Insertion of subclavian hemodialysis catheters in difficult cases: value of fluoroscopy and angiographic techniques.

Double-lumen hemodialysis catheters designed to be placed via a subclavian vein approach have gained rapid acceptance over the past several years. Several studies have shown a significant rate of subclavian vein stenosis or occlusion after placement of these catheters. A large number of these patients require repeat placement of catheters with access often becoming increasingly difficult to obtain. Over the past 5 years, we have been asked to place 38 catheters in 34 patients that could not be placed at the bedside. Our procedure consists of obtaining a preliminary venogram to evaluate the reason for difficulty. The subclavian vein is then cannulated under direct fluoroscopic visualization while the peripheral venous line is injected with contrast material. Percutaneous angiographic techniques are then used to position the catheter. Satisfactory placement was obtained in all 38 cases. There were no complications, which is surprising considering the number of complications seen with the standard methods of insertion. This represents a new role for the interventional radiologist, one that can be important in minimizing the number of new dialysis sites in any one patient.