Systematic review: malfunction of totally implantable venous access devices in cancer patients

Assessing the time-to-removal of totally implantable venous access devices comparing valved-versus open-ended catheters in patients treated with chemotherapy

BACKGROUND

Totally IntraVenous Acess Devices (TIVAD) are used to have long-term bloodstream access. The catheter connected to the subcutaneous chamber may be valved (TIVAD-V) or open-ended (TIVAD-O). Infectious and occlusion complications require the removal of the TIVAD. We compared the two types of catheters (TIVAD-V and TIVAD-O) in terms of time-to-removal and complication rates.

METHODS

A retrospective study of 636 patients treated for any malignancy using a TIVAD were included. TIVAD complication was defined as the occurrence of infection or occlusion requiring TIVAD removal. Risk factors of complications and time-to-removal of TIVAD were assessed by a Cox proportional hazard analysis.

RESULTS

A total of 55 TIVADs (8.7%) were removed including 47 for infection and eight for occlusion in 54 months. There was no significant difference in the frequency of complications between TIVAD-V and TIVAD-O. There was no significant difference in time-to-removal between TIVAD-V and TIVAD-O (17.0 months, IQR [10.5-25.0] and 18.4 months, IQR [11.5-22.9], p = 0.345, respectively).

CONCLUSION

There was no difference between TIVAD with valved and open catheter in terms of complications and time-to-removal in patients treated by chemotherapy.

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.

Availability of totally implantable venous access devices in cancer patients is high in the long term: a seven-year follow-up study

PURPOSE

Totally implantable venous access devices (TIVADs) currently have an important place in medical oncology practice; however, their long-term availability deserves further investigation, since they are usually required by patients for prolonged periods. This study aimed to evaluate long-term availability of TIVADs in adult cancer patients, in conjunction with complication/removal rates over time and associated risk factors during 7-year follow-up.

METHODS

A total of 204 adult cancer patients who underwent TIVAD placement via subclavian vein using the Seldinger technique were included in this study. Medical data and catheter follow-up records were investigated retrospectively. Complications and port removals due to complications were evaluated over time.

RESULTS

During median 21.9 (range, 0.7-82.9) months of follow-up, great majority of the patients did not require catheter removal due to complications (91.7%). During a total follow-up of 183,328 catheter days, 20 (9.8%) patients had complications with an incidence of 0.109 cases per 1000 catheter days and 18 (8.8%) of them required TIVAD removal (0.098 cases per 1000 catheter days). Most device removals due to complications (15/18, 83.3%) occurred within the first 24 months. Multivariate analysis identified left-sided device location as the only significant independent predictor of short device availability (OR, 3.5 [95% CI, 1.1-11.1], p = 0.036).

CONCLUSION

TIVADs in cancer patients appear to be safe and their availability appears to be high in the long term. A decision for early removal might be revisited. Opting for the accustomed side (right side in the present study) for implantations seems to be associated with better outcomes.

Introduction of a specialized consultation prior to insertion of totally implantable access venous devices: Impact on cancellation rate and patient satisfaction

OBJECTIVES

Preoperative consultation is usually not performed before insertion of a totally implantable venous access device (TIVAD). In our experience, an incomplete preoperative assessment, a predictable medical condition contraindicating surgery, or no-show patients the day of surgery led to several surgery cancellations. Therefore, we introduced a specific preoperative surgical consultation for TIVAD that took place shortly before surgery. The aim of the present study is to evaluate the patients' satisfaction and to establish the rate of cancellation after the adoption of this strategy.

METHODS

Two-hundred and four patients who benefited from the preoperative consultation before TIVAD insertion from August 2014 to August 2016 were included. Satisfaction of patients and cancellation rate were documented.

RESULTS

With that strategy, no TIVAD insertion was either delayed or cancelled. The overall level of satisfaction was high (91.8%); 184 patients (90.2%) judged the consultation useful in preparation for the surgery. The surgical procedure met their expectations in 92.2% of cases. Patients known for a psychiatric comorbidity were more likely to express dissatisfaction.

CONCLUSIONS

The introduction of a specific preoperative surgical consultation for TIVAD insertion led to a high level of patients' satisfaction. After the preoperative consultation, no cancellation was recorded. Special approaches have to be considered for patients with a psychiatric comorbidity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical outcomes of totally implantable venous access port placement via the axillary vein in patients with head and neck malignancy

PURPOSE:

To evaluate the clinical outcomes and complications of totally implantable venous access port implantation via the axillary vein in patients with head and neck malignancy.

