Mechanism of Hemodialysis-Associated Subclavian Vein Stenosis

Dr. J.M. Campistol Plana, Nephrology Service, Hospital Clinic i Provincial, 170, Villarroel, E-08036 Barcelona (Spain) Dear Sir, Erben et al. [1] described first the routine use of subclavian vein cannulation for hemodialysis (HD). More recently, it was popularized by Uldall et al. [2] in conjunction with the development of a ‘single-needle’ subclavian HD catheter. Nowadays, it is being widely used all over the world. Its advantages are considered to be rapid insertion, no impairment of the patients mobility, and no damage to blood vessels that could result in arteriove-nous fistulas [3]. Minor complications such as local pain or hemorrhage, arterial puncture, and catheter thrombosis cause usually no problems. Nevertheless, several serious complications such as sepsis, pneumothorax, life-threatening events, and thrombosis-stenosis of the subclavian vein, specially after the creation of an arteriove-nous fistula on the ipsilateral side of the catheter, have been reported [4– 6]. Little is known about the causes of this subclavian vein thrombosis-stenosis, although several authors have speculated on the role of prior subclavian vein cannulation. Also incidence and natural history of subclavian thrombosis-stenosis following the use of subclavian dialysis catheters are still unknown. Therefore, we have performed subclavian venograms in a group of patients who had a subclavian catheter inserted for HD after catheter removal. Methods Single-lumen catheters of polyurethane (Med-West, Salt Lake City, Utah, USA) were placed atraumatically using the technique of Uldall et al. [2]. Following each dialysis session, the catheter was flushed with 2.5 cm3 of heparin (1,000 IU/cm3). The catheter was used only for HD purposes. From February to May 1988,15 patients (8 males and 7 females) suffering from renal failure requiring HD were dialyzed using these catheters, and after removal of the catheter, a peripheral venogram was performed. Eleven patients suffered from chronic and 4 from acute renal failure. The mean age of the patients was 57 years (range 25–75 years). The mean duration of catheter placement was 7 days (range 6–77 days). The peripheral venogram was performed 10–148 days (mean 67 days) after removal of the catheter and prior to fistula creation. A 21-gauge needle was placed in a peripheral vein of the ipsilateral side in which a subclavian catheter had previously been placed. As contrast medium