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

Catheter Tip Migration in Female Patients With Breast Cancer: A Retrospective Comparative Study of Right- and Left-Sided Chest Ports

Introduction: Chest ports are typically inserted via the right internal jugular vein with the left side being utilized in certain patient populations. The purpose of this study was to evaluate the dynamic position of the chest port and catheter tip, comparing a demographically matched cohort of female breast cancer patients with right- or left-sided chest ports. Methods: 142 female patients with breast cancer requiring chest port insertion for chemotherapy and imaging confirming catheter tip position initially with supine fluoroscopy and follow-up with erect chest radiography over a 5-year period were identified. Data points analyzed were catheter tip-to-carina distance and the distance from the port to the ipsilateral infraclavicular border. Intraprocedural measurements were taken in the supine position during chest port insertion and compared with follow-up erect chest radiography. The catheter tip position was also allocated a zone within the venous system on both image sets to assess for significant retraction to a more proximal zone in the erect position. Imaging within 12-months of chest port insertion was also screened to identify port-related complications. Results: The whole cohort showed significant retraction of the catheter tip (cephalad) (p < 0.001) and protraction of the port (caudal) (p < 0.001). The median tip-to-carina distance decreased from 38.3 mm to 28.6 mm and the port-to-clavicle distance increased from 31.3 mm to 64.6 mm. Right-sided chest ports had increased tip-to-catheter retraction (15 mm) compared with left-sided (6.9 mm) (p=0.310). A complication was identified in 8.5% of the right-sided and 11% of the left-sided ports. Zone migration was significantly associated with the occurrence of a complication in left-sided ports (p=0.023). Conclusion: When assessing chest port catheter tip position between supine and erect radiographic studies in female patients with breast cancer, retraction cephalad will occur and this is more apparent in right-sided ports. Change in catheter tip position was not associated with a significant increase in complication rate unless it occurred in left-sided ports where zone migration was evident.

A Monocentric Analysis of Implantable Ports in Cancer Treatment: Five-Year Efficacy and Safety Evaluation

BACKGROUND

Daily clinical practice requires repeated and prolonged venous access for delivering chemotherapy, antibiotics, antivirals, parenteral nutrition, or blood transfusions. This study aimed to investigate the performance and the safety of totally implantable vascular access devices (TIVADs) over a 5-year follow-up period through a standardized well-trained surgical technique and patient management under local anesthesia.

METHODS

In a retrospective, observational, and monocentric study, 70 patients receiving POLYSITE® TIVADs for chemotherapy were included. The safety endpoints focused on the rate of perioperative, short-term, and long-term complications. The performance endpoints included vein identification for device insertion and procedural success rate.

RESULTS

The study demonstrated no perioperative or short-term complications related to the TIVADs. One (1.4%) complication related to device manipulation was identified as catheter flipping, which led to catheter adjustment 56 days post-placement. Moreover, one (1.4%) infection due to usage conditions was observed, leading to TIVAD removal 3 years and 4 months post-surgery. Catheter placement occurred in cephalic veins (71.4%), subclavian veins (20%), and internal jugular veins (8.6%). The procedural success rate was 100%. Overall, the implantable ports typically remained in place for an average of 22.4 months.

CONCLUSIONS

This study confirmed the TIVADs' performance and safety, underscored by low complication rates compared to published data, thereby emphasizing its potential and compelling significance for enhancing routine clinical practice using a standardized well-trained surgical technique and patient management.

Machine learning risk prediction model for bloodstream infections related to totally implantable venous access ports in patients with cancer

Objective

This study aimed to develop and validate a machine learning-based risk prediction model for catheter-related bloodstream infection (CRBSI) following implantation of totally implantable venous access ports (TIVAPs) in patients.

Methods

A retrospective cohort study design was employed, utilizing the R software package mlr3. Various algorithms including logistic regression, naive Bayes, K nearest neighbor, classification tree, and random forest were applied. Addressing class imbalance, benchmarks were used, and model performance was assessed using the area under the curve (AUC). The final model, chosen for its superior performance, was interpreted using variable importance scores. Additionally, a nomogram was developed to calculate individualized risk probabilities, enhancing clinical utility.

Results

The study involved 755 patients across both development and validation cohorts, with a TIVAP-CRBSI rate of 14.17%. The random forest model demonstrated the highest discrimination ability, achieving a validated AUC of 0.94, which was consistent in the validation cohort.

