Complications of the subclavian vascular approach for hemodialysis

The authors report their experience of subclavian vein catheterisation and compare their results with those of previously reported series. One hundred and sixty-four subclavian catheters were inserted in 111 patients, 66 with acute renal failure and 49 with chronic renal failure. The total number of hemodialysis sessions was 984. The catheters were left in situ for an average of 14.5 +/- 2 days or 19 +/- 2 patient days. The main immediate complications were pneumothorax (1 case) and subclavian artery puncture (2 cases). Seventeen catheters were complicated by septicemia with one fatal outcome. In addition, 5 cases of subclavian vein thrombosis, diagnosed clinically and confirmed by venography, were observed. Percutaneous subclavian vein catheterisation is a useful technique for emergency renal dialysis. However, septic and thrombotic complications are fairly frequent and potentially serious. Although measures can be taken to reduce the risk of infection, the prevention of thrombosis seems to be more difficult.     

Combination of thrombolytic therapy and angioplastic stent insertion in a patient with Budd-Chiari syndrome

A 31-year-old female who had well-established polycythemia vera one year before, presented with the sudden onset. She had severe ascites and hepatic encephalopathy 12 d prior to admission. Real-time ultrasonography revealed a supra hepatic thrombosis extending toward the inferior vena cava （IVC）. Thrombolytic therapy with systemic streptokinase （250000 IU loading ＋ 100000 IU/h infusion） was started. At the end of 72 h infusion, the patient＇s general condition improved. A color Doppler ultrasonography then showed complete and partial resolution of the thrombosis in the supra hepatic vein and IVC, respectively. Despite this good response, 12 d later, the symptoms recurred. Venography detected complete obstruction of the IVC. Percutanous balloon angioplasty with stent insertion was performed successfully and the patient was discharged without any evidence of liver disease. A combination of systemic streptokinase and radiological intervention was effective in our patient.     

Percutaneous transluminal angioplasty of proximal subclavian artery stenosis after left internal mammary to left anterior descending artery bypass surgery.

A patient is described who underwent percutaneous transluminal angioplasty, through a brachial approach, of a high grade stenosis at the proximal portion of the left subclavian artery 1.5 years after coronary artery bypass grafting including left internal mammary to left anterior descending artery anastomosis. Symptoms of class IV angina, vertebrobasilar insufficiency and occupational arm claudication that developed after bypass surgery were promptly relieved after balloon dilation. Percutaneous transluminal angioplasty of the subclavian artery can be performed safely and provides an alternative to carotid-subclavian or axillary-axillary bypass surgery for treatment of internal mammary artery graft malfunction.     

Balloon venoplasty of acute subclavian vein thrombosis

Two patients with subclavian vein thrombosis are presented in which a balloon venoplasty led to recanalization of the subclavian vein and complete remission of clinical symptoms. In patients with extreme symptoms and unsuccessful initial catheter-directed local thrombolysis, this non-operative approach can be considered despite known favourable spontaneous outcome of subclavian vein thrombosis.     

Correction of subclavian artery stenosis by percutaneous angioplasty

Subclavian artery stenosis is an infrequently recognized cause of left-sided chest and arm pain that can mimic the signs and symptoms of angina pectoris. In addition, more proximal subclavian artery stenoses can be associated with cerebrovascular symptoms in the "subclavian steal syndrome." This article reviews the clinical experience in four patients who presented with different manifestations of subclavian artery stenosis and who were all successfully treated by percutaneous angioplasty. Their clinical presentation, angiographic findings, and post-angioplasty results are documented. In conclusion, it is felt that nonsurgical correction of critical subclavian artery stenosis, using current angioplasty techniques, is the preferred method of treatment.     

Venous haemodynamics of the upper extremity after subclavian vein thrombosis

Late post-thrombotic complaints after subclavian vein thrombosis are reported with highly varying frequencies (8-80% severe disability). The therapeutic approach depends partly on this frequency. With the aim to evaluate late sequelae a questionnaire was answered by 26 patients with arm-shoulder symptoms leading to arm phlebography, but where the examination did not reveal any thrombi. 65% had remaining symptoms 2-9 years after the examination. 3 had to change profession. 36 patients with phlebographically shown subclavian vein thrombosis answered the same questionnaire. Only 9 (25%) had remaining symptoms and in 4 it was classified as mild, in 4 as moderate and only in 1 patient as severe leading to change of profession. Venous haemodynamics in the upper extremity were also studied in 3 groups of patients; I) healthy volunteers (n = 16 arms), II) patients with arm-shoulder disabilities with negative arm phlebography (n = 7 disabled arms, n = 7 non-disabled arms), III) patients with phlebographically verified subclavian vein thrombi (n = 10 arms with DVT, n = 8 arms without DVT). Strain gauge plethysmography was used measuring venous capacity and maximal venous outflow. Venous pressure measurements were made both with the arms in a resting position and in a military position with and without work-load. Repeat phlebography of arms with symptoms were made. Maximal venous outflow was significantly lower in arms with previous subclavian vein thrombi (p less than 0.05) and venous pressure measurements with the arm in military position was significantly higher in those arms. However, no correlation between these measurements and the degree of arm disability was noted.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnostic and therapeutic approach to axillary-subclavian vein thrombosis

