Why is a subclavian (subclavian vein catheter) line avoided in patients with advanced kidney disease, and is an internal jugular (IJ) line preferred?

Why Subclavian Lines Are Avoided in Advanced Kidney Disease Patients

Subclavian vein catheterization should be strictly avoided in patients with advanced kidney disease due to the high risk of central venous stenosis, which can permanently preclude the use of the entire ipsilateral arm for future vascular access. 1

Central Venous Stenosis: The Primary Concern

• Subclavian vein catheterization is strongly associated with central venous stenosis, which can render an entire arm unusable for creating arteriovenous (AV) fistulas or grafts needed for long-term hemodialysis access 1
• Studies have shown that subclavian vein stenosis occurs in up to 34% of patients with previous subclavian catheterization 2
• Once central venous stenosis develops, it can permanently compromise the ability to create a functioning vascular access in the affected arm 1

Why Internal Jugular (IJ) Vein is Preferred

• Internal jugular vein catheterization has a significantly lower risk of causing central venous stenosis compared to the subclavian approach 1
• IJ catheters preserve potential access sites in the arms for future permanent vascular access creation 1
• IJ access allows for easier catheter maintenance and typically provides better blood flow rates 1

Evidence Supporting IJ Over Subclavian

• Clinical practice guidelines explicitly recommend against subclavian vein catheterization in patients with kidney disease 1
• Research has demonstrated that subclavian catheters can lead to significant vessel damage in 19-34% of patients 2, 3
• Multiple studies have shown that subclavian vein thrombosis can occur even in asymptomatic patients, with one study finding complete thrombosis or severe stenosis in 19% of patients with previous subclavian catheters 3

Impact on Long-Term Vascular Access

• Patients with advanced kidney disease will likely need permanent vascular access (AV fistula or graft) for long-term hemodialysis 1
• Subclavian stenosis can lead to venous hypertension and arm swelling when an AV access is created downstream from the stenosis 4
• Loss of potential access sites significantly impacts patient morbidity and mortality, as vascular access complications are a leading cause of hospitalization in dialysis patients 1

Clinical Implications and Best Practices

• For temporary vascular access in patients with advanced kidney disease, the internal jugular vein should be the first choice 1
• If IJ access is not possible, femoral vein catheterization is preferable to subclavian, despite its own limitations (higher infection risk in ambulatory patients) 1
• Peripherally inserted central catheters (PICCs) should also be avoided in patients with advanced kidney disease due to similar risks of venous damage 1
• Ultrasound guidance should be used for IJ catheter placement to minimize insertion complications 1

Vein Preservation Strategy

• All patients with advanced kidney disease should have their arm veins preserved for potential future vascular access 1
• Healthcare professionals should be educated about the importance of vein preservation in these patients 1
• Venipuncture and IV lines should preferentially use the dorsum of the hand rather than arm veins 1
• Patients with progressive kidney disease (creatinine >3 mg/dL) should be instructed to protect their arms from venipuncture and IV catheters 1

By avoiding subclavian vein catheterization in patients with advanced kidney disease, clinicians can help preserve future vascular access options, which is critical for long-term hemodialysis success and patient survival.