Delayed Onset of Hemothorax: An Unusual Complication of Subclavian Access for Hemodialysis

Abstract

Subclavian catheterization for acute hemodialysis has become routine in many institutions. Immediate complications of this technique are dramatic and easily recognized, whereas late complications are less common, frequently insidious and tend to be more severe. We report the delayed occurrence of a right hemothorax following two hemodialysis treatments with a left subclavian access. Pertinent literature is reviewed.

Prevalence of Delayed Hemothorax in Blunt Thoracic Trauma

“…DPTX has been reported 12 hours to 3 days after stab wounds. 31 Delayed hemothorax can be classified as: a) Iatrogenic: resulting after invasive procedures like placement of central subclavian access lines for monitoring or hemodialysis, 11,32,33 coronary stent placements, 26 other thoracic procedures and surgeries. 32 b) Traumatic: after blunt 7, 9, 13, 22-25 or penetrating trauma.…”

“…Weigelt et al 10 reported 9 per cent incidence of delayed pneumothorax or hemothorax within 48 hours of admission in 110 asymptomatic stab-wound patients. DHTX following subclavian access for hemodialysis was reported by Waldman et al 11 Ross and Cardoba 12 were first to publish two cases of DHTX associated with rib fractures. McLoughlin et al 13 reported that HTX was delayed for up to 4 weeks in 53 per cent of their 30 patients.…”

Thoracic Duct Injury: An Unusual Complication following Subclavian Catheterization for Hemodialysis

“…Advantages of subclavian access for hemodialysis in clude its ready availability, ease of insertion, the rela tively low incidence of complications and the fact that its use avoids sacrificing peripheral vessels as temporary access sites [1,5]. Potential acute complications of this procedure are air embolism, subclavian artery puncture, atrial or caval perforation, pneumothorax, catheter em bolism and thoracic duct injury [2,7], Major complica tions generally have a sudden onset, allowing corrective measures to be rapidly instituted [5], Verification of proper catheter positioning and the absence of major complications are routinely confirmed by chest X-ray taken immediately after placement [1,3,6],…”

“…Sporadic reports of subclavian catheter-related complications, such as pulmonary embolism, atrial or caval perforation, air em bolism, hydrothorax, hemothorax, infections and throm bosis, have appeared in the literature. Most complica tions occur within a few days of catheter implantation [2][3][4][5], We report herein a thoracic duct injury with cutane ous lymphatic fistula, related to a subclavian dialysis catheter placement on the left side. This complication has not been previously reported.…”