Conclusions

This study successfully developed a robust predictive model for TIVAP-CRBSI risk post-implantation. Implementation of this model may aid healthcare providers in making informed decisions, thereby potentially improving patient outcomes.

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.

Central venous access device terminologies, complications, and reason for removal in oncology: a scoping review

BACKGROUND

Lack of agreed terminology and definitions in healthcare compromises communication, patient safety, optimal management of adverse events, and research progress. The purpose of this scoping review was to understand the terminologies used to describe central venous access devices (CVADs), associated complications and reasons for premature removal in people undergoing cancer treatment. It also sought to identify the definitional sources for complications and premature removal reasons. The objective was to map language and descriptions used and to explore opportunities for standardisation.

METHODS

A systematic search of MedLine, PubMed, Cochrane, CINAHL Complete and Embase databases was performed. Eligibility criteria included, but were not limited to, adult patients with cancer, and studies published between 2017 and 2022. Articles were screened and data extracted in Covidence. Data charting included study characteristics and detailed information on CVADs including terminologies and definitional sources for complications and premature removal reasons. Descriptive statistics, tables and bar graphs were used to summarise charted data.

RESULTS

From a total of 2363 potentially eligible studies, 292 were included in the review. Most were observational studies (n = 174/60%). A total of 213 unique descriptors were used to refer to CVADs, with all reasons for premature CVAD removal defined in 84 (44%) of the 193 studies only, and complications defined in 56 (57%) of the 292 studies. Where available, definitions were author-derived and/or from national resources and/or other published studies.

CONCLUSION

Substantial variation in CVAD terminology and a lack of standard definitions for associated complications and premature removal reasons was identified. This scoping review demonstrates the need to standardise CVAD nomenclature to enhance communication between healthcare professionals as patients undergoing cancer treatment transition between acute and long-term care, to enhance patient safety and rigor of research protocols, and improve the capacity for data sharing.

Targeted Therapies, Biologics, and Immunotherapy in the Neoadjuvant and Adjuvant Settings: Perioperative Risks

Cancer therapeutics has been revolutionized by the introduction of molecularly targeted therapies and immune checkpoint inhibitors (ICIs). The paradigm of neoadjuvant therapy is commonly employed across multiple solid tumors, exhibiting significant clinical benefit as exemplified with ICIs in melanoma and non-small-cell lung cancer. However, neoadjuvant therapy can be associated with treatment-related adverse events. As the incorporation of these novel therapies in the preoperative space expands, it is crucial for surgical oncologists to understand the potential perioperative implications of these treatments. This article focuses on surgical considerations tied to these treatments, highlighting potential drug-surgery interactions and complications.

A Spectrum of Chemoport-Associated Complications and Their Management in Cancer Patients

INTRODUCTION

Chemotherapy is part and parcel of the multimodality approach to cancer treatment. Chemoports are frequently used to administer chemotherapy, preventing complications associated with the use of peripheral lines. However, chemoports have their own set of complications and can be very debilitating at times. Accurate knowledge and correct technique can help prevent and manage these complications properly.

METHODS

We retrospectively analyzed all patients who underwent chemoport insertion for chemotherapy infusion over three years between July 2020 and June 2023. The patient's profile, type of cancer, the technique of chemoport insertion, complications related to chemoport, and its management were recorded retrospectively from patient records.

RESULTS

The total number of patients in our study was 119. The age group of patients ranged from 13 years to 76 years. Of the 119 patients, 55 had breast cancer, 23 had ovarian cancers, 29 had GI cancers including gastroesophageal junction (GEJ)/ stomach/periampullary/colorectal, and 12 had leukemias. The most common intraoperative complication was catheter tip malposition (9.2%). The most common postoperative complications were infection (7.5%), followed by drug extravasation (5.0%), thrombosis (3.3%), wound dehiscence (2.5%), and skin necrosis (0.8%) in decreasing order of frequency. Serious complications such as hemothorax, pneumothorax, air emboli, brachial plexus injury, and pericardial tamponade, commonly reported in the literature, were not seen in any of our cases.

CONCLUSION

 Totally implanted venous access devices (TIVAD)/chemoports are indispensable in the management of cancer patients, especially in patients requiring long duration of infusion and prolonged treatment. Although chemoports are associated with a spectrum of complications, proper technique of implantation and use makes it a safe and reliable tool.

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.

A fragmented segment of a central venous catheter caused delayed ventricular fibrillation: a case report

BACKGROUND

Central venous port systems may be safely used for chemotherapy of patients with cancer, but several complications may occur associated with their use.

