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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1997  |  Volume : 8  |  Issue : 2  |  Page : 119-122
Central Vein Stenosis in Patients with Prior Subclavian Vein Catheterization for Maintenance Dialysis

1 Division of Vascular Surgery, King Saud University, Riyadh, Saudi Arabia
2 Division of Nephrology, King Saud University, Riyadh, Saudi Arabia
3 Department of Radiology, King Saud University, Riyadh, Saudi Arabia

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We evaluated the prevalence of central vein stenosis in patients with prior central vein catheterization for vascular access for hemodialysis. A total of 36 patients with end-stage renal disease (ESRD) who were referred to the division of vascular surgery at King Khalid University Hospital in Riyadh were evaluated. Bilateral ascending venogram was performed in all cases. The patients were divided into three groups: Group I included 38 extremities in 32 patients who were referred for construction of an arteriovenous fistula. All these patients had previous history of subclavian vein catheterization. This included six patients who had bilateral catheter insertion. Venography demonstrated greater than 50% central vein lesions in 13 of the 38 extremities yielding a prevalence of 34%. Group II included four extremities in four patients who were on hemodialysis for many years all of whom presented with features suggestive of venous obstruction in their already existing arteriovenous fistulae. All four patients gave history of prior subclavian vein catheterization for dialysis. Three of these patients had > 50% subclavian vein stenosis while one showed complete occlusion of the vein. Group III included 30 extremities without history of prior central vein cannulation and none of them showed any lesions on venography. Our study further confirms previous reports that show a high prevalence of central vein stenosis following use of subclavian catheter as vascular access. We suggest that the subclavian route should be abandoned in patients with ESRD and temporary venous cannulation, if needed, should be performed in the femoral or internal jugular veins. Also, in individuals with history of prior central vein cannulation, venography is strongly recommended before an arteriovenous fistula is made.

Keywords: Central vein stenosis, Vascular access, Venogram, Hemodialysis.

How to cite this article:
Al-Salman MM, Rabee H, Abu-Aisha H, Trengganu N, Al-Damegh S, Al-Smeyer S, Freigoun T. Central Vein Stenosis in Patients with Prior Subclavian Vein Catheterization for Maintenance Dialysis. Saudi J Kidney Dis Transpl 1997;8:119-22

How to cite this URL:
Al-Salman MM, Rabee H, Abu-Aisha H, Trengganu N, Al-Damegh S, Al-Smeyer S, Freigoun T. Central Vein Stenosis in Patients with Prior Subclavian Vein Catheterization for Maintenance Dialysis. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2021 May 17];8:119-22. Available from: https://www.sjkdt.org/text.asp?1997/8/2/119/39382

   Introduction Top

Adequate blood flow is crucial for the proper functioning of an arteriovenous (AV) fistula as vascular access for chronic hemodialysis [1] . Insertion of subclavian dialysis catheters has the drawback of causing subclavian vein stenosis, the prevalence of which is reportedly as high as 50% [2] . This can considerably compromise the blood flow in a fistula leading to venous obstruction and upper extremity edema with blood recirculation in the ipsilateral limb during the subsequent hemodialysis sessions [3] . Also, the number of hospitalization days per dialysis patient per year caused by vascular access complications has increased dramatically and at a faster pace than any other cause. Most hemodialysis access morbidity is produced by mechanical problems such as graft stenosis or thrombosis [4],[5] . Thus, every effort must be made by the vascular surgeon to avoid creation of a permanent vascular access in a limb with pre-existing, sub-clinical venous outflow obstruction. While the occurrence of subclavian vein stenosis following catheterization has been well documented, [6],[7] its frequency has not been fully appreciated. This is because peripheral venography is not routinely performed following subclavian vein catheter placement for temporary vascular access [3] . We present here our experience in evaluating 72 upper extremities, using contrast venography and digital subtraction angiography (DSA), in 36 end-stage renal disease (ESRD) patients referred to us for creation of a permanent vascular access.

   Materials and Methods Top

During the period between January 1993 and December 1995, we evaluated 36 patients with ESRD for possible central vein stenosis. They were referred to, and managed in, the division of vascular surgery at the King Khalid University Hospital in Riyadh, Saudi Arabia. There were 20 males and 16 females. The age ranged from 35 to 64 years with a mean of 49 years. For the sake of analysis, the upper extremities included in this study (72 limbs) were distributed into three groups: Group I included 38 extremities in 32 patients who had previous temporary subclavian vein catheterization and were referred for creation of a permanent vascular access. Six of these patients had bilateral and 26 had unilateral previous subclavian vein catheterization.