We report the cases of four patients who complained of post-exertional shoulder and/or arm discomfort, and who were diagnosed with acute or possible impending axillary-subclavian vein thrombosis. One regained full patency of a stenotic and obstructed vein after local streptokinase infusion, first rib surgical resection, and transvenous angioplasty. A second with a patent but narrowed and tented vein was treated with heat and elevation, and was referred for possible surgical correction of thoracic outlet syndrome. The third patient, who presented two weeks after the thrombotic event, experienced a poor clinical outcome characterized by recurrent thrombosis despite aggressive therapy. The fourth, whose thrombosis was the presenting sign of mediastinal lymphoma, was treated with heat and elevation with resolution of pain and swelling.     

Median sternotomy for an unexpected complication of permanent hemodialysis catheters: "stuck catheter"

Cuffed tunneled venous access catheters are commonly used for temporary and permanent access in patients undergoing hemodialysis. These catheters play an essential role in providing permanent access in patients in whom all other access options have been exhausted. However, they are prone to several complications like catheter thrombosis, catheter fibrin sheating and infection. Herein, we report two uncommon cases of stuck hemodialysis cuffed tunneled catheters causing stenosis and thrombosis in central veins which needed to be removed by median sternotomy.     

Thrombotic complications of silicone rubber catheters during autologous marrow and peripheral stem cell transplantation: prospective comparison of Hickman and Groshong catheters.

Thrombosis is common after placement of silicone rubber subclavian vein catheters in patients with malignancy receiving conventional doses of chemotherapy. To determine the incidence of this complication in marrow transplant patients and the effect of different catheter designs on thrombosis rates, patients were randomized to receive either open-ended Hickman catheters or valve-ended Groshong catheters for venous access during the transplantation procedure. A total of 35 catheters were placed, of which 23 were double-lumen (11 Groshong and 12 Hickman) and 12 were single-lumen (six Groshong and six Hickman). Arm venograms were performed on all patients at the time of hematopoietic recovery or occurrence of symptoms of subclavian vein thrombosis. There were 10 cases of total subclavian vein thrombosis (three were symptomatic) and 12 cases of asymptomatic non-occlusive mural thrombi. Only 13 normal veins were found. There was no difference in thrombosis rate between the Hickman and Groshong catheters. Double lumen catheters tended to be more likely to cause total venous occlusion (nine of 23) than single lumen catheters (one of 12) (p = 0.06, Fisher's exact test). We conclude that subclavian vein thrombosis is a common occurrence after placement of silicone rubber catheters for venous access during marrow transplantation. Most cases are asymptomatic. Groshong catheters are just as likely to cause this complication as Hickman catheters.     

Treatment of chronic obstruction of the axillary, subclavian, and innominate veins

Of 79 patients seen at the University of Minnesota with symptomatic chronic obstruction of the axillary subclavian or innominate vein, 65 were considered surgical candidates. Etiology of the obstruction was as follows: Group A (n=45), previous subclavian effort thrombosis; Group B (n=14), stenosis caused by occupation or sport activities; and Group C (n=6), long segments (4–7.2 cm) of obstruction caused by chronic intraluminal placement of devices (catheters, pacemaker, or defibrillator leads).Fifty-nine patients (Groups A and B) underwent, via a subclavicular incision, removal of the first rib and vein patch angioplasty. Six patients (Group C) needed to have the incision extended transsternally to expose the entire length of the obstructed vein. In four of them, the subclavian-innominate vein was replaced with a cryopreserved small thoracic aortic homograft. In the other two, a long vein patch was used.The long-term success rate with the standard subclavicular incision (Groups A and B) was 85%; with the extended incision (Group C) it was 83% (patency of homograft, 100%; with the patch, 50%). In nine patients the vein occluded postoperatively (15%) due to inadequate exposure. We designed a new extended approach through the sternum in six patients and achieved a 100% success rate.Presented in part at the 39th Annual World Congress, International College of Angiology, Istanbul, Turkey, June 1997.     

