Polyurethane versus silicone port a cath: What's going on at removal?

Central Venous Catheter Consideration in Pediatric Oncology: A Systematic Review and Meta-analysis From the American Pediatric Surgical Association Cancer Committee

BACKGROUND

Tunneled central venous catheters (CVCs) are the cornerstone of modern oncologic practice. Establishing best practices for catheter management in children with cancer is essential to optimize care, but few guidelines exist to guide placement and management.

OBJECTIVES

To address four questions: 1) Does catheter composition influence the incidence of complications; 2) Is there a platelet count below which catheter placement poses an increased risk of complications; 3) Is there an absolute neutrophil count (ANC) below which catheter placement poses an increased risk of complications; and 4) Are there best practices for the management of a central line associated bloodstream infection (CLABSI)?

METHODS

Data Sources: English language articles in Ovid Medline, PubMed, Embase, Web of Science, and Cochrane Databases.

STUDY SELECTION

Independently performed by 2 reviewers, disagreements resolved by a third reviewer.

DATA EXTRACTION

Performed by 4 reviewers on forms designed by consensus, quality assessed by GRADE methodology.

RESULTS

Data were extracted from 110 manuscripts. There was no significant difference in fracture rate, venous thrombosis, catheter occlusion or infection by catheter composition. Thrombocytopenia with minimum thresholds of 30,000-50,000 platelets/mcl was not associated with major hematoma. Limited evidence suggests a platelet count <30,000/mcL was associated with small increased risk of hematoma. While few studies found a significant increase in CLABSI in CVCs placed in neutropenic patients with ANC<500Kcells/dl, meta-analysis suggests a small increase in this population. Catheter removal remains recommended in complicated or persistent infections. Limited evidence supports antibiotic, ethanol, or hydrochloric lock therapy in definitive catheter salvage. No high-quality data were available to answer any of the proposed questions.

CONCLUSIONS

Although over 15,000 tunneled catheters are placed annually in North America into children with cancer, there is a paucity of evidence to guide practice, suggesting multiple opportunities to improve care.

LEVEL OF EVIDENCE

III. This study was registered as PROSPERO 2019 CRD42019124077.

Complications after removal of totally implanted central venous access devices: A single-center retrospective study

BACKGROUND

Complications after removal of totally implanted vascular access devices. (TIVADs) have not been studied widely. The aim of this study was to assess the prevalence and risk factors of these complications.

METHODS

This was a single-center retrospective study conducted in Gustave Roussy hospital in Villejuif, Ile-de-France, France. All adult patients scheduled for TIVAD removal between January 2015 and November 2019 were eligible for the study. The record of complications was compiled by noting the reason for a surgical or emergency department consultation during the month following removal, and also by calling the patients during the week of TIVAD removal to assess whether surgical advice was needed.

RESULTS

There were 2533 included patients, representing 2583 TIVAD removals. The prevalence of complications was 1.47% (n = 38), of which 0.31% were infectious complications (n = 8). These complications required surgical or interventional radiology management in 50% of cases. In multivariate analysis, two independent risk factors were associated with these complications: the duration of the surgical procedure (p = 0.04) and the active status of the underlying malignant disease (p = 0.07).

CONCLUSIONS

Complications after TIVAD removal are uncommon (prevalence = 1.47%), but their morbidity appears to be high, with interventional procedures frequently needed. The duration of the removal procedure and the active status of cancer appear to be associated with the occurrence of complications.

Oral formulation of Wnt inhibitor complex reduces inflammation and fibrosis in intraperitoneal implants in vivo

The use of implantable biomaterials to replace physiological and anatomical functions has been widely investigated in the clinic. However, the selection of biomaterials is crucial for long-term function, and the implantation of certain biomaterials can cause inflammatory and fibrotic processes, triggering a foreign body reaction that leads to loss of function and consequent need for removal. Specifically, the Wnt signaling pathway controls the healing process of the human body, and its dysregulation can result in inflammation and fibrosis, such as in peritoneal fibrosis. Here, we assessed the effects of daily oral administration of a Wnt pathway inhibitor complex (CD:LGK974) to reduce the inflammatory, fibrotic, and angiogenic processes caused by intraperitoneal implants. CD:LGK974 significantly reduced the infiltration of immune cells and release of inflammatory cytokines in the implant region compared to the control groups. Furthermore, CD:LGK974 inhibited collagen deposition and reduced the expression of pro-fibrotic α-SMA and TGF-β1, confirming fibrosis reduction. Finally, the CD:LGK974 complex decreased VEGF levels and both the number and area of blood vessels formed, suggesting decreased angiogenesis. This work introduces a potential new application of the Wnt inhibitor complex to reduce peritoneal fibrosis and the rejection of implants at the intraperitoneal site, possibly allowing for longer-term functionality of existing clinical biomaterials.