MATERIALS AND METHODS:

A total of 176 totally implantable venous access ports were placed via the axillary vein in 171 patients with head and neck malignancy between May 2012 and June 2015. The patients included 133 men and 38 women, and the mean age was 58.8 years (range: 19-84 years). Medical records were retrospectively reviewed.

RESULTS:

This study included a total of 93,237 totally implantable venous access port catheter-days (median 478 catheter-days, range: 13-1380 catheter-days). Of the 176 implanted totally implantable venous access port, complications developed in nine cases (5.1%), with the overall incidence of 0.097 events/1000 catheter-days. The complications were three central line-associated blood-stream infection cases, one case of keloid scar at the needling access site, and five cases of central vein stenosis or thrombosis on neck computed tomography images. The 133 cases for which neck computed tomography images were available had a total of 59,777 totally implantable venous access port catheter-days (median 399 catheter-days, range: 38-1207 catheter-days). On neck computed tomography evaluation, the incidence of central vein stenosis or thrombosis was 0.083 events/1000 catheter-days. Thrombosis developed in four cases, yielding an incidence of 0.067 events/1000 catheter-days. All four patients presented with thrombus in the axillary or subclavian vein. Stenosis occurred in one case yielding an incidence of 0.017 events/1000 catheter-days. One case was catheter-related brachiocephalic vein stenosis, and the other case was subclavian vein stenosis due to extrinsic compression by tumor progression. Of the nine complication cases, six underwent port removal.

CONCLUSION:

These data indicate that totally implantable venous access port implantation via the axillary vein in patients with head and neck malignancy is safe and feasible, with a low axillary vein access-related complication rate.

Effect of catheter diameter on left innominate vein in breast cancer patients after totally implantable venous access port placement

PURPOSE:

To evaluate the effect of catheter diameter on left innominate vein stenosis in breast cancer patients after placement of totally implantable venous access ports.

MATERIALS AND METHODS:

Totally implantable venous access ports were placed via the left internal jugular vein in 241 women with right breast cancer from January 2010 to December 2014 (mean age, 51.5 years; range, 19-83 years). There were 67 totally implantable venous access ports with a 6.5F catheter and 142 totally implantable venous access ports with an 8F catheter. Medical records were retrospectively reviewed. The presence of significant left innominate vein stenosis and tip location of the catheter was evaluated on chest computed tomography images. Statistical analysis was performed.

RESULTS:

Left innominate vein stenosis developed in 1 (1.5%) and 13 (9.2%) patients after implantation with 6.5 and 8F catheters, respectively. Difference in the cumulative incidence of left innominate vein stenosis was statistically significant between the two groups (log rank test p-value: 0.002). In Cox regression analysis, the hazard ratio for left innominate vein stenosis was 20.766 ( p = 0.005) for an 8F catheter.

CONCLUSION:

The incidence of left innominate vein stenosis was higher after implantation of totally implantable venous access ports with 8F catheter rather than with 6.5F catheter. Considering that using 8F catheter versus 6.5F catheter has no advantage in terms of performance of the device, the results of our study suggest that ports with catheters >7F should be avoided.

Percutaneous versus Cut-Down Technique for Indwelling Port Placement

The superiority of surgical cut-down of the cephalic vein versus percutaneous catheterization of the subclavian vein for the insertion of totally implantable venous access devices (TIVADs) is debated. To compare the safety and efficacy of surgical cut-down versus percutaneous placement of TIVADs. This is a single-institution retrospective cohort study of oncologic patients who had TIVADs implanted by 14 surgeons. Primary outcomes were inability to place TIVAD by the primary approach and postoperative complications within 30 days. Multivariate analysis was performed by logistic regression. Secondary outcomes included operative time. Two hundred and forty-seven (55.9%) percutaneous and 195 (44.1%) cephalic cut-down patients were identified. The 30-day complication rate was 5.2 per cent: 14 patients (5.7%) in the percutaneous and nine (4.6%) in the cut-down group. The technique was not a significant predictor of having a 30-day complication (odds ratio = 0.820; 95% confidence interval 0.342–1.879). Implantation failure was observed in 16 percutaneous patients (6.5%) and 28 cut-down patients (14.4%) (adjusted odds ratio for cephalic vs cut-down = 2.387; 95% confidence interval 1.275–4.606). The median operative time for percutaneous patients was 46 minutes (interquartile range = 35, 59) versus 37.5 minutes (interquartile range = 30, 49) for cut-down patients(P < 0.0001). Both the percutaneous and cut-down technique are safe and effective for TIVAD implantation. Operative times were shorter and the odds of implantation failure higher for cephalic cut-down. As implantation failure is common, surgeons should familiarize themselves with both techniques.

