Evaluation of totally implantable central venous access devices with the cephalic vein cut-down approach: Usefulness of preoperative ultrasonography

Scarless totally implantable venous access port (TIVAP) implantation: Surgical technique, preliminary results, learning curve, and patients-reported outcome in 125 breast cancer patients

BACKGROUND

Minimal-access (endoscopic or robotic-assisted) breast surgery has been increasingly performed and shown better cosmetic results. However, location of totally implantable venous access port (TIVAP) for systemic treatment at anterior chest may compromise its aesthetic benefits. Therefore, we proposed a new scarless technique for TIVAP implantation, and reported the preliminary results, learning curve, and patients-surveyed outcome.

METHODS

Surgical technique of the new "scarless" TIVAP implantation was proposed. Patients receiving this procedure in a single institution were included. The preliminary results of the scarless TIVAP implantation, learning curve, and patient-reported outcome were analyzed and reported.

RESULTS

A total of 125 breast cancer patients received scarless TIVAP procedures were enrolled. The primary success rate of the scarless TIVAP implantation was 100%. Mean operative time was 46 ± 14 min. Mean amount of blood loss was 8.5 ± 3.2 ml. The cumulative sum plot showed operation time significantly decreased after 24th cases. In the initial learning phase, the mean operative time was 55 ± 17 min, and decreased to 43 ± 12 min in the later mature phase (P = 0.003). There were 5 (4%) complications detected, which included 1 (0.8%) seroma formation, 2 (1.6%) revisions, and 2 (1.6%) unplanned explantations. From patients-evaluated questionnaires, more than 90% of responders were satisfied with aesthetic results, experience during surgery, and application of scarless TIVAP for systemic therapy.

CONCLUSIONS

The scarless TIVAP implantation is a safe & reliable procedure with high patients-reported aesthetic satisfaction, and could be an alternative TIVAP procedure for patients requiring chemotherapy and desiring a less noticeable scar.

Success rate and safety of totally implantable access ports placed by the cephalic vein cutdown technique in oncological patients - a single-center study

INTRODUCTION

Totally implantable access ports (TIAPs) are commonly used in oncologic patients undergoing ongoing chemotherapy. The methods of choice for implantation are the subclavian vein puncture approach and the cephalic vein cutdown technique, followed by internal jugular vein access and external jugular vein access.

Cephalic Vein Cut Down for Total Implantable Venous Access Ports: A Retrospective Review of a Single Institution Series

Objective

The aim of this work was to describe the early and late success rates of cephalic vein cut down (CVC) in the implantation of totally implantable venous access ports (TIVAP) for chemotherapy treatment in oncological patients.

Methods

This was a retrospective study of 1 047 TIVAP performed in a private institution between 2008 and 2021. The CVC with pre-operative ultrasound (PUS) was the initial approach. All cephalic veins (CVs) were mapped pre-operatively with Doppler ultrasound, measuring their diameter and course in oncological patients who required a TIVAP. With a CV diameter ≥ 3.2 mm TIVAP was carried out by CVC; with CV diameter < 3.2 mm, subclavian vein puncture (SVP) was performed.

Results

1 047 TIVAPs were implanted in 998 patients. The mean age was 61.5 ± 11.5 years, 624 were women (65.5%). Male patients were significantly older and with a higher incidence of colonic, digestive system, and laryngeal cancer. Initially, TIVAP was indicated in 858 cases (82%) by CVC and 189 (18%) by SVP. The success rate was 98.5% for CVC and 98.4% for SVP. There were no complications for CVC (0%) but five early complications (2.5%) in the SVP group. The rates of late complications were 4.4% in the CVC group and 5.0% in the SVP group, foreign body infection being the most frequent (57.5% of the cases) (p = .85).

Conclusion

The CVC or SVP using PUS for TIVAP deployment, performed through a single incision, is a safe and effective technique. This open but minimally invasive technique should be considered in oncological patients.

Comparison of Central Venous Port Procedures Between Puncture vs. Cut-down and Residents vs. Senior Surgeons

BACKGROUND/AIM

To compare operative results between venous puncture (P) with real-time ultrasonography vs. cut-down (CD) with preoperative ultrasonography for totally implantable central vein access device (TICVAD) implantation performed by residents (R) vs. senior surgeons (S).

