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In the present report, we describe the case of a 76-year-old hemodialysis patient who was admitted with clinical features of neurological thoracic exit syndrome due to subclavian artery pseudoaneurysm following the insertion of a dual lumen vascular internal jugular catheter (vascath) with excellent outcome after endo-arterial stent placement.

A 65-year-old male with type II diabetes who had been on antidiabetic medication for 10 years was admitted to our hospital due to an altered state of consciousness, attributed to hypoglycemia, renal failure, and metabolic acidosis. From his medical history it was known that an artificial urinary sphincter (AUS) had been placed 9 years previously due to incontinence caused by reduced outlet resistance (also known as intrinsic sphincter deficiency) following prostate surgery. On placement of the AUS his renal function was normal (serum creatinine 1 mg/dL) and two years later he was diagnosed with a slightly deteriorated renal function (serum creatinine 1.8 mg/dL) without any urological follow-up until the day of admission to our clinic. On examination he was tachycardic (120 bpm) with tachypnoe, arterial hypertension (170/100 mmHg), edema of the lower extremities, and fine crackles on the lung bases. He was also suffering from dribbling during the last days and on palpation there was also found to be significant bladder distension. From the paraclinical examination he showed normochromic anemia (Ht=22%, Hb=7.6 gr/dL), severely compro- Accepted: May 11, 2011 CASE REPORT mised renal function (serum creatinine 6.4 mg/dL, serum urea 200 mg/dL), metabolic acidosis (pH=7.15, pCO 2 =20 mmHg, HCO 3 =10 mEq/L) and sterile leucocyturia (>100 per high power field). The urinary culture was negative. Pulmonary congestion was detected on the chest x-ray. A renal ultrasound revealed bilateral hydronephrosis with kidneys of normal size (left: 10.7 cm, right: 11.2 cm) increased echogenicity, and reduced thickness of the cortex, as well as the presence of an AUS in the pelvic area and the scrotum that was reconfirmed in the plain abdominal x-ray. Intravenous urography showed a slow parenchymal infiltration of the contrast media and a very slow excretory stage with a significant bladder distension. Other urological problems like ureteral or urethral stenosis were excluded as the urine flow was strong and uninterrupted after the activation of the AUS. Transdermal nephrostomies were inserted in order to assess the functional capacity of each kidney; the left one functioned properly with a urine volume of 2.5 L to 3 L per 24 hours. Despite the satisfactory urine output his renal function did not improve and he started chronic hemodialysis 22 days post-insertion of the nephrostomies.

In the present report, we describe an unusual case of an adult patient with Down syndrome and ectopic right kidney, who developed end-stage renal disease due to chronic obstructive nephropathy and secondary amyloidosis and was successfully treated with hemodialysis.