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Subclavian vein flexible guidewire knotting. A potential serious complication in hemodialysis patients
Chr. Koundouris, G. Tornaris, I. Charopoulos, A. Vounasis, G. Solomou
Subclavian vein catheterization for hemodialysis was first introduced in the late 1970s, and has since proven to be a relatively safe and effective method to provide temporary vascular access for acute settings (1, 2). However this procedure is not rid of complications, some of them have been well described in the literature and include: ipsilateral pneumothorax, hemothorax and hydrothorax, mediastinal hematoma, pericardial effusion with tamponade, hemorrhage, infection, subclavian vein stenosis and thrombosis and misplacement of the catheter (3, 4). To our knowledge, this is the first case of subclavian vein catheterization flexible guidewire knotting reported. We report it because of its rarity, to raise awareness of such a complication and to emphasize on its successful outcome.

Report of a case

A 72 year old woman with a history of end-stage renal disease secondary to diabetes, had been on hemodialysis for eight years. She presented with her left upper extremity AV-F thrombosed on the scheduled hemodialysis day. A right subclavian vein catheterization for hemodialysis was then decided. Her right subclavian vein had also been recatheteri-zed twice for hemodialysis, once prior to the creation of the AV-F and again for the same problem, thrombosis of the AV-F.
The patient was placed in a supine Trendelenburg’s position and the puncture of the vein was an easy task. The return of venous blood into the syringe attached to the needle confirmed entry into the vein. The flexible guidewire was easily inserted through the needle but after several centimeters of advancement into the vein lumen, the operator felt a difficulty in further advancing. That difficulty was overcome by simply pushing the guidewire, but after a couple of centimeters advancement again the guidewire couldn’t be further advanced, as was impossible its withdrawal. At that point, chest radiography was performed and showed the guidewire knotting (fig. 1).
The kit’s dilator was introduced and splinted the guidewire up to border of the knot, by strict radioscopic control. By pushing and pulling and at the same time rotating clock and counterclockwise the guidewire, depending of the image, step by step it has been managed to untie (fig. 2, 3, 4), mainly due to guidewire’s memory (tendency to regain its original shape). Unfortunately, we could not obtain the final picture because the guidewire slipped out of the vein when it was fully unknit. The procedure lasted less than ten minutes and no extra anesthesia was needed than the local one given for the insertion of catheter.
A new chest x-ray showed no other pathology and the patient was in excellent condition. No attempt was made for catheterization of the same or the contralateral subclavian vein. A right femoral vein hemodialysis catheter was placed and after the dialysis session the patient was referred to a vascular center for AV-F thrombus removal.
Figura 1
Figura 2
Figura 3
Figura 4

