Peripheral venous access ports: outcomes analysis in 109 patients

Infectious complications of radiologically placed upper arm ports: A single center analysis

OBJECTIVES

Infections are common complications in venous access ports. The presented analysis aimed to investigate the incidence, microbiological spectrum, and acquired resistances of pathogens in upper arm port associated infections to provide a decision aid in the choice of therapy.

MATERIALS AND METHODS

In total, 2667 implantations and 608 explantations were performed at a high-volume tertiary medical center between 2015 and 2019. In cases with infectious complications (n = 131, 4.9%), procedural conditions and results of microbiological testing were reviewed retrospectively.

RESULTS

Of 131 port associated infections (median dwell time 103 days, interquartile range 41-260), 49 (37.4%) were port pocket infections (PPI) and 82 (62.6%) were catheter infections (CI). Infectious complications occurred more often after implantation in inpatients compared to outpatients (P < 0.01). PPI were mainly caused by Staphylococcus aureus (S. aureus, 48.3%) and coagulase-negative staphylococci (CoNS, 31.0%). Other gram-positive and gram-negative species were encountered in 13.8% and 6.9%, respectively. CI were caused less frequently by S. aureus (8.6%) than CoNS (39.7%). Other gram-positive and gram-negative strains were isolated in 8.6% and 31.0%, respectively. Candida species were seen in 12.1% of CI. An acquired antibiotic resistance was detected in 36.0% of all significant isolates, occurring especially in CoNS (68.3%) and gram-negative species (24.0%).

CONCLUSIONS

Staphylococci comprised the largest group of pathogens in upper arm port associated infections. However, gram-negative strains and Candida species should also be considered as a cause of infection in CI. Due to the frequent detection of potential biofilm-forming pathogens, port explantation is an important therapeutic measure, especially in severely ill patients. Acquired resistances must be anticipated when choosing an empiric antibiotic treatment.

Comparison of the Quality of Life of Patients with Breast or Colon Cancer with an Arm Vein Port (TIVAD) Versus a Peripherally Inserted Central Catheter (PICC)

Introduction: Venous access is a crucial element in chemotherapy delivery. It remains unclear whether cancer patients prefer a port to a peripherally inserted central catheter (PICC). Our study aimed to assess cancer patients’ satisfaction with their venous access device and to compare the quality of life (QoL) of subjects with a PICC to those with a port. Methods: In this prospective cohort study, EORTC QLQ-C30, and a locally developed quality of life survey (QLAVD), designed to assess satisfaction with venous access devices, were administered to breast or colorectal cancer patients over a one-year period following the device insertion. Mixed effects models were used to assess changes on mean scores at different time points. Results: A total of 101 patients were recruited over a three-year period, (PICC group, n = 50; port group, n = 51). Survey response rates for months one and three were 72% and 48%, respectively. Overall, no significant differences were noted between the two groups in relation to EORTC QOL. At three months, the mean pain scores were 3.5 ± 2.3 for the port and 1.3 ± 0.75 for PICC (<0.001). The mean score for a negative effect of the venous access device on psychosocial well-being was 6.0 ± 4.1 for PICC and 3.0 ± 2.7 for the port (p = 0.005). Complications related to PICCs occurred in 38% patients versus 41% with a port (p > 0.24). Conclusions: Although subjects with a port experienced more pain during the device insertion or access for chemotherapy, it had a smaller negative impact on psychosocial scores than the PICC. No significant differences in complications rates were observed between the two devices.

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.

PICC-PORT totally implantable vascular access device in breast cancer patients undergoing chemotherapy

BACKGROUND AND OBJECTIVES

The increasing use of arm totally implantable vascular access devices for breast cancer patients who require chemotherapy has led to a greater risk of complications and failures and, in particular, to upper extremity deep vein thrombosis. This study aims to investigate the outcomes of the arm peripherally inserted central catheter-PORT technique in breast cancer patients.

METHODS

The peripherally inserted central catheter-PORT technique is an evolution of the standard arm-totally implantable vascular access device implant based on guided ultrasound venous access in the proximal third of the upper limb with subsequent placement of the reservoir at the middle third of the arm. A prospective study was conducted on 418 adult female breast cancer patients undergoing chemotherapy. The primary study outcome was peripherally inserted central catheter-PORT failure.

RESULTS

Median follow-up was 215 days. Complications occurred in 29 patients (6.9%) and failure resulting in removal of the device in 11 patients (2.6%). The main complication we observed was upper extremity deep vein thrombosis, 10 (2.4%); all patients were rescued by anticoagulant treatment without peripherally inserted central catheter-PORT removal. The main reason for removal was reservoir pocket infection: 4 (0.9%) with an infection rate of 0.012 per 1000 catheter days. Cumulative 1-year risk of failure was 3.6% (95% confidence interval, 1.3%-7.1%). With regard to the patients' characteristics, body mass index <22.5 was the only significant risk for failure (p = 0.027).

CONCLUSION

The peripherally inserted central catheter-PORT is a safe vascular device for chemotherapy delivery that achieves similar clinical results as traditional long-term vascular access devices (peripherally inserted central catheter and arm totally implantable vascular access device, in particular) in breast cancer patients.

The peripheral portacath provides safe and convenient venous access in pediatric and adolescent patients

INTRODUCTION

Adolescent patients with chronic conditions rely on permanent venous access for safe treatment and supportive care. Traditionally this is provided by a central venous access device (CVAD) e.g. Hickmann catheter or totally implanted subcutaneous port or also called Port-a-Cath (PaC). We reviewed the patient experience, safety and feasibility of insertion of peripheral inserted implanted subcutaneous port (peripheral PaC).

METHODS

Medical records of patients who underwent insertion of peripheral PaC under ultrasound guidance at our institution since between 2012-2017 were reviewed to ascertain specific details including duration of insertion and complication rate. Short structured questionnaires were used to assess nursing and patient satisfaction.

RESULTS

Twenty eight peripheral PaC were inserted at our institution. There were 17 female and 11 male patients aged between 12.3 and 18.7 years (median = 16.1). Six were inserted under local anesthetic (LA) in patients who were not fit for general owing to mediastinal mass or lung disease. At the time of analysis 2 PaCs remained in situ with a median duration of 8 months (range 3-48). Removal of 26 PaCs was under LA in 15 cases and under GA in 11. Complications were observed in 9 cases but only necessitated early removal or replacement in 3 cases (displacement and disconnection) and repositioning in 1 case. Thrombosis was seen in 2 patients who required systemic anticoagulation but had complete resolution.

CONCLUSION

This study shows that the use of peripheral PaC is safe. The feedback from patients and nursing staff supports the use of the peripheral PaC. We are exploring additional patient groups that might benefit from this device.

