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The number of patients undergoing chemotherapy for tumor disease has considerably increased in the last years. One of the problems of these long-term treatment modalities is the destruction of the peripheral venous system due to the repeated venous punctures for the therapy itself as well as for the laboratory analyses. This has been the motive for the research on permanent perfusion systems which would work at long term in a reliable way. Nowadays, several industrial products are available, devices for the standard implantation intravenously but also devices for intraarterial and intraperitoneal use. In our hands, the access through the subclavian vein with the end of the catheter in the superior caval vein has proven to be a safe and easy method. The port is placed in the triangle between the coracoid process and the clavicula. The large experience made by the centers in Basle and Berne as well as our own experiences in Bienne have clearly demonstrated the benefit of these systems for the patient. Nevertheless, some complications have to be mentioned such as the wellknown complications of the puncture of the subclavian vein. The risk of complete occlusion of the catheter must be expected at the rate of 0.5%. Hematomas immediately after the punction of the port have also been described. We would like to outline that complications of these permanent infusion systems are rare, especially in comparison with the complication rate of the normal percutaneous central venous sets. We therefore strongly advocate the implantation of these devices in the first instance before the beginning of any treatment in order to save the peripheral venous system of these patients.

We report a case of traumatic chylothorax which occurred after a right subclavian vein catheterisation. Chyle output exceeded 4 L.day-1 despite a continuous drainage of the pleural space, cessation of oral intake and mechanical ventilation. It was cured by addition of PEP to ventilation. The various causes and therapeutic approaches are reviewed.

Inserting a thoracic drain is an invasive procedure which can cause several complications. We describe a new complication unreported to date: perforation-intubation of the subclavian vein. This case confirms the need to carefully choose the drainage point before insertion. Deformation of the thorax, especially in obese patients may require incision and digital palpation of the pleural space before insertion of the drain.

Thrombosis or stenosis of the vessel is an usual complication of the long term catheterization of the veins. In hemodialysis, thrombosis and/or stenosis of the subclavian vein occur in 35% of the patients receiving a subclavian dialysis catheter. This complication is usually asymptomatic but, in some cases, the thrombosis or the stenosis of the subclavian vein leads to a painful oedema of the arm when an arteriovenous fistula is created on the same side. Sometimes, the closure of the fistula is required and a whole arm is excluded for future vascular access. Thrombosis or stenosis of central veins is significantly less frequent (3%) when the jugular veins are used for the insertion of the dialysis catheter. When the thrombosis is acute, spontaneous resolution may occur following catheter removal. When the thrombus does not resolve, anticoagulation with heparin or thrombolytic therapy with or without angioplasty has been used. Surgery with by pass of the subclavian vein may be necessary as a final option in an attempt to salvage a fistula. Taken into account these stenotic or thrombotic complications of dialysis catheters, subclavian route should be abandoned in chronic uremic patients and femoral route should be preferred for a short period access while jugular route could be used for long term temporary vascular access for hemodialysis.

From January 1986 to December 1990, we studied angiographically the subclavian-brachiocephalic vein of 100 patients dialysed on subclavian catheter for 50 (first group) and on internal jugular catheter for the 50 others (second group). These 2 groups are not statistically different for age: 61.6 +/- 11.3 years in the first and 61 +/- 11.1 in the second, for sex: respectively 48% and 56% of women, for time-length of catheter insertion: respectively 31 +/- 21.8 days and 31.7 +/- 16, and for number of dialysis sessions: respectively 13.5 +/- 9.1 and 13.6 +/- 7.1. The type of catheters, the frequency of removal for poor flow (16% in both groups) or for infections (6% in both groups) and the local nursing are similar in the 2 groups. Only the side of cannulation differs: the right side is used in 58% of cases in the first group and 78% in the second one. The angiographic study reveals a stenosis of the vein in 42% of the subclavian group and in 10% of the internal jugular group. The left side presents more risks of stenosis than the right, what can be explained by anatomical features. The strictures, whose severity is variable, are mainly located at and slightly above the junction of jugular and subclavian veins. This significative difference in favour of the internal jugular route asserts its superiority on subclavian route in respect of venous access of dialysed patients.

The authors report a case of acute tamponnade as result of the collection under pressure of a lipid solution in the pericardium following perforation of the right atrium by a sub-clavian catheter. Diagnosis and treatment were practically siumultaneous. Aspiration of the lipid solution (450 ml) via the catheter confirmed the diagnosis and successfully treated the problem. With regard to the case, the following are discussed: - diagnostic features of acute tamponnade (acetiological, clinical, heemodynamic, electrocardiographic and radiological signs); - the physiopathological mechanism of tamponnade with changes in intra-pericardiac and ventricular pressure/volume cures; - finally, the management of tamponnade.