Prevertebral lesions of the subclavian artery: long-term results of reconstructive surgery and percutaneous angioplasty

Short and long-term results were compared after reconstructive surgery and percutaneous transluminal angioplasty (PTA) of aortic arch trunks and subclavian arteries in 2 groups of patients (10 after dilatation and 12 after surgery). The technique used for treatment was selected as a function of distribution of lesions, their number and their appearance. Gruntzig's method was applied for PTA, while surgery consisted of either reimplantation of subclavian arteries into the main carotid artery or prosthetic by-pass procedures. Immediate and long-term (mean: 14 months) review examinations were by Doppler velocimetry and digital subtraction angiography. Thromboembolic complications secondary to PTA were not observed and there were no cases of recurrence of stenosis in the 10 patients after follow up for 13 months. Complications after surgery were one case of recurrence of stenosis requiring a repeat operation after 20 months, one case of thrombosis of carotid-axillary shunt after 19 months and one case of repeat surgery for lymphorrhea. Long-term results were very good in this series of 12 patients. It is difficult to compare results of the two techniques, patients treated by surgery having multiple lesions requiring combined procedures, and the number of cases treated being too low. However, PTA appears to be effective therapy for localized, non-ulcerated stenosis, and surgery for long or ulcerated stenosis, complete thrombosis and multiple lesions of aortic arch trunks justifying associated procedures.     

Successful percutaneous aortic valve implantation via a stenotic left subclavian artery access

Severe aortic valve stenosis may be tackled with percutaneous aortic valve replacement instead of surgical replacement. At present, two CE marked prosthetic valves are available. The CoreValve ReValving System is primarily designed to be introduced transfemorally, while implantation via subclavian arteries has been described in cases of unsuitable femoral access. However, this route has been used when subclavian artery is free of disease. In this case report we describe a successful CoreValve ReValving System implantation via a diseased and tortuous left subclavian artery after predilatation balloon angioplasty. The prosthesis was then advanced in the native aortic valve, deployed, and successfully implanted. Techniques and manipulations are provided.     

Subclavian vein stenosis as a complication of subclavian catheterization for hemodialysis

Thirteen patients had placement of a subclavian vein catheter for temporary vascular access for hemodialysis. Peripheral venography was performed within two to six weeks of catheter placement. Forty-six percent (six of 13 patients) developed subclavian vein narrowing, which resolved in two patients. The duration of catheter placement had no impact on the incidence of this complication. Subclavian vein catheterization can frequently lead to subclavian vein stenosis, which often will resolve spontaneously. Consideration should be given to placement of subclavian lines on the contralateral side of a planned permanent vascular access.     

A Patient with Recurrent Arteriovenous Graft Thrombosis

Arteriovenous grafts (AVGs) are prone to frequent thrombosis that is superimposed on underlying hemodynamically significant stenosis, most commonly at the graft-vein anastomosis. There has been great interest in detecting AVG stenosis in a timely fashion and performing preemptive angioplasty, in the belief that this will prevent AVG thrombosis. Three surveillance methods (static dialysis venous pressure, flow monitoring, and duplex ultrasound) can detect AVG stenosis. Whereas observational studies have reported that surveillance with preemptive angioplasty substantially reduces AVG thrombosis, randomized clinical trials have failed to confirm such a benefit. There is a high frequency of early AVG restenosis after angioplasty caused by aggressive neointimal hyperplasia resulting from vascular injury. Stent grafts prevent AVG restenosis better than balloon angioplasty, but they do not prevent AVG thrombosis. Several pharmacologic interventions to prevent AVG failure have been evaluated in randomized clinical trials. Anticoagulation or aspirin plus clopidogrel do not prevent AVG thrombosis, but increase hemorrhagic events. Treatment of hyperhomocysteinemia does not prevent AVG thrombosis. Dipyridamole plus aspirin modestly decreases AVG stenosis or thrombosis. Fish oil substantially decreases the frequency of AVG stenosis and thrombosis. In patients who have exhausted all options for vascular access in the upper extremities, thigh AVGs are a superior option to tunneled internal jugular vein central vein catheters (CVCs). An immediate-use AVG is a reasonable option in patients with recurrent CVC dysfunction or infection. Tunneled femoral CVCs have much worse survival than internal jugular CVCs.     