PATIENTS AND METHODS

Adult oncologic patients (n=268) undergoing TICVAD implantations were retrospectively compared between 172 Ps and 96 CDs. Then, we compared Ps performed by R (P-R, n=131) and S (P-S, n=41) and CDs performed by R (CD-R, n=59) and S (CD-S, n=37).

RESULTS

Median operation times were 40 min in the P group and 53.5 min in the CD group, and times were significantly shorter for P-S and CD-S. Completion rates were comparable for each method and each surgeon. Intraoperative complication rates were 3.8% (P-R), 2.4% (P-S), and 0% (CD-R and CD-S).

CONCLUSION

P with real-time ultrasonography did not avoid complications compared to CD with preoperative ultrasonography. The latter performed safely even by residents.

Forty years after the first totally implantable venous access device (TIVAD) implant: the pure surgical cut-down technique only avoids immediate complications that can be fatal

Aim

Even though TIVADs have been implanted for a long time, immediate complications are still occurring. The aim of this work was to review different techniques of placing TIVAD implants to evaluate the aetiology of immediate complications.

Methods

A systematic literature review was performed using the PubMed, Cochrane and Google Scholar databases in accordance with the PRISMA guidelines. The patient numbers, number of implanted devices, specialists involved, implant techniques, implant sites and immediate complication onsets were studied.

Results

Of the 1256 manuscripts reviewed, 36 were eligible for inclusion in the study, for a total of 17,388 patients with equivalent TIVAD implantation. A total of 2745 patients (15.8%) were treated with a surgical technique and 14,643 patients (84.2%) were treated with a percutaneous technique. Of the 2745 devices (15.8%) implanted by a surgical technique, 1721 devices (62.7%) were placed in the cephalic vein (CFV). Of the 14,643 implants (84.2%) placed with a percutaneous technique, 5784 devices (39.5%) were placed in the internal jugular vein (IJV), and 5321 devices (36.3%) were placed in the subclavian vein (SCV). The number of immediate complications in patients undergoing surgical techniques was 32 (1.2%) HMMs. In patients treated with a percutaneous technique, the number of total complications were 333 (2.8%): 71 PNX (0.5%), 2 HMT (0.01%), 175 accidental artery punctures AAP (1.2%) and 85 HMM (0.6%). No mortality was reported with either technique.

Conclusion

The percutaneous approach is currently the most commonly used technique to implant a TIVAD, but despite specialist’s best efforts, immediate complications are still occurring. Surgical cut-down, 40 years after the first implant, is still the only technique that can avoid all of the immediate complications that can be fatal.

Ultrasound guided percutaneous cephalic venipuncture for implantation of cardiac implantable electronic devices

BACKGROUND

Preoperative ultrasound (US) for cephalic cut-down is related to shorter procedure time and higher success rate. This study aimed to assess efficiency of US-guided percutaneous cephalic vein (CV) puncture for placement of cardiac implantable electronic devices (CIEDs).

METHODS

Patients undergoing a procedure including both US-guided pectoral nerve block (PECS) and percutaneous CV puncture were retrospectively investigated. Patient medical history and demographic data was collected. Clinical features of the procedures and intra- and post-operative complications occurring were collected from patient records. Clinical data included target vessel features, and the time taken for the following: CV puncture; CV and PECS puncture; total procedure.

RESULTS

In total 34 patients had CV puncture with US-guided PECS block was attempted in all patients and the procedure was successful in 27 of 34 (79.4%) patients. The total number of CV puncture attempts was 62 for 34 leads (mean attempts per lead = 1.82). The mean ± standard deviation time for CV puncture was 137.5 ± 27.4 s. There were no venous access-related complications.

CONCLUSION

US-guided CV puncture appears feasible and safe with an acceptable success rate. In case of failure of the US-guided axillary or subclavian vein approach, it may be preferred as an alternative to the cephalic cut-down procedure, where the success rate is relatively lower and the risk of bleeding is higher.

Perioperative and Postoperative Complications of Ultrasound-Guided Totally Implantable Venous Access Ports via the Brachiocephalic Vein in Patients with Cancer: A Prospective Study

Objectives: To evaluate the safety and efficacy of ultrasound (US)-guided totally implantable venous access ports (TIVAPs) via the right brachiocephalic vein (BCV) or the left BCV approach.

