| Abstract|| |
Subclavian vein catheterization, the most commonly used temporary vascular access for hemodialysis, is associated with a variety of complications. This retrospective study was done on 96 patients who had 150 percutaneous subclavian vein catheterizations over a one year period using Quinton double lumen polyurethane catheters. A total of 56 complications were seen of which 12 were immediate and 44 delayed. Immediate complications seen were six cases of failure of insertion of catheter and three cases each of subclavian artery puncture and inadvertent entry of the catheter into the jugular vein. Delayed complications seen were infection in 33 cases, thrombosis of subclavian vein in six patients, delayed pneumothorax in four cases and hemothorax in one. One patient, who required repeated catheterizations since he refused creation of AV fistula, died of septicemia. The remaining patients responded well to the treatment of the respective complications.
Keywords: Subclavian catheterization, Hemodialysis, Complications, Subclavian stenosis, Pneumothorax, Hemothorax.
|How to cite this article:|
Al Shohaib S, El Johary M, Zawawi T. Complications of subclavian catheterization in hemodialysis patients. Saudi J Kidney Dis Transpl 1994;5:479-82
|How to cite this URL:|
Al Shohaib S, El Johary M, Zawawi T. Complications of subclavian catheterization in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 1994 [cited 2020 Mar 29];5:479-82. Available from: http://www.sjkdt.org/text.asp?1994/5/4/479/41138
| Introduction|| |
The insertion of a subclavian dialysis catheter is the preferred mode of vascular access for acute dialysis by most nephrologists over the other modes of temporary vascular access. However, this procedure is associated with a variety of complications including infection, hemorrhage, arterial puncture, pneumothorax and subclavian stenosis ,, . Chronic subclavian stenosis can jeopardize the success of a fistula or graft placed in the involved extremity at a future date  . Unfortunately most of our patients are referred to us in advanced uremia and therefore require subclavian catheter for dialysis until their fistula matures. In this paper, we have reviewed the complications of subclavian venous catheterization seen at the King Khalid National Guard Hospital, Jeddah and King Fahad Hospital in Al Baha, Saudi Arabia.
| Methods and Materials|| |
This was a retrospective study. The charts of 96 patients from the two above mentioned hospitals over a one year period were reviewed. A total of 150 subclavian catheterizations for hemodialysis were performed during this period. The catheter used was Quinton double lumen polyurethane catheters in all cases. All were inserted percutaneously either by the treating consultant or under his supervision, by a resident. Insertions were always performed using complete aseptic precautions. The catheter was dressed with sterile gauze and the dressings were changed at least three times a week. Aqueous based povidone iodine solution was used to clean the exit site. All dialysis sessions were performed using universal infection control precautions. Each catheter was left in only as long as it was required or for a maximum period of six weeks provided there was no infection.
| Results|| |
During the period of the study, 96 patients had 150 subclavian catheterizations for hemodialysis. Sixty patients had chronic renal failure (CRF) among whom, 30 were catheterized for their first dialysis and 30 for failed previous access. The remaining 36 patients had acute renal failure (ARF). Age range was from 18 to 60 years with a mean age of 36.5 years. There were 67 males and 29 females. Twenty-six patients had diabetes mellitus. The mean duration of catheter stay was 20 days.
During the period of the study, a total of 56 complications were observed, 12 were immediate and 44 delayed [Table 1].
Failure to Insert the Catheter
In six patients, attempts to insert the catheter failed. The policy being followed is to have only three attempts at inserting the catheter and not to proceed further if all three failed. We either looked for another access or asked someone else to try at a later time.
Puncture of the Subclavian Artery
Inadvertent puncture of the subclavian artery occurred in three patients (2%). The needle was removed immediately in each case and no further complications were seen.
Inadvertent entry of the Catheter into the Jugular Vein
This occurred in three patients and was diagnosed when the patients complained of ear ache at the time of insertion. This complication occurred when the insertion was being performed for the second time. The catheter was removed and no other complications were noticed in each case.
Infection occurred in 33 patients (22%) Exit-site infection manifested mainly by redness was seen in 16 patients (48%). Tunnel infections indicated by redness at the exit-site and pus was seen in 4 (2.6%) patients. All these patients had negative blood culture.