Central Venous Port Catheters: Evaluation of Patients' Satisfaction with Implantation under Local Anesthesia

Purpose

Evaluation of pain perception and patient satisfaction after implantation of a central venous port catheter system under local anesthesia.

Methods

A total of 100 consecutive patients (25 outpatients, 75 inpatients) who underwent successful implantation of a port catheter into the internal jugular vein from May through August 2007 were given an 8-item questionnaire. The extent of information about the implantation, the pain perception during implantation and the friendliness of the physician and nurse were evaluated. Furthermore, the patients were asked to assess their degree of anxiety and the pain they experienced during the intervention and to give an appraisal of whether local anesthesia was adequate. Each question was assessed on a 10–point scale (10 = very true to 1 = not at all true). In addition, the overall duration of the intervention (including patient preparation, implantation, patient aftercare, disinfection of the room) was documented.

Results

Patients felt highly satisfied with the way they were informed (mean score of 9.65) and considered the treating physician (9.89) and nurse (9.9) extremely friendly. Local anesthesia was rated as nearly completely adequate (9.56) and the degree of pain experienced was low (9.05; 10 = no pain). The average anxiety score was 8.56 (10 = not afraid at all). Overall satisfaction with the treatment was very high (9.62; outpatients: 9.72) and patients would recommend port catheter implantation at our department to others (9.77). The mean overall duration of the intervention was 76 min (range 40–120 min).

Conclusion

Positive patient reactions indicate that radiologic port catheter implantation under local anesthesia is a minimally invasive intervention with high patient satisfaction that can be performed on an outpatient basis and is a valid alternative to surgical implantation.

Brachial insertion of fully implantable venous catheters for chemotherapy: complications and quality of life assessment in 35 patients

Objective

To prospectively evaluate the perioperative safety, early complications and satisfaction of patients who underwent the implantation of central catheters peripherally inserted via basilic vein.

Methods

Thirty-five consecutive patients with active oncologic disease requiring chemotherapy were prospectively followed up after undergoing peripheral implantation of indwelling venous catheters, between November 2013 and June 2014. The procedures were performed in the operating room by the same team of three vascular surgeons. The primary endpoints assessed were early postoperative complications, occurring within 30 days after implantation. The evaluation of patient satisfaction was based on a specific questionnaire used in previous studies.

Results

In all cases, ultrasound-guided puncture of the basilic vein was feasible and the procedure successfully completed. Early complications included one case of basilic vein thrombophlebitis and one case of pocket infection that did not require device removal. Out of 35 patients interviewed, 33 (94.3%) would recommend the device to other patients.

Conclusion

Implanting brachial ports is a feasible option, with low intraoperative risk and similar rates of early postoperative complications when compared to the existing data of the conventional technique. The patients studied were satisfied with the device and would recommend the procedure to others.

Application and comparison of different implanted ports in malignant tumor patients

Background

The current study aims to compare the application and convenience of the upper arm port with the other two methods of implanted ports in the jugular vein and the subclavian vein in patients with gastrointestinal cancers.

Methods

Currently, the standard of practice is placement of central venous access via an internal jugular vein approach. Perioperative time, postoperative complications, and postoperative comfort level in patients receiving an implanted venous port in the upper arm were retrospectively compared to those in the jugular vein and the subclavian vein from April 2013 to November 2014.

Results

Three hundred thirty-four patients are recruited for this analysis, consisting of 107 in the upper arm vein group, 70 in the jugular vein group, and 167 in the subclavian vein group. The occurrence of catheter misplacement in the upper arm vein is higher than that in the other two groups (13.1 vs. 2.9 vs. 5.4 %, respectively, P = 0.02), while the other complications in the perioperative period were not significantly different. The occurrence of transfusion obstacle of the upper arm vein group is significantly lower than that of the jugular and subclavian groups (0.9 vs. 7.1 vs. 7.2 %, P = 0.01). The occurrence of thrombus is also lower than that of other two groups (0.9 vs. 4.3 vs. 3.6 %, P = 0.03). Regarding the postoperative comfort, the influences of appearance (0 vs. 7.1 vs. 2.9 %, P = 0.006) and sleep (0.9 vs. 4.2 vs. 10.7 %, P = 0.003) are significantly better than those of the jugular and subclavian vein groups.

Conclusions

Compared to the jugular and the subclavian vein groups, the implanted venous port in the upper arm vein has fewer complications and more convenience and comfort, and might be a superior novel choice for patients requiring long-term chemotherapy or parenteral nutrition.

A retrospective analysis on the utility and complications of upper arm ports in 433 cases at a single institute

Background

We have employed upper arm central venous ports (UACVPs) since 2006 for long-term intravenous chemotherapy (CTx) or fluid supplementation. We evaluated the long-term availability of CVPs implanted in the upper arm to determine whether UACVPs could be one of the treatment options besides chest CVPs in terms of CVP-related complications.

Methods

We reviewed the medical records of all patients who underwent subcutaneous implantation of UACVPs at Kyoto University Hospital from 1 April, 2006 to 30 June, 2009. We assessed the indwelling duration of the UACVPs and the incidences of early and late UACVP-related complications.

Results

A total of 433 patients underwent subcutaneous implantation of UACVPs during this time period. The cumulative follow-up period was 251,538 catheter days, and the median duration of UACVP indwelling was 439.0 days (1–2, 24). There was no UACVP-related mortality throughout the study period. A total of 83 UACVP-related complications occurred (19.2 %), including 43 cases of infection (9.9 %, 0.17/1000 catheter days), ten cases of catheter-related thrombosis (2.3 %, 0.040/1000 catheter days), ten cases of occlusion (2.3 %, 0.040/1000 catheter days), nine cases of catheter dislocation (2.0 %, 0.036/1000 catheter days), five cases of port leakage (1.2 %, 0.019/1000 catheter days), four cases of skin dehiscence (0.9 %, 0.015/1000 catheter days) and two cases of port chamber twist (0.5 %, 0.008/1000 catheter days). The removal-free one-year port availability was estimated at 87.8 %.

Conclusions

UACVPs were of long-term utility, with complication rates comparable to those of chest CVPs previously reported.

Radiology-Implanted Arm Ports: A Review of the Literature

Introduction: Placement of totally implanted venous access devices, or port systems, in the upper arm is becoming a common practice in interventional radiology. To gain a better understanding of the literature in this area, we performed a search for and analysis of previous publications related to upper arm implantation of these devices by members of interventional radiology departments.

Methods: A review of the literature pertaining to upper arm port systems implanted in human beings by members of interventional radiology departments was performed, assessing publications between the years 1992 and 2014. Only English-language publications were assessed.

Results: Eighteen publications met selection criteria during the time frame reviewed. None of the studies used a prospective, randomized design; rather, all studies consisted of case–cohort descriptions of outcomes for a single device or for multiple devices. Analysis of the available literature for interventional radiology-inserted arm ports was performed. The technical success rate ranged between 93.7% and 100%, with an average of 98.9%.

