The incorrect placement of hemodialysis catheters in veins. The necessity for urgent X-ray evaluation for its position

We describe a 56-year-old woman with end stage renal failure, who has an un usual complication in relation to catheter placement. She started hemodialy sis in 1992 and until October of 1996 had many arteriovenous fistulas in he r upper arms and we placed a lot of grafts. Because she had no vascular acc ess for hemodialysis, we decided to place a polyurethane catheter in the le ft internal jugular vein. The woman had been in good health for 15 months w hen the blood flow decreased rapidly, so we replaced the catheter with a ne w one stablized with silicone in the same place. Because the blood flow aga in was insufficient for a good dialysis session we decided to check the cat heter position angiographically, and were surprised to ascertain that the c atheter was placed in the internal thoracic (mammalian) vein. We discuss th is patient because she is the first in the international bibliography.