Infections Related to Totally Implantable Venous-Access Ports: Long-Term Experience in One Center

Risk factors of infection of totally implantable venous access port: A retrospective study

BACKGROUND

Infection is the most frequent complication associated with the use of totally implantable venous access port (TIVAP). This retrospective study was conducted to determine the risk factors affecting TIVAP-related infection.

METHODS

A total of 1406 patients implanted with TIVAP at our center were included in this retrospective study. Incidence of perioperative infection, patient characteristics and bacteriologic data were retrieved and analyzed. Univariable analyses and multiple logistic regression analyses were used to determine the risk factors.

RESULTS

Overall, 72 (5.1%) patients had perioperative infection, and TIVAP was finally removed from 12 (0.85%) patients. There was significantly more hematologic malignancy in the infection group, compared to the non-infection group. Patients with chemotherapy and infection within 30 days before operation also had more infections. There were more inpatients in the infection group than in the non-infection group. The rate of hematoma was higher in the infected patients. Multivariate logistic analysis revealed that hematoma (OR 5.695, p < 0.001), preoperative hospital stay (⩾14d) (OR 2.945, p < 0.001), history of chemotherapy (OR 2.628, p = 0.002), history of infection (within 30 days) (OR 4.325, p < 0.001) were independent risk factor for infection.

CONCLUSIONS

This study demonstrated that hematoma, preoperative hospital stay (⩾14d), history of chemotherapy and history of infection (within 30 days) are independent risk factor for all patients.

Risk factors and prognostic significance of infection of totally implantable vascular access port in solid tumor patients: A prospective cohort study

OBJECTIVES

Totally implantable venous access ports (TIVAP) are devices mainly used to deliver antineoplastic chemotherapies, of which the insertion may be complicated by TIVAP-related infection (TIVAP-RI). This study aims to provide data on the risk factors for TIVAP-RI and its influence on patient prognosis.

PATIENTS AND METHODS

Prospective observational study including adult patients with solid tumors, in whom a TIVAP was inserted to deliver antineoplastic chemotherapy between January 2018 and October 2019. Factors associated with TIVAP-RI and one-year mortality were determined using multiple logistic regressions.

RESULTS

More than a thousand (1014) patients were included, among whom 48 (4.7%) presented with TIVAP-RI. Gram-positive cocci and Gram-negative bacilli represented 51% and 41% of the pathogens isolated, respectively. Young age (odds ratio [OR] 0.67; 95% Confidence Interval [0.53-0.83] per 10-year increase), WHO performance status ≥ 1 (OR 3.24 [1.52-7.79]), chemotherapy administration in the month before TIVAP placement (OR 2.26 [1.17-4.26]), and radiation therapy of the homolateral chest wall (OR 3.28 [1.51-6.67]) were independently associated with TIVAP-RI occurrence. During the year following TIVAP insertion, 287 (28%) patients died. TIVAP-RI was not associated with one-year mortality (OR 1.56 [0.75-3.19]).

CONCLUSION

TIVAP insertion in adult patients with solid tumors is associated with a low infection rate, which did not influence one-year mortality. In addition to young age and impaired health status, TIVAP insertion in the month following initiation of the antineoplastic chemotherapy and TIVAP insertion in an irradiated area are two newly reported preventable TIVAP-RI risk factors.

Risk Factors of Catheter-Related Infection in Unplanned Extubation of Totally Implantable Venous-Accessportsin Tumor Patients

Background

Totally implantable intravenous ports (TIVAPs) are mostly used for long-term intravenous infusion therapy in cancer patients and can be left in the body for long periods of time for easy management, making them a simple and safe infusion device. Although the risks associated with long-term retention of fully implantable IV ports are less than those associated with other intravenous catheters, various complications may still occur at the time of implantation or during long-term use.

Purpose

To provide a scientific basis for clinical reduction of implantable intravenous port-associated infection complications by studying the risk factors for catheter-associated infection complications in patients applying implantable intravenous ports.

Methods

A retrospective study was conducted on oncology patients treated with TIVAP at our hospital between January 2017 and November 2021, with a review of patients who were unplanned for extubation. Their demographic data, underlying disease status, and surgery-related data were counted to summarize and analyze the complications and related influencing factors of implantation and postimplantation.