Conclusions: The high technical success rate of arm port implantation and the elimination of the potential for pneumothorax, hemothorax, catheter pinch-off syndrome, and subclavian and carotid artery injury are strengths of the arm implantation strategy. There was wide variation in the rates of complications detected, in addition to inconsistent study design and study implementation strategies.

Short-term and long-term outcome of radiological-guided insertion of central venous access port devices implanted at the forearm: a retrospective monocenter analysis in 1704 patients

OBJECTIVES

The objectives are to analyze the technical success rate as well as the short-term and long-term complications of totally implantable venous access ports (TIVAPs) at the forearm.

METHODS

Retrospective analysis of 1,704 consecutively implanted TIVAPs was performed. Primary endpoints were defined as technical success rate, clinical outcome, device service interval, and rates of major complications. Minor complications not requiring port explantation were defined as secondary endpoints.

RESULTS

The technical success rate was 99.2 % with no major complications. During follow-up, a total of 643,200 catheter-days were documented, the mean device service interval was 380.6 days/patient. A total of 243 complications (14.4 %) in 226 patients were observed (0.4/1000 catheter-days), in 140 patients (8.3 %) the port device had to be explanted. Disconnection between the port device and the catheter (1.6 %) was more frequent than fracture (0.8 %) and leakage (0.6 %) of the catheter, which occurred more frequently when the catheter was inserted via the cephalic versus the brachial vein.

CONCLUSION

TIVAP implantation at the forearm is a simple and safe procedure with a low rate of early and late complications.

Upper arm central venous port implantation: a 6-year single institutional retrospective analysis and pictorial essay of procedures for insertion

Background

The requirement of central venous (CV) port implantation is increasing with the increase in the number of cancer patients and advancement in chemotherapy. In our division, medical oncologists have implanted all CV ports to save time and consultation costs to other departments. Recently, upper arm implantation has become the first choice as a safe and comfortable method in our unit. Here we report our experience and discuss the procedure and its potential advantages.

Methods

All CV port implantations (n = 599) performed in our unit from January 2006 to December 2011 were analyzed. Procedural success and complication rates between subclavian and upper arm groups were compared.

Results

Both groups had similar patient characteristics. Upper arm CV port and subclavian implantations were equivalently successful and safe. Although we only retrospectively analyzed data from a single center, the upper arm group had a significantly lower overall postprocedural complication rate than the subclavian group. No pneumothorax risk, less risk of arterial puncture by ultrasound, feasibility of stopping potential arterial bleeding, and prevention of accidental arterial cannulation by targeting the characteristic solitary basilic vein were the identified advantages of upper arm CV port implantation. In addition to the aforementioned advantages, there is no risk of “pinch-off syndrome,” possibly less patient fear of manipulation, no scars on the neck and chest, easier accessibility, and compatibility with the “peripherally inserted central catheter” technique.

Conclusions

Upper arm implantation may benefit clinicians and patients with respect to safety and comfort. We also introduce our methods for upper arm CV port implantation with the videos.

Catheter Fracture and Embolization Associated with Arm Implantation of the Cook Vital Port

Purpose

To determine the frequency of arm port catheter fracture and embolization related to the Cook Vital Port Mini Titanium.

Materials and Methods

A retrospective audit of our Cerner Radiology Information System was performed between June 1, 2006, and June 30, 2011, to determine the number of Cook arm venous ports implanted and the frequency of foreign body retrievals related to catheter fracture for these arm ports.

Results

A total of 691 arm implantations of the Cook Vital Port during the 5-year time frame were analysed. Eleven of these patients (1.6%) required intravenous foreign body retrieval in the interventional radiology suite related to catheter fracture and embolization. Three of these fractured catheters were retrieved from the peripheral venous system upstream of the pulmonary circulation, whereas 8 embolized to the pulmonary arteries. All were successfully extracted with an intravenous snare by interventional radiology.

Conclusion

We discovered a 1.6% frequency of catheter fracture and embolization associated with arm implantation of the Cook Vital Port. All the catheters fractured at the vein entry site and did not detach from the port housing. The cause for catheter fracture and embolization is uncertain. Pulmonary embolization of the fractured catheters puts the patients at risk for possible further complications. No patients had ancillary complications related to catheter embolization or to catheter extraction procedures. Further investigation is required in an attempt to determine the circumstances that may result in catheter fracture and embolization related to this venous access device.

Radio-opacity and incidental identified mechanical complications of totally implantable venous access devices placed in the chest

BACKGROUND

Totally implantable venous access devices (TIVAD) may be associated with different complications. Certain mechanical port disorders can easily be diagnosed on chest radiographs if the implanted systems are radiopaque and well visible. There are no reports regarding the visibility of TIVAD on chest X-rays.

PURPOSE

To assess the radio opacity of TIVAD implanted in the chest as well as type and frequency of mechanical complications of ports on chest X-ray images.

MATERIAL AND METHODS

Chest X-rays of 985 patients from the time period 2007-2009 were analyzed retrospectively. In these patients 1190 TIVAD were inserted. All parts of the TIVAD, i.e. port chamber, connection, and port catheter, were checked for their visibility on chest radiographs. An opacity score was used here as follows: ++ well visible; + visible; - partly or completely invisible. Mechanical complications of TIVAD incidentally detected on chest X-ray were also analyzed retrospectively.

RESULTS

Nineteen TIVAD models with diverse configuration and visibility of port chambers, connections, and catheters were identified in our study. Eighty-eight percent of the analyzed port systems were well visible or visible on chest radiographs. Twelve percent of the port chambers and catheters were partly visible or completely invisible. In 9% of the TIVAD, different mechanical complications were diagnosed on chest X-ray images.

CONCLUSION

TIVADs should be evaluated carefully on every chest X-ray. Ideally, they should be radio-opaque and well visible on thoracic X-ray images. Unfortunately, this is not always the case. Therefore, manufacturers of TIVAD should take into consideration to use exclusively radio-opaque materials that allow sufficient visibility of each port component on chest radiographs.

Central venous port-related infection in patients with malignant tumors: an observational study

PURPOSE

We evaluated the characteristics of central venous port (CVP)-related infection with microbiological assessments in patients with malignant tumors.

MATERIALS AND METHODS

In a prospective setting, patients with CVP for the treatment of malignant tumors were enrolled in this study. The incidence of CVP-related infection during three months was determined. Microbiological surveillance from skin swab was performed before and after CVP placement.