Methods: Patients requiring TIVAP for chemotherapy were included in the study. US-guided TIVAPs via BCV were used for patients from July 2018 to December 2018. General information about the patients (sex, age, and diagnosis), side (right or left), surgical procedures and complications were recorded.

Results: A total of 107 TIVAPs in 107 patients (ages 38-73 years) were included, 75 via the right BCV and 32 via the left BCV. All of the patients underwent successful surgery. The BCV was successfully punctured on the first attempt in 99 patients (92.52%). Two attempts were needed in 6 patients (5.61%), and three attempts were necessary in 2 patients (1.87%). The mean operation time was 29 ± 5 min (range: 24 to 38 min). No serious complications occurred during the surgery, except the formation of a local haematoma in 1 case after artery puncture. During the follow-up period of 12 months, the incidence of long-term complications was 3.74% (4/107), including 2 cases of catheter-related infection and 2 cases of fibrin sheath formation. No serious complications such as catheter malposition or rupture were found.

Conclusion: US-guided TIVAP via the BCV offers an alternative for adults with good needle guidance and a low rate of perioperative and postoperative complications.

Risk of venous thromboembolism associated with totally implantable venous access ports in cancer patients: A systematic review and meta-analysis

BACKGROUND

Totally implantable venous access ports (TIVAPs) for chemotherapy are associated with venous thromboembolism (VTE). We aimed to quantify the incidence of TIVAP-associated VTE and compare it with external central venous catheters (CVCs) in cancer patients through a meta-analysis.

METHODS

Studies reporting on VTE risk associated with TIVAP were retrieved from medical literature databases. In publications without a comparison group, the pooled incidence of TIVAP-related VTE was calculated. For studies comparing TIVAPs with external CVCs, odds ratios (ORs) were calculated to assess the risk of VTE.

RESULTS

In total, 80 studies (11 with a comparison group and 69 without) including 39 148 patients were retrieved. In the noncomparison studies, the overall symptomatic VTE incidence was 2.76% (95% confidence interval [CI]: 2.24-3.28), and 0.08 (95 CI: 0.06-0.10) per 1000 catheter-days. This risk was highest when TIVAPs were inserted via the upper-extremity vein (3.54%, 95% CI: 2.94-4.76). Our meta-analysis of the case-control studies showed that TIVAPs were associated with a decreased risk of VTE compared with peripherally inserted central catheters (OR = 0.20, 95% CI: 0.09-0.43), and a trend for lower VTE risk compared with Hickman catheters (OR = 0.75, 95% CI: 0.37-1.50). Meta-regression models suggested that regional difference may significantly impact on the incidence of VTE associated with TIVAPs.

CONCLUSIONS

Current evidence suggests that the cancer patients with TIVAP are less likely to develop VTE compared with external CVCs. This should be considered when choosing the indwelling intravenous device for chemotherapy. However, more attention should be paid when choosing upper-extremity veins as the insertion site.

Cephalic Vein Cut-down for Totally Implantable Central Venous Access Devices With Preoperative Ultrasonography by Surgical Residents

BACKGROUND/AIM

Cephalic vein (CV) cut-down for totally implantable central venous access devices (TICVADs) is not frequently used due to its low success rate. We compared the outcomes of CV cut-down using preoperative ultrasonography (US) performed by experienced surgeons versus surgical residents.

PATIENTS AND METHODS

From December 2015 to December 2017, 10 surgeons implanted 212 TICVADs using CV cut-down with preoperative US. The surgeons were divided into two groups of five each: surgical residents (Group A, n=124 procedures) and experienced surgeons (Group B, n=88 procedures). Duration of operation time, completion rate, and complications were retrospectively analyzed.

RESULTS

The completion rate was significantly higher in Group A (98.4% versus 92.0%, p=0.04). Duration of operation time (45.2±14.5 versus 42.0±13.1 minutes, p=0.22), rates of early complications (1.6% versus 1.1%, p=0.77) and late complications (3.2% versus 2.3%, p=0.68) were equivalent between the two groups. No fatal complications occurred in either group.

CONCLUSION

CV cut-down can be safely performed by surgical residents under the use of preoperative US.