Long-term clinical outcomes of the single-incision technique for implantation of implantable venous access ports via the axillary vein

Purpose

To evaluate long-term clinical outcomes and complications of the single-incision technique for implantation of totally implantable venous access ports (TIVAPs) via the axillary vein.

Materials and Methods

A total of 932 TIVAPs were placed in 927 patients between May 2012 and October 2014 using a single-incision technique. Patients included 620 men and 307 women with a mean age of 60.0 years. TIVAPs were placed via the left (n = 475) and right (n = 457) axillary veins after making a single oblique vertical incision and medial side pocket without subcutaneous tunneling. We retrospectively reviewed medical records to evaluate status of the patients and TIVAPs, complications, and reasons for explantation. In patients who still had a TIVAP in place, we calculated the duration of TIVAP use from the cut-off day of November 1, 2015.

Results

Clinical follow-up was obtained for a total device service period of 311,069 days with a median indwelling time of 467 days (range: 3-1097 days). A total of 37 (4.0%) complications developed. Early complications (n = 4) were one case each of stenosis of the brachiocephalic vein by tumor growth, thrombosis of axillary vein, intravascular migration, and malfunction depending on patient's position. Late complications (n = 33) were suspected catheter-related blood stream infection (n = 23), local infection of the pocket (n = 4), symptomatic stenosis and thrombosis of central vein (n = 4), malfunction by fibrin sleeve (n = 1), and intravascular migration (n = 1).

Conclusions

A single-incision technique for TIVAP implantation via the axillary vein seems to be safe with a low risk of complication.

Mechanical recanalization for clot occlusion of venous access ports: experimental study using ports with clot occlusion

PURPOSE

To test the hypothesis that mechanical injection of saline is safe and effective in restoring patency of totally implantable venous access ports (TIVAPs) with clot occlusion. We devised an experimental port model for the evaluation of mechanical TIVAP recanalization prior to its clinical application.

MATERIALS AND METHODS

The clot TIVAP occlusion model was constructed by filling the catheter with swine blood and incubating it at 37.5°C. The model was incubated for different lengths of time ranging from 1 day to 7 days. Each incubation time point included 20 ports. Total catheter occlusion of the TIVAPs was assessed with a 10-mL saline syringe equipped with a non-coring needle. Occlusion was defined as no passage of saline through the catheter when it was aspirated and infused gently with the 10-mL saline syringe. Pressure was evaluated during recanalization with an indeflator. Histological examination was performed on the clot obtained during recanalization.

RESULTS

Among the 140 total experimental ports, 65 occlusions (46.4%) were detected. Of these 65 occlusions, 56 (86.1%) were recanalized by mechanical saline pressure via the indeflator. The indeflator pressure ranged from 29 pound per square-inch (psi) to 265 psi at mechanical catheter recanalization (mean: 110 psi). Histologically, all specimens from the model ports exhibited a similar appearance; specifically, erythrocytes, cells, and fibrin were evenly scattered throughout the clot.

CONCLUSIONS

Our data indicate that it is feasible to generate a TIVAP clot occlusion model with swine blood. Moreover, mechanical recanalization was suitable for resolving occluded catheters without thrombolytic agents.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices: a meta-analysis of comparative studies

Background

A totally implantable venous access device (TIVAD) provides reliable, long-term vascular access and improves patients’ quality of life. The wide use of TIVADs is associated with important complications. A meta-analysis was undertaken to compare the internal jugular vein (IJV) with the subclavian vein (SCV) as the percutaneous access site for TIVAD to determine whether IJV has any advantages.

Methods

All randomized controlled trials (RCTs) and cohort studies assessing the two access sites, IJV and SCV, were retrieved from PubMed, Web of Science, Embase, and OVID EMB Reviews from their inception to December 2015. Random-effects models were used in all analyses. The endpoints evaluated included TIVAD-related infections, catheter-related thrombotic complications, and major mechanical complications.

