Late Appearance of Pneumothorax after Subclavian Catherization for Hemodialysis

J.M. Campistol, Nephrology Service, Hospital Clinic, 170 Villarroel, E-08036 Barcelona (Spain) Dear Sir, Subclavian cannulation for hemodialysis was first reported by Erben et al. [1] in 1969 and is now being widely used all over the world. Pneumothorax is a well-recognized complication of subclavian vein catheterization. Chest radiography on expiration is advised soon after the procedure. Patients at particular risk for pneumothorax are those receiving positive-pressure respiratory support and those with air trapping. An unusual case of late pneumothorax is reported herein. A 62-year-old man was admitted to our hospital because of deterioration on renal function of renovascular origin. A hemodialysis catheter was placed into the right subclavian vein without remarkable incidents. X-ray examination after the procedure showed that the catheter was properly placed. No abnormalities were noted in the pleural space. Forty-eight hours later, a splenorenal shunt was performed. Postoperatively, thoracic examination disclosed diminished breath sounds and hyperres-onance to percussion of the right hemithorax. Chest X-ray showed a massive right pneumothorax. An apical chest drain was inserted, and complete recovery was uneventful. Reviewing the literature, we could find only 3 case reports describing late pneumothorax after subclavian vein catheter insertion [2, 3]. In the present case, the 1 We thank Mrs. M. Lázaro for her secretarial assistance. presumed mechanism for the late appearance of a pneumothorax is a slow air leak from a pleural tear that could not be detected soon; 48 h after subclavian venipuncture a progressive pneumothorax developed when the patient required positive-pressure ventilation for surgery. Late pneumothorax should be considered in a patient with a subclavian vein catheter in whom respiratory difficulty develops, despite negative chest X-ray findings immediately after the surgical procedure. In patients with a subclavian vein catheter undergoing elective intubation and positive-pressure breathing, we recommend that repeated chest radiography should be considered to exclude the late development of a pneumothorax. References Erben, J.; Kvasniska, J.; Basfecky, J.: Long-term experience with the technique of subclavian vein cannulation in hemodialysis. Proc. Eur. Dial. Transplant Ass. 8:59 (1969). Mitchell, A.; Steer, H.W.: Late appearance of pneumothorax after subclavian vein cathezisation: an anaesthetic hazard. Br. med. J. 257:1339(1980).