Septicemia was diagnosed in 13 patients (40%) who had positive blood culture. They all had redness at the exit-site and in six patients there was pus at the exit-site.
The organisms were Staphylococcus aureus in 80%, Pseudomonas in 19% and E. coli in 1% of the cases. The mean duration of catheter stay in this group was 36 days.
All patients received vancomycin and an aminoglycoside as initial treatment. Appropriate antibiotics were added or substituted later based on the bacterial culture reports. Thirty-two of the patients responded to treatment. However, the catheter had to be removed in 11 (36%) patients since the infection persisted in spite of appropriate antibiotic therapy. One patient died of septicemia. This particular patient refused both AV fistula construction and permcath insertion and was' dialyzed through the subclavian line for eight months during which period the catheter was changed six times.
Thrombosis of the Subclavian Vein
Six patients developed thrombosis of the subclavian vein, three on the left side and three on the right side. They were all confirmed by venogram [Figure 1]. They all had swelling of the involved arm. In each patient, the catheter was removed and anticoagulants were administered. Two of these patients had fistula on the side of the thrombus and the fistulae failed. The mean duration of the catheter stay in this group was 50 days. All patients improved on anticoagulation. They remained on anticoagulants for six months. All these patients except one had repeated catheterizations before the occurrence of thrombosis.
This was detected 48 to 72 hours post insertion in four patients. Pneumothorax resolved by itself in these patients and none required chest tube.
This was detected in one patient who required chest tube drainage and 500 ml of blood was drained. The bleeding stopped spontaneously.
| Discussion|| |
Subclavian vein catheterization for hemodialysis is preferred by many because catheters can be left in longer than femoral or jugular catheters in mobile patients. However, subclavian vein catheterization is associated with a variety of complications including subclavian stenosis, thrombosis, infection, hemo-pneumothorax and bleeding ,, .
In our series, complications occurred in 34.4% of the patients. The prevalence of complications was high, possibly because the catheters were retained in place for a long period of time.
Subclavian thrombosis and stenosis is an under-diagnosed complication of subclavian catheterization , . It can be speculated that trauma to the endothelium by the catheter tip as well as barotrauma from blood flowing at a high rate and pressure during hemodialysis, coupled with infection, lead to stenosis , . Computerized tomography and magnetic resonance imaging can be used to detect subclavian thrombosis , . However, in our series, we used only the standard angiogram to confirm the diagnosis. In fact, not all of our patients had florid symptoms of thrombosis but an angiogram was performed whenever the diagnosis of thrombosis was suspected. We were able to demonstrate the block quite well with this procedure.
It is our policy to create the AV fistula on one side and the subclavian on the other. However, on occasions the AV fistula has to be established on the same side because it had failed on the other side. We noticed that these fistulae had less blood flow and higher venous pressure which suggests the development of subclavian stenosis. Subclavian vein stenosis may be asymptomatic or may lead to florid symptoms and rarely to the superior vena cava syndrome  .
The rate of infection was high in our series and this again is most likely due to the catheters being left in for a long time. Unfortunately most of our patients are referred late and dialysis is required before permanent access can be arranged which forces us to use catheter for vascular access for a prolonged period of time. The commonest organism is Staphylococcus aureus  as was observed in our series. Most of the patients who had infection and all the patients who had thrombosis had chronic renal failure. Patients with acute renal failure had less, and only minor, complications. This is possibly because catheters were not left for long duration and most of the patients did not have repeated catheterizations.
Delayed pneumothorax is a recognized complication of subclavian catheterisation  . The symptoms usually appear 48 to 72 hours post catheterization  which was the case in our patients also. Once diagnosed, prompt action is necessary if respiratory distress is present. However, our patients did not require invasive procedures and responded to conservative treatment alone.
In conclusion, subclavian vein catheterization is associated with several complications. There are increased chances of complications with repeated catheterizations and when catheters are left for long duration. We recommend that the catheterization should be performed only by trained personnel, under complete aseptic technique. It is also advisable to remove the catheter as soon as the need is over. However, one should remember that the most important factor is to identify and refer patients with end-stage renal disease early to a dialysis center so that an access for dialysis can be created in advance, which will then avoid the need for this procedure.
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Saad Al Shohaib
Consultant Nephrologist, King Khalid National Guard Hospital, P.O. Box 9515, Jeddah 21423