Flow confirmation study for central venous port in oncologic outpatient undergoing chemotherapy: Evaluation of suspected system-related mechanical complications

Vascular Port Complication Leading to Surgery of Pulmonary Artery Branch-A Case Report

A vessel port, implanted into the central venous system, is used for long-term intravenous drug administration in oncology patients. Although essential for frequent chemotherapy and other treatments, ports can lead to complications such as infection and thrombosis. This article discusses a rare but serious complication: the displacement of a catheter fragment. A 67-year-old gastric cancer patient, experienced malignant recurrence with jaundice and bile duct infiltration post Roux-Y subtotal gastrectomy and D2 lymphadenectomy. After nine cycles of chemotherapy, a catheter fragment from the venous port detached and lodged in a branch of the pulmonary artery in segment VIII of the right lung. Thoracotomy was performed to remove the foreign body. Our aim is to report on the surgical treatment of a displaced detached catheter and to raise awareness about the potential rare complications associated with the use of vascular ports in patients undergoing chronic oncological treatment. Additionally, we screened the PubMed database for similar surgical treatment reports and compared the collected data. Venous port malfunction or non-specific patient symptoms may indicate rare complications, such as port component detachment, necessitating a multidisciplinary approach for prompt diagnosis and management in oncological patients.

Effectiveness of a flow confirmation study of a central venous port of the upper arm versus the chest wall in patients with suspected system-related mechanical complications

Background

If mechanical complications associated with a central venous port (CVP) system are suspected, evaluation with a flow confirmation study (FCS) using fluorescence fluoroscopy or digital subtraction angiography should be performed. Evaluations of mechanical complications related to CVP of the chest wall using FCS performed via the subclavian vein have been reported. However, the delayed complications of a CVP placed in the upper arm have not been sufficiently evaluated in a large population. We evaluated the effectiveness of FCS of CVPs implanted following percutaneous cannulation of the subclavian (chest wall group) or brachial (upper arm group) vein.

Methods

A CVP was implanted in patients with advanced cancer requiring chemotherapy. FCS was performed if there were complaints suggestive of CVP dysfunction when initiating chemotherapy.

Results

CVPs were placed in the brachial vein in 390 patients and in the subclavian vein in 800 patients. FCS was performed in 26/390 (6.7%) patients in the upper arm group and 40/800 (5.0%) patients in the chest wall group. The clinical characteristics of the patients were similar in both groups. The duration of CVP implantation until FCS was significantly shorter in the upper arm group (136 ± 96.6 vs. 284 ± 260, p = 0.022). After FCS, the incidence of CVP removal/reimplantation being deemed unnecessary was higher in the upper arm group (21/26 [80.8%] vs. 26/40 [65.0%], p = 0.27). In the upper arm group, no cases of catheter kinking or catheter-related injury were observed, and the incidence of temporary obstruction because of blood clots that could be continued using CVP was significantly higher than that in the chest wall group (10/26 [38.5%] vs. 4/40 [10.0%], p = 0.012).

Conclusions

FCS was effective in evaluating CVP system-related mechanical complications and deciding whether removal and reimplantation were required in both groups.

Sternal Retraction and Subclavian Vein Catheter Occlusion during Cardiac Surgery

Background

Subclavian vein (SV) catheterization is a method for the delivery of fluids, drugs, and blood products, venous blood sampling, and central vein pressure monitoring in cardiac surgery. Catheter occlusion is a serious complication of SV catheterization during cardiac surgery, especially after sternal retractor expansion.

Methods

In this observational study, 303 patients who had successful right infraclavicular SV catheterization from September 2019 to April 2020 were enrolled to determine the incidence of catheter occlusion. After catheterization, the lumens of all catheters were checked for the ability to infuse and withdraw blood from the catheter before and after sternal retractor expansion. The patients’ characteristics, cannulation approach, on-pump or off-pump technique, occlusion of the catheter and its lumens, and any associated complications were recorded. The data were analyzed using IBM SPSS ver. 22.0 (IBM Corp., Armonk, NY, USA).

Results

Of the 303 patients studied, 205 were male (67.7%) and 98 were female (32.3%). Catheter occlusion occurred in 11 patients with on-pump cardiopulmonary bypass (CPB) (227 patients) and 4 patients with off-pump CPB (76 patients) (p=0.863). The incidence of catheter occlusion was 4.95% (15 of 303 patients) with no cases of simultaneous 3-lumen occlusion in a catheter. The most commonly occluded lumen was the distal lumen (57.92%). Simultaneous 2-lumen occlusion occurred in 4 patients. Catheter occlusion was found in 3 of 13 malpositioned catheters (23.07%).

Conclusion

The current study showed that malpositioning of the catheter tip was a risk factor for catheter occlusion and that the distal lumen of a triple-lumen catheter was the most commonly occluded lumen.

