Venous Access Ports: Indications, Implantation Technique, Follow-Up, and Complications

An Autonomous Implantable Device for the Prevention of Death from Opioid Overdose

Opioid overdose accounts for nearly 75,000 deaths per year in the United States, representing a leading cause of mortality amongst the prime working age population (25-54 years). At overdose levels, opioid-induced respiratory depression becomes fatal without timely administration of the rescue drug naloxone. Currently, overdose survival relies entirely on bystander intervention, requiring a nearby person to discover and identify the overdosed individual, and have immediate access to naloxone to administer. Government efforts have focused on providing naloxone in abundance but do not address the equally critical component for overdose rescue: a willing and informed bystander. To address this unmet need, we developed the Naloximeter: a class of life-saving implantable devices that autonomously detect and treat overdose, with the ability to simultaneously contact first-responders. We present three Naloximeter platforms, for both fundamental research and clinical translation, all equipped with optical sensors, drug delivery mechanisms, and a supporting ecosystem of technology to counteract opioid-induced respiratory depression. In small and large animal studies, the Naloximeter rescues from otherwise fatal opioid overdose within minutes. This work introduces life-changing, clinically translatable technologies that broadly benefit a susceptible population recovering from opioid use disorder.

Predictive model for totally implanted venous access ports‑related long‑term complications in patients with lung cancer

Totally implanted venous access ports (TIVAPs), which are typically used in oncological chemotherapy and parenteral nutritional support, are convenient and safe, and thus offer patients a higher quality of life. However, insertion or removal of the device requires a minor surgical operation. Long-term complications (>30 days post insertion), such as catheter migration, catheter-related thrombosis and infection, are major reasons for TIVAP removal and are associated with a number of factors such as body mass index and hemoglobin count. Since management of complications is typically time-consuming and costly, a predictive model of such events may be of great value. Therefore, in the present study, a predictive model for long-term complications following TIVAP implantation in patients with lung cancer was developed. After excluding patients with a large amount of missing data, 902 patients admitted to The First Affiliated Hospital with Nanjing Medical University (Nanjing, China) were ultimately included in the present study. Of the included patients, 28 had complications, indicating an incidence rate of 3.1%. Patients were randomly divided into training and test cohorts (7:3), and three machine learning-based anomaly detection algorithms, namely, the Isolation Forest, one-class Support Vector Machines (one-class SVM) and Local Outlier Factor, were used to construct a model. The performance of the model was initially evaluated by the Matthew's correlation coefficient (MCC), area under curve (AUC) and accuracy. The one-class SVM model demonstrated the highest performance in classifying the risk of complications associated with the use of the intracavitary electrocardiogram method for TIVAP implantation in patients with lung cancer (MCC, 0.078; AUC, 0.62; accuracy, 66.0%). In conclusion, the predictive model developed in the present study may be used to improve the early detection of TIVAP-related complications in patients with lung cancer, which could lead to the conservation of medical resources and the promotion of medical advances.

Totally implantable venous ports in infants and children: a single-center retrospective study of indications and safety

Introduction

Totally Implantable Venous Access Devices (TIVADs) contribute significantly to the treatment progress and comfort of patients requiring long-term therapy. However, the procedure for implanting TIVADs, as well as its very presence, may be associated with complications.

Aim

This study evaluates the indications, safety, and complication rates of venous port implantations in pediatric patients. It also explores factors influencing the occurrence of early and late complications post-implantation.

Materials and methods

The study included 383 pediatric patients treated at the Department of Pediatric Surgery, Traumatology, and Urology in Poznan between 2013 and 2020 who underwent 474 implantations of intravenous ports. Venous access was achieved using the Seldinger technique. Statistical analysis was performed using Statistica 13 with TIBCO and PQStat 1.8.2.156 with PQStat.

Results

Venous ports were used in 345 oncology patients requiring chemotherapy (90% of the total group) and in 38 children (10%) with non-oncology indications. There were 36 early complications (7.6%) and 18 late complications (3.8%), excluding infectious complications. The most common early, non-infectious complications included pneumothorax (15 patients; 3%) and port pocket hematoma (12 patients; 2.5%). The most common late, non-infectious complications observed were venous catheter obstruction (8 children; 1.7%) and port system leakage (5 children; 1%). Infectious complications occurred in 129 cases (27.2%). Children with a diagnosis of non-Hodgkin's lymphoma, acute myeloid leukemia, and acute lymphoblastic leukemia had a significantly higher incidence of port infections. Venous ports equipped with a polyurethane catheter, compared to systems with a silicone catheter, functioned significantly shorter.

Conclusions

The Seldinger method of port implantation is quick, minimally invasive, and safe. The type of port, including the material of the port's venous catheter, and the underlying disease have an impact on the durability of implantable intravenous systems. The experience of the surgeon is related to the frequency of complications associated with the procedure.

Comparing ethanol lock therapy versus vancomycin lock in a salvation strategy for totally implantable vascular access device infections due to coagulase-negative staphylococci (the ETHALOCK study): a prospective double-blind randomized clinical trial

OBJECTIVES

Little is known about efficacy and safety of ethanol lock therapy (ELT) to treat totally implantable venous access device (TIVAD) infections. The objective of this trial was to evaluate the effectiveness and safety profile of a local treatment with ELT without removal for TIVAD infection due to coagulase-negative staphylococci.

METHODS

We performed a prospective, multicenter, double-blind, randomized clinical trial comparing the efficacy of 40% ELT versus vancomycin lock therapy (VLT) in TIVAD infections due to coagulase-negative staphylococci, complicated or not by bloodstream infection.

RESULTS

Thirty-one patients were assigned to the ELT group and 30 to the VLT arm. Concomitant bacteremia was present in 41 patients (67.2%). Treatment success was 58.1 % (18 of 31) for the ELT arm and 46.7% (14 of 30) for the VLT arm (p = 0.37). The overall treatment success was 52.5% (32). The risk of treatment failure due to uncontrolled infections, superinfections, and mechanical complications did not differ significantly between participants receiving ELT (13 out of 31 [42%]) and those receiving VLT (16 out of 30 [53%]) with a hazard ratio of 0.70 (p = 0.343; 95% CI [0.34-1.46], Cox model). Catheter malfunctions were significantly more frequent in the ELT arm (11 patients versus 2 in the VLT group, p = 0.01).

CONCLUSIONS

We found an overall high rate of treatment failure that did not differ between the ELT arm and the VLT arm. TIVAD removal must be prioritized to prevent complications (uncontrolled infections, superinfections, and catheter malfunctions) except in exceptional situations.