CASE PRESENTATION

An 83-year-old man with heat stroke was transferred to our emergency department, where he was treated and became able to eat on the same day. He had been fit and healthy, except for colorectomy and chemotherapy using a central venous access port placed in the right upper jugular vein 8 years ago. The next day, he suddenly had ventricular fibrillation. Cardiopulmonary resuscitation was successful. Emergency coronary angiography showed a catheter-like foreign body in the coronary sinus. Physicians failed to remove the foreign body using catheter therapy, and ventricular fibrillation occurred repeatedly. After induction of general anesthesia, the fractured catheter was removed surgically. Postoperative course was uneventful.

CONCLUSIONS

A fragmented segment of a catheter may suddenly cause ventricular fibrillation years later.

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.

Alternate Cervical Venous Access Sites for Implantable Port Catheters: Experience at a Single Quaternary Care Institution

INTRODUCTION

Clinical outcomes of implantable port catheters (IPCs) placed via alternative veins such as the external jugular and cervical collaterals have not been well established. This investigation evaluates the short- and long-term outcomes of IPCs inserted via alternate cervical veins (ACV) compared to traditionally inserted IPCs via the internal jugular vein (IJV).

MATERIALS AND METHODS

A total of 24 patients who received an IPC between 2010 and 2020 via an ACV-defined as the external jugular vein, superficial cervical vein, or unnamed collateral veins-were identified. Based on power analysis, a matched control group of 72 patients who received IPCs via the IJV was identified. Non-inferiority analysis for port complications was performed between the two groups based on the selected non-inferiority margin of 20%. Secondary end points included complication-free survival and comparison of complications by the time at which they occurred.

RESULTS

ACV access was non-inferior to traditional access for overall complications. Alternate access resulted in fewer complications than traditional access with an estimated reduction of - 7.0% [95% CI - 23.6%, 39.7%]. There was no significant difference in peri-procedural and post-procedural complications between the two groups. Complication-free survival was also equivalent between the two groups.

CONCLUSION

IPC placement via ACVs was non-inferior to IPCs placed via traditional access through the IJV. When abnormal pathology obviates the use of IJV access, other cervical veins may be considered prior to seeking alternate locations such as femoral, translumbar, inferior vena cava, and hepatic veins.

Ultrasound-guided totally implantable venous access ports placement via right brachiocephalic vein in pediatric population: A clinical debut

BACKGROUND AND OBJECTIVES

To investigate the feasibility and safety of ultrasound-guided totally implantable venous access ports (TIVAPs) via the right brachiocephalic vein (BCV) in pediatric patients.

METHODS

A single-institute retrospective review was performed on 35 pediatric patients with predominantly hematological malignancies (88.6%) who underwent TIVAP implantation via ultrasound-guided right BCV approach from July 2018 to June 2021. The catheter tip was adjusted to be positioned at the cavoatrial junction under pulsed fluoroscopic guidance. Technical success rate, procedural information, and TIVAP-related complications were evaluated.

RESULTS

All the pediatric TIVAP devices were successfully implanted via right BCV access. Venous access was successful by first attempt in 32 children (91%), two cases (5.7%) required a second attempt, and one patient (2.9%) required a third attempt. The mean procedural time was 44.6 ± 6.4 minutes (range: 34-62 minutes). No intraoperative complications occurred. The average TIVAP indwelling time was 564 ± 208 days (range: 193-1014 days), with a cumulative 19,723 catheter-days. Overall, three patients (8.6%) experienced four postoperative complications (two cases of local hematoma and two catheter dysfunctions) at a rate of 0.2 per 1000 catheter-days. No other complications such as wound dehiscence, delayed incision healing, catheter-related thrombosis (CRT), catheter malposition/fracture, surgical site infection, catheter-related bloodstream infection (CRBSI), pinch-off syndrome, and drug extravasation were observed during follow-up.

CONCLUSIONS

Ultrasound-guided right BCV access for TIVAP placement in pediatric patients appears to be technically feasible, safe, and effective. Further large-sample, prospective studies are warranted.

Outcomes of Port A Catheter Implantations in Cancer Patients: Experience in 102 Cases

Aim

This study evaluates cancer patients undergoing port catheter implantation.

Patients and methods

The study was conducted among patients admitted to the cardiovascular department of Düzce State Hospital from June 2018 to July 2020. The inclusion criterion was the implantation of a vascular port for at during 2 years. One hundred and two patients were enrolled in the study. The most common acute outcomes such as pneumothorax, haemothorax, thoracic duct damage and cardiac tamponade and the demographic characteristics of all patients were recorded. Patients were evaluated for the late complications of port catheter, such as thrombosis, infection and kinking, catheter fracture and occlusion.

