Mediastinal Hematoma: A Rare Complication of Subclavian Catheterization for Hemodialysis

Dr. Nurol Arik, Hacettepe Hastanesi Nefroloji Bölümü, TR-06100 Hacettepe-Ankara, (Turkey) Fig. 1a, b CT scans of the thorax demonstrating a large mediastinal hematoma (H). Dear Sir, Subclavian vein catheterization was first introduced in the late 1970s and has become a preferred method of temporary vascular access for acute hemodialysis. Now, it is widely used all over the world. However, acute complications such as hemothorax, pneumotho-rax, atrial perforation, air embolism and delayed complications such as stenosis and bac-teremia associated with the placement of catheters continue to occur [1]. This report describes a rare complication of subclavian catheter insertion for hemodialysis in a patient with end-stage renal failure. A 51 -year-old man with chronic renal failure was started on chronic hemodialysis in July 1986. He underwent cadaveric renal transplantation in November 1989. As a result of graft loss due to chronic rejection, the patient returned to a hemodialysis program by arteriovenous fistula which was formed at the wrist in his left arm in June 1990. He had been hospitalized because of fistula occlusion, and a new fistula was created at the wrist in his right arm on December 7, 1991. While awaiting the maturation of the new fistula, he developed symptoms of hypervolemia. So, it was decided to place a subclavian hemodialysis catheter for immediate access. Before the placement of the catheter, a chest x-ray was taken and showed no abnormality except for cardiac enlargement present on previous radiographs. A doublelumen hemodialysis catheter was inserted via the left subclavian vein using the Seldinger technique. Following the procedure the patient complained about shortness of breath; subsequently dyspnea increased, and orthopnea appeared within a few hours after the insertion of the catheter. A marked reduction of blood pressure was recorded as well. A postinsertion chest x-ray revealed a large opacity covering the media-