Comparison between ultrasound-guided TIVAD via the right innominate vein and the right internal jugular vein approach

BACKGROUND

To compare the efficacy and safety of right internal jugular vein (IJV) approach and right innominate vein (INV) approach for US-guided totally implantable venous access devices (TIVADs), and to explore the advantages and disadvantages of the two approaches.

METHODS

Six hundred and nineteen adult patients had long-term infusion and chemotherapy needs and inconvenience of peripheral venous infusion. Right INV approach was used to implant 339 cases of TIVADs, and right IJV approach was used to implant 280 cases of TIVADs. The success rate of one-time catheterization and the incidence of complications in the two groups were retrospectively analyzed.

RESULTS

All patients were successfully implanted in TIVAD. The success rates of one-time puncture in INV group and IJV approach group were 98.53% (334/339) and 95.36% (267/280), respectively. There was significant difference between the two groups (P = 0.020). The incidence of perioperative complications and long-term complications in the right INV group were 1.18% (4/339) and 3.54% (12/339), respectively, while those in the right IJV group were 1.43% (4280) and 3.93% (11280). There was no significant difference in the incidence of perioperative or long-term complications between the two groups (P = 0.785, P = 0.799, respectively).

CONCLUSIONS

US-guided TIVADs via the right INV approach and the right IJV approach are both safe and reliable. The right INV approach improves the one-time puncture success rate, as long as the technique is properly operated, serious complications rarely occur.

A Five-Year Data Report of Long-Term Central Venous Catheters Focusing on Early Complications

BACKGROUND

Long-term venous access has become the standard practice for the administration of chemotherapy, fluid therapy, antibiotics, and parenteral nutrition. The most commonly used methods are percutaneous puncture of the subclavian and internal jugular veins using the Seldinger technique or surgical cutdown of the cephalic vein.

METHODS

This study is based on a quality registry including all long-term central venous catheter insertion procedures performed in patients >18 years at our department during a five-year period. The following data were registered: demographic data, main diagnosis and indications for the procedure, preoperative blood samples, type of catheter, the venous access used, and the procedure time. In addition, procedural and early postoperative complications were registered: unsuccessful procedures, malpositioned catheters, pneumothorax, hematoma complications, infections, nerve injuries, and wound ruptures. The Seldinger technique using anatomical landmarks at the left subclavian vein was the preferred access. Fluoroscopy was not used.

RESULTS

One thousand one hundred and one procedures were performed. In eight (0.7%) cases, the insertion of a catheter was not possible, 23 (2.1%) catheters were incorrectly positioned, twelve (1.1%) patients developed pneumothorax, nine (0.8%) developed hematoma, and three (0.27%) developed infection postoperatively. One (0.1%) patient suffered nerve injury, which totally recovered. No wound ruptures were observed.

CONCLUSIONS

We have a high success rate of first-attempt insertions compared with other published data, as well as an acceptable and low rate of pneumothorax, hematoma, and infections. However, the number of malpositioned catheters was relatively high. This could probably have been avoided with routine use of fluoroscopy during the procedure.

Ultrasound-guided totally implantable venous access ports via the right innominate vein: a new approach for patients with breast cancer

Background

To evaluate the feasibility and safety of ultrasound-guided totally implantable venous access port (TIVAP) implantation via the right innominate vein in patients with breast cancer.

Methods

Sixty-seven breast cancer patients underwent ultrasound-guided implantation of TIVAPs via the right innominate vein for administration of chemotherapy. Clinical data including technical success, success rate for the first attempt, periprocedural, and postoperative complications were recorded and retrospectively studied.

Results

All patients underwent successful surgery. The success rate of the first attempt was 95.52% (64/67). The operation time was 28 to 45 min, with an average of 36 ± 6 min. Periprocedural complications included artery punctures in 1 (1.50%, 1/67) patient. Prior to this study, the mean TIVAP time was 257 ± 3 days (range 41 to 705 days). The rate of postoperative complications was 4.48% (3/67), including catheter-related infections in 1 case and fibrin sheath formation in 2 cases. Up to the present study, three people had unplanned port withdrawal due to complications, and the TIVAPs for 25 patients were still in normal use.

