The incorrect placement of hemodialysis catheters in veins. The necessity for urgent x-ray evaluation for its position.

We describe a 56-year-old woman with end stage renal failure, who has an unusual complication in relation to catheter placement. She started hemodialysis in 1992 and until October of 1996 had many arteriovenous fistulas in her upper arms and we placed a lot of grafts. Because she had no vascular access for hemodialysis, we decided to place a polyurethane catheter in the left internal jugular vein. The woman had been in good health for 15 months when the blood flow decreased rapidly, so we replaced the catheter with a new one stabilized with silicone in the same place. Because the blood flow again was insufficient for a good dialysis session we decided to check the catheter position angiographically, and were surprised to ascertain that the catheter was placed in the internal thoracic (mammalian) vein. We discuss this patient because she is the first in the international bibliography.