Discussion
Patients requiring hemodialysis frequently need temporary vascular access when an AV-F is not functional. Because blood flow of 200-300 ml/min is needed, venous cannulation is limited to large accessible vessels such as the subclavian, internal jugular or femoral veins.
Complications of acute vascular access for hemodialysis are generally of two types, those directly related to insertion and those related to the presence of an indwelling venous catheter.
Subclavian vein catheterization for hemodialysis is often a successful and uncomplicated procedure. Reported complication rates range from 0.3 to 12 percent, according to the experience of the physician and the definition of complications (3, 5, 6). However, some complications related to hemodialysis catheter inserted into the subclavian vein for temporary access can be a significant clinical problem. To our knowledge, this is the first case of subclavian vein flexible guidewire knotting reported. There has been another report of subclavian vein catheter knotting but it occurred between two catheters inserted from opposite sides (7).
Possible explanation of the complication occurred in our case is, subclavian vein and eventually superior vena cava abnormalities (stenosis and thrombosis), due to previous catheterizations and long standing of the indwelling catheters in the vein lumen. The guidewire met an obstacle in the lumen of the veins and its tip turned backwards and formed a knott. The knott tighted up when the operator tried to remove ghe guidewire. Postcatheterization subclavian vein stenosis and thrombosis are not infrequent complications and have been reported to be as high as 33 to 50 percent (8, 9). These complications are not clinically manifested until a vascular access is created distal to the lesion, when venous blood flow increases or specially sought by venous angiography or ultrasound (10, 11). Intimal trauma with endothelial disruption at the puncture site is a frequent cause of vein stricture. Moreover, the to-and-fro movement of the blood from the pump, the motion of the catheter tip by heart beats, and the rubbing and irritation of the catheter against the vein wall have been implicated as causes of venous stenosis and thrombosis (10). Also, the physiologic extrinsic compression where the subclavian vein crosses between the clavicle and the first rib, has been proposed as a cause of venous narrowing, facilitating subsequent stenosis and thrombosis (12).
The seriousness of guidewire knotting into the subclavian vein lumen cannot be overemphasized. We cannot imagine other solution of the complication than direct surgical approach, exposure of the right subclavian vein and venotomy or the procedure we followed. Splinting the guidewire with the kit’s dilator and pushing, pulling and rotating it clock or counterclockwise under radioscopic control, depending on the image, we gave it the possibility to express its memory, that is, the ability to regain its original shape and to unknit. The whole system works like an articulation and the procedure has to be done under strict radioscopic control.
We still believe that although temporary subclavian vein catheters may lead to various well known complications, including the one reported here, their ability however to provide relatively trouble-free hemodialysis vascular access, represents a compelling reason to continue their use. In addition to, as the status of the subclavian vein subjected to repeated cannulation for hemodialysis is unknown, one should consider evaluating the vein patency by ultrasound before venous recatheterization.

References
1. SCHWARZBECK A, BRITTING WE, VON HENNING GE, et al. - Cannulation of subclavian vein for hemodialysis using seldinger’s technique. Trans Am Soc Artif Intern Organs, 1978, 24:27-29
2. TWARDOWSKI ZJ - Percutaneous blood access for hemodialysis. Semin Dial, 1995, 8:175-186
3. VANHERWEGHEM JL, CABOLET P, DHAENE M, et al. - Complications related to subclavian catheters for hemodialysis. Am J Nephrol, 1986, 6:339-345
4. CLARK DD, ALBINA JE, CHAZAN JA - Subclavian vein stenosis and thrombosis: A potential serious complication in chronic hemodialysis patients. Am J kidney diseases, 1990, XV(3):265-268
5. MUGHAL MM - Complications of intravenous feeding catheters. Br J Surg, 1989, 76:15-21
6. DEJONG PCM, VON MEYENFELDT MR, ROUFLART M, WESDORP RIC, SOETERS PB - Complications of central venous catheterization of the subclavian vein: the influence of a parenteral nutrition team. Acta Anaesthesiol Scand Suppl., 1985, 81:48-52
7. SWARROP S - Knotting of two central venous monitoring catheters. Am J Med, 1972, 53:386-388
8. VANHERWEGHEM JL, YASSINE T, GOLDMAN M et al. - Subclavian vein thrombosis. A frequent complication of subclavian vein cannulation for hemodialysis. Clin Neprol, 1986, 26:235-238
9. SCHWAB SJ, QUARLES D, MIDDLETON JP, et al. - Hemodialysis - associated subclavian vein stenosis. Kidney Int, 1988, 33:1156-1159
10. SCHILLINGER F, SCHILLINGER D, MONTAGNAC R, MILCENT T. - Postcatherisation vein stenosis in hemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant, 1991, 6:722-724
11. MANSFIELD P, HOHN D, FORNAGE B, et al. - Complications and failures of subclavian vein catheterization. N Engl J Med, 1994, 331:1735-1738
12. GLANZ S, GORDON D, BUTT K, HONG J, LIPKOWITZ G. - The role of percutaneous angioplasty in the management of chronic hemodialysis fistulas. Ann Surg, 1987, 206:777-78

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