Results

A total of 70 individuals with a mean age of 56.49 ± 12.19 years were included in the study. Among them, 39 were male and 64 had the highest percentage of epithelial tumors, followed by tumors of the lymphopoiesis system and mesenchymal tumors with 4 and 2 cases, respectively. Forty-eight of these patients did not have their ports removed as planned due to the occurrence of catheter-related hematogenous infections. In univariate analysis, BMI and neutropenia were risk factors for catheter-associated infections. In the multivariate analysis, BMI (OR = 1.38, 95% CI: 1.07–1.78, p=0.013) was an independent risk factor for catheter-associated infections.

Conclusions

The overall complication rate of fully implanted intravenous ports was high, but most complications improved with symptomatic management, and no deaths due to port complications were identified. Infection was the most common complication, with catheter-associated bloodstream infection being the most common cause of unplanned port extraction. Patients with a higher BMI were at high risk of developing implantable IV port-associated infections, which may be an independent risk factor for implantable IV port-associated infections.

Risk factors for unsuccessful removal of central venous access ports implanted in the forearm of adult oncologic patients

Purpose

To evaluate the risk factors for unsuccessful removal of a central venous access port (CV port) implanted in the forearm of adult oncologic patients.

Materials and methods

This study included 97 adult oncologic patients (51 males, 46 females; age range, 30–88 years; mean age, 63.7 years) in whom removal of a CV port implanted in the forearm was attempted at our hospital between January 2015 and May 2021. Gender, age at removal, body mass index, and diagnosis were examined as patient characteristics; and indwelling period, indwelling side, and indication for removal were examined as factors associated with removal of a CV port. These variables were compared between successful and unsuccessful cases using univariate analysis. Then, multivariate analysis was performed to identify independent risk factors for unsuccessful removal of a CV port using variables with a significant difference in the univariate analysis. A receiver-operating characteristics (ROC) curve was drawn for significant risk factors in the multivariate analysis and the Youden index was used to determine the optimum cut-off value for predicting unsuccessful removal of a CV port.

Results

Removal of CV ports was successful in 79 cases (81.4%), but unsuccessful in 18 cases (18.6%) due to fixation of the catheter to the vessel wall. Multivariate logistic regression analysis showed that the indwelling period (odds ratio 1.048; 95% confidence interval 1.026–1.070; P < 0.0001) was a significant independent risk factor for unsuccessful removal of a CV port. ROC analysis showed that the cut-off value for successful removal was 41 months, and 54% of cases with an indwelling period > 60 months had unsuccessful removal.

Conclusion

The indwelling period is an independent risk factor for unsuccessful removal of a CV port implanted in the forearm of adult oncologic patients, with a cut-off of 41 months.

The Profile of Microorganisms Responsible for Port-Related Bacteremia in Pediatric Hemato-Oncological Patients

Patients with pediatric cancer face an increased risk of infections. In most cases, these infections are associated with the use of a long-term central venous catheter. This study describes the epidemiology of a port-associated bacteremia as well as a profile of microorganisms responsible for port-associated bloodstream infections (PABSIs) in pediatric patients with cancer treated in a single center. The retrospective analysis included patients with cancer who had implanted a port, hospitalized between 2010 and 2015 at the Department of Pediatric Oncology, Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences. The medical records of patients were reviewed for demographic characteristics, diagnosis, port-related complications, and their management. Data were collected from patients' electronic medical records containing complete information on medical examinations and supplementary tests, diagnosis, timing, and type of port-associated complications. In a study period, 277 ports were inserted to 241 patients. A total of 183 094 catheter days were analyzed. Sixteen patients had more than 1 insertion of a port. The commonest observed complication was PABSI (40.07%) and the incidence density was 0.6 per 1000 port-days. Staphylococcus was the most commonly isolated organisms from patients with PABSI. From all port-associated complications, bloodstream infections and mechanical complications were the most often observed complications. The commonest pathogens responsible for PABSI were coagulase-negative staphylococci. Pathogens resistant to standard antibiotic treatment play an important role in PABSI, with methicillin-resistant Staphylococcus epidermidis being the predominant pathogen. Port-associated bloodstream infections are a common reason for preterm removal of a port.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Incidence of and risk factors for totally implantable vascular access device complications in patients with gastric cancer: A retrospective analysis

