Avoid the Subclavian Vein for Central Access of any Type in a Dialysis Patient or Possible Dialysis Patient
Michael J. Moritz MD
There are almost 300,000 hemodialysis patients in the United States today, and the number increases by about 4% to 5% annually. The median age of the dialysis patient in the United States has risen to 65 years. The aging population and the relative scarcity of renal transplants (about 10,000 done annually in the United States) means that dialysis will be required for longer periods of time and in many patients will be lifelong. In parallel, the critical nature of the vascular access in hemodialysis patients is amplified by longer dependence on this access for dialysis. Provision of vascular access is the greatest problem in dialysis today, with the solution involving the patient, nephrologist, surgeon, and interventional radiologist.
In the optimal situation, the patient presents early enough that the surgeon can place a permanent access in advance of dialysis. However, more commonly, patients present with an acute need for dialysis that requires temporary dialysis access via percutaneous catheters. As the majority of these patients will go on to require chronic dialysis, it is vital that the temporary-access catheter not compromise the anatomy required for permanent-access procedures. The preferred sites for temporary-access catheter placement are the internal jugular veins and the femoral veins; the subclavian veins should be avoided.
What Not to Do
Temporary percutaneous dialysis access catheters are placed via central veins. They are very large in diameter compared with other venous catheters and can be associated with cannulated vein and an increased risk of thrombosis or stenosis of the vein, which can occur acutely or can present much later. The venous damage can be at the site of entrance into the vein or more centrally. In studies examining damage from short-term use (2 to 4 weeks), dialysis catheters placed by the subclavian route resulted in venous stenosis or thrombosis in 50% to 70% of veins, in contrast to a 0% to 10% incidence in catheters placed by the internal jugular route. Although the risk of injury to the vein is less than with dialysis catheters, in dialysis patients the subclavian vein should be avoided for placement of smaller-bore central
venous catheters such as triple-lumen catheters, TPN (total parenteral nutrition) lines, or catheters that permit pulmonary artery catheters to be threaded through them.
venous catheters such as triple-lumen catheters, TPN (total parenteral nutrition) lines, or catheters that permit pulmonary artery catheters to be threaded through them.
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