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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Vascular accesses represent a serious problem in patients with chronic kidney disease &#40;CKD&#41; who are undergoing haemodialysis&#46; Arteriovenous fistulae &#40;AV&#41; with native vessels or grafts are ideal accesses because of their long life and low rate of complications during use&#46; In patients for whom it is not possible to create an AV fistula&#44; it is necessary to implant central catheters in order to carry out the haemodialysis treatment&#46; However&#44; during their placement and use&#44; these catheters generate various complications&#44;<span class="elsevierStyleSup">1</span> one of which is thrombosis of the vessels in which they are inserted&#46; This means that with the passing of time&#44; patients run out of conventional vessels &#40;internal jugular&#44; subclavian&#44; axillary vein&#41; in the upper hemithorax&#44; and it becomes necessary to access the superior vena cava through uncommonly used vessels in order to perform haemodialysis&#46; In this article&#44; we present an alternative approach to the placement of haemodialysis catheters in the brachiocephalic vein&#44; also known as the innominate vein&#44; in patients with a history of thrombosis in the more conventional vessels&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE DESCRIPTION</span></p><p class="elsevierStylePara">The patients selected for catheter placement in a brachiocephalic vein were those who had catheters previously inserted in their internal jugular and axillary veins and in whom ultrasound showed those sites to be thrombosed&#44; whether due to previous catheterisation or to congenital malformation&#46; All of the patients gave written consent to have the procedure performed&#59; exclusion criteria were coagulation test abnormalities &#40;PTT and PT&#41;&#44; thrombocytopenia &#40;a platelet count below 50&#44;000 platelets&#41; or refusal to accept the procedure&#46; The characteristics of the selected patients are shown in table 1&#46;</p><p class="elsevierStylePara">The inclusion criteria are based on our Kidney Unit&#191;s protocol for the insertion of central venous catheters in which the preferred site is the right jugular vein first&#44; followed by the left jugular vein and finally the axillary veins&#46; We do not generally puncture the subclavian vein because of the risk of complications as explained below&#46;</p><p class="elsevierStylePara">All the patients had an initial ultrasound scan of the neck vessels and the infraclavicular region to exclude the existence of thrombosis in both internal jugular veins&#44; the subclavian and axillary veins and this was consistently documented&#46; For all patients&#44; we were able to determine the location of the brachiocephalic vein by placing the transducer just above the clavicle&#46;</p><p class="elsevierStylePara">Patients were positioned supine and the supra- and infraclavicular regions were cleaned&#46; Using aseptic technique and local anaesthetic&#44; the needle was introduced with sustained aspiration directly above the clavicle between the sternal and clavicular heads of the sternocleidomastoid muscle&#44; toward the mediastinum and parallel to the anterior thoracic wall&#44; until obtaining a good flow of blood&#46; We achievement puncture the vein easily&#44; 2-4cm from the skin puncture site&#59; once the vein had been reached&#44; we proceeded to thread the guidewire&#44; dilate the tunnel and place the permanent catheter&#46; It is then tunnelled through and brought out the right hemithoracic wall&#46;</p><p class="elsevierStylePara">Three patients had four catheters placed in the innominate vein&#58; three on the right side &#40;all permanent&#41;&#44; and one on the left side&#44; which was temporary&#46; No complications arose that could be attributed to the procedure&#46;</p><p class="elsevierStylePara">The temporary catheter was removed 15 days after its insertion due to it not functioning properly&#59; the three permanent catheters continue to work properly to date&#44; an average of eight months after their implantation&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">The implantation of central catheters is a routine procedure for most nephrologists&#46; The internal jugular vein approach is the most commonly used&#44; due to the ease of cannulation and the low rate of complications&#46;<span class="elsevierStyleSup">2</span> The subclavian route is not recommended because of its propensity for stenosis and thrombosis&#44; which subsequently prevent use of the ipsilateral side for AV fistulae creation&#46;<span class="elsevierStyleSup">3</span> The axillary vein may also be used for the placement of central catheters&#44; but reaching this vein requires medical personnel familiar with the cannulation procedure&#46;<span class="elsevierStyleSup">4</span> The femoral route is easy to access&#44; but its drawbacks are high rates of thrombosis and infections<span class="elsevierStyleSup">5 </span>making this site unsuitable for long-term catheter placement&#46; Other routes that are used in special situations are the transhepatic and translumbar routes&#46;<span class="elsevierStyleSup">6&#44;7</span></p><p class="elsevierStylePara">One of the complications associated with long-term