A Platform for Testing the Biocompatibility of Implants: Silicone Induces a Proinflammatory Response in a 3D Skin Equivalent

Biocompatibility testing of materials is carried out in 2D cell cultures or animal models despite serious limitations. 3D skin equivalents are advanced in vitro models for human skin. Silicone has been shown to be noncytotoxic but capable of eliciting an immune response. Our aim was to (1) establish a 3D skin equivalent to (2) assess the proinflammatory properties of silicone. We developed a coculture of keratinocytes and fibroblasts resulting in a 3D skin equivalent with an implant using samples from a breast implant. Samples with and without the silicone implant were studied histologically and immunohistochemically in comparison to native human skin samples. Cytotoxicity was assessed via LDH-assay, and cytokine response was assessed via ELISA. Histologically, our 3D skin equivalents had a four-layered epidermal and a dermal component. The presence of tight junctions was demonstrated in immunofluorescence. The only difference in 3D skin equivalents with implants was an epidermal thinning. Implanting the silicone samples did not cause more cell death, however, an inflammatory cytokine response was triggered. We were able to establish an organotypical 3D skin equivalent with an implant, which can be utilised for studies on biocompatibility of materials. This first integration of silicone into a 3D skin equivalent confirmed previous findings on silicone being non-cell-toxic but capable of exerting a proinflammatory effect.

Vertebral Venous Congestion That May Mimic Vertebral Metastasis on Contrast-Enhanced Chest Computed Tomography in Chemoport Inserted Patients

OBJECTIVE

This study aimed to determine the prevalence of vertebral venous congestion (VVC) in patients with chemoport insertion, evaluate the imaging characteristics of nodular VVC, and identify the factors associated with VVC.

MATERIALS AND METHODS

This retrospective single-center study was based on follow-up contrast-enhanced chest computed tomography (CT) of 1412 adult patients who underwent chemoport insertion between January 2016 and December 2016. The prevalence of venous stenosis, reflux, and VVC were evaluated. The imaging features of nodular VVC, including specific locations within the vertebral body, were analyzed. To identify the factors associated with VVC, patients with VVC were compared with a subset of patients without VVC who had been followed up for > 3 years without developing VVC after chemoport insertion. Toward this, a multivariable logistic regression analysis was performed.

RESULTS

After excluding 333 patients, 1079 were analyzed (mean age ± standard deviation, 62.3 ± 11.6 years; 540 females). The prevalence of VVC was 5.8% (63/1079), with all patients (63/63) demonstrating vertebral venous reflux and 67% (42/63) with innominate vein stenosis. The median interval between chemoport insertion and VVC was 515 days (interquartile range, 204-881 days). The prevalence of nodular VVC was 1.5% (16/1079), with a mean size of 5.9 ± 3.1 mm and attenuation of 784 ± 162 HU. Nodular VVC tended to be located subcortically. Forty-four patients with VVC underwent CT examinations with contrast injections in both arms; the VVC disappeared in 70% (31/44) when the contrast was injected in the arm contralateral to the chemoport site. Bevacizumab use was independently associated with VVC (odds ratio, 3.45; P < 0.001).

CONCLUSION

The prevalence of VVC and nodular VVC was low in patients who underwent chemoport insertion. Nodular VVC was always accompanied by vertebral venous reflux and tended to be located subcortically. To avoid VVC, contrast injection in the arm contralateral to the chemoport site is preferred.

Technical Feasibility and Safety of Central Venous Ports for Intravenous Chemotherapy in Infants With Retinoblastoma: A Retrospective Study

PURPOSE

The central venous port (CVP) is widely used for intravenous chemotherapy (IVC) in adult patients because of its lower infection rates and easier management than that of a central venous catheter. However, the feasibility and safety of the CVP for IVC in infants remain unknown. This study evaluated the usefulness of CVP for IVC in infants with retinoblastoma.

METHODS

The usefulness of CVP was retrospectively evaluated using technical success rates, the safety of CVP placement, and postoperative procedure-related complications in 18 infants with retinoblastoma. This study was conducted at the National Cancer Center Hospital, Chuo-Ku, Tokyo, Japan.

RESULTS

The technical success rate was 100% (18/18) without any procedure-related complications. The sum duration of CVP implantation was 12,836 days (mean: 713 ± 453 days, range: 10-1,639 days). Postoperative complications were observed in two cases; one was a port reversal after 20 days, which was reversed by incisional surgery, and another was a catheter-related bloodstream infection after eight days, resulting in CVP removal. The total incidence of CVP-related infections was 5.6% (1/18) and 0.08/1000 catheter days. No other CVP-related complications were noted.

CONCLUSION

The use of the CVP for IVC in infants with retinoblastoma was feasible with few complications.

Minimal invasive aortic arch repair with suture-mediated closure system

Port implantation can be associated with an array of serious vascular complications, typically involving the subclavian artery. We report a case in which implantation of a port resulted in iatrogenic perforation of the aortic arch at the level of the left subclavian artery, which was sealed off using a percutaneous vascular closure device.

Revisiting the Anatomical Landmark-Guided Central Venous Access Device Insertion: A Retrospective Cohort Study

BACKGROUND

Ultrasound (USG) guidance is superior to blind and open cut-down techniques for accurate puncture of the internal jugular vein (IJV) or subclavian vein, but it increases the cost and duration of the procedure. Here, we report our experience with the reliability and consistency of anatomic landmark-guided technique for Central Venous Access Device (CVAD) insertion in a low-resource setting.

MATERIAL AND METHODS

A retrospective analysis of the prospectively maintained database of patients undergoing CVAD insertion through one of the jugular veins was performed. Central venous access was achieved using a standardized anatomic insertion landmark (apex of Sedillot's triangle). Ultrasonography (USG) and/or fluoroscopy assistance was taken as and when required.

RESULTS

Over 12 months (October 2021 to September 2022), a total of 208 patients underwent CVAD insertion. Central venous access was successfully achieved using anatomic landmark-guided technique in all but 14 patients (6.7%), in whom USG guidance or C-arm was used. Eleven out of 14 patients who needed guidance for CVAD insertion had body mass index (BMI) of more than 25, one had thyromegaly while the remaining two had an arterial puncture during cannulation. CVAD insertion-related complications included deep vein thrombosis (DVT) in five, extravasation of chemotherapeutic agent in one, spontaneous extrusion related to a fall in one, and persistent withdrawal-related occlusion in seven patients.

CONCLUSION

Anatomical landmark-guided technique of CVAD insertion is safe and reliable, and can reduce the need for USG/C-arm in 93% of the patients.

Complications of Central Venous Access Devices Used in Palliative Care Settings for Terminally Ill Cancer Patients: A Systematic Review and Meta-Analysis

(1) Background: Central venous access devices (CVADs) have been commonly employed during various courses of anticancer treatment. Currently, there are a few types of clinically available CVADs, which are associated with short-term and long-term complications. However, little is known about the complication rates when CVADs are used only in palliative care settings. We therefore performed a systematic review and meta-analysis of all the published literature to evaluate the complication rates of CVADs in this clinical setting. (2) Methods: A systematic review and meta-analysis were conducted to identify publications from PubMed/MEDLINE, Embase (Ovid), Scopus, Cochrane Library, CINAHL, Google Scholar, and trial registries. Publications reporting the complication rates of PICCs, central lines, and PORTs in palliative settings for terminally ill cancer patients were included, while those on the use of systemic anticancer therapy and peripheral venous catheters were excluded. The outcome measures included overall complication rate, rate of catheter-related bloodstream infection (CRBSI), and rate of thromboembolism (TE). This systematic review was registered with PROSPERO (CRD42023404489). (3) Results: Five publications with 327 patients were analyzed, including four studies on PICCs and one study on central lines. No studies on PORTs were eligible for analysis. The overall complication rate for PICCs (pooled estimate 7.02%, 95% CI 0.27-19.10) was higher than that for central lines (1.44%, 95% CI 0.30-4.14, p = 0.002). The risk of CRBSI with PICCs (2.03%, 95% CI 0.00-9.62) was also higher than that with central lines (0.96%, 95% CI 0.12-3.41, p = 0.046). PICCs also had a trend of a higher risk of TE (2.10%, 95% CI 0.00-12.22) compared to central lines (0.48%, 95% CI 0.01-2.64, p = 0.061). (4) Conclusions: PICCs for palliative cancer care were found to have greater complications than central lines. This might aid in the formulation of future recommendation guidelines on the choice of CVAD in this setting.

