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Prof. Michele Buemi, Via Salita Villa Contino 30, I-98100 Messina (Italy) Dear Sir, Insertion of a catheter into the subclavian vein is frequently carried out to obtain a rapid vascular temporary access in hemodialysis. Yet, such a technique often presents complications [1, 2]. We report a patient with end-stage kidney failure and thoracic outlet syndrome who, after having been fitted with a 2-way catheter in the right subclavian vein, showed marked edema of the right superior limb. A., a 65-year-old male, with advanced chronic renal failure secondary to nephroan-giosclerosis with an early history of hypertension and after sudden and rapid impairment of his renal function had to be put on hemodialysis. Although an A-V fistula in the left forearm had already been made, it was not working, so we were obliged to insert a 2-way catheter into the right subclavian vein (Mahurkar catheter kit 11.5 Fr× 19.5 cm with vitacuff-Qwinton). After a few weeks, we needed to a new A-V fistula into the right forearm, and it was possible to remove the catheter using the new vascular method. Yet, months later edema of the right arm was noted and a subclavian occlusive stenosis with extensive collateral circulation was seen on fistulography. Our study pointed out a reduction of the anatomical space housing the vascular bundle, from which the so-called thoracic outlet syndrome appeared. Following an increase of the left arm edema, the patient was submitted to open surgery for placement of a venous bypass. The intervention was performed through a 2-way opening: (i)subclavicular cut (12 cm in length), parallel to the lower clavicular edge, and (ii)-longitudinal right cervicotomy between the two ends of the sternocleidomas-toid muscle. After cutting the clavicular insertion of the pectoralis major, we prepared the axillary subclavicular vein and the outlet of the cephalic vein. In order to decompress the thoracic outlet, the forepart of the first rib was resected, together with the subclavian muscle. Through the cervicotomic cut, the internal jugular vein was prepared and mobilized along its entire length. After having resected its proximal end, at the outlet of the

Obstruction of the Subclavian Vein due to Placement of a Hemodialysis Catheter in a Subject with Thoracic Outlet Syndrome