use of central venous catheters is vein thrombosis and stenosis&#46; Various alternatives have been suggested for recanalization of occluded vessels&#44; including implanting stents8 and prostheses that replace stenosed segments&#44;<span class="elsevierStyleSup">9</span> but these are associated with a high rate of re-occlusion a few months later&#46; This fact obliges us to explore other routes to guarantee that haemodialysis patients have a satisfactory access&#44; and the innominate vein is an alternative that is not often used&#46;</p><p class="elsevierStylePara">It is important that we do not confuse the approach to the innominate vein with the supraclavicular approach used to reach the subclavian vein&#46; This is done by puncturing directly above the clavicle&#44; but on the external side of the clavicular head of the sternocleidomastoid &#40;figure 1&#41; in the medial direction&#44; requiring patency of the subclavian vein&#46;<span class="elsevierStyleSup">10&#44;11</span></p><p class="elsevierStylePara">We recommend puncturing the right innominate vein&#44; given that in the left hemithorax the pulmonary cupola is higher and the thoracic duct crosses directly over those planes intersected by the needle&#44; which exposes the patient to complications such as pneumothorax and chylothorax&#46;</p><p class="elsevierStylePara">In 1977&#44; Rao et al&#46;<span class="elsevierStyleSup">12</span> published their experience with developing a new technique for placing central venous catheters using the innominate vein&#46;</p><p class="elsevierStylePara">The technique of placing catheters in the innominate vein has been performed successfully in patients with thrombosis or stenosis of the internal jugular and subclavian veins&#44; being widely used for anesthesiologists&#44; and has become the main route for venous access in some medical centers&#46;<span class="elsevierStyleSup">13</span></p><p class="elsevierStylePara">For patients with chronic kidney disease who undergo haemodialysis treatment&#44; few studies exist in the international literature regarding the use of the innominate vein for vascular access&#46; The first report was presented by Apsner et al&#46;<span class="elsevierStyleSup">14</span> in 1996&#44; with four catheters being inserted in four patients&#44; all of whom had similar characteristics to those we describe&#46; Lau et al&#46;<span class="elsevierStyleSup">15</span> described a further two cases in 2001&#44; and the largest study led by Falk A was published in 2006&#44;<span class="elsevierStyleSup">16</span> in which 44 innominate vein catheters were placed in 33 patients&#44; importantly without serious complications during the procedure and with long-term patency&#46;</p><p class="elsevierStylePara">In conclusion&#44; approaching the superior vena cava through the innominate vein is an alternative route&#44; but with practice&#44; it can come to represent an excellent option for patients with multiple thrombosed veins in their upper hemithorax&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12718078&#95;f1&#95;355&#46;jpg" class="elsevierStyleCrossRefs"><img src="12718078_f1_355.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;12718078&#95;f2&#95;356&#46;jpg" class="elsevierStyleCrossRefs"><img src="12718078_f2_356.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; </p><p class="elsevierStylePara"><a href="grande&#47;12718078&#95;f3&#95;356&#46;jpg" class="elsevierStyleCrossRefs"><img src="12718078_f3_356.jpg"></img></a></p><p class="elsevierStylePara">Figure 3&#46; </p><p class="elsevierStylePara"><a href="grande&#47;12718078&#95;t1&#95;356&#46;jpg" class="elsevierStyleCrossRefs"><img src="12718078_t1_356.jpg" alt="Characteristics of patients selected for catheter placement in the innominate vein"></img></a></p><p class="elsevierStylePara">Table 1&#46; Characteristics of patients selected for catheter placement in the innominate vein</p>"
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        "resumen" => "<p class="elsevierStylePara">Se estudian tres pacientes con enfermedad renal cr&#243;nica en terapia hemodial&#237;tica&#44; en los cuales se hab&#237;an agotado los accesos venosos cl&#225;sicos en el hemit&#243;rax superior &#40;yugular interno&#44; subclavio&#44; axilar&#41; para hemodi&#225;lisis&#44; debido principalmente a trombosis de los mismos por cateterismos anteriores&#46; En ellos se opt&#243;&#44; mediante la t&#233;cnica de Rao et al&#46;&#44; por puncionar la vena innominada&#44; logr&#225;ndose la implantaci&#243;n posterior de cat&#233;teres y su tunelizaci&#243;n subcut&#225;nea&#46; Los cat&#233;teres permanentes3 funcionaron adecuadamente y est&#225;n permeables a la fecha despu&#233;s de un periodo promedio de ocho meses&#46;</p>"
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                0 => array:3 [
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              "identificador" => "bib13"
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            13 => array:3 [
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              "identificador" => "bib15"
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              "identificador" => "bib16"
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                    0 => null
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