Results

Complications of port catheter occurred early (≤30 days) and delayed (>30 days) at rates of up to 8% and 15%, respectively. The most common early and late complications were pneumothorax and non-functional port (occlusion, thrombosis, kinking), respectively.

Conclusions

Thrombosis is the most common cause of dysfunction in central port catheters used in the treatment of cancer patients. Routine radiological imaging can help in early detection of catheter-related complications.

Technical factors and outcomes in pediatric central venous port placement

Purpose While central venous port placement is common, there remains variation in placement technique and rates of technical complications. The aim of this study was to assess variability in techniques and identify predictors of complications for children undergoing port placement. Methods We retrospectively reviewed all 331 patients who underwent venous port placement at a single tertiary children's hospital from May 2018 to June 2020. The primary outcome was early revision or replacement (R/R) for complications occurring within 30 days. Secondary outcomes included radiation exposure and rate of intraoperative conversion to a secondary site. Results The median age was 7 years (Interquartile Range 3-13 years) and the most common diagnoses were leukemia (30.2%), solid tumors (27.8%), and brain tumors (16.9%). Initial approach for port placement was ultrasound-guided internal jugular (IJV) in 255 (147 by surgery and 108 by interventional radiology [IR]) and landmark subclavian vein (SCV) in 76 (all by surgery). Early R/R occurred in 5.1%, including 9.0% of patients with leukemia but 1.1% with solid tumors. Individual proceduralist volume ranged from 2 to 98 cases and was inversely correlated with early R/R (r = -0.12, p = 0.30). In univariate analysis, ports placed by IR had an increased rate of early R/R (9.3%, n = 10) compared to those placed by surgery (3.2%, n = 7, p = 0.036) but this was not significant in multivariable regression controlling for diagnosis and age (Hazard Ratio 2.04; p = 0.19). Mean fluoroscopy time was significantly longer for ports placed by IR (59.9 s) compared to those placed by surgery (15.1 s, p < 0.001). Initial SCV access was associated with an increased (14.5 vs 0.4%) rate of conversion to a secondary site. Conclusions Though venous port placement is a largely safe procedure in children, a substantial minority of patients, particularly those with leukemia, require early R/R. Proceduralist volume and training may influence early R/R, fluoroscopy exposure, and anatomic site preferences.

Safety of immediate use of totally implantable venous access ports in adult patients with cancer: a retrospective single-center study

Purpose

Totally implantable venous access ports (TIVAPs) can be used long-term for safe administration of intravenous drugs. TIVAP complications include catheter-related infections, venous thrombosis, extravasation, TIVAP migration, and pain. The relationship between the timing of the first chemotherapy administration after port implantation and complications is controversial. This study aimed to investigate the safety of immediate use of TIVAPs and the associated risk factors for complications.

Methods

Between January 2016 and December 2018, 305 patients (median age, 53 years; 256 women) who underwent TIVAP placement at our institution were included. Chemotherapy was administered within 2 days of implantation. A retrospective analysis of patients' clinical data was performed to investigate catheter days and complications of TIVAPs.

Results

Overall, 305 patients were evaluated over 57,324 catheter days (median, 168 catheter days; interquartile range, 105). The median interval between placement and first use of TIVAPs was 0.98 days. The overall morbidity rate was 2.95%. Nine complications occurred in nine patients, including TIVAP-related infection (4), pain (2), port occlusion (1), thrombosis (1), and scar disunion (1), of which five required port removal (1.64%). The median number of catheter days before complications occurred was 61 (range, 10-457 days; interquartile range, 51). No complications occurred within 7 days of implantation. Body mass index was an independent risk factor for TIVAP-related complications in the Cox proportional hazards model (multivariable analysis: hazard ratio, 1.221; 95% confidence interval, 1.054-1.414; P=0.008).

Conclusion

This study suggests the safe long-term use of TIVAPs following their immediate chemotherapy administration within 2 days of implantation.

Comparison of Central Venous Port Procedures Between Puncture vs. Cut-down and Residents vs. Senior Surgeons

BACKGROUND/AIM

To compare operative results between venous puncture (P) with real-time ultrasonography vs. cut-down (CD) with preoperative ultrasonography for totally implantable central vein access device (TICVAD) implantation performed by residents (R) vs. senior surgeons (S).