Results

Twelve studies including 3905 patients published between 2008 and 2015, were included. Our meta-analysis showed that incidences of TIVAD-related infections (odds ratio [OR] 0.71, 95 % confidence interval [CI] 0.48–1.04, P = 0.081) and catheter-related thrombotic complications (OR 0.76, 95 % CI 0.38–1.51, P = 0.433) were not significantly different between the two groups. However, compared with SCV, IJV was associated with reduced risks of total major mechanical complications (OR 0.38, 95 % CI 0.24–0.61, P < 0.001). More specifically, catheter dislocation (OR 0.43, 95 % CI 0.22–0.84, P = 0.013) and malfunction (OR 0.42, 95 % CI 0.28–0.62, P < 0.001) were more prevalent in the SCV than in the IJV group; however, the risk of catheter fracture (OR 0.47, 95 % CI 0.21–1.05, P = 0.065) were not significantly different between the two groups. Sensitivity analyses using fixed-effects models showed a decreased risk of catheter fracture in the IJV group.

Conclusion

The IJV seems to be a safer alternative to the SCV with lower risks of total major mechanical complications, catheter dislocation, and malfunction. However, a large-scale and well-designed RCT comparing the complications of each access site is warranted before the IJV site can be unequivocally recommended as a first choice for percutaneous implantation of a TIVAD.

Written Information Improves Patient Knowledge About Implanted Ports

BACKGROUND

Implanted ports are frequently used for patients with cancer who require IV chemotherapy. In addition to verbal communication with healthcare providers, patients with cancer may benefit from written information.

OBJECTIVES

This pre/post study evaluated the effectiveness of an informational booklet by improving knowledge about ports and assessed the history, need, and preferences for information.

METHODS

Patients with cancer who had an implanted port for at least six months were provided with an informational booklet about ports. Knowledge about ports was tested before (T0) and after (T1) patients read the booklet. Information needs and preferred sources of information were also assessed at T0. Patients reported their opinions of the booklet at T1.

FINDINGS

The sample included 129 patients; 49% were male, with a mean age of 59 years. Most patients want to receive as much information as possible, preferably before the port is implanted. However, 43% of patients reported they had received little information about ports. After reading the booklet, patients' knowledge, which was measured with a validated seven-item instrument, improved from T0 to T1 (p < 0.001, effect size = 0.689). Oncology nurses, by providing written and verbal information, can increase patients' knowledge about implanted ports and their confidence in caring for their ports.

Effectiveness of Breast Fixation to Reduce Migration of the Tip of a Totally Implantable Venous Access Port in Women

Purpose

To evaluate effectiveness of breast fixation to reduce migration of the catheter tip of a totally implantable venous access port (TIVP) in women.

Materials and Methods

TIVPs were placed in 129 women via the right axillary vein from July 2012 to December 2014, with a final study population of 118 patients (mean age, 55.3 ± 13.8 years; range, 21-91 years). The patients were divided into two groups according to breast fixation during TIVP placement. A total of 56 patients received TIVP placement without breast fixation (Group 1); the remaining 62 received TIVP placement in the supine position after fixation of the ipsilateral breast on the abdominal wall in the sitting position (Group 2). Medical records were retrospectively reviewed for age, weight, height, body mass index, and underlying malignancy. We evaluated the difference in distance ratios between the port chamber and the catheter tip on supine chest and erect chest radiographs, respectively. Statistical analysis was performed using Student's t test.

Results

Differences in all parameters between Group 1 and Group 2 were not statistically significant. Mean distance ratio between the port chamber and the catheter tip was 1.95 ± 0.97 in Group 1 and 1.33 ± 0.59 in Group 2. Differences in distance ratios between the port chamber and the catheter tip were statistically significant between Group 1 and Group 2 (p = 0.001).

Conclusions

Breast fixation seems to be effective in reducing migration of the port chamber and catheter tip with position changes in female patients during TIVP placement.

Long-term venous access insertion: 'the learning curve'

BACKGROUND

The central venous access port device (CVAPD) provides reliable vascular access and is used for delivery of fluids and for obtaining blood samples. However, it can carry some intra- and post-operative complications such as thrombosis, pneumothorax, catheter fracture and port malposition. This article describes one surgeon's experience over a 16-year period and strategies to avoid complications.

METHODS

The data were prospectively collected from 1996 to 2012 (16-year period). Collected data included age and gender of the patient, pathology, type of port used, anaesthetic type, side and site of insertion, and complications.