Difficult removal of totally implantable venous access devices in adult patients: Incidence, risk factors, and management

BACKGROUND

Totally implantable venous access devices (TIVADs) have played an important role of medical oncology practice. However, operators sometimes encounter considerable difficulty when removing TIVADs. This study aimed to investigate the incidence of difficult TIVAD removal, determine associated risk factors, and investigate interventional radiology (IR) approaches to difficult removal.

METHODS

A total of 514 TIVAD removal procedures performed in a single-center between January 2014 and May 2021 were retrospectively analyzed to determine incidence of difficult removal and associated risk factors. IR approaches applied in difficult removal cases were also reviewed.

RESULTS

The incidence of difficult removal was 7.4% (38/514). In univariable analysis, indwelling duration, silicone catheter, and subcutaneous leakage of fluid were identified as significant risk factors for difficult removal. Multivariable analysis showed that indwelling duration per year (odds ratio (OR), 1.46; 95% confidence interval (CI), 1.28-1.67; p < 0.01) and subcutaneous leakage of fluid (OR, 6.04; 95% CI, 2.45-14.91; p < 0.01) were significantly associated with difficult removal. In the 38 difficult removal cases, 32 TIVADs could be removed using more dissection and traction than the standard removal method. In the other 6, TIVADs were successfully removed by using several IR techniques, including insertion of a guide wire (n = 1), dissection using an introducer sheath (n = 2), pushing with a dilator (n = 1), and pulling with a snare (n = 2).

CONCLUSION

Difficult TIVAD removal is uncommon. However, operators should expect it when removing long indwelling TIVADs and those with subcutaneous leakage. IR approaches to difficult removal are minimally invasive and can be useful.

Guidelines for Central Venous Port Placement and Management (Abridged Translation of the Japanese Version)

The central venous port has been widely used for patients who require long-term intravenous treatments, and the number of palcement has been increasing. The Japanese Society of Interventional Radiology developed a guideline for central venous port placement and management to provide evidence-based recommendations to support healthcare providers in the decision-making process regarding the central venous port. The guideline consisted of two parts: (i) a comprehensive review of topics including preoperative preparation, techniques for placement or removal, complications, and maintenance methods and (ii) recommendations for the six clinical questions regarding blood vessels for central venous port placement, port implantation site, prophylactic antibiotic therapy, imaging guidance for puncture, disinfectant prior to accessing the central venous port, and the optimal procedure at the end of drug administration via the central venous port, generated on the basis of the rating quality of evidence by systematic review.

Quantification of mechanical properties in long-term in vivo used silicone catheter lines according to DIN 10555-3

BACKGROUND

Totally implantable central venous access port devices are crucial for intravenous application of chemotherapeutics and long-term therapy for chronic disease. Common complications include thrombosis and device fracture related to altered material properties through exposure in situ. This study exhibits whether uniaxial tensile properties (DIN 10555-3) of in vivo used catheters prove inferior to unused catheters.

MATERIAL AND METHODS

5 unused, originally packed silicone catheters were cut into 6 segments of 50 mm: 3 segments each were cleaned via cleaning solution (n = 15) while 3 segments were left unattended (n = 15). Distal segments (50 mm) of long-term in vivo used silicone catheters were cleaned before testing (n = 33). Overall mechanical behavior was tested in a custom-made self-centering, torsion free carrier. Maximum force stress at failure, strain at failure and Young's modulus were determined and statistically analyzed.

FINDINGS

Unused catheters showed no significant difference in testing. in vivo used catheters exhibited 20% lower maximal force than unused catheters (p < 0.001), strain at break (p 〈0,001), and 7% higher elastic modulus (p = 0.004; power: 0.845). Due to a constant cross section area, stress at failure was proportional to maximum force (p < 0.001). Relation between determined parameters and dwell times was non-significant.

INTERPRETATION

In vivo long-term used silicone catheters showed significantly lower ultimate strength than unused ones. It is likely that in situ altering changes the mechanical properties of catheters and may potentially lead to failure.

Bleeding Complications in Uremic Patients After Ultrasound-Guided Central Venous Catheter Placement

Introduction

Bleeding associated with elevated blood urea nitrogen (BUN) is a known complication. Patients with uremia require a central venous catheter insertion by dialysis. The relation between BUN and bleeding complications during central venous catheter insertion is not yet clear.

Objective

We described the frequency of complications associated with central venous catheter implantation in uremic patients and evaluated the statistical relationship between bleeding complications and catheter type, number of punctures, and catheter insertion site. Also, we determined if any value of BUN is associated with bleeding complications.

Methods

We included patients with a serum value of BUN >70 mg/dl that required insertion of a central venous catheter. The quantitative variables were expressed through the measure of central tendency. A bivariate analysis and a ROC curve were performed.

Results

A total of 273 catheters were included in this study. Bleeding complications were detected in 69 cases (25.3%), and local bleeding was the most frequent complication in 51/69 cases. Statistically significant association was not established. We did not find a specific cut-off value directly related to BUN levels and the rate of complications.

Conclusion

Bleeding complications associated with the insertion of central venous catheter and the suspected disorder of hemostasis given by BUN levels >70 mg/dl are common. It was not possible to determine a BUN cut-off value to predict complications. The association analysis was not conclusive. High BUN levels should not be considered a high-risk condition for central venous cannulation under ultrasound guidance performed by trained personnel.

Usefulness of peripherally inserted central catheter port system (PICC-PORT) implantation in the sitting position: a new technique for cases unsuitable for conventional implantation

PURPOSE

Totally implantable central venous access port implantation is typically performed in the supine position. However, some patients cannot adopt the supine position due to severe pain and/or dyspnea. The present study evaluated the technical feasibility of peripherally inserted central catheter port system (PICC-PORT) implantation in the sitting position in such cases.

MATERIALS AND METHODS

In the sitting position method, PICC-PORT implantation was performed with the patients seated on a videofluoroscopy chair positioned between the limbs of an angiographic C-arm and the operative upper arm positioned on an arm stand. From January 2019 to September 2021, eight patients underwent PICC-PORT implantations using this sitting method. We also evaluated 251 consecutive patients with conventional supine position PICC-PORT implantation as controls. Differences in technical success, procedure time and complications were retrospectively assessed between the two groups.