Conclusions

The success rate of ultrasound-guided TIVAPs via the right innominate vein is high with low complications, thus safe and feasible. This technique can provide a new option for chemotherapy of breast cancer patients.

Cephalic vein approach for the implantable central venous access: A retrospective review of the single institution's experiences; Cohort Study

Long-term venous access is usually required in patients receiving chemotherapy. We hypothesized that, out of the various central line approach techniques, the cephalic vein cut-down technique can be a safe and simple alternative in terms of surgical safety, feasibility, cost-effectiveness, and functional outcomes.We retrospectively reviewed the medical records of 569 patients who underwent implantable central venous access between January 2012 and December 2014 at our hospital.We classified our cohort according to access routes, as follows: 230 patients underwent subclavian vein access, 134 patients underwent internal jugular vein access, 25 patients underwent external jugular vein access, and 119 patients underwent cephalic vein access. The cephalic vein group had a significantly longer operation time than the subclavian group (P < .01); however, there was no difference in operation time between the internal jugular vein and cephalic vein groups (P = .59). The procedure-related complications and functional outcomes of the implanted venous port during chemotherapy were comparable between the cephalic group and other groups. Additionally, body mass index, operation time, and age did not correlate with catheter dysfunction in the multivariate logistic regression analysis (P = .53; P = .66; P = .19, respectively).We suggest that a cut-down central venous catheter insertion through the cephalic vein can be performed easily and safely with no differences in surgical and clinical outcomes compared to those of conventional percutaneous approaches. Moreover, the cephalic vein approach requires no specialized equipment, including percutaneous vascular kits, tunneling instruments, and intraoperative ultrasonography. Therefore, this technique might incur less medical expenses than conventional approaches and would be helpful for both patients and surgeons.

Arm port vs chest port: a systematic review and meta-analysis

Background

Two prevailing, totally implantable venous access ports are routinely utilized in oncology: chest port or arm port. This systematic review with meta-analysis was conducted to compare safety and efficiency of the two techniques.

Methods

We performed evidence acquisition intensively from PubMed, Embase, and Cochrane Library. Available comparative studies that evaluated both techniques were identified. The outcomes of interest included total complication events, procedure-related infections, thrombosis, intra-operative complications, mechanical complications, conversion rate, early port removal, and operating time.

Results

Thirteen comparative studies including 3,896 patients (2,176 for chest ports, and 1,720 for arm ports) were identified. The present study showed that arm port was associated with higher procedure conversion rate (2.51% in chest port group and 8.32% in arm port group; odd ratios [OR] 0.27, 95% confidence interval [CI] 0.15-0.46; p<0.001), but lower incidence of intra-operative complications (1.38% in chest port group and 0.41% in arm port group; OR 2.38, 95% CI 1.07-5.29; p=0.03). There were no between-group differences with respect to total complication events, procedure-related infections, thrombosis, mechanical complications, early port removal, and operating time. Subgroup analysis of patients under 60 years revealed that no significant difference was detected in intra-operative events (1.19% in chest port group and 0.02% in arm port group, OR 2.59, 95% CI 0.74-9.08; p<0.14), indicating that age may be a risk factor for intra-operative events. Sensitivity analysis did not change conclusions of all endpoints of interest.

Conclusion

Arm port is associated with higher procedure conversion rate, but lower incidence of intra-operative complications, and age may be a risk factor for intra-operative events.

Surgical Venous Cutdown for the Insertion of Totally Implantable Venous Access Devices

Purpose:

Stable insertion of totally implantable venous access devices (TIVADs) is mandatory for the administration of chemotherapy and parenteral nutrition. Subclavian venipuncture is the most popular route; however, perioperative complications occur in up to 12% of patients. We inserted TIVADs by surgical venous cutdown of the cephalic vein at the deltopectoral groove with the intention of a safe and stable implantation.

Methods:

We implanted TIVADs in 318 consecutive patients (331 cases) from January 2011 to December 2015. We retrospectively analyzed short- and long-term treatment outcomes and risk factors for primary failure of implantation and removal due to catheter-related complications.