Totally implantable vascular access devices (TIVADs) are often used to administer chemotherapy by prolonged intravenous infusion. The objective of the present study was to investigate the incidence of long-term complications and identify risk factors associated with TIVAD placement in patients with gastric cancer. A total of 121 patients with gastric cancer who had undergone 150 TIVAD placement procedures for chemotherapy or supportive care were enrolled in the present retrospective cohort study. A number of risk factors were analyzed, including age, sex, hypertension, diabetes mellitus, history of thrombosis, body mass index, disease stage, and site and purpose of TIVAD. In total, 40 TIVADs (26.7%) developed long-term complications, of which 27 (18.0%) were infections, seven (4.7%) were catheter-related deep vein thrombosis (CR-DVT), and six (4.0%) were obstructions. Chemotherapy was associated with an increased rate of infectious adverse events (odds ratio 2.925; 95% CI, 1.104-7.750; P=0.031) according to the multivariate analysis. CR-DVT occurred more frequently in upper arm ports than in chest wall ports; however, this difference was not statistically significant (7.5 vs. 0.0%; P=0.084) according to the univariable analysis. All CR-DVTs developed in the upper arm sites. Chemotherapy and the upper arm site were associated with long-term complications in patients with TIVAD. However, further studies are needed to confirm the findings of the present study and to determine the reasons for the high incidence of long-term complications in these patients.

Risk Factors of Infection and Role of Antibiotic Prophylaxis in Totally Implantable Venous Access Port Placement: Propensity Score Matching

BACKGROUND

To evaluate risk factors of infection and effectiveness of preprocedural single-dose intravenous prophylactic antibiotic (PABX) during totally implantable venous access port (TIVAP) placement in preventing procedure-related infections.

METHODS

This was a retrospective single-institution multicenter study evaluating short-term (30-day) infection outcomes after TIVAP placement. Correlation between infection rates and clinical factors, including hematologic versus non-hematologic malignancy, inpatient versus outpatient status, single versus double lumen and PABX, was investigated using univariate and multivariable analysis in the overall study population as well as the propensity-score-matched cohort.

RESULTS

Overall, 5967 patients underwent TIVAP placement from 2005 to 2016, of which 3978 (67%) patients received PABX. On propensity score matching, 1952 patients with PABX were matched to the same number of patients without PABX. TIVAP was removed due to infection concern in 48 patients in unmatched and 30 patients in matched population. There was no difference in the rate of infection between those who received PABX and those who did not in both unmatched and matched population (p = 0.5387 and 0.9999). Although infection rate was significantly higher in patients who had TIVAP placement in inpatient setting (p < 0.0001), who received a double-lumen TIVAP (p < 0.0001), or who had hematologic malignancy (p = 0.0004) on univariate analysis, inpatient status was the sole factor associated with higher rate of TIVAP infection on multivariable analysis of both overall (odds ratio 2.31, p < 0.0001) and matched populations (odds ratio 4.36, p = 0.0004).

CONCLUSION

Placement of TIVAP in inpatient setting increases the risk of TIVAP infection. PABX before TIVAP placement does not prevent short-term procedure-related infections.

Long-Term Management of Vascular Access Ports in Nonhuman Primates Used in Preclinical Efficacy and Tolerability Studies

Vascular access ports (VAPs) are an essential tool for long-term vascular access in preclinical studies and disease modeling in non-human primates (NHPs). We retrospectively reviewed central (inferior vena cava, IVC) and portal VAP implantation with the maintenance at our center from 15 January 2010 to 31 January 2018. In total, 209 VAPs were implanted for long-term drug administration and sampling. Patency was >95% at 6 months and >80% at 1 year for IVC VAPs and >90% at 6 months and >85% at 1 year for portal VAPs. The majority of animals had no complications and access was generally durable with device use ranging up to 7 years. In IVC, VAPs loss of patency occurred in 13% (0.035/100 d), surgical site infection in 2.9% (0.097/100 d), port pocket infection in 2.2% (0.004/100 d), erosion in 2.9%, 0.008/100 d), and mechanical failure in 4.3% (0.012/100 d). In portal, VAPs loss of patency occurred in 11.3% (0.028/100 d) and port pocket infection in 1.4% (0.003/100 d). About 12% of VAPs were removed as a result of complications.This study confirms VAP implant and maintenance is a beneficial and safe practice in NHPs resulting in favorable outcomes. High patency rates and low complication rates are comparable to the clinical setting. In addition to enabling comprehensive data collection, VAPs increase satisfaction and well-being by minimizing interference with daily routines and fostering cooperation. VAP implantation, together with an effective maintenance regimen and co-operative handling, is a reliable and convenient refined method for drug administration and blood sampling.Keywords: Vascular access port; nonhuman primates; refinement; central vascular access; portal vascular access; surgical technique; experimental surgery; animal model.