RESULTS

A total of 958 devices were implanted. The average age of the patient was 57.8 years. Sixty-eight complications were recorded with an average complication rate of 7.1%. This rate decreased from 23% between 1996 and 1997 to 3.6% from 2010 to 2013. Venous thrombosis was the main source of complications with an incidence of 2.5%. This complication occurred in seven of the first 86 patients (8.1%, 1996-1998) and decreased to 1.9% between 2000 and 2013. Twenty infections (2%), five pneumothoraces secondary to insertion (0.5%), one port malposition (0.1%) and three fractures of the catheter (0.3%) occurred over the 16 years.

CONCLUSION

The surgeon's complications of CVAPD insertion requiring removal or revision of the port were considerably reduced as the surgeon's experience increases. It is suggested that all surgeons whose practice includes CVAPD insertion will have an initial learning curve, and strategies described in this paper may help decrease the number of complications.

Complicated vascular access port removals: incidence, antecedents and avoidance

PURPOSE

Port removal is usually a straightforward procedure delegated to trainees. However, some port removals are complicated by central venous catheter (CVC) fragmentation, a challenge for even experienced surgeons. This study aimed to determine the incidence of, and risk factors for, complicated port removal in children.

METHODS

A single-centre study assessed the outcome of removal for all paediatric ports inserted from 1996 to 2012. Data were recorded detailing patient, insertion, device and removal characteristics. Risk factors for complicated removals were scrutinised using Chi-square tests; p < 0.05 significant.

RESULTS

Of 628 ports inserted from 1996 to 2012, 443 were subsequently removed at the same centre. 8/443 (1.8%) removals were complicated by CVC fragmentation, a median of 3.3 (2.4-3.9) years after insertion. Of complicated cases, 8/8 underwent formal neck dissection, 3/8 intravascular dissection, and 1/8 endovascular retrieval. 2/8 cases have retained intravascular CVC fragments. Risk factors for complication were CVC caliber <6Fr (p < 0.001) and use duration >2 years (p < 0.001).

CONCLUSION

Greatest care and senior supervision should be ensured when removing ports with CVC caliber <6Fr and/or >2 years since insertion. However, complications also occur with larger CVCs or after shorter durations. Therefore, the key to avoiding complicated port removal may simply be: preparation, preparation, neck preparation.

Improving cancer patients' knowledge about totally implantable access port: a randomized controlled trial

PURPOSE

Providing patients with written information about totally implantable access ports (TIAPs) is recommended during the pre-implantation period to reduce anxiety and to help recalling information. No study tested the effectiveness of information about TIAP neither with oral communication nor with booklets. This study aimed at evaluating the effectiveness of an information booklet, alone or together with answers to clarification questions, both in improving patients' short- and long-time knowledge about TIAP and in decreasing patients' physiological indicators of anxiety immediately after TIAP implantation.

METHODS

This is a randomized controlled trial with three parallel groups: group A (n = 34) receiving only the booklet, group B (n = 34) receiving the booklet with answers to clarification questions, and group C (n = 37) receiving routine care.

RESULTS

After 3 months, pair comparisons revealed a significant improvement in knowledge of TIAP in each group (p < 0.001), together with a significant difference in group C compared with groups A (p < 0.001) and B (p < 0.001), similar to each other. Physiological indicators of anxiety decreased in the intervention groups compared to control group immediately after TIAP implantation.

CONCLUSIONS

The interventions provided resulted effective in decreasing patients' physiological indicators of anxiety immediately after TIAP implantation and improving patients' knowledge about TIAP immediately and at 3 months. Adding answers to clarification questions to the booklet was not more effective than the booklet alone. A well-designed booklet with attention both to scientific content and to communication techniques is useful in improving patients' knowledge about TIAP and reducing anxiety.

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.

Innominate Vein Stenosis in Breast Cancer Patients after Totally Implantable Venous Access Port Placement

Purpose

To evaluate the risk factors for central vein stenosis after placement of the totally implantable venous access ports (TIVPs) and the clinical relevance of this condition in breast cancer patients.

Materials and methods

TIVPs were placed in 191 women with breast cancer via the internal jugular vein (IJV) from January 2009 to December 2012 (mean age, 51.42 years) by left-side ( n = 102) and right-side ( n = 89) approaches. Medical records were retrospectively reviewed. The presence of significant central vein stenosis, tip location of the catheter and retrosternal space were evaluated on chest computed tomography images. Statistical analysis was performed.