Results:

The aim of implantation was chemotherapy in 198 cases, nutrition in 92 cases, and frequent intravenous drip in 41 case. Surgical venous cutdown was performed in 321 of 331 cases (97%); primary failure occurred in 42 cases (13.1%). Short-term complications occurred in 4 cases (1.2%), and there were no serious complications, such as pneumothorax. In the analysis of risk factors for primary failure, aim of implantation (chemotherapy versus nutrition versus frequent intravenous drip) was the only risk factor (P = 0.02). Removals occurred in 35 cases (11.5%). In the analysis of risk factors for removal due to complications, presence of infectious disease was identified as the only significant risk factor (P &lt; 0.001).

Conclusions:

We confirmed the safety and efficacy of the cutdown method and clarified the risk factors for primary failure and removal. The cutdown method was safe and was not associated with serious complications; however, selective implantation was needed to achieve a high success rate.

A Prospective, Comparative Evaluation on Totally Implantable Venous Access Devices by External Jugular Vein versus Cephalic Vein Cutdown

The request for totally implantable venous access devices (TIVADs) has rapidly grown up through the last decades. TIVADs are implanted by direct vein puncture or by surgical approach with vein cutdown. The authors present a comparative prospective study evaluating external jugular vein (EJV) and cephalic vein cutdown techniques. Two hundred and fifteen patients were consecutively submitted to TIVAD implantation to perform chemotherapy. Patients were divided in two groups, depending on the implantation technique. Group A patients (106) underwent implantation via EJV cutdown and group B (109) patients underwent implantation by cephalic vein cut-down. The following variables were investigated: operating time, need for conversion to other approaches, complications, and intraoperative and postoperative pain. In Group A patients, the success rate of the procedure was 100 per cent, whereas in 11 patients (10.1%) of Group B, a modification of the initial approach was needed. Mean operative time was 23.9 ± 9.2 minutes in Group A and 35.4 ± 11.9 in Group B, and this was statistically significant (P < 0.05). Complication rates at 30 days were similar. Considering intraoperative pain, a difference was found between the two groups because the mean value of pain in Group Awas lower than that in Group B (4.13 ± 0.3 vs 5.22 ± 1.24), even if not significant. External jugular vein cutdown approach is quick and safe and allows a very high success rate with very low risk of complications. For these reasons, this approach could be considered as a first choice in TIVAD placement.

A novel "shrug technique" for totally implantable venous access devices via the external jugular vein: A consecutive series of 254 patients

BACKGROUND

The external jugular vein (EJV) approach for totally implantable venous access devices (TIVADs) is safe. However, the success rate is unsatisfactory because of the difficulty in catheterization due to the acute angle between the EJV and the subclavian vein (SCV). A novel "shrug technique" to overcome this difficulty was developed, and its efficacy was assessed in a consecutive case series.

METHODS

TIVAD placement was performed via the EJV cut-down approach. "Shrug technique," a simple way to straighten the EJV-SVC angle by shrugging the patient's shoulder, was applied to facilitate the passage of the guidewire and sheath-introducer when there was acute angulation between the EJV and SCV.

RESULTS

A total of 254 patients underwent TIVAD implantation by the EJV cut-down approach. The "shrug technique" was applied in 51 cases (20%), and catheterization was successful in all cases. Thus, TIVAD implantation was successfully completed in all 254 cases (100%) in a single operative setting. The median operating time was 38 [IQR 30-45] min. Eleven complications (4%) were observed, but none of them were EJV-specific.

CONCLUSION

The "shrug technique" is simple but very useful to achieve a higher success rate and safer insertion of TIVADs from the EJV. J. Surg. Oncol. 2017;115:291-295. © 2016 Wiley Periodicals, Inc.

Successful Retrieval of a Dismembered Central Venous Catheter Stuck to the Right Pulmonary Artery Using a Stepwise Approach

Recent advances in anticancer chemotherapy have resulted in an increase in the number of patients requiring a central venous port catheter, and the incidence of catheter pinch-off syndrome has been increasing. Catheter pinch-off syndrome is a rare and unusual complication. It is difficult to retrieve dislodged catheters from the pulmonary artery, especially if the catheter is stuck to the peripheral pulmonary artery. We herein describe the successful removal of a catheter stuck in the pulmonary artery with a stepwise approach. First, a pigtail catheter was used to tug the dislodged catheter in order to free the unilateral end. Then, a gooseneck snare was used to catch and pull the catheter out of the patient. The key to success is to free the end of the catheter.