Diagnosis and management of subclavian vein thrombosis occurring in association with subclavian cannulation for hemodialysis

With the aim of improving the diagnosis and treatment of subclavian vein thrombosis, associated with subclavian cannulation for hemodialysis, we performed Doppler examination of the subclavian vein and clinical inspection of the ipsilateral arm at every dialysis in 50 consecutive patients who received subclavian hemodialysis catheters over 1 year. Edema of the arm and disappearance of the subclavian vein bruit correctly detected 3 cases of subclavian vein obstruction which were confirmed by X-ray venograms. All 3 cases failed to respond to systemic heparin, but were successfully recanalized within 36 h with continuous local streptokinase infusion at a rate of 10,000 U in 1 ml/h. In 4 other cases of edema of the arm, Doppler examination correctly predicted patency of the vein, also confirmed radiologically. In 2 cases of thrombosis, there was an underlying stenosis of the left innominate vein close to its union with the superior vena cava. These were dilated by balloon angioplasty; the stenosis recurred in both cases without recurrent thrombosis, and the angioplasty was repeated. Doppler surveillance seems to be a promising aid to the detection of subclavian vein thrombosis from hemodialysis catheters. Local streptokinase infusion is effective in treating thrombosis. Underlying venous stenosis should be looked for because this may be at least partly remediable by balloon angioplasty.