Results

Central vein stenosis developed in 1 and 14 patients after placement via the right and left IJV, respectively. Differences in the cumulative incidence of central vein stenosis were statistically significant between left- and right-side approach groups (log rank test p-value: 0.009). In Cox regression analysis, the hazard ratio for central vein stenosis was 9.441 (p = 0.031) in the left-side approach. The distance between the sternum and the left innominate vein was found to be significantly and independently related to the development of central vein stenosis (p = 0.026). The hazard ratio of distances between the sternum and left innominate vein <16 mm was 10.133 (1.319-77.841).

Conclusions

The incidence of central vein stenosis in breast cancer patients was higher after placement of TIVPs via the left IJV. When left-side TIVP placement is required in a patient with right-side breast cancer, the possibilities of left innominate vein stenosis should be considered.

Fractures of Totally Implantable Central venous Ports: More than Fortuity. A Three-Year Single Center Experience

Purpose

Totally implantable venous access devices (Ports) represent the mainstay for infusion therapy in patients undergoing chemotherapy, total parenteral nutrition and/or long-term antibiotic treatment. Amongst mechanical complications, lesions of the catheter wall represent a rare but potentially severe condition. We report our experience with the accidental detection of catheter ruptures in a series of ports removed for complication or for end of use.

Methods

All ports removed from January 2011 to June 2013 were considered. All removed ports had been inserted according to a standardized protocol including ultrasound-guided percutaneous venipuncture (out-of-plane or in-plane approaches) and electrocardiogram-guided positioning of the tip. Once removed, each catheter was checked by inspection and saline instillation in order to evaluate the integrity of the device itself and rule out possible ruptures.

Results

In over 338 removed ports, 12 Groshong catheters out of 65 (18.5%) had evidence of partial rupture of the catheter wall. Amongst considered variables, “out-of-plane” approach and type of port (silicon, closed tip with Groshong valve) were the only ones significantly associated with catheter ruptures (p=0.0003 and 0.0008, respectively). We could detect no evidence of rupture in any silicon open-ended catheter (Celsite ports) or in any catheter inserted by “in-plane” approach to the vein.

Conclusions

The actual advantage of using port connected with Groshong silicon catheters should be questioned, since apparently they are more fragile than standard catheters. Furthermore, ultrasound-guided “out-of-plane” puncture of the internal jugular vein should be discouraged.

Nurses' knowledge regarding the handling of the totally-implanted venous access device

In the light of nurses' questions regarding the handling of the totally-implanted venous access device, this study aimed to evaluate these professionals' knowledge. This is a descriptive study with a qualitative approach, whose sample was made up of 28 nurses working on the Internal Medicine ward and in the Emergency Room. The study was undertaken in two stages: interviewing, to evaluate knowledge regarding the handling of the implanted port; and an integrative review to clarify the doubts identified. The results indicated that the nurses' knowledge was inadequate regarding when to use the implanted port, its purpose, the puncture technique, maintenance and handling. It is concluded that the knowledge of the subjects evaluated is inadequate, and that it is necessary for these professionals' clinical skills to be standardized and for them to receive theoretical-practical training.

Safe management of chemotherapy: infusion-related complications

The following is a reprint from Chapter 8 in Chemotherapy and Biotherapy Guidelines and Recommendations for Practice (Fourth Edition) by Martha Polovich, PhD, RN, AOCN®, MiKaela Olsen, MS, RN, AOCNS®, and Kristine B. LeFebvre, MSN, RN, AOCN® (Eds.).

Chest radiograph-based algorithm for managing malfunctioning ports

PURPOSE

To evaluate a chest x-ray-based algorithm for managing malfunctioning ports.

MATERIALS AND METHODS

A review of interventional radiology procedures on malfunctioning ports during the period 2000-2012 was performed. Events were divided into two periods: before and after implementation of an algorithm beginning with tip position evaluation using a chest x-ray. Time to return to usability, frequency of interventions to restore function, and frequency of malfunctioning ports remaining in use after the procedure were calculated.

RESULTS

The review included 303 procedures before implementation of the algorithm on 237 access sites in 227 patients (mean age, 56 y; 38% male) and 155 procedures after implementation of the algorithm on 131 access sites in 130 patients (mean age, 55 y; 35% male). Implementation of the algorithm was associated with significantly fewer repeat checks on the same access (27% before algorithm, 9% after algorithm, P < .001) and reduced frequency of a malfunctioning port remaining in use after the interventional radiology procedure (43% before algorithm to 14% after algorithm, P < .001). Median time from consultation to revision was significantly less after implementing the algorithm (13 days before algorithm, 1 day after algorithm, P < .001). Median time from consultation to port usability was also less after implementing the algorithm (2.7 days before algorithm, 1 day after algorithm, P < .001).