RESULTS

Fifty-nine patients were enrolled in this study, and 60 CVPs were implanted. Thirty-six (61%) patients had head and neck malignancies. Access route was subclavian vein in 43 (71.7%) CVPs and forearm vein in 17 (28.3%). CVP-related infection was observed in three (5.1%) patients: port-pocket infection in one and probable CVP-related infection in two patients, respectively. No definitive CVP-related bloodstream infection was observed. Before the placement of CVP, colonization at the insertion site was observed in ten subclavian CVP patients, while no colonization was observed in the forearm CVP patients. At 1 and 4 weeks, detection rates of colonization were also higher in subclavian CVP patients. No definitive relationship was demonstrated between skin colonization and clinical development of CVP-related infection.

CONCLUSION

The rate of CVP-related infection in this prospective evaluation in patients with malignant tumors was comparable to previous studies. Colonization of the skin was more prominent in the subclavian site than in the forearm site. Although skin colonization was not proven to be a risk factor of infection, these results may draw attention to the adequate maintenance of CVP. (

TRIAL REGISTRATION

UMIN000003664).

Complications after percutaneous placement of totally implantable venous access ports in the forearm

This article focuses on radiological imaging of complications after interventional percutaneous insertion of totally implantable venous access ports (TIVAPs) which were placed in the forearm. Thus far most reviews have dealt with pectorally-placed TIVAPs. Compared with the pectoral approach, implantation in the forearm has been associated with certain complications owing to a longer route of the port catheter within a smaller vein, and owing to the route across the elbow joint, resulting in higher rates of catheter-associated thrombosis and possible mechanical complications. The purpose of this review is to describe the complications after implantation of TIVAPs in the forearm, and to make radiologists familiar with the key findings of the complications during radiological imaging, including colour-coded and compression Duplex ultrasound, computed tomography, and digital subtraction venography.

Common and uncommon complications of totally implantable central venous ports: a pictorial essay

PURPOSE

The purpose of this study is to present the characteristic radiologic features of common and uncommon complications in totally implantable central venous ports.

MATERIAL AND METHODS

The authors reviewed 138 implantations of central venous ports in oncologic patients during an 18-month period and present the characteristic imaging features of the complications detected.

RESULTS

All chest ports were placed via the internal jugular vein using both fluoroscopic and ultrasound guidance. The technical success rate was 99.3% (137/138). All catheter or port-related complications were retrospectively assessed. Sixteen complications were detected during the follow-up period, and catheter removal was required in 10 patients.

CONCLUSIONS

Image-guided central venous port catheter implantation is a very safe procedure with a low rate of complications. The typical imaging features of common and uncommon complications are very helpful in establishing the correct diagnosis and thus tailoring the appropriate therapy.

Percutaneous retrieval of intravascular venous foreign bodies in children

BACKGROUND

The use of vascular lines both venous and arterial in children has significantly increased in the last decade with the potential risk that an intravascular device may become an intravascular foreign body. Percutaneous retrieval by interventional radiology has become an accepted method of foreign body removal.

OBJECTIVE

The objective of this study is to describe a single center's experience of percutaneous intravascular foreign body removal in pediatric patients.

MATERIALS AND METHODS

Between January 2000 and December 2008, 18 patients underwent percutaneous intravascular foreign body retrieval as a complication of venous access devices. The mean catheter days were 181.2 catheter days (1 to 1,146 days). A retrospective review was performed and demographic data and clinical information were recorded, including type, duration, location of access device, embolization location and retrieval technique.

RESULTS

Eighteen of 19 (94.7%) retrievals were performed with single-loop snares and 1/19 (5.3%) was a triple-loop snare. Seventeen of 19 (89.5%) retrievals were successful. One unsuccessful retrieval was successfully removed by surgery, while the other was retained.

CONCLUSION

Percutaneous intravascular foreign body retrieval by interventional radiologists is a safe and effective method of retrieving embolized fragments from venous access devices in pediatric patients.

[How should urologists perform implantation of subcutaneous central venous port systems? A single center experience of 347 cases]

BACKGROUND

Since 1999 urologists at the University of Essen in Germany have performed subcutaneous implantation of venous port systems, controlled by intravasal ECG.

METHODS

Between December 1999 and June 2011 implantation of venous port systems was performed in 241 male (69.5%) and 106 (30.5%) female patients. The port systems were implanted subcutaneously above the pectoralis major muscle under local anesthesia. If it was not possible to isolate the cephalic vein or safe catheter implantation was not feasible, puncture of the subclavian vein was performed.

RESULTS

The median follow-up was 491.6 days (2-2568), and 163.254 catheter days (mean 239 days, range 2-2604) were documented. During the follow-up period 191 (55.1%) patients died. The mean surgical implantation and explantation time was 36.5 min (14-85 min) and 25.4 min (10-46 min), respectively; 79.7% were implanted and controlled by ECG. Altogether, 390 devices were used in 379 surgical procedures, 355 implantations (91.1%) and 35 explantations (8.9%). Implanted vessels were the cephalic vein in 303 patients (85.6%) and the subclavian vein in 51 (14.4%) patients. Of 35 explanted devices, the explantation was necessary due to complications in 28 (8.0%) cases: infection n=6 (1.7%, 0.036 per 1,000 catheter days), occlusion n=8 (2.3%, 0.049 per 1,000 catheter days), dislocation n=7 (2.0%, 0.042 per 1,000 catheter days), deep vein thrombosis of the upper extremity n=6 (1.7%, 0.037 per 1,000 catheter days), and clotting n=1(0.3%, 0.006 per 1,000 catheter days). Premature catheter removal (<30 days post-op) was required in six cases (1.9%, 0.036 per 1,000 catheter days) due to complications: three catheter dislocations/malfunctions (0.9%, 0.019 per 1,000 catheter days), one port-related infection, one pocket port infection, and one deep vein thrombosis of the upper extremity (0.3%, 0.006 per 1,000 catheter days). Other problems described in the literature like pneumothorax, vein perforation, or pinch-off syndrome did not occur.

CONCLUSIONS

Implantation of port systems with ECG control of the catheter tip position is related to a few cases of adverse events and good surgical outcomes. Furthermore, it has also shown great advantages in offering immediate support and early therapy initiation with a fast learning curve for the training urologists. The results of the presented analysis are comparable to those of surgical or radiological departments reported in the literature and provide good evidence that this procedure should be extended to urological centers with a high volume of chemotherapy patients.

Identification of Risk Factors for Catheter-Related Thrombosis in Patients with Totally Implantable Venous Access Ports in the Forearm

Purpose

To identify risk factors for the development of catheter-related thrombosis (CRT) in patients with totally implant-able venous access ports (TIVAP) in the forearm, and to analyze the effect of prophylaxis and treatment.

Methods

We retrospectively identified 200 patients (94 men, 106 women, mean age 57.7 +/-14 y) with TIVAP implantation in the forearm between 3/2010 and 11/2010. Type, number of punctures and sonographically defined diameter of the accessed vein were analyzed. Chemotherapy administered prior to the implantation procedure and history of thrombo-embolic events were assessed. Thrombo-embolic prophylaxis (TEP) following port implantation and treatment as well as course of CRT were analyzed.

