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A 67-year-old woman with end-stage renal disease (polycystic kidney disease) who had been on dialysis for 10 years came to our department for a second opinion about upper left arm edema homolateral to the arteriovenous fistula (AVF). Because of the suspicion of venous stenosis she had already been submitted to angiographic examination of the AVF which, however, did not show any occlusive process. In addition to the kidney problem, the clinical history included dilated cardiomyopathy, and 2 years earlier a biventricular implantable cardioverter defibrillator (ICD) had been placed. The patient had never had a central venous catheter (CVC). She presented a typical superior vena cava syndrome picture with arm, neck and hemifacial edema and superficial cutaneous venous reticulum. The venous pressure during extracoroporeal circulation was high and blood recirculation was documented. Angio-CT was performed to look for a compressive process in the chest, but this was excluded. We then performed a new trans-AVF angiography to study extensively the axillary-subclavian-superior vena cava district. At first, no stenosis or thrombosis was observed, but the presence of ICD and its leads (left-sided implanted) in the anonymous vein created obstacles to diagnosis. Repeated injections of contrast medium and focusing imaging on the leads route allowed us to highlight a venous stenosis in the anonymous vein. Transluminal angioplasty was successfully carried out during the same procedure. 1) In hemodialysis patients the appearance of signs of intrathoracic vein drainage obstacles is not always associated with previous CVC implantation; 2) in the hemodialysis patient, any device (PM, ICD) should be implanted contralaterally to the fistula arm in order to avoid the risk that a venous stenosis may cause AVF dysfunction.

Six haemodialyzed patient are reported in whom subclavian and brachiocephalic vein stenosis secondary to subclavian vein catheterization and to permanent cardiac pacemakers led to massive congestive edema of the same arm after an arteriovenous fistula/grafts were created. In view of the fact that subclavian vein stenosis or occlusion is not associated with any clinical findings and it is not possible to identify any predisposing factors associated with the use of the catheters, all patients who have had previous subclavian vein catheters or with permanent pacemakers should be evaluated to determine the patency of the subclavian vein before creation of a permanent access in that arm. Therapeutic answers as to haemodialysis access are discussed in these patients with permanent pacemakers who need haemodialysis. Because of all of these problems, the practice of subclavian cannulation in patients with end-stage renal failure has been discontinued in our centre. Good and reliable technology is now available for repeated short-term or long-term cannulation of the jugular veins for hemodialysis.