Placement of a Subclavian Tunneled Hemodialysis Catheter with the Patient's Arm Raised May Reduce the Risk of Complications: Two Cases Report

Abstract

The subclavian vein is an uncommon route for tunneled hemodialysis catheter (tHDC) placement because of its potency for future dialysis access. However, when favored access routes have been exhausted because of repeated catheterization or limited life expectancy, the subclavian vein can be used for urgent hemodialysis. A subclavian catheterization has a technical problem. The subclavian vein often forms a right angle with the vena cava, and advancing stiff peel-away sheath can cause a vascular injury. However, raising the patient's arm can alter the position of the guidewire and, therefore, change the angle of the vein favorable for tHDC placement. Herein, we report two patients who underwent subclavian catheterization; one experienced an injury to the superior vena cava after undergoing the conventional procedure, whereas the other patient with raised arm during the catheterization procedure had safe catheter placement.

Keywords: Catheters; Hemothorax; Renal Dialysis; Subclavian Vein.

Fig. 1. Case 1.

A. A fluoroscopic thoracic image of a 74-year-old female during placement of a tunneled hemodialysis catheter shows the near right angle of the subclavian vein relative to the superior vena cava and a small amount of contrast medium (arrow) around the innominate vein. A hemodialysis catheter was placed over a 0.035-inch guidewire and through a subclavian peel-away sheath. B. A CT image shows a small hemorrhage in the mediastinum (arrow).

Fig. 2. Case 2.

A. A fluoroscopic thoracic image of a 72-year-old female reveals the right angle of the subclavian vein into which a 0.018-inch guidewire (arrows) was inserted. B. A second fluoroscopic image obtained after the patient raised her right arm reveals the change in the angle (arrow) of the guidewire. C. A peel-away sheath (arrow) was inserted into the cavoatrial junction using a J-tip 0.038-inch guidewire. D. The final fluoroscopic image shows the successful placement of the tunneled hemodialysis catheter through the subclavian vein.