CONCLUSIONS

Implementation of the algorithm was associated with significantly less frequent repeat procedures on the same port and a lower frequency of malfunctioning ports remaining in place. Use of the algorithm was associated with significantly reduced time from consultation to revision and to return to usability. These findings suggest the algorithm allows triage of patients with malfunctioning ports to the appropriate intervention before undergoing a procedure.

A single-incision technique for placement of implantable venous access ports via the axillary vein

PURPOSE

To evaluate the technical feasibility and safety of a single-incision technique for placement of implantable venous access ports via the axillary vein.

MATERIALS AND METHODS

Ports were placed in 216 patients between May and October 2012 using a single-incision technique via the axillary vein. Patients included 112 men and 104 women with a mean age of 58.2 years. After making a single vertical incision without subcutaneous tunneling, ports were placed via the left axillary vein in 172 patients and via the right axillary vein in 44 patients. Axillary vein punctures were directed medially at the incision site under ultrasound guidance. We retrospectively reviewed success rates, technical difficulties, procedure times, and immediate and delayed complications of the procedure.

RESULTS

All single-incision port placements were technically successful. Technical difficulties occurring during the procedure included advancement of the wire or catheter into an unintended vein (n = 33), kinking at the cuff-catheter junction (n = 13), bleeding via the puncture tract (n = 5), bending of the peel-away sheath (n = 3), and puncture of the axillary artery (n = 3). All technical problems were overcome with additional manipulation. The only immediate complication was puncture site hematoma in two patients. The mean follow-up period was 165.7 days, and there were no reports of port malfunction. Axillary vein thrombosis was observed in one patient.

CONCLUSIONS

The single-incision technique for placing ports via the axillary vein was a feasible and safe procedure with high technical success and low risk of complications.

Maintaining patency in totally implantable venous access devices (TIVAD): a time-to-event analysis of different lock irrigation intervals

PURPOSE

To evaluate the effectiveness of irrigating totally implantable venous access devices (TIVADs) every eight weeks instead of every four in maintaining the patency of the device.

METHODS

An explorative, pragmatic, prospective study design was conducted in two day hospital centres located in the northeast of Italy, from January 2011 to September 2012. Twenty patients who had skipped an appointment and were thus washing their TIVAD every eight weeks (exposed) were included, as were 17 patients following the typical wash regimen of every four weeks (controls). TIVAD occlusion-defined as the inability of the device to aspirate blood and/or the inability to properly irrigate the device-was the principal study end-point.

RESULTS

A total of six occlusions were documented in six patients. Four cases were observed among the exposed group (4/20; 20.0%), while two were observed among the control group (2/17; 11.7%). No statistically significant differences were observed in the occurrence of occlusion between the groups (RR: 1.29, 95%CI: 0.67-2.50, p = 0.49). No statistically significant differences emerged between groups in the time that elapsed from study inclusion to occlusion occurrence according to the time-to-event analysis performed using the Kaplan-Meier estimation model (Log Rank [Mantel-Cox] = χ(2) 0.284, df 1, p = 0.594).

CONCLUSIONS

Within the limitations of the study which should be addressed with further research based on double-blinded randomised clinical trials, postponing the irrigation regimen of TIVADs to eight weeks seems to be sufficient to maintain device patency.

Variability in management of implantable ports in oncology outpatients

PURPOSE OF THE RESEARCH

To describe the variability in practice regarding the management of vascular access ports in adult oncology patients at Spanish outpatient clinics and to evaluate its compliance with the recommended procedural guidelines.

METHODS AND SAMPLE

Three e-mailings or three postal mail-outs were sent to all Spanish outpatient clinics, in accordance with the hospital's preference. An additional fourth postal mail-out was made to all units. In total 185 units at Spanish outpatient clinics out of a total 256 completed the survey questionnaire.

KEY RESULTS

A number of variations exist in the techniques used for insertion, withdrawal of needle from vascular access ports, blood sampling and unblocking procedure. There is considerable agreement in relation to the use of a special beveled needle, the use of gloves in the access and withdrawal procedures and checking of reservoir permeability by aspirating blood. In most cases, sterile gloves are used but there is a lesser occurrence of both scrubbed hands and correct antiseptic use.