Results

Twenty-one patients (10.5%) were diagnosed with CRT. Accessed vessels and mean diameter were basilic (n=150, 3.7 mm), brachial (n=39, 3.5 mm) and cephalic (n=11, 3.5 mm) vein. Neither type nor vessel diameter had effect on CRT development (P>.05). Implantation in the left forearm resulted in a significantly higher rate of CRT (P=.04). Ninety-five patients (47.5%) received chemotherapy and 30 patients (15.0%) had a history of thrombosis prior to implantation; both had no effect on development of CRT. Low molecular weight heparin (LMWH) was prescribed in 94/200 patients (47.0%) and had no effect on development of CRT (P>.05). Therapeutic anticoagulation with LMWH resulted in clinical improvement in 12/21 patients (57.4%).

Conclusions

TIVAPs of the forearm may be associated with a certain rate of early and late CRT. The simplest vein to puncture should be selected for vascular access. Thrombo-embolic prophylaxis appears to be rather ineffective for prevention of CRT.

Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm

BACKGROUND

Conventional totally implantable venous access ports (TIVAPs) are not approved for power contrast injections but often remain the only venous access site in oncologic patients. Therefore, these devices can play an important role if patients with a TIVAP are scheduled for a contrast-enhanced computed tomography (ceCT) as vascular access may become more difficult during the course of chemotherapy.

PURPOSE

To evaluate the feasibility and safety of power injections in conventional TIVAPs in the forearm and to analyze the feasibility of bolus triggering during CT scans.

MATERIAL AND METHODS

In this retrospective study we analyzed 177 power injections in 141 patients with TIVAPs in the forearm. Between October 2008 and March 2010 all patients underwent power injections (1.5 mL/s, 150 psi) via the TIVAP for ceCT because conventional vascular access via a peripheral vein had failed. Adequate functioning and catheter's tip location after injection were evaluated. Peak injection pressure and attenuation levels of aorta, liver and spleen were analyzed and compared with results of 50 patients who were injected via classical peripheral cannulas (3 mL/s, 300 psi). Feasibility of automatic scan initiation was evaluated. In vitro the port was stressed with 5 mL/s (300 psi).

RESULTS

One TIVAP showed tip dislocation with catheter rupture. Three (2.1%) devices were explanted owing to assumed infection within 4 weeks after the injection. Mean injection pressure was 121.9 +/-24.1 psi. Triggering with automatic scan initiation succeeded in 13/44 (29.6%) scans. Injection via classical cannulas resulted in significantly higher enhancement (p < 0.05). In vitro the port system tolerated flow rates of up to 5 mL/s, injection pressures of up to 338 psi.

CONCLUSION

Power injection is a safe alternative for patients with TIVAPs in the forearm if classic vascular access ultimately fails. Triggering was successful in one-third of the attempts. Image quality in the arterial phase scan may be hampered. In vitro results suggest that the device tolerates even higher flow rates.

Explanation of Totally Implantable Venous Access Ports of the Forearm: Reasons for Removal and Observed Complications

Purpose

To evaluate indications for, and complications during, explantation of interventionally placed totally implantable venous access ports (TIVAPs) of the forearm.

Background

Many studies analyze the explantation procedure of pectorally placed TIVAPs. The literature on TIVAPs in the forearm is limited, and the explantation procedure of these devices in the forearm has not been sufficiently evaluated yet.

Methods

We retrospectively reviewed the archives of our institute between May 2006 and May 2009 and identified 850 TIVAPs that had been implanted in the forearm. Of these TIVAPs, 145/850 (80 in women, 65 in men; mean age 52 years, range 15–82 years) were explanted during this period either by interventionists (n=109) or by general surgeons (n=36).

Results

Mean catheter survival was 322 days. Reasons for explantation were end of therapy (63.4%), infection (29.0%), thrombosis (3.4%), occlusion (1.4%), or dislocation (1.4%) of the TIVAP. Primary technical success rate was 97.2% for the surgical as well as for the interventional procedure. The overall success rate was 100%. The reasons for retrieval failure by interventionists (3/108) as well as by surgeons (1/36) were post-thrombotic adhesions of the port catheter to the blood vessel wall.

Conclusions

Removal of TIVAPs of the forearm shows a high technical success rate and a low complication rate. End of therapy is the most common indication for explantation. There is a low risk of interventional removal failure with a resulting need for open surgery to remove the device.

Features and selection of vascular access devices

OBJECTIVE

To review venous anatomy and physiology, discuss assessment parameters before vascular access device (VAD) placement, and review VAD options.

DATA SOURCES

Journal articles, personal experience.

CONCLUSION

A number of VAD options are available in clinical practice. Access planning should include comprehensive assessment, with attention to patient participation in the planning and selection process. Careful consideration should be given to long-term access needs and preservation of access sites.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses are uniquely suited to perform a key role in VAD planning and placement. With knowledge of infusion therapy, anatomy and physiology, device options, and community resources, nurses can be key leaders in preserving vascular access and improving the safety and comfort of infusion therapy.

Central vein dilatation prior to concomitant port implantation

Implantation of subcutaneous port systems is routinely performed in patients requiring repeated long-term infusion therapy. Ultrasound- and fluoroscopy-guided implantation under local anesthesia is broadly established in interventional radiology and has decreased the rate of complications compared to the surgical approach. In addition, interventional radiology offers the unique possibility of simultaneous management of venous occlusion. We present a technique for recanalization of central venous occlusion and angioplasty combined with port placement in a single intervention which we performed in two patients. Surgical port placement was impossible owing to occlusion of the superior vena cava following placement of a cardiac pacemaker and occlusion of multiple central veins due to paraneoplastic coagulopathy, respectively. In both cases the affected vessel segments were dilated with balloon catheters and the port systems were placed thereafter. After successful dilatation, the venous access was secured with a 25-cm-long, 8-Fr introducer sheath, a subcutaneous pocket prepared, and the port catheter tunneled to the venipuncture site. The port catheter was introduced through the sheath with the proximal end connected to a 5-Fr catheter. This catheter was pulled through the tunnel in order to preserve the tunnel and, at the same time, allow safe removal of the long sheath over the wire. The port system functioned well in both cases. The combination of recanalization and port placement in a single intervention is a straightforward alternative for patients with central venous occlusion that can only be offered by interventional radiology.

Central venous access ports in children treated for hematopoietic malignancies

During past 10 years 234 central venous access ports (CVAP) were implanted in 225 patients at the Department of Pediatric Hematology and Oncology in Zabrze. Mean exposure time was 745 days and total implantation time reached 173,768 days. Complications were encountered in 17 patients (7.6%). This mainly concerned central venous line infection, which led to removal of 10 CVAP (4.4%). The remaining complications necessitating removal of the CVAP consisted mainly of mechanical problems (catheter fracture, occlusion, and erroneous implantation to artery). In the opinion of the authors, subcutaneously implanted CVAP are a safe and effective option for high-dose chemotherapy deliverance in childhood cancer patients.