PATIENTS AND METHODS

Adult oncologic patients (n=268) undergoing TICVAD implantations were retrospectively compared between 172 Ps and 96 CDs. Then, we compared Ps performed by R (P-R, n=131) and S (P-S, n=41) and CDs performed by R (CD-R, n=59) and S (CD-S, n=37).

RESULTS

Median operation times were 40 min in the P group and 53.5 min in the CD group, and times were significantly shorter for P-S and CD-S. Completion rates were comparable for each method and each surgeon. Intraoperative complication rates were 3.8% (P-R), 2.4% (P-S), and 0% (CD-R and CD-S).

CONCLUSION

P with real-time ultrasonography did not avoid complications compared to CD with preoperative ultrasonography. The latter performed safely even by residents.

Chinese expert consensus and practice guideline of totally implantable access port for digestive tract carcinomas

Totally implantable access port is a fully implantable drug delivery system that is implanted subcutaneously and can be retained for a long time. Advantages of ports include a simple nursing process, low risk of infection and embolism, and high patient comfort. In order to promote the standardized application of ports in the treatment of digestive tract tumors and reduce port-related complications, the Chinese Research Hospital Association Digestive Tumor Committee, the Chinese Association of Upper Gastrointestinal Surgeons, the Chinese Gastric Cancer Association, and the Gastrointestinal Surgical Group of Chinese Surgical Society Affiliated to Chinese Medical Association have organized multidisciplinary expert discussions at the General Hospital of the People’s Liberation Army and nation-wide expert letter reviews and on-site seminars, and formulated an expert consensus of the operation guidelines.

Incidence, severity and outcome of central line related complications in pediatric oncology patients; A single center study

BACKGROUND

Central venous access device (CVAD)-related complications are associated with high morbidity rates. This study was performed to underline the importance of CVAD-complication prevention and treatment.

METHODS

An audit of practice of CVAD-related complications in pediatric oncology patients receiving a CVAD between January 2015 and June 2017 was performed. CVADs included were totally implantable venous access ports (TIVAPs), Hickman-Broviac® (HB), nontunneled, and peripherally inserted CVADs.

RESULTS

A total of 201 children, with 307 CVADs, were analyzed. The incidence rates per 1000 CVAD-days for the most common complications were 1.66 for malfunctions, and 1.51 for central line-associated bloodstream infections (CLABSIs). Of all CVADs inserted, 37.1% were removed owing to complications, of which 45.6% were owing to CLABSIs. In 42% of the CLABSIs, the CLABSI could be successfully cured with systemic antibiotic treatment only. Of all included patients, 5.0% were admitted to the intensive care unit owing to CLABSI. The HB-CVAD compared to the TIVAP was a risk factor for CVAD-related complications, CLABSIs and dislocations in particular.

CONCLUSIONS

The incidence of CVAD-related complications is high. Research on the prevention and treatment of CVAD-related complications in pediatric oncology patients should be a high priority for all health care professionals.

TYPE OF STUDY

Prognosis study (retrospective).

LEVEL OF EVIDENCE

Level II.

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.

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

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

The Safety Level of Total Central Venous Access Port Implantation Performed by Residents

OBJECTIVE

The implantation of totally implantable venous access ports (TIVAPs) is one of the first procedures surgical residents learn. Complications after implantation procedures have a major impact on patient outcomes, as it may lead to a delay of chemotherapy regimens or of parenteral nutrition. The aim of this study was to compare the outcomes after totally implantable venous access ports implantations done by resident and attending surgeons.

DESIGN

The study was performed as a retrospective analysis.

SETTING

The study took place in primary care at the Department of General and Visceral Surgery at Frankfurt University Hospital.

PARTICIPANTS

A total of 760 primary totally implantable venous access ports implantations performed between March 2008 and December 2016 were included in a database. Three groups of surgeons doing the implantations were defined: Group A (residents alone), Group B (resident with help), and Group C (attending surgeons).