RESULTS

Procedural success rates were 100% in both groups. Median procedure times in the sitting and conventional groups were 42 and 44 min, respectively. No complications were observed in the sitting group. There were no significant differences between the two groups in procedure time (p = 0.674) and complications (p = 1.000).

CONCLUSION

Implantation of PICC-PORT in the sitting position is technically feasible and useful.

Complications of Totally Implantable Central Venous Catheters (Ports) Inserted via the Internal Jugular Vein Under Ultrasound and Fluoroscopy Guidance in Adult Oncology Patients: A Single-Center Experience

Introduction

In this retrospective study, the safety and complication rates of port implantations via the internal jugular vein under ultrasound and fluoroscopy guidance in adult oncology patients were analyzed.

Material and methods

Eight hundred seven ports implanted in 799 adult oncology patients at a tertiary Oncology-Anticancer Hospital during a 36-month period from January 1, 2017 to December 31, 2019 were retrospectively reviewed. Data acquisition was obtained until December 31, 2020. All procedures were performed by two specialized interventional radiologists under ultrasound and fluoroscopy guidance. The vein access was via the internal jugular vein. Catheter days (the total number of days of maintenance of the port by all of the patients until removal, death, or December 31, 2020), technical success rates, and complication rates were evaluated based on the interventional radiological reports and patient medical records. Multivariate analysis regarding patients such as age, sex, body mass index (BMI), marital status, educational level, cancer type, side of insertion, diameter of internal jugular vein, diabetes, anticoagulants/antiplatelets, purpose of implantation, and catheter material as to the risk of complications was conducted.

Results

A total of 369,329 catheter maintenance days were observed (457.7±345.0). The technical success rate was 99.9%, and a total of 85 (10.5%) complications occurred, of which 24 (28.2%) occurred early (<30 days) and the remaining 61 (71.8%) were late (>30 days) complications. Specifically, 28 (3.5%) were catheter-related thrombosis (CRT), 27 (3.4%) related to infection, 17 (2.1%) were mechanical complications (16 fibrin sheath formation and one catheter occlusion), six (0.7%) related to catheter migration, four (0.5%) related to incision healing problems, and the remaining three (0.4%) related to ischemic skin necrosis. Forty-seven (5.8%) ports were removed due to complications. On multivariate analysis, cancer type was found as a risk factor for the development of a complication. Additionally, there was an indication that hematologic malignancy is related to infection.

Conclusion

Placement of ports via the internal jugular vein under ultrasound and fluoroscopy guidance is a safe procedure, with low rates of early and late complications.

Asymptomatic Spontaneous Migration of the Tip of Port-A-Cath System Into the Right Internal Jugular Vein: A Case Report of an Uncommon Complication

Venous port catheters are devices that allow access to the central venous system and, in clinical practice, are used for patients who require long-term intravenous therapy. The ideal position of the catheter tip is the distal superior vena cava and can be confirmed by a postoperative chest X-ray. Complications during and after the implantation are not rare, but spontaneous migration of the catheter tip into the internal jugular vein is an uncommon complication. Catheter migration may be accompanied by neck, shoulder, and ear pain. Venous phlebitis and thrombosis, and neurological complications, can become potentially life-threatening. We report a case of a spontaneous catheter tip migration into the right internal jugular vein that was diagnosed in a random chest roentgenography. The patient was taken to the operative room, and the catheter was successfully removed.

Totally implantable venous access ports: A systematic review and meta-analysis comparing subclavian and internal jugular vein punctures

Background

Totally implantable venous access port (TIVAP) is a completely closed intravenous infusion system that stays in the human body for a long time. It is used for the infusion of strong irritating or hyperosmotic drugs, nutritional support treatment, blood transfusion and blood specimen collection, and other purposes. There are two common ways of TIVAP: internal jugular vein implantation and subclavian vein implantation. However, the postoperative complications of the two implantation methods are quite different, and there is no recommended implantation method in the relevant guidelines. Therefore, we conducted a meta-analysis to evaluate the difference in complications of the two implantation methods, and choose the better implantation method.

Methods

Computer search in PubMed, Embase, Web of Science, and Cochrane Library database was conducted for randomized controlled trials (RCTs) from the establishment of the database to October 2021. Two researchers independently screened the literature according to the inclusion and exclusion criteria, extracted data, and evaluated the risk of bias in the included studies. RevMan5.4 software was used for meta-analysis.

Results

A total of 1086 patients in five studies were finally included. The results of meta-analysis showed that there was no significant difference in the incidence of infection (RR = 0.80, 95% CI: 0.43–1.48, p = .47), catheter blockage (RR = 0.72, 95% CI: 0.15–3.46, p = .68), port squeeze (RR = 1.07, 95% CI: 0.14–8.02, p = .95), catheter-related thrombosis (RR = 0.86, 95% CI: 0.22–3.38, p = 0.83), catheter displacement (RR = 0.50, 95% CI: 0.22–1.12, p = .09), extravasation (RR = 0.12, 95% CI: 0.01–2.15, p = .15), and catheter rupture (RR = 3.77, 95% CI: 0.16–89.76, p = .41) between the two implantation paths.

Conclusions

There is little difference in the complication rate of TIVAP between internal jugular vein insertion and subclavian vein insertion. Due to the small number of included studies, there are certain limitations, and more studies need to be included for analysis in the future.

Peripheral Blood Smear Detection of Asymptomatic Central Line Infection in a Patient With Sickle Cell Disease

Sickle cell disease is a lifelong disorder which may be managed by chronic red cell transfusion including exchange transfusion. Chronic indwelling vascular catheters including ports offer convenient and reliable access for red cell exchange but confer risk of complications including infection and thrombosis. Detection of these complications is essential for preserving vascular access and relies on both clinical and laboratory observation. Here we describe a case of asymptomatic port infection detected by manual screening of a peripheral blood smear.

The Effect of Virtual Reality Distraction Intervention on Pain, Anxiety, and Vital Signs of Oncology Patients Undergoing Port Catheter Implantation: A Randomized Controlled Study

BACKGROUND

Although the port catheters have many beneficial effects on the patient's quality of life, it was reported in the literature that patients experience pain in the incision area after the implantation or anxiety before, during or, after the implantation.Distraction is a simple and effective method in the management of pain and anxiety.

AIMS

To determine the effect of virtual reality (VR) distraction intervention on pain, anxiety, and vital signs of oncology patients undergoing port catheter implantation.

DESIGN

Randomized controlled study METHODS: The study was carried out with 139 participants (69 intervention, 70 control) between September 2019 and January 2020. Data were collected before, during, and after the implantation by using a patient identification form, State Anxiety Inventory (SAI), a table for vital signs, and a visual analog scale for pain severity. In the intervention group, a virtual reality device, movies, and relaxing music were provided and patients were instructed to use it during the implantation and when they felt pain after the implantation. There wasn't any blinding for patients or researchers throughout the study.

RESULTS

There was an increase in pain scores of both groups after the implantation; however, pain scores in the intervention group were lower and there was a statistically significant difference between the groups after the implantation. In the intervention group, there was a decrease in anxiety, systolic blood pressure, diastolic blood pressure, heart rate, and respiratory rate, and an increase in SpO2. VR use has a great effect on pain scores (Cohen's d = 3.023) and a great effect on SAI scores (Cohen's d = 8.770).