Group II comprised of four extremities in four patients who were on chronic hemodialysis with an AV fistula for several years, all of whom presented with venous obstruction including venous hypertension, aneurysmal dilatation and vascular access failure. The limb with the permanent vascular access in all these patients had a history of previous placement of subclavian vein catheters.

Group III included 30 extremities without a history of previous central vein cathete­rization. They were the contralateral limbs of the patients mentioned in groups I and II excluding the six in group I who had bilateral catheterization.

All patients were subjected to thorough history taking with emphasis on previous placement of temporary dialysis catheter. Furthermore, the areas of catheter insertion were clinically inspected for skin scars documenting this invasive procedure. Bilateral ascending venography with digital subtraction was performed in all cases using a large-bore angiocath. About 25 ml of contrast material (Conray-280) was injected and imaging performed over the appropriate locations to cover venous drainage of the upper arm, the axillary, subclavian and the brachiocephalic veins as well as the superior vena cava. The stenotic venous segment was classified as less than 50% stenotic, greater than 50% stenotic or occluded, based on the venogram findings.

   Results Top

Among patients in group I, upper extremity contrast venography demonstrated central vein lesions in 13 of the 38 extremities yielding a prevalence of 34%. The lesions included subclavian vein stenosis of > 50% (n = 10). complete subclavian vein occlusion (n=l) and superior vena caval stenosis (n = 2) [Figure - 1],[Figure - 2]. Nine of the 13 lesions (69%) were on the right side and four (31 %) were located on the left. Among patients in group II, venography revealed that three cases had > 50% subclavian vein stenosis and one case showed subclavian vein occlusion with extensive venous outflow­obstruction [Figure - 3]. In group III, all the 30 limbs had normal venogram. A stati­stically significant difference (P < 0.001) was found between group III and groups I or II.

   Discussion Top

Subclavian dialysis catheters are frequently used as temporary vascular access in situations such as acute renal failure and in patients with ESRD during the period prior to the maturation of a permanent AV fistula [8],[9] . The technique of catheter insertion, advantages as well as complications of subclavian vein cannulation relative to the transfemoral approach is well documented [5],[6] . In addition to the acute complications (malposition, hemothorax, pneumothorax, sepsis, etc.), long-term use of subclavian hemodialysis catheter can be associated with major late obstructive complications [6],[10] . It seems that central vein stenosis occurs slowly, allowing time for adequate venous collateral formation. Thus, the stenosis commonly goes undetected until venous flow rates are increased by the creation of an AV fistula in the ipsilateral extremity [1],[11] .

Our study showed a 34% prevalence of > 50% central vein stenosis in 38 extremities with history of prior placement of temporary dialysis catheter. [Table - 1] summarizes some other studies that have evaluated the pre­valence of this complication.

In spite of its high frequency, central vein stenosis remains asymptomatic until creation of an AV fistula in the same limb. The consequent increase in blood flow may manifest venous outflow obstruction if the stenosis is hemodynamically significant. The problems of venous hypertension, aneurysmal dilatation, recirculation dialysis as well as vascular access failure were the main presenting features among the patients in group II of our study. No stenosis was diagnosed in group III, the extremities wherein dialysis catheters had never been inserted before. Thus, it is clear from our results that every effort should be made to avoid insertion of a temporary dialysis catheter on the side in which the permanent vascular access is likely to created [4] .

Also, one should always remember that it might become necessary to construct a fistula in the opposite limb due to failed access at the first site. Hence, the safest approach seems to be total avoidance of subclavian vein cannulation in patients with ESRD [15] .

In limbs with a history of previous central vein catheterization, imaging of the subclavian vein is crucial to identify those with stenosis. We believe, as others do, that contrast venography is the method of choice for screening this group of limbs [10],[16] . It is simple, easily available and time and cost effective. Digital subtraction venography offers several real and theoretical advantages over conventional venography and is also recommended in cases of suspected occlusion of superior vena cava, subclavian vein and central venous catheters [10] . Magnetic resonance imaging (MRI) may prove to be a very helpful technique for imaging vascular structure but its wide application is limited by the high cost and relative lack of availability [10] . Duplex scan is not very useful for detection of stenosis in the subclavian vein since it lies behind the clavicle [17] .

