LEARNING FROM IMAGES Subclavian or Internal Jugular Tunneled Dialysis Catheter: Can we Divulge the Location?

A reliable and safe vascular access is critical for providing life sustaining hemodialysis therapy to patients with end stage renal disease (ESRD). Although a permanent arteriovenous access such as an arteriovenous fistula or arteriovenous graft is preferred, the United States Renal Data System (USRDS) data reports that nearly 80 percent of incident hemodialysis patients initiate treatment with a central venous catheter [1]. While the ability to use a tunneled hemodialysis catheter (THDC) immediately after placement is a significant advantage, it is often offset by a wide array of disadvantages such as increased likelihood of catheter related blood stream infection, catheter thrombosis, and fibrin sheath formation leading to catheter dysfunction resulting in a higher incidence of associated morbidity and mortality. In addition, there is a substantial risk of central venous stenosis (CVS) or occlusion, specially in the setting of long-term use of multiple catheters [2]. The true incidence and prevalence of CVS in the ESRD population are unknown; however, it has been reported to be as high as 3050% with subclavian vein catheters and potentially the lowest (around 10%) with an internal jugular vein (IJ) THDC [2, 3]. Moreover, placement of THDC can permanently compromise future access placement in the ipsilateral extremity.