CONCLUSIONS

VR distraction intervention was found an effective way to reduce pain, anxiety, systolic blood pressure, diastolic blood pressure, heart rate, and respiratory rate and increase the SpO2 of the patients undergoing port catheter implantation.

Portocath insertion technique: retrospective study & step-by-step surgical description without tunneling in a high-complexity service

OBJECTIVE

to demonstrate that the use of the portocath implantation technique without tunneling the catheter is not associated with a higher rate of complications in the short or long term. In addition, we aim to improve the implantation technique of the portocath device, with the presentation of a step-by-step guide for surgeons in training.

METHODS

this is a retrospective descriptive study, with analytical components. Data were analyzed using information extracted from electronic medical records linked to the National Health Care procedure code between the years 2019-2020.

RESULTS

none of the 94 procedures resulted in complications on the day they were performed. Complications were recorded seven days after the procedure in only two patients (2.13%). Intraoperative radioscopy had been performed in both cases. Thirty days afters the procedure, complications were observed in two patients among the remaining 92 (2.17%), both undergoing catheter implantation without tunneling. There were no complications in the six months after portocath implantation in 57.4% of patients and there is no information about the other 42.6%.

CONCLUSION

the portocath insertion technique without tunneling is a safe outpatient procedure, with a low risk of complications, and can be adopted to shorten procedure time and patient discomfort, without functional or safety impairments. There was no association of not tunneling the catheter, laterality of the punctured vein and performing radioscopy in the transoperative period with the rate of complications.

Percutaneous implantation of peripherally inserted totally implantable venous access systems in the forearm in adolescent patients

BACKGROUND

Children with different underlying malignant diseases require long-term central venous access. As for port systems in a pectoral position, peripherally implanted port systems in the forearm revealed high levels of technical and clinical success in adult cohorts.

OBJECTIVE

To investigate the technical and clinical outcomes of percutaneous central venous port implantation in the forearm in adolescents.

MATERIALS AND METHODS

Between April 2010 and August 2020, 32 children ages 9 to 17 years with underlying malignancy received 35 totally implantable venous access ports (TIVAPs) in the forearm. All venous port systems were peripherally inserted under ultrasound guidance. Correct catheter placement was controlled by fluoroscopy. As primary endpoints, the technical success, rate of complications and catheter maintenance were analyzed. Secondary endpoints were the side of implantation, vein of catheter access, laboratory results on the day of the procedure, procedural radiation exposure, amount of contrast agent and reasons for port device removal.

RESULTS

Percutaneous TIVAP placement under sonographic guidance was technically successful in 34 of 35 procedures (97.1%). Procedure-related complications did not occur. During the follow-up, 13,684 catheter days were analyzed, revealing 11 complications (0.8 per 1,000 catheter-duration days), Of these 11 complications, 7 were major and 10 occurred late. In seven cases, the port device had to be removed; removal-related complications did not occur.

CONCLUSION

Peripheral TIVAP placement in the forearms of children is a feasible, effective and safe technique with good midterm outcome. As results are comparable with standard access routes, this technique may be offered as an alternative when intermittent venous access is required.

The effect of chemotherapy type and timing among the other factors on patency of totally implantable vascular access devices in colorectal carcinoma

PURPOSE

Catheter-related complications are observed in infusion of chemotherapy, and these were encountered with targeted therapies. Our principle is to study non-mechanical effects of type and initiation time of chemotherapy among the other factors on patency of totally implantable vascular access devices (TIVAD) inserted in patients with colorectal carcinoma.

METHODS

This is a one-center retrospective cohort study. We analyzed TIVAD related complications in 624 patients with colorectal carcinoma. The patients were categorized by chemotherapy type (non-target-directed chemotherapy agents (Group A), bevacizumab (Group B), and cetuximab (Group C)). Additionally, we divided the patients into groups by the time interval between TIVAD insertion and chemotherapy initiation. According to our study, a 3-day period was optimal. Therefore, we named the groups as within 3 days and beyond 3 days, and called this process 3 days cut-off. Age, gender, jugular-subclavian access, platelet count, INR, the types of chemotherapy, and the initiation time of chemotherapy were investigated by survival tests. We compared chemotherapy type groups both one-by-one and combined into one group.

RESULTS

The TIVADs were removed due to the complications in 11 patients of Group A, 6 patients of Group B, and 3 patients of Group C. Only chemotherapy type was significant (p = 0.011) in Cox regression test. A clear difference (p = 0.010) was detected between the catheter patency of Group A and combination of Groups B and C, because of skin necrosis and thrombosis. Within 3 days of their first chemotherapy day, an important difference between Group A and Group C (p = 0.013) was observed in the TIVAD patency. The same observation was made between Group A and Group B (p = 0.007). Beyond this period, no major difference was detected (p = 0.341).

CONCLUSION

A major effect on catheter patency was detected by using the target-directed chemotherapy agent within 3 days, which should be considered in target-directed chemotherapy.

A totally implantable venous access device (TIVAD) abandoned for 5 years is re-accessed normally: A case report and literature review

Regular flushing and locking of totally implantable venous access devices (TIVADs) is recommended to maintain their patency when not in use. In this case report, a 73-year-old male patient received radical resection for rectal carcinoma in January 2010. A TIVAD was implanted in 2014 and a total of 12 rounds of chemotherapy of FOLFIRI was completed in 2015. During the period from 2015 to 2020, the patient never used or conducted the monthly infusion port flushing because of the inconvenience, the COVID-19 pandemic, and so on. On 18th April 2020, the patient was admitted to the radiotherapy department of Yiwu Central Hospital. The nurse evaluated the TIVAD upon admission, finding that the skin around the reservoir was normal without any sign of infection as erythema or induration of the skin overlying the implantable port but there was intraluminal occlusion of the devices. In order to re-access the catheter, discussion of a MDT was performed and several days of unremitting efforts were tried. Gratifyingly, the patient's port was re-accessed successfully without any adverse reactions. This is a rare infusion port that has not been used and maintained for 5 years. For the port that has not been used and maintained for a long time up to 5 years, the medical staff should not give up easily. During the COVID-19 pandemic, prolonging the flushing interval of TIVADs can be an optimal clinical strategy without negative outcomes.

Contrast examination of central venous access port implanted through internal jugular vein for evaluation of suspected complications

PURPOSE

We summarized the findings, diagnosis, and outcomes of cases for which contrast examination of central venous access ports (CV-ports) were attempted to detect complications.

MATERIALS AND METHODS

Fifty-seven contrast examinations were attempted for 45 patients with 46 CV-ports (median, 162 days after implantation). Contrast examination was performed due to three suspicion catheter fractures or 54 CV-port dysfunctions (combinations of an absence of blood reflux on aspiration and 9 sufficient, 21 insufficient, or 24 impossible drip infusions).