Risk factors for complications in cancer patients with totally implantable access ports: A retrospective study and review of the literature

OBJECTIVES

To analyze the risk factors for complications associated with the use of totally implantable access ports (TIAPs) in cancer patients.

METHODS

Data for 2,713 cancer patients who received a TIAP between January 2010 and September 2016 at a single center were analyzed retrospectively.

RESULTS

The average age of the patients was 54.2 ± 9.92 years, and 1,247 (47.5%) were women. The right subclavian vein was the preferred insertion site. Seventy-seven patients developed early complications and 50 developed late complications. The incidence of complications increased as the number of punctures increased. Percutaneous intervention increased the risk of complications during port insertion, but age, sex, body mass index, and the use of physiological saline solution instead of heparin for washing after port insertion did not increase the risk. The use of ultrasonography during insertion reduced the risk of complications.

CONCLUSIONS

Various factors may affect the function of TIAPs in cancer patients both during insertion and follow-up. Age, sex, body mass index, and the use of physiological saline solution for washing did not affect the incidence of complications, but the use of ultrasonography during insertion did affect the complication rate.

Infection of totally implantable venous access devices: A review of the literature

Totally implantable venous access devices, or ports, are essential in the therapeutic management of patients who require long-term intermittent intravenous therapy. Totally implantable venous access devices guarantee safe infusion of chemotherapy, blood transfusion, parenteral nutrition, as well as repeated blood samples. Minimizing the need for frequent vascular access, totally implantable venous access devices also improve the patient's quality of life. Nonetheless, totally implantable venous access devices are not free from complications. Among those, infection is the most relevant, affecting patients' morbidity and mortality-both in the hospital or outpatient setting-and increasing healthcare costs. Knowledge of pathogenesis and risk factors of totally implantable venous access device-related infections is crucial to prevent this condition by adopting proper insertion bundles and maintenance bundles based on the best available evidence. Early diagnosis and prompt treatment of infection are of paramount importance. As a totally implantable venous access device-related infection occurs, device removal or a conservative approach should be chosen in treating this complication. For both prevention and therapy, antimicrobial lock is a major matter of controversy and a promising field for future clinical studies. This article reviews current evidences in terms of epidemiology, pathogenesis and risk factors, diagnosis, prevention, and treatment of totally implantable venous access device-related infections.

Complication-related removal of totally implantable venous access port systems: Does the interval between placement and first use and the neutropenia-inducing potential of chemotherapy regimens influence their incidence? A four-year prospective study of 4045 patients

BACKGROUND

Totally implantable venous access port systems are widely used in oncology, with frequent complications that sometimes necessitate device removal. The aim of this study is to investigate the impact of the time interval between port placement and initiation of chemotherapy and the neutropenia-inducing potential of the chemotherapy administered upon complication-related port removal.

PATIENTS AND METHODS

Between January 2010 and December 2013, 4045 consecutive patients were included in this observational, single-center prospective study. The chemotherapy regimens were classified as having a low (<10%), intermediate (10-20%), or high (>20%) risk for inducing neutropenia.

RESULTS

The overall removal rate due to complications was 7.2%. Among them, port-related infection (2.5%) and port expulsion (1%) were the most frequent. The interval between port insertion and its first use was shown to be a predictive factor for complication-related removal rates. A cut-off of 6 days was statistically significant (p = 0.008), as the removal rate for complications was 9.4% when this interval was 0-5 days and 5.7% when it was ≥6 days. Another factor associated with port complication rate was the neutropenia-inducing potential of the chemotherapy regimens used, with removal for complications involved in 5.5% of low-risk regimens versus 9.4% for the intermediate- and high-risk regimens (p = 0.003).

CONCLUSION

An interval of 6 days between placement and first use of the port reduces the removal rate from complications. The intermediate- and high-risk for neutropenia chemotherapy regimens are related to higher port removal rates from complications than low-risk regimens.