of implantation, requiring subsequent repositioning.

• Imaging Findings: Pacemaker lead malposition at unexpected locations (e.g., venous confluence instead of right atrium/ventricle) (CXR).

• Illustrative Case: Patient asymptomatic after pacemaker placement, but initial CXR showed one lead mispositioned at the confluence of the superior vena cava and left brachiocephalic vein (Case 24).

Procedure Details and Reproducibility

1. CXR:

• Portable AP or supine views, standard for immediate post-procedural control.
• Limitations: Reduced sensitivity for small pneumothoraces or subtle malpositions.
• Strengths: Rapid bedside availability.

• Bedside assessment of pleural effusions, pneumothorax (lung sliding sign), and vascular patency.
• Operator-dependent but reproducible with standardized protocols.

• Gold standard to delineate complex complications (vascular perforations, deep extraluminal paths, small tears in the trachea).
• Typically multiplanar reconstructions (MPR) facilitate precise localization of device tips and extent of injury.

All imaging studies were interpreted by experienced radiologists in close collaboration with ICU teams, ensuring prompt corrective measures (e.g., repositioning ETT/NGT, chest tube adjustment, or urgent surgery).