RESULTS

Contrast examination was successfully performed in 52 cases and revealed 45 normal findings, 5 pericatheter fibrin sheath formations, and 2 partial catheter fractures. In 23 of 45 cases with normal findings, the resistance to injection was initially mild or moderate but resolved after the CV-port was flushed slowly with heparinized saline solution. Subsequent contrast examination demonstrated normal findings. All fibrin sheath formations disappeared after thrombolytic therapy. Five cases could not undergo contrast examination due to high resistance. After contrast examination, nine of 46 CV-ports were removed or exchanged, while the use of the remaining 37 continued.

CONCLUSION

Contrast examination of CV-port allowed the assessment of suspected complications and early treatment.

Image-guided placement of totally implanted vascular access device: retrospective analysis of the clinical outcomes and associated risk factors

OBJECTIVES

To determine risk factors for catheter survival and complications after image-guided implantation of a totally implanted vascular access device (TIVAD).

METHODS

A total of 2883 TIVADs (2735 patients, 63.5±13 years old, 1060 men, 1675 women) implanted under guidance by ultrasound and fluoroscopy in our institution from January 2010 to December 2019 were evaluated retrospectively. We used the log rank test and logistic regression to analyse risk factors associated with catheter survival and complications.

RESULTS

Female patients (n=1778; 61.7%; mean catheter survival days: 780.6 days) and those with a haematological malignancy (n=277; 10.1%; mean catheter survival days: 1019 days) had significantly better catheter survival than male patients (n=1105; 38.3%; mean catheter survival days: 645.9 days) and those with a solid organ malignancy (n=2447; 89.5%; mean catheter survival days: 701 days) (p<0.001 and p=0.003). Patients with haematological malignancies and benign vascular inflammatory disease (n=11; 0.4%) were vulnerable to infection (n=96; 3.3%) (p<0.001 and p=0.004). Thrombotic malfunction (n=38; 1.3%) was significantly more common in females than males (p=0.005). Non-thrombotic malfunction (n=16; 0.6%) showed a significant association with left positioning of the TIVAD (n=410; 14.2%) (p=0.043). Wound dehiscence (n=3; 0.1%) was significantly more frequent in punctured veins other (n=23; 0.8%) than the internal jugular vein (p<0.001).

CONCLUSIONS

Increased attention should be paid to patients with an underlying haematological malignancy, underlying vascular inflammatory disease, female patients, older patients, those accessed via a vein other than the IJV, those with left positioning of the TIVAD system or those with a prolonged TIVAD maintenance.

A rare cause of stroke: fail-implanted venous port catheter system - a case report

Background

We present the case of a 75-year-old female with acute embolic cerebral infarction caused by a fail-implanted venous port catheter system in the left subclavian artery.

Case presentation

A 75-year-old woman presented to our emergency room after acute onset of a right-sided hemiparesis and dysarthria. Within 2 days after admission, she developed a left-sided hemiparesis, ataxia with concordant gait disturbance and incoordination of the left upper limb. DWI-MRI showed acute multiple infarcts in both cerebral and cerebellar hemispheres. Laboratory examination, 24-h Holter electrocardiography and transthoracic echocardiography provided no pathological findings. Further examination revealed an arterially fail-implanted port catheter, placed in the left subclavian artery with its tip overlying the ascending aorta, as the source of cerebral embolism.

Conclusion

This is the first case report of thromboembolic, cerebral infarction due to a misplaced venous port catheter in the subclavian artery, emphasizing the imperative need for a thorough diagnostic workup, when embolism is suspected but cannot be proven at first glance.

Primary Open Versus Closed Implantation Strategy for Totally Implantable Venous Access Ports: The Multicentre Randomized Controlled PORTAS-3 Trial (DRKS 00004900)

OBJECTIVES

PORTAS-3 was designed to compare the frequency of pneumothorax or haemothorax in a primary open versus closed strategy for port implantation.

BACKGROUND DATA

The implantation strategy for totally implantable venous access ports with the optimal benefit/risk ratio remains unclear.

METHODS

PORTAS-3 was a multicentre, randomized, controlled, parallel-group superiority trial. Adult patients with oncological disease scheduled for elective port implantation were randomized to a primary open or closed strategy. Primary endpoint was the rate of pneumothorax or haemothorax. Assuming a difference of 2.5% between the 2 groups, a sample size of 1154 patients was needed to prove superiority of the open group. A logistic regression model after the intention-to-treat principle was applied for analysis of the primary endpoint.

RESULTS

Between November 9, 2014 and September 5, 2016, 1205 patients were randomized. Of these, 1159 (open n = 583; closed n = 576) were finally analyzed. The rate of pneumothorax or haemothorax was significantly reduced with the open strategy [odds ratio 0.27, 95% confidence interval (CI) 0.09-0.88; P = 0.029]. Operation time was shorter for the closed strategy. Primary success rates, tolerability, morbidity, dose rate of radiation, and 30-day mortality did not differ significantly between the groups.

CONCLUSION

A primary open strategy by cut-down of the cephalic vein, if necessary enhanced by a modified Seldinger technique, reduces the frequency of pneumothorax or haemothorax after central venous port implantation significantly compared with a closed strategy by primary puncture of the subclavian vein without routine sonographic guidance. Therefore, open surgical cut-down should be the reference standard for port implantation in comparable cohorts.

TRIAL REGISTRATION

German Clinical Trials Register DRKS 00004900.

The Effect of Immediate Versus Delayed Port Access on 30-Day Infection Rate

This study compared the 30-day infection risk of chest ports accessed on the same day as placement and chest ports with delayed initial access. The aim was to evaluate a larger data set that provided evidence for the development of port access guidelines. A retrospective chart review of 3322 chest port placement procedures performed between October 15, 2003, and June 10, 2015, was conducted at the interventional radiology department of a single institution. Procedure notes and health records were reviewed to determine time of initial port access, evidence of infection within a 30-day window of port placement, and causal organism(s) of infection. The results demonstrated that 64 ports (1.93%) met infection criteria within 30 days of placement, including 30 of the 945 ports immediately accessed and 34 of the 2377 ports not immediately accessed (3.17% vs 1.43%; P < .005). Dual lumen devices had a statistically significant higher rate of infection compared with single lumen devices (P = .006). This study concluded that there is a statistically significant higher rate of infection if a port is accessed immediately versus when access is deferred to later than 24 hours after placement.

Port Pocket Infections: Hydrogel Reduces Time to Healing and Clinic Visits Compared with Iodoform Gauze

Pocket infections are an occasional complication of totally implanted central venous catheters. The purpose of this study was to compare the safety, efficacy, and efficiency of the use of hydrogel after port removal vs the conventional method of packed iodoform gauze. In a cohort of 31 patients, the hydrogel group (n = 13) healed significantly faster than the group treated with the conventional method (15.5 vs 26.8 d; P = .009) and required fewer scheduled clinic visits (1.2 vs 10.8; P < .001). There were no differences in complications. This study suggests that hydrogel effectively promotes healing of port pocket infections, with advantages over the established technique.