RESULTS

There was a significant difference between the surgeon groups in operation time (p < 0.001). The groups differed between Group A (mean, 49; SD, 22) and Group C (mean, 39; SD, 20); p < 0.001) and Group B (mean, 53; SD, 23) and Group C (mean, 39; SD, 20; p < 0.001). The incidence of surgical site infections between Groups A and C (3.6% vs. 0.3%; p = 0.003) and Groups B and C (2.5% vs. 0.3%; p = 0.027) differed also significantly. Based on multivariable logistic regression analysis operation time in minutes (OR, 1.04; 95%CI, 1.03-1.06; p < 0.001) was an independent risk factor for any intraoperative complications. For any postoperative complications younger age of the patient (OR, 0.98; 95%CI, 0.97-0.99; p = 0.004) and benign primary disease (OR, 3.25; 95%CI, 1.55-6.64; p = 0.002) were independent risk factors based on multivariable regression analysis. Based on multivariable regression analysis a lower body mass index of the patient (OR, 0.93; 95%CI, 0.86-0.99; p = 0.044), benign primary disease (OR, 2.89; 95%CI, 1.07-7.79; p = 0.036), and no chemotherapy (OR, 3.55; 95%CI, 1.50-8.39; p = 0.004) were independent risk factors for postoperative catheter infections. Surgeon group was no risk factor, neither for intraoperative and postoperative complications, nor for catheter explantation due to complications.

CONCLUSION

Residents performing alone or residents performing with help can safely handle a central venous access port implantation. In patients with several risk factors, however, an attending should assist.

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.

Surgical Venous Cutdown for the Insertion of Totally Implantable Venous Access Devices

Purpose:

Stable insertion of totally implantable venous access devices (TIVADs) is mandatory for the administration of chemotherapy and parenteral nutrition. Subclavian venipuncture is the most popular route; however, perioperative complications occur in up to 12% of patients. We inserted TIVADs by surgical venous cutdown of the cephalic vein at the deltopectoral groove with the intention of a safe and stable implantation.

Methods:

We implanted TIVADs in 318 consecutive patients (331 cases) from January 2011 to December 2015. We retrospectively analyzed short- and long-term treatment outcomes and risk factors for primary failure of implantation and removal due to catheter-related complications.

Results:

The aim of implantation was chemotherapy in 198 cases, nutrition in 92 cases, and frequent intravenous drip in 41 case. Surgical venous cutdown was performed in 321 of 331 cases (97%); primary failure occurred in 42 cases (13.1%). Short-term complications occurred in 4 cases (1.2%), and there were no serious complications, such as pneumothorax. In the analysis of risk factors for primary failure, aim of implantation (chemotherapy versus nutrition versus frequent intravenous drip) was the only risk factor (P = 0.02). Removals occurred in 35 cases (11.5%). In the analysis of risk factors for removal due to complications, presence of infectious disease was identified as the only significant risk factor (P &lt; 0.001).

Conclusions:

We confirmed the safety and efficacy of the cutdown method and clarified the risk factors for primary failure and removal. The cutdown method was safe and was not associated with serious complications; however, selective implantation was needed to achieve a high success rate.

Experience in totally implantable venous port catheter: Analysis of 3,000 patients in 12 years

BACKGROUND

This study aims to present our experience with patients who were performed totally implantable venous port catheter.

METHODS

Demographics-clinical features, surgical results and complications of 3,000 patients (1,824 males, 1,176 females; mean age 61.04±11.5 years; range, 18 to 88 years) who were performed totally implantable venous port catheter between March 2005 and March 2017 were evaluated retrospectively. Totally implantable venous port catheter indications, complications, catheter duration of stay, reasons for catheter removal and statistical analysis information were reported in detail by reviewing patient records.

RESULTS

Of the cases, the Seldinger method was used in 98%, 1% (n=36) had the catheter inserted with superficial Doppler ultrasonography, while the veins were not found in 1% (n=29) and these patients were excluded from the study. Totally implantable venous port catheter was inserted via right internal jugular vein in 2,095 patients (70%), via right subclavian vein in 470 patients (16%), via left internal jugular vein in 290 patients (10%), and via left subclavian vein in 106 patients (3%). Mean duration of stay for totally implantable venous port catheter was 46.7 months (range, 1 to 78 months). Complications were detected in a total of 288 patients (9.6%), 153 (5.1%) being early and 135 (4.5%) being late. The most common oncologic indication was colorectal cancer. The rate of port removal was 298/3,000 (9.9%) and the main reasons were infection, thrombosis, pain, and end of treatment. Totally implantable venous port catheter was required to be inserted twice in 33 patients (1%) and thrice in 14 patients (0.5%). Totally implantable venous port catheter had malposition in eight patients and all were revised successfully with over the guide method.

CONCLUSION

Totally implantable venous port catheter may increase the quality of life in cancer patients. Despite possible complications, totally implantable venous port catheter is safe and comfortable for long-term intravenous treatment. Possible complications may be prevented or managed when totally implantable venous port catheter is performed by surgeons with adequate experience.

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.