In conclusion, we believe that temporary dialysis catheters when placed in chronic dialysis patients are most appropriately placed in the internal jugular or femoral veins and that the subclavian route should be abandoned. Also, patients with a history of transient catheterization of the subclavian vein should be screened with venography prior to creation of a permanent access in the same limb.

   References Top

1.Surratt RS, Picus D, Hicks ME, Darcy MD, Kleinhoffer M, Jendrisak M. The importance of preoperative evaluation of the subclavian vein in dialysis access planning. Am J Roentgenol 1991;156:623-5.  Back to cited text no. 1    
2.Barrett N, Spencer S, Mclvor J, Brown EA. Subclavian stenosis: a major complication of subclavian dialysis catheter. Nephrol Dial Transplant 1988;3:423-5.  Back to cited text no. 2    
3.Criado E, Marston WA, Jaques PF, et al. Proximal venous outflow obstruction in patients with upper extremity arteriovenous dialysis access. Ann Vase Surg 1994;8:530-35.  Back to cited text no. 3    
4.Spinowitz BS, Galler M, Golden RA, et al. Subclavian vein stenosis as a complication of subclavian catheterization for hemodialysis. Arch Intern Med 1987;147:305-7.  Back to cited text no. 4  [PUBMED]  
5.Vanholder R, Lameire N, Verbanck J, Van Rattinghe R, Kunnen M, Ringoer S. Complications of subclavian catheter hemodialysis: 5 year prospective study in 257 consecutive patients. Int J Artif Organs 1982^5:297-303.  Back to cited text no. 5    
6.Schwarzbeck A, Brittinger WD, Henning GE, Strauch M. Cannulation of subclavian vein for hemodialysis using Seldinger's technique. Trans Am Soc Artif Intern Organs 1978;24:27-31.  Back to cited text no. 6  [PUBMED]  
7.Davis D, Petersen J, Feldman R, Cho C, Stevick CA. Subclavian venous stenosis. A complication of subclavian dialysis. JAMA 1984;252:3404-6.  Back to cited text no. 7    
8.Fant GF, Dennis VW, Quarles LD. Late vascular complications of the subclavian dialysis catheter. Am J Kidney Dis 1986;7:225-8.  Back to cited text no. 8  [PUBMED]  
9.Venkatraman G, Digard N, Goodall, et al. Alternative permanent access for home dialysis. Dial Transplant 1984;13:626-29.  Back to cited text no. 9    
10.Benenati JF, Becker GJ, Mail JT, Holden RW. Digital subtraction venography in central venous obstruction. Am J Roentgenol 1986;147:685-8.  Back to cited text no. 10    
11.Andersen JT, Gammelgaard J, Nielsen LM, Clausen E. Subclavian vein catheterization for acute and chronic hemodialysis. A safe temporary vascular access. Int Urol Nephrol I986;18:327-32.  Back to cited text no. 11    
12.Schwab SJ, Quarles LD, Middleton JP, Cohan RH, Saeed M, Dennis VW. Hemodialysis associated subclavian vein stenosis. Kidney Int 1988;33:1156-59.  Back to cited text no. 12  [PUBMED]  
13.Vanherweghem JL, Cabolet P, Dhaene M, et al. Complications related to subclavian catheters for hemodialysis. Report & review. Am J Nephrol 1986;6:339-45.  Back to cited text no. 13    
14.Cimochowski GE, Worley E, Rutherford WE, Sartain J, Blondin J, Harter H. Superiority of the internal jugular over the subclavian access for temporary dialysis. Nephron 1990;54:154-61.  Back to cited text no. 14    
15.De Moor B, Vanholder R, Ringoir S. Subclavian vein hemodialysis catheters: advantages and disadvantages. Artif Organs 1994;18(4):293-7.  Back to cited text no. 15    
16.Okadome K, Komori K, Fukumitsu T, Sugimachi K. The potential risk for subclavian vein occlusion in patients on hemodialysis. Eur J Vase Surg 1992;6(6):602-6.  Back to cited text no. 16    
17.Knudson GJ, Wiedmeyer DA, Erickson SJ, et at. Color Doppler sonographic imaging in the assessment of upper extremity deep venous thrombosis. Am J Roentgenol 1990;154:339-403.  Back to cited text no. 17    

Correspondence Address:
Mussaad M.S Al-Salman
Vascular Surgery Unit, Department of Surgery, P.O. Box 7805, Riyadh 11472
Saudi Arabia
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PMID: 18417788

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