In Reply to: Case 997_04 -- Complications of central venous access after venous stent placement posted by Editor on September 16, 1997 at 10:57:39:
Subclavian stents are certainly a last resort and used only when all other options including repeated aggressive angioplasty have failed. Despite their dismal performance in terms of primary patency, there is still a valid role for their use especially in patients with a graft and severe arm swelling due to a severe subclavian stenosis or occlusion that does not respond to venoplasty alone. If you can gain an additional 6 months to a year from that site with repeated interventions, I think you have actually provided a benefit to that patient.
How to alert everyone to the presence of a subclavian stent? A medical alert braclet is a good idea. A tatoo can also be used. However, the way to prevent this complication is to educate.
As we place almost all the temporary and permanent dialysis cathetersat our institution, the issue does not arise in our practice. The critical issue here is that placement of a dialysis catheter into the subclavian vein in a patient with renal failure should never occur. Subclavian vein catherization for dialysis acces should be considered medical negligence and I feel is below the standard of care for this patient population. Through the dialysis coordinator and directors of the dialysis centers, it should be made quite clear that no catheters should ever be placed in the subclavian until all other access routes have been exhausted or the patient is not a candidate for a graft or fistula in that extremity. If the individual placing the line is uncomfortable or unable to place an IJ line, they should find someone who is. Along the same lines, stents shouldn't be placed across the orifice of a patent IJ as you basically loose access to that IJ for catheter placement. Once word gets out that subclavian line placement is taboo, the incidence of this described complication should decrease tremendously.