Long-term outcomes of peripheral arm ports implanted in patients with colorectal cancer

BACKGROUND

Venous ports are mandatory for chemotherapy in cancer patients because prolonged infusions are required. The aim of this study was to assess the safety of peripheral arm ports for chemotherapy in patients with colorectal cancer.

METHODS

A peripheral venous access port was placed in the upper arm in 113 consecutive patients with metastatic colorectal cancer (MCRC). All patients received modified FOLFOX (5-fluorouracil [5-FU]/l-leucovorin [LV]/oxaliplatin [L-OHP]) 6 or FOLFIRI (5-FU/LV/irinotecan hydrochloride [CPT-11]) regimens at least once via the venous access port. All patients were followed up at least once every 2 weeks.

RESULTS

Puncture of the basilic veins was successfully completed under real-time sonographic guidance or radiographic guidance in all patients. The median operative time was 30 min. The cumulative follow-up period was 29 886 catheter days (range, 9-560 days; mean, 264 days). No procedural complications, such as pneumothorax, hemothorax, arterial puncture, or cardiovascular problems, occurred in our series. A total of nine patients (8.0%) had complications. Port-site infection occurred in six patients (5.3%; 0.20 infections per 1000 catheter-days). One patient (0.9%) had an episode of ultrasound-documented deep vein thrombosis in the ipsilateral upper extremity (0.03/1000 catheter-days). Dislocation or migration of the catheter tip occurred in two patients (0.07/1000 catheter-days). A second port was placed in six patients (5.3%) after removal of the fi rst port.

CONCLUSION

Peripheral arm ports can be maintained with excellent short-and long-term outcomes. Peripheral arm ports are considered to be a good alternative to central venous ports implanted in the chest in patients with MCRC.

Intravenous Port Catheter Embolization: Mechanisms, Clinical Features, and Management

Venous catheters are important therapeutic devices for the administration of fluid and chemotherapeutic agents; however, their use may be associated with serious complications, such as catheter rupture and embolism. Most data on port catheter embolization consist of isolated case reports; only a few studies have examined a large number of patients with port catheter embolism. The purpose of this study was to identify the incidence of clinical symptoms in patients with catheter dislocation and to determine the role of catheter fragment localization in combination with the presenting symptoms. We conducted a retrospective analysis of patients admitted to Martin-Luther University Hospital Center from January 1994 to September 2005. In total, 41 patients with centrally dislocated catheter fragments were analyzed. Most catheter fragments were located in the pulmonary artery, superior vena cava, and right atrium. Of the patients in whom the catheter fragments were located in the right atrium, right ventricle, and the pulmonary artery, 7.3% presented cardiac symptoms. Catheter malfunction occurred in 39%. In 53.7%, catheter embolism was found incidentally. The embolized catheter fragments were retrieved by a goose-neck snare under fluoroscopy within 24 hours after the diagnosis without any complications. The mean length of these fragments was 11.6 cm. Catheter embolism may go undiagnosed for a prolonged period and be found incidentally. In these patients, predominantly local symptoms occur; however, severe systemic clinical signs may develop. The risk of serious complications in asymptomatic catheter embolism is unknown. Catheter fragments should be removed to prevent further complications.

Subcutaneous venous port implantation in patients with bilateral breast surgery

The purpose of this study was to evaluate the long-term follow-up results of subcutaneous venous ports implanted in patients with bilateral mastectomies. We retrospectively reviewed the hospital charts and the electronic database of 17 patients with bilateral mastectomies whom had venous port implantation in our interventional radiology suit. A total of 17 ports were implanted to the paramedian (n = 3) and anterolateral (standard; n = 12) chest wall, on the trapezius muscle (n = 1), and to the antecubital fossa (n = 1). The mean age was 48.29 years (range: 35-60 years). The mean time interval from time of surgery to port implantation was 34 months (range: 1-84 months). The mean follow-up time was 15 months (range: 7-39 months). Follow-up parameters and classification of the complications was defined according to the SIR guidelines. No procedure-related complication occurred. A single case of mild late infection was noted and the infection rate was 0.19/1000 catheter days. Infusion chemotherapy administration was still going on in eight patients. Two patients died during the follow-up and four patients were lost after 6 months. Port removal was performed in three patients at follow-up because of the end of treatment. One trapezius port and one paramedian port weres among the removed ports without any problem. Although we have a limited number of patients, port placement to the anterior chest wall, either paramedian or anterolateral, on the trapezius muscle or to the antecubital fossa depending on the extent of the bilateral breast surgeries that can be performed with low complication rates by a careful patient and anatomical location selection by involving the patients in the decision-making process. We believe that patient education and knowledge of possible complications have high importance in follow-up.

Prevention of central venous catheter-associated thrombosis: a meta-analysis

PURPOSE

Anticoagulant prophylaxis in patients with central venous catheters is controversial. We performed a meta-analysis of randomized controlled trials of anticoagulant prophylaxis in patients with central venous catheters.

METHODS

MEDLINE and EMBASE were searched up to May 2006, supplemented by manual searches of conference proceedings and bibliographies.

RESULTS

Fifteen trials were included. Unfractionated heparin infusion, oral fixed low-dose vitamin K antagonist, and subcutaneous low-molecular-weight heparin were evaluated. For all catheter-associated deep vein thrombosis (symptomatic and asymptomatic combined), the summary relative risks ranged from 0.31 to 0.73 (all achieved statistical significance). For symptomatic deep vein thrombosis, the summary relative risks ranged from 0.28 to 0.72, but did not achieve statistical significance for any individual regimen.

CONCLUSION

Anticoagulant prophylaxis is effective for preventing all catheter-associated deep vein thrombosis in patients with central venous catheters. The effectiveness for preventing symptomatic venous thromboembolism, including pulmonary embolism, remains uncertain.

Is radiologic placement of an arm port mandatory in oncology patients?

BACKGROUND

The objective of the current study was 2-fold: to evaluate a radiologically placed percutaneous arm port device (PRAPD) in a large series of 1000 consecutive cancer patients undergoing chemotherapy (in terms of safety, efficacy, complications, and quality of life [QoL]) and to propose future recommendations.

METHODS

From 1998 to August 2002, all patients who had cancer required chemotherapy underwent insertion of a PRAPD and were prospectively included. All patients were followed for technical feasibility, overall device-related complications, and QoL.