Reducing central vein catheterization complications with a focused educational program: a retrospective cohort study

Central venous catheters (CVCs) are frequently used, but the rate of complications is high. This study evaluates the effects of a short training program for CVC insertion in a university-based teaching hospital. A sample of adults with CVCs inserted outside the intensive care unit was selected from two academic years: 2015, year without structured training, and 2016, year with structured training. Clinical and laboratory information, as well as the procedure’s characteristics and complications (mechanical and infectious) were collected. The incidence of complications before and after the training was compared. A total of 1502 punctures were evaluated. Comparing the pre- and post-training period, there was an increase in the choice for jugular veins and the use of ultrasound. A numerical reduction in the rate of complications was identified (RR 0.732; 95% CI 0.48–1.12; P = 0.166). This difference was driven by a statistically significant lower rate of catheter-related infections (RR 0.78; 95% CI 0.64–0.95; P = 0.047). In the multivariate analysis, aspects regarding technique (ultrasound use, multiple punctures) and year of training were associated with outcomes. Structured training reduces the rate of complications related to CVC insertion, especially regarding infections.

Right atrial catheter "ghost" removal by cardiac surgery: A pediatric case series report

Fibrin sheath formation around long-term indwelling central venous catheters is common and usually benign. Fibrin sheath can persist after catheter removal and rarely leads to complications. This is a report of three pediatric oncology patients that required cardiac surgery for cardiac embolization of a "ghost" catheter several years after catheter removal. One case required tricuspid valve replacement for complete tricuspid valve destruction and two had erosion through the atrial wall. The severity of these rare complications mandates follow-up of "ghost" catheters in pediatric oncology patients.

Late complications associated with totally implantable venous access port implantation via the internal jugular vein

PURPOSE

Several studies have analyzed late complications associated with totally implantable venous access ports (TIVAP) implantation via the internal jugular vein (IJV); however, the reported results are inconclusive. The aim of the study is to elucidate the characteristics and risk factors of late complications associated with TIVAP implantation via the IJV.

METHODS

The study included 482 patients who underwent TIVAP implantation for long-term chemotherapy and/or nutritional support between April 2012 and December 2017. Most patients (95.2%) had malignant diseases. Events requiring TIVAP removal were defined as TIVAP-related complications.

RESULTS

The median TIVAP and global follow-ups were 319 days (IQR 152-661) and 218,971 catheter days, respectively. The 3-year cumulative TIVAP availability rate was 70%. There were 44 complications (incidence of 9.1%; 0.201 complications/1000 catheter days). Infectious, catheter-related, and port-related complications occurred in 21, 14, and 9 patients, respectively with infectious complications occurring earlier and more frequently than catheter- and port-related complications. Multivariate analysis revealed that age < 65 years and presence of non-gastrointestinal diseases were significant unfavorable factors for TIVAP-related complications. Patients with 1 and 2 of these factors had an elevated risk (2.2 and 5.4 times, respectively) compared with those without.

CONCLUSIONS

Among the late complications associated with TIVAP implantation via the IJV, infectious complications occur earlier and more frequently than catheter- and port-related complications. Patients with an age < 65 years and having non-gastrointestinal diseases have a significantly high risk of TIVAP-related complications.

Complications of central venous port systems: a pictorial review

Central venous port devices are indicated for patients, who need long-term intravenous therapy. Oncologic patients may require intermittent administration of chemotherapy, parenteral nutrition, infusions, or blood transfusions. A venous port system is composed of a port chamber attached to a central catheter, which is implanted into the central venous system. The subcutaneous location of the catheter chamber improves the patients’ quality of life and the infection rate is lower than in non-totally implantable central venous devices. However, proper implantation, use, and care of a port system are important to prevent short- and long-term complications. Most common early complications (< 30 days) include venous malpositioning of catheter and perforation with arterial injury, pneumothorax, hemothorax, thoracic duct injury, or even cardiac tamponade. Delayed complications include infection, catheter thrombosis, vessel thrombosis and stenosis, catheter fracture with extravasation, or fracture with migration or embolization of catheter material. Radiologic imaging has become highly relevant in intra-procedural assessment and postoperative follow-up, for detection of possible complications and to plan intervention, e.g., in case of catheter migration. This pictorial review presents the normal imaging appearance of central venous port systems and demonstrates imaging features of short- and long-term complications.

The case for using implanted ports

Uses of central venous access devices (CVADs) include the administration of vital fluids and medications. Implanted ports are a type of CVAD that is used when long-term vascular access is required. The device is discreet and associated with a low risk of catheter-related bloodstream infection. This article describes the different types and components of ports and how to select them. It explains how to insert ports, and provides guidance on accessing and de-accessing them

Investigation of Complications Following Port Insertion in a Cancer Patient Population: A Retrospective Analysis

Central venous access devices, specifically implantable ports, play an essential role in the care of oncology patients; however, complications are prevalent. This retrospective single-institutional review was performed to identify rates of complications from port placement and potential factors associated with these events. A retrospective analysis of 539 cancer patients who underwent port insertion between March 2016 and March 2017 at our institution was conducted. Data examining 18 potentially predictive factors were collected, and multivariate analysis was conducted using logistic regression and odds ratios (ORs) with standard errors to determine predictive factors. Out of 539 patients, 100 patients (19%) experienced 1 complication, and 12 patients (2%) experienced 2 or more complications. An overall lower rate of complications was seen in patients on therapeutic anticoagulation (OR: 0.17, P < .001) or on antiplatelet agents (OR: 0.47, P = .02). No patients on therapeutic anticoagulation developed venous thromboembolism (VTE; 0%). Right-sided port insertion was associated with decreased rates of infection (OR: 0.44, P = .04). Insertion as inpatient was associated with an increased risk for mechanical failure (OR: 4.60, P < .01). This analysis identified multiple predictive factors that can potentially put patients at a higher risk of experiencing complications following port insertion. Our data show lower rates of VTE for patients on anticoagulation or antiplatelet therapy. Further analysis is also necessary to determine why port insertion as an inpatient places patients at a higher risk of complications. This study highlights the risks associated with port placement and prompts the clinician to have an informed discussion with the patient weighing the risks and benefits.

The “Arm-to-Chest Tunneling” technique: A modified technique for arm placement of implantable ports or central catheters

Purpose:

Central venous catheters or “venous access devices” include totally implantable venous access devices or “ports,” peripherally inserted central catheters, and tunneled lines. Venous access devices are now the standard of care in patients requiring long-term intravenous drug administration. Arm venous access device placement is a valuable option for vascular access yet often complicated or rendered practically impossible by the condition and size of peripheral veins. We describe a modification of the arm venous access device implantation technique that we use in our department in order to offer this option to our patients, regardless of their peripheral veins condition.

Methods:

After ultrasound guided venous access of a suitable neck vein, we create a port pouch—in case of a totally implantable vascular access device—or a skin nick—in case of a venous access device—in the inner aspect of the mid-arm. Using a straight metal tunneler, we tunnel the line from the neck to the arm in two stages, externalizing and re-inserting the line into a skin nick made on the deltopectoral groove. We call this technique “Arm-to-Chest Tunneling” and use it to place venous access devices in the arm using a neck venous access.

Results:

The Arm-to-Chest Tunneling technique allows us to use larger arm venous access device catheters irrespective of the arm veins condition. Thus, this technique has the advantages of arm venous access device placement, with the added benefit of saving the arm veins.