Complications of central venous port systems: a pictorial review

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

Endovascular Treatment of Hepatic Artery Pseudoaneurysm after Pancreaticoduodenectomy: Risk Factors Associated with Mortality and Complications

PURPOSE

To evaluate risk factors predicting death and complications of primary therapy for hepatic and gastric duodenal artery pseudoaneurysms following endovascular treatment (EVT) after pancreaticoduodenectomy (PD).

MATERIALS AND METHODS

Between April 2004 and December 2014, 28 patients (mean age, 64.7 y) with post-PD hemorrhage underwent EVT. Prevention of hepatic artery blockage via stents or side-holed catheter grafts was stratified in cases without a replaced hepatic artery. Mortality and major hepatic complications following EVT were evaluated according to age; sex; surgery-EVT interval; presence of portal vein stenosis, shock, and coagulopathy at EVT onset; and post-EVT angiographic findings.

RESULTS

All hemorrhages were successfully treated with microcoils (n = 17; 61%), covered stents (n = 1; 3%), bare stent-assisted coil embolization (n = 5; 18%), or catheter grafts with coil embolization (n = 5; 18%). Hepatic arterial flow was observed after EVT in 18 patients (64%). Mortality and major hepatic complication rates were 28.6% and 32.1%, respectively. Hemorrhagic shock and coagulopathy at EVT onset (n = 8 each; odds ratio [OR], 27; 95% confidence interval [CI], 3.1-235.7; P < .01) were significantly associated with mortality. Coagulopathy at EVT onset (adjusted OR [aOR], 48.1; 95% CI, 3.2-2,931), portal vein stenosis (n = 16; aOR, 16.9; 95% CI, 1.3-721.9), and no visualization of hepatopetal flow through the hepatic arteries (n = 10; aOR, 29.5; 95% CI, 2.1-1,477) were significantly associated with major hepatic complications.

CONCLUSIONS

EVT should be performed as soon as possible before the development of shock or coagulopathy. Hepatic arterial flow visualization decreases major hepatic complications.

Ultrasonography-guided central venous port placement with subclavian vein access in pediatric oncology patients

BACKGROUND/PURPOSE

To evaluate the technical success and complications of image-guided central venous port (CVP) placement with subclavian vein (SCV) access in pediatric oncology population.

MATERIALS AND METHODS

Ninety-two children (52 boys, 40 girls; mean age, 8.5 years) underwent CVP implantation under local anesthesia with conscious sedation. SCV access was firstly attempted under ultrasonographic guidance and CVP implantation was performed under fluoroscopic guidance. Technical success, peri-procedural (<24h) complication, and post-procedural (>24h) complication were assessed.

RESULTS

In total, 102 CVPs were implanted in 92 children with a mean catheter time of 364 days (total, 38,224 days; range, 14-1911 days). In three small children, conversion of SCV access to internal jugular vein access yielded a primary technical success rate of 97.1% and overall technical success rate of 100%. Three minor peri-procedural complications were observed (2.9%) and seven post-procedural infectious complications occurred (infection rate, 6.7%; 0.18/1000 catheter days). No pneumothorax, catheter malposition, venous thrombosis, or mortality occurred.

CONCLUSION

Image-guided CVP placement with SCV access in a pediatric population was performed with high technical success and low complication rate without general anesthesia. This procedure can be taken into account as a choice of procedure when internal jugular venous access is not possible.

Mechanical thrombolysis of thrombosed central venous port

PURPOSE

To evaluate the effectiveness of a mechanical thrombolysis for thrombosed central venous port (CVP).

METHODS

A total of 38 patients (22 women and 16 men, median age of 55 years) were referred to our interventional unit for thrombosed implanted CVPs. The period between CVP implantation and the initial suspicion of mechanical complication varied from 2 to 35 months (mean 11.5 months) and the interval since last use of the CVP averaged 47 days (range 28-324 days). Our mechanical thrombolysis technique was performed to fragment thrombus in the port chamber by whirling the floppy tip of 0.018-inch hair-wire. Only 19-gauge noncoring needle and 0.018-inch hire-wire were used without cut-down. After removing the hair-wire and placing a second needle, the fragmented thrombi was slowly aspirated with a negative pressure and the remnant thrombus was flushed out by pushing a saline fluid. The degree of fragmentation of thrombus was evaluated with posttreatment angiography; incomplete lysis was defined as more than 50 % of thrombus remaining, significant lysis was 10-50 % of initial thrombosis remaining, and near-complete lysis was less than 10 % thrombus remaining.

RESULTS

We observed near-complete lysis in 22 patients (58 %), significant lysis in 14 patients (37 %), and incomplete lysis in two patients (5 %). The technical success rate was 82 % (31 of 38 patients). There were no major or minor complications in the recovery room during a 30-min observation period or late complications at outpatient follow-up.

CONCLUSION

A mechanical thrombolysis technique can be used to dissolve thrombus effectively from thrombosed implanted CVP on an outpatient basis.