RESULTS

Technical failures (6.3%) were caused by the inability to perform an arm venogram in 22 patients or to catheterize the brachial vein in 41 patients. Septic complications (3.2%) included septicemia (n = 7 patients), catheter sepsis (n = 9 patients), and febrile neutropenia (n = 16 patients). Mechanical complications (4%) included a twisted port (n = 2 patients), extravasation (n = 7 patients), catheter leaks (n = 7 patients), port obstruction (n = 7 patients), skin dehiscence of the port (n = 11 patients), catheter rupture and occlusion (n = 5 patients), and median nerve compression (n = 1 patient). Central venous thrombosis occurred in 12 patients (1.2%), and arm phlebitis occurred in 7 patients (0.7%). Procedure-related death occurred in 0.4%. Early port removal was performed in 5.3% of patients. Good QoL was reported at port removal.

CONCLUSIONS

The PRAPD was found to be safe, effective, and well tolerated in oncology patients. PRAPD could be recommended in selected patients instead of a surgical port device.

Peripherally inserted central venous catheter-associated thrombosis: retrospective analysis of clinical risk factors in adult patients

BACKGROUND

Peripherally inserted central catheters (PICC) are common venous access devices. Clinical conditions and therapies that increase the risk of PICC-associated thrombosis have not been studied.

METHODS

We performed a retrospective case-control analysis of all adult patients who underwent placement of a PICC at our hospital over a three-year period (n = 1296). Clinical variables examined were indication for PICC placement, active cancer treatment, history of DVT, diabetes mellitus, and use of prophylactic anticoagulation.

RESULTS

The overall incidence of PICC-associated DVT was 2% (n = 27). Active cancer therapy was significantly associated with PICC-associated DVT (OR 3.5, 95% CI 1.3-9.8). The use of prophylactic anticoagulation did not reduce this risk.

CONCLUSIONS

Patients who suffered a PICC-associated DVT were more likely to be undergoing treatment for cancer. This risk was not lowered by the use of prophylactic anticoagulation. These results suggest a need for prospective studies on effective anticoagulation for patients at high risk for PICC-associated DVT.

The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies

OBJECTIVE

To better understand the absolute and relative risks of bloodstream Infection (BSI) associated with the various types of intravascular devices (IVDs), we analyzed 200 published studies of adults In which every device in the study population was prospectively evaluated for evidence of associated infection and microbiologically based criteria were used to define IVD-related BSI.

METHODS

English-language reports of prospective studies of adults published between January 1, 1966, and July 1, 2005, were identified by MEDLINE search using the following general search strategy: bacteremla [Medical Subject Heading, MeSH] OR septicemia [MeSH] OR bloodstream Infection AND the specific type of intravascular device (e.g., central venous port). Mean rates of IVD-related BSI were calculated from pooled data for each type of device and expressed as BSIs per 100 IVDs (%) and per 1000 IVD days.

RESULTS

Point incidence rates of IVD-related BSI were lowest with peripheral Intravenous catheters (0.1%, 0.5 per 1000 IVD-days) and midline catheters (0.4%, 0.2 per 1000 catheter-days). Far higher rates were seen with short-term noncuffed and nonmedicated central venous catheters (CVCs) (4.4%, 2.7 per 1000 catheter-days). Arterial catheters used for hemodynamic monitoring (0.8%, 1.7 per 1000 catheter-days) and peripherally inserted central catheters used in hospitalized patients (2.4%, 2.1 per 1000 catheter-days) posed risks approaching those seen with short-term conventional CVCs used in the Intensive care unit. Surgically implanted long-term central venous devices--cuffed and tunneled catheters (22.5%, 1.6 per 1000 IVD-days) and central venous ports (3.6%, 0.1 per 1000 IVD-days)--appear to have high rates of Infection when risk Is expressed as BSIs per 100 IVDs but actually pose much lower risk when rates are expressed per 1000 IVD-days. The use of cuffed and tunneled dual lumen CVCs rather than noncuffed, nontunneled catheters for temporary hemodlalysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI.

CONCLUSIONS

Expressing risk of IVD-related BSI per 1000 IVD-days rather than BSIs per 100 IVDs allows for more meaningful estimates of risk. These data, based on prospective studies In which every IVD in the study cohort was analyzed for evidence of infection by microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by the various types of IVDs In use at the present time. Since almost all the national effort and progress to date to reduce the risk of IVD-related Infection have focused on short-term noncuffed CVCs used in Intensive care units, Infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVDs.

Atypical pulmonary embolism of port catheter fragments in oncology patients

GOALS OF WORK

Embolization of venous catheter fragments to the pulmonary vasculature is a very rare form of pulmonary embolism which is only sporadically reported in the literature. The incidence and clinical picture of this complication are unknown.

PATIENT AND METHODS

In this retrospective analysis between 1999 and 2004, in our clinic, 1,014 port catheters were implanted. In this 5-year period, the patients' files were screened for the incidence of pulmonary embolism of catheter fragments and the accompanying complication rate.

MAIN RESULTS

In 11 patients, port catheter dislodgment and embolism into the pulmonary artery occurred. In all the patients' port examination by fluoroscopy, catheter dislocation and embolization were shown. In these 11 patients, no obvious clinical signs indicating dislocation of catheter fragments into the pulmonary circulation were found. None of these patients demonstrated respiratory symptoms. Heart rate, blood pressure, respiration frequency, and even oxygen saturation were normal. In 7 of the 11 patients, malfunction of port catheter was the first indicator of catheter dislocation. In four patients, embolized catheter fragments were an incidental finding. The main cause of catheter embolization was the pinch off syndrome. All embolized catheter fragments were retrieved by a 'goose-neck' snare without complication.

CONCLUSION

These results suggest that the migration of fractured catheter into the pulmonary artery occurs in 1% of the central port catheter implantation. It is often asymptomatic, and malfunction of the catheter may be the first sign of this complication. The pinch off syndrome might be prevented by using the internal jugular vein or by implantation of the port catheter more laterally in the subclavian vein.

Radiological and surgical placement of port devices: a 4-year institutional analysis of procedure performance, quality of life and cost in breast cancer patients

PURPOSE

The present study is designed to evaluate and compare percutaneous radiologic arm port (R) and surgical subclavian port (S) devices in two homogeneous sets of breast cancer patients in terms of safety, efficacy, quality of life (QoL) and cost analysis.

MATERIAL AND METHODS

This study involved a retrospective review of a prospective databank including 200 consecutive port device implantation attempted procedures performed over a 4-year period, in two similar groups of 100 breast cancer women who underwent either the surgical cephalic vein cutdown approach or the percutaneous basilic vein catheterization for intravenous adjuvant chemotherapy. Parameters analyzed included technical success, procedure duration, complications, QoL and cost evaluation for both techniques.

RESULTS

The success rate for port implantation was higher for R than for S placement (96% versus 91%). Mean implant duration time was 5.6 and 7.6 months for R and S, respectively. The overall complication rate was 10 and 16% for R and S, respectively. Mean implant duration time, without any complication or death, was 6.4 and 7.8 months for R and S, respectively. Six and seven percent for R and S, respectively, had to be removed prematurely. Both techniques exhibited very good QoL. Direct costs were respectively euro 230.8 and 219.1 for R and S, respectively.