CONCLUSIONS

There are considerable differences in the management of the vascular access ports in terms of the recommendations published in the main international guidelines, though these are based on low level evidence. The results highlight the need for further quality studies in ports use and manipulation to lessen the variability between published recommendations and clinical practice.

Comparing normal saline versus diluted heparin to lock non-valved totally implantable venous access devices in cancer patients: a randomised, non-inferiority, open trial

BACKGROUND

Heparin has been used for years as a locking solution in totally implantable venous access devices. Normal saline (NS) might be a safe alternative for heparin. However, evidence of non-inferiority of NS versus heparin is lacking.

PATIENTS AND METHODS

We randomly allocated 802 cancer patients with a newly inserted port either to heparin lock (300 U/3 ml) or to NS lock groups in a 1:1 assignment ratio. The primary outcome was the number of functional complications, which was defined as 'easy injection, impossible aspiration' at port access. Secondary outcomes included all functional problems and catheter-related bacteraemia. We hypothesised that NS locks do not cause more functional problems and catheter-related bacteraemia than heparin locks. Non-inferiority is established if the upper limit of the confidence interval (CI) for the relative risk of NS versus heparin is <1.4.

RESULTS

Three hundred and eighty-two patients from the NS group and 383 from the heparin lock group were included in the analysis. The incidence rate of our primary outcome (easy injection, impossible aspiration) was 3.70% (95% CI 2.91%-4.69%) and 3.92% (95% CI 3.09%-4.96%) of accesses in the NS and heparin groups, respectively. The relative risk was 0.94% (95% CI 0.67%-1.32%). Catheter-related bloodstream infection was 0.03 per 1000 catheter days in the NS group and 0.10 per 1000 catheter days in the heparin group.

CONCLUSION

NS is a safe and effective locking solution in implantable ports if combined with a strict protocol for device insertion and maintenance.

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.

Ultrasound and fluoroscopy-guided placement of central venous ports via internal jugular vein: retrospective analysis of 1254 port implantations at a single center

Objective

To assess the technical success and complication rates of the radiologic placement of central venous ports via the internal jugular vein.

Materials and Methods

We retrospectively reviewed 1254 central venous ports implanted at our institution between August 2002 and October 2009. All procedures were guided by using ultrasound and fluoroscopy. Catheter maintenance days, technical success rates, peri-procedural, as well as early and late complication rates were evaluated based on the interventional radiologic reports and patient medical records.

Results

A total of 433386 catheter maintenance days (mean, 350 days; range 0-1165 days) were recorded. The technical success rate was 99.9% and a total of 61 complications occurred (5%), resulting in a post-procedural complication rate of 0.129 of 1000 catheter days. Among them, peri-procedural complications within 24 hours occurred in five patients (0.4%). There were 56 post-procedural complications including 24 (1.9%, 0.055 of 1000 catheter days) early and 32 (2.6%, 0.074 of 1000 catheter days) late complications including, infection (0.6%, 0.018 of 10000 catheter days), thrombotic malfunction (1.4%, 0.040 of 1000 catheter days), nonthrombotic malfunction (0.9%, 0.025 of 1000 catheter days), venous thrombosis (0.5%, 0.014 of 1000 catheter days), as well as wound problems (1.1%, 0.032 of 1000 catheter days). Thirty six CVPs (3%) were removed due to complications. Bloodstream infections and venous thrombosis were the two main adverse events prolonging hospitalization (mean 13 days and 5 days, respectively).

Conclusion

Radiologic placement of a central venous port via the internal jugular vein is safe and efficient as evidenced by its high technical success rate and a very low complication rate.

The ongoing challenges with renal vascular access

Renal vascular access is pivotal in the care of the haemodialysis patient; however, it remains a significant challenge to maintain vascular access in the dialysis population. There are a number of renal vascular accesses in use: arteriovenous fistula, arteriovenous graft, and central venous catheter, with the arteriovenous fistula being the ideal choice. Poor vascular access can lead to serious consequences for patients, resulting in morbidity and even mortality. There are also significant cost implications for healthcare providers in terms of hospital admissions, and other associated costs for patients who are admitted late for vascular access referral or as a result of associated complications of vascular access. The nurse and other members of the healthcare team are fundamental in the management of a patient's renal vascular access.