Conclusion:

The “Arm-to-Chest Tunneling” method offers the alternative to place a venous access device in a more discreet site in the arm, even in cases in which arm veins are inadequate.

Right- versus Left-Sided Chest Ports in Oncologic Patients with a History of Right-Sided Port Removal: Are There Any Differences in the Complication Rates?

PURPOSE

To compare chest port (port)-related complication rates between right- and left-sided ports placed in adult oncologic patients with a history of right-sided port removal.

MATERIALS AND METHODS

A retrospective chart review identified 90 adult oncologic patients with a history of right-sided port removal. Of these, 60 patients had a second port placed on the right side (right-side group), while 30 patients had a second port placed on the left side (left-side group). Median time between first port removal and second port placement was 217 days (range, 0-3808 days). Port-related complications included infection (port-site and/or bloodstream), mechanical, thrombotic, and port-site skin complications. Complication rates between groups were compared. Proportional subdistribution hazard regression (PSHREG) was conducted to determine if laterality of the second port is an independent risk factor for port-related complications.

RESULTS

The cumulative follow-up period was 34,748 catheter-days (median, 233; range, 9-2162 days). Eleven patients (18.3%) in the right-side group and 2 patients (6.7%) in the left-side group had port-related complications (P = .21), accounting for complication rates of 0.5 and 0.2/1000 catheter-days (P = .24), respectively. No statistical difference was found in the incidence of infection (9/60 vs 1/30, P = .16), mechanical (0/60 vs. 1/30, P = .33), thrombotic (1/60 vs 0/30, P = 1.0), and skin-related (1/60 vs 0/30, P = 1.0) complications between groups. In multivariate PSHREG, laterality of the second port (hazard ratio = 3.09, 95% confidence interval = 0.81-11.76, P = .10) was not a significant risk factor for port-related complications.

CONCLUSIONS

In adult oncologic patients with a history of right-sided port removal, no significant differences in port-related complication rates were observed between right- and left-sided second ports.

Treatment patterns and healthcare resource utilization among patients with hereditary angioedema in the United States

BACKGROUND

Real-world data on usage and associated outcomes with hereditary angioedema (HAE)-specific medications introduced to the United States (US) market since 2009 are very limited. The purpose of this retrospective study was to evaluate real-world treatment patterns of HAE-specific medications in the US and to assess their impact on healthcare resource utilization (HCRU). This analysis used IMS PharMetrics PlusTM database records (2006-2014) of patients with HAE, ≥1 insurance claim for an HAE-specific medication, and continuous insurance enrollment for ≥3 months following the first HAE prescription claim.

RESULTS

Of 631 total patients, 434 (68.8%) reported C1-INH(IV) use; 396 (62.8%) reported using ecallantide and/or icatibant. There were 306 episodes of prophylactic use of C1-INH(IV) (defined by continuous refills averaging ≥1500 IU/week for ≥13 weeks) in 155 patients; use of ≥1 on-demand rescue medication was implicated during 53% (163/306) of those episodes. Sixty-eight (20.2%) of 336 C1-INH(IV) users eligible for the HCRU analysis were hospitalized at least once, and 191 (56.8%) visited the emergency department (ED). Eighteen patients (5.4%) had a central venous access device (CVAD); of these, 5 (27.7%) required hospitalization and 14 (77.7%) had an ED visit. The adjusted relative risk of hospitalization and/or ED visits for patients with a CVAD was 2.6 (95% CI: 0.17, 39.23) compared to C1-INH(IV) users without a CVAD.

CONCLUSIONS

Despite widespread availability of modern HAE medications in the US, we identified a subset of patients requiring long-term prophylaxis who continue to be burdened by frequent rescue medication usage and/or complications related to the use of CVADs for intravenous HAE medication.

Vascular access for therapeutic plasma exchange

Therapeutic plasma exchange is an apheresis modality in which plasma is separated from the blood cellular components ex vivo, discarded, and replaced with an isosmotic fluid (most commonly 5% albumin) to maintain appropriate oncotic pressure in the patient. Therapeutic plasma exchange is used in the treatment of many diseases and indications. The recent seventh edition of the American Society for Apheresis guidelines indicates approximately 72 diseases and 116 indications for which therapeutic plasma exchange may be effective. One of the critical aspects for the successful performance of therapeutic plasma exchange is appropriate vascular access to provide high blood flow for the collection and return phases of the procedure, especially because most patients who need therapeutic plasma exchange will require more than one treatment over days to weeks. This article provides an overview of the characteristics of therapeutic plasma exchange, the clinical diseases and indications that may be treated with therapeutic plasma exchange, and the different types of vascular access employed, with their advantages and disadvantages. The latter may include peripheral venous access and intravascular or implantable access devices, such as arteriovenous grafts and fistulas, central venous catheters, and central venous catheters tunneled with ports.

Analysis of peripheral central venous access ports at the forearm: An observational study

The aim of this study was to analyse the characteristics of central venous catheters with brachial-implanted reservoirs and the complications associated with their use over a 4-years period. This observational study was carried out in an onco-haematological day hospital in Spain. Information was collected about 125 catheters inserted in patients requiring intravenous chemotherapy. There were more catheters implanted in women than men and the mean age was 58.6 years. Seventy of the implanted catheters were made of polyurethane and 55 of silicone. Left laterality prevailed with a mean catheter dwell-time of 347.1 days. A total of 164 complications were registered, 124 of them came from blood draws, where the most frequent complication was "inability to withdraw, ability to infuse". Forty complications were associated with the administration of treatments. Furthermore, there were 21 catheter removals, caused by several other complications different from those mentioned before. Statistically significant differences were found when associating types of catheters, laterality, blood draws and administration of treatments. Results showed how silicone ports would be more appropriate for patients who carry these types or ports than polyurethane because they reduce the number of complications causes by thrombosis.

Perioperative antibiotics should be used for placement of implanted central venous ports: A propensity analysis evaluating risk

OBJECTIVE

To quantify risk for CRI based on PABX use in CVAP placement for cancer patients.

SUMMARY BACKGROUND DATA

Central venous access ports (CVAP) are totally implanted devices used for chemotherapy. There is a temporal risk for catheter related infection (CRI) to insertion and perioperative prophylactic antibiotics (PABX) use is a contested issue among practitioners.

METHODS

Data was collected from a single center, academic oncology center. Treatment with a perioperative PABX was compared to non-treatment, to examine the incidence of 14-day CRI. Propensity scores with matched weights controlled for confounding, using 15 demographic, procedural and clinical variables.

RESULTS

From 2007 to 2012, 1,091 CVAP were placed, where 59.7 % received PABX. The 14-day CRI rate was 0.82%, with 78% of those not receiving PABX. While results did not achieve statistical significance, use of PABX was associated with a 58% reduction in the odds of a 14-day CRI (OR = 0.42, 95% CI: 0.08-2.24, p = 0.31).

CONCLUSION

The findings suggest a reduction in early CRI with the use of PABX. Since CRI treatment can range from a course of oral antibiotics, port removal, to hospital admission, we suggest clinicians consider these data when considering PABX in this high-risk population.