CONCLUSION

The significant advantages of R over S include higher success rate, higher cosmetic results despite a 15% relative overcost for R placement. Both are indicated for breast cancer chemotherapy treatment, nevertheless R placement is mandatory in anxious patients who fear surgery, in case of previous cervico-thoracic irradiation or upper extremity venous thrombosis, or in patients at risk of respiratory insufficiency.

Cathéters à chambre implantable : épidémiologie des complications et étude microbiologique des dispositifs après ablation

Totally implantable venous access ports (TIVAP) are valuable medical devices for long-term intravenous treatment such as parenteral nutrition, cancer chemotherapy or antiviral therapy. Implantation and use of these devices are each associated with infectious or mechanical complications.

AIMS OF THE STUDY

To determine the frequency of complications and to analyze bacterial contamination of different parts of TIVAP (tip, septum, internal lumen of the port).

MATERIAL AND METHODS

Clinical charts of patients, which TIVAP was removed between April 20th to December 31st 2003, were retrospectively reviewed. Infectious complications (local and septicemic) and non-infectious complications (i.e. obstruction, thrombosis, drug extravasation...) were defined using clinical and/or microbiological criteria. Quantitative culture from different parts of the TIVAP was performed.

RESULTS

One hundred and ten patients (age 57 +/- 14-years-old, 94.3% cancers) were included, corresponding to 57,018 catheter-days: 39.1% had one or more non-infectious complications (density incidence: 0.86 for 1000 catheter-days). Among the 49 complications, obstruction, thrombosis, extravasations and malposition accounted for 30.6%, 30.6% 4.1% and 6% of cases. Twenty-one patients (19.1%) had an infectious complication: 11 were local and 14 were systemic (density incidence 0.43 for 1000 catheter-days). Bacteria responsible for TIVAP-associated bacteraemia were coagulase negative staphylococci (N = 2), Staphylococcus aureus susceptible to methicilline (N = 3), micrococci (N = 1), corynebacteria (N = 1) or Gram-negative bacilli (N = 8). Comparison of quantitative culture of the different parts of TIVAP with a threshold at 10(3) CFU/ml showed that culture of tip, septum and port has a sensitivity of 47.6% 57.1% and 61.9 %, respectively and a specificity of 100% 92.1% and 92.1%, respectively for the diagnosis of TIVAP infection.

CONCLUSION

Complications associated to TIVAP are frequent but incidence that we have reported is comparable with previous studies. Analysis of internal lumen of the port is the most sensitive method for the diagnosis of TIVAP-associated infections.

Retention of lepirudin at the tip of a silicone catheter: a better catheter flush solution?

Because central venous catheters often become blocked by clot at their tip despite heparin flushes, a more effective anticoagulant is needed. We hypothesize that lepirudin, a recently introduced protein anticoagulant, might be more effective than heparin because of its tendency to adsorb to silicone, a commonly used catheter material. We preliminarily tested this hypothesis in vitro by measuring residual lepirudin and heparin activity at the tip of a catheter that had been submerged in a flowing stream of water for various periods of time. We observed that lepirudin is less readily removed than heparin from the catheter by fluid washing over it. This "slow-release" property of lepirudin might provide prolonged protection against clot formation at the catheter tip. A clinical trial will be necessary, however, to determine whether this property translates into significant improvement in catheter function.

Lower-extremity deep venous thrombosis after upper-extremity port catheter placement: an unusual complication

We describe the case of a woman with breast carcinoma who experienced deep venous thrombosis of the right lower extremity after placement of a double-lumen central venous chemotherapy port catheter in the left upper extremity. Color Doppler sonography revealed a linear tubular structure within the right common femoral vein and sonographic features of thrombosis, suggesting deep venous thrombosis secondary to displacement of the port catheter.

Subcutaneous chest ports via the internal jugular vein. A retrospective study of 117 oncology patients

PURPOSE

To review image-guided chest port insertion using the right internal jugular vein as the access site of choice.

MATERIAL AND METHODS

One hundred and eighteen subcutaneous chest ports were placed via the internal jugular vein in 117 patients with malignancies using both fluoroscopic and US guidance in interventional radiology suites.

RESULTS

The technical success rate was 100% with no procedural complications. Follow-up was obtained in all patients with total access days of 40,450 days (mean, 342.8 days). Premature catheter removal was required in 8 patients (6.8%, 0.20 per 1,000 access days) due to non-treatable complications: 2 catheter occlusions/malfunctions (1.7%, 0.05 per 1,000 access days), 1 catheter-related skin erosion (0.85%, 0.024 per 1,000 access days), and 5 infections (4.2%, 0.15 per 1,000 access days). Two symptomatic right upper extremity venous thromboses also occurred (1.7%, 0.05 per 1,000 access days) that were treated successfully with anticoagulation.

CONCLUSION

Image-guided placement of internal jugular vein chest ports has a high success rate and low complication rate compared with reported series of unguided subclavian vein port insertion. The internal jugular vein should be used as the preferred venous access site compared to the subclavian vein.

Risk of deep venous thrombosis associated with chest versus arm central venous subcutaneous port catheters: a 5-year single-institution retrospective study

PURPOSE

To determine the risk of deep venous thrombosis (DVT) in patients undergoing placement of central (chest) versus peripheral (arm) ports.

MATERIALS AND METHODS

Between January 1996 and December 2000, a total of 440 implantable chest or arm ports were placed in 422 patients. Data pertaining to the first port placed for each patient was analyzed. Ports were placed for chemotherapy (n = 415) or blood transfusion (n = 7). Subset analysis was performed, taking into consideration whether patients received prophylactic or therapeutic doses of warfarin sodium (Coumadin), to determine if there was any difference in the incidence of DVT between patients undergoing some form of anticoagulation versus those undergoing none. The medical records of these patients were reviewed to determine outcome with reference to development of DVT.

RESULTS

In 273 chest ports placed, there were 13 (4.8%) instances of DVT; in 149 peripheral ports, there were 17 (11.4%). Censoring data on patients receiving some form of anticoagulation, the respective incidences were eight of 245 (3.3%) and 14 of 129 (10.9%). With use of Kaplan-Meier analysis and log-rank tests to examine comparisons of interest, the probability of thrombosis occurring over a period of 180 days was higher with peripheral ports irrespective of Coumadin use (P =.007 for all patients considered, P =.002 when analyzed only for those not receiving Coumadin). The difference in incidence of thrombosis for all ports between patients receiving Coumadin versus those not receiving Coumadin was not significant.

CONCLUSIONS

Compared to chest ports, peripheral ports are associated with a significantly higher incidence of DVT.