Percutaneous subclavian vein catheterization for hemodialysis: a report of 57 insertions

The authors report an analysis of 57 subclavian vein catheterizations for hemodialysis. A total of 51 patients (34 men, 17 women) kept the Cobe single- and double-lumen catheters for 1,726 days. The youngest patient was eighteen and the oldest seventy-two years of age. There were no catheter-related deaths. Complications were encountered in 9 patients. The only life-threatening complication was cardiac arrest, which occurred during flushing of the catheter. The patient was successfully revived. The other complications were pneumothorax and hydrothorax in 1 patient, catheter site infection in 5 patients, and arrhythmias in 2 patients, which stopped after readjustment of the catheter tips. Their experience indicates that percutaneous subclavian vein catheterization is safe and provides quick access for hemodialysis with no morbidity and mortality if done correctly, patiently, and meticulously. The authors believe that this should be the first choice in patients with reversible renal failure and in patients with chronic renal failure, who are usually elderly and medically compromised, till a permanent vascular access is ready for use.     

Catheter-Directed Thrombolysis Is a Safe and Alternative Therapeutic Approach in the Management of Postpartum Lower Limb Deep Venous Thrombosis

Deep vein thrombosis (DVT) is a major health problem in pregnancy and postpartum period. Catheter-directed thrombolysis (CDT) is safe and effective in management of symptomatic DVT. Value of CDT in postpartum DVT is not fully evaluated. We describe five patients presenting with acute iliofemoral DVT in their early postpartum period who were treated with mechanical thromboaspiration and CDT. The CDT was done using streptokinase infusion and unfractionated heparin. Percutaneous angioplasty was done in patients with symptomatic residual lesion following thrombolysis. Patients were discharged with oral anticoagulant and compression stockings. This approach was successful in all four cases. Percutaneous endovascular therapy using CDT, mechanical thromboaspiration, and balloon angioplasty is safe and effective in iliofemoral DVT in postpartum period.     

Percutaneous insertion of subclavian Hickman catheters

We have assessed the percutaneous insertion of Hickman catheters implanted directly into the subclavian vein; 116 catheters were inserted in 86 patients. The catheters were all inserted by members of the haematology staff. The majority of the catheters were inserted under local anaesthetic in a haematology ward with filtered positive pressure ventilation. X-ray screening was not routinely used. The average patient age was 45 years and the average platelet count was 155 x 10(9)/l. Sixty-seven per cent of the catheters either remain in situ or have been removed electively or at death. The remainder have been removed for a variety of reasons (infection 10%, suspected infection 8%, accidental dislodgement 7%, thrombosis 4%, catheter blockage 3%, catheter fracture 0.9%). The only complication specific to direct subclavian puncture was pneumothorax (4%). This disadvantage may be offset by rapid insertion, a cosmetically superior result and the avoidance of surgical and operating theatre time.     

Transluminal angioplasty of the subclavian artery. Apropos of a case

The authors described a case of left subclavian artery stenosis, treated by percutaneous transluminal angioplasty (PTA), in a patient with subclavian steal and arm claudication. The excellent technical and immediate clinical success justify this case report in consideration to the severe subocclusive lesion. The Authors present the clinical and technical aspects of subclavian artery PTA.     

Multiple pulmonary emboli with pulmonary hypertension caused by effort thrombosis and effective balloon venoplasty of the subclavian vein

A 36-year-old woman with effort thrombosis of the subclavian vein associated with multiple pulmonary emboli was successfully treated with local thrombolysis of the subclavian vein using a pulse-spray catheter and systemic anticoagulation. Balloon venoplasty of the residual stenosis of subclavian vein was carried out and in follow-up venography 6 months later, there was no restenosis, and the patient has been asymptomatic for 12 months. Pulmonary embolism is not a rare complication of upper extremity deep vein thrombosis and should be managed as aggressively as lower extremity deep vein thrombosis.     

锁骨下静脉穿刺置管术在造血干细胞移植中的应用

目的:探讨锁骨下静脉穿刺置管术在造血干细胞移植中的操作方法,失误分析及并发症的预防。方法:回顾性分析1996～2004年30例造血干细胞移植患者锁骨下静脉穿刺置管的应用及并发症防治。结果:28例患者成功地经右侧锁骨下静脉穿刺置管,其中1例损伤锁骨下动脉,2例误入颈内静脉。2例经右侧穿刺失败,改行左侧锁骨下静脉穿刺成功。置管平均39d(27～65d),3例分别于置管后18d,22d,36d发生部分阻塞,2例分别于置管后24d,38d发生脱落。30例均未发生经导管感染。结论:锁骨下静脉穿刺置管是造血干细胞移植中的重要环节。熟悉锁骨下静脉的解剖位置和正确操作是置管成功和避免并发症的关键,预防性应用抗生素,全环境保护,精心护理是预防导管感染、阻塞、脱落的保征。