Why do subcutaneous ports get stuck? A case-control study

PURPOSE

We sought to identify clinical features associated with difficult subcutaneous port removals in children.

METHODS

Ports placed between April 2014 and September 2017 at our institution were prospectively tracked for difficult removals. A case-control analysis was performed. Patients with ports that were difficult to remove (stuck; cases) were compared to biological sex and age-matched controls in a ratio of 1:3. Logistic regression determined the association between case/control status and clinical features adjusting for biological sex and age as covariates. A multivariable analysis was performed to identify independent associations.

RESULTS

57 stuck ports (28 extreme [10 endovascular intervention] and 29 moderate) and 171 controls were analyzed. Stuck ports were associated with a diagnosis of acute lymphoblastic leukemia (86% cases versus 22.2% controls; p < 0.001) and a longer placement duration (median 2.6 years [interquartile range (IQR) 2.5-2.6] versus 0.8 years [IQR 0.5-1.4]; p < 0.001). On univariate analysis, procedural and device features associated with stuck ports included subclavian access (71.9% cases versus 48.5% controls; p = 0.0126), a polyurethane versus silicone catheter (96.5% cases versus 79.9% controls; p = 0.001), and a rough catheter appearance at removal (92.6% cases versus 9.4% controls; p < 0.0001). A diagnosis of ALL and duration of line placement were associated with having a stuck port on multivariate analysis.

CONCLUSION

Polyurethane central venous catheters placed for the two-year treatment of acute lymphoblastic leukemia may become difficult to remove. This constellation of factors warrants more extensive preoperative discussion of risk, endovascular backup availability, and scheduling for longer operating room time.

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.

Does catheter material affect functional performance of intravenous ports via the superior vena cava?

Introduction

The catheter is the only intravascular portion of an implanted port and plays a crucial role in catheter related complications. Both polyurethane and silicone are biocompatible materials which are utilized for catheter manufacturing, but their correlation to complications remains controversial. The aim of this study was to try to analyze the relationship between catheter materials and complications.

Materials and methods

A total of 3144 patients who underwent intravenous port implantation between March 2012 and December 2018 at Chang Gung Memorial Hospital, Linkou, Taiwan were recruited. Of these, 1226 patients received silicone catheter port implantation and 1679 received polyurethane catheter ports. Case matching was done prior to analysis and catheter related complications and cumulative complication incidence for each group were compared.

Results

Intergroup differences were identified in entry vessel (p = 0.0441), operation year (p < 0.0001), operation method (p = 0.0095), functional period (p < 0.0001), patient follow up status (p < 0.0001), operating time for vessel cutdown (p < 0.0001) and wire assisted approach (p = 0.0008). Stratified by specific entry vessel, no statistical difference was found in complication rate or incidence between the silicone and polyurethane groups. We further compared the cumulative complication incidence of the silicone and polyurethane groups, and also found no statistical difference (p = 0.4451).

Conclusion

As long as external stress forces generated by surrounding structures and focused on potential weak points are avoided, both silicone and polyurethane materials provide sufficient structural stability to serve as reliable vascular access for patients.

Midline or long peripheral catheters in difficult venous access conditions? A comparative study in patients with acute cardiovascular diseases

BACKGROUND

Midline catheters (MCs) are commonly inserted in patients with difficult venous access (DVA) needing peripheral access. Recently, the alternative placement of ultrasound-guided long peripheral catheters (LPCs) has spread. However, no study has compared the reliability of the 2 devices. This study aims to compare the safety and reliability of MCs and LPCs in DVA patients.

METHODS

A retrospective cohort study was conducted, enrolling 184 DVA patients. Polyurethane MCs and 2 lengths of polyethylene LPCs (8/10 cm and 18 cm) were compared. The independent effect of catheter type on uncomplicated catheter survival was determined through a Cox regression analysis.

RESULTS

The relative incidences of overall catheter-related complications (CRCs) were 15.84 of 1,000, 10.64 of 1,000, and 6.27 of 1,000 catheter-days for 8/10 cm-LPCs, 18 cm-LPCs, and MCs, respectively. The relative incidences of catheter-related bloodstream infections were 0.72 of 1,000 for both length LPCs and 0.48 of 1,000 catheter-days for MCs. Compared to MCs, a significant increase in CRC risk for 8/10 cm LPCs (hazard ratio [HR] 5.328; 95% confidence interval [CI] 2.118-13.404; P < 0.001) was found, along with a nonsignificant trend toward an increased risk for 18 cm-LCPs (HR 2.489; 95% CI 0.961-6.448; P = 0.060).

CONCLUSION

MCs allow for longer uncomplicated indwelling times than LPCs. The decision regarding which catheter to use should consider the planned duration of intravenous therapy, the patient's clinical condition, and the cost of the device.

Long-term vascular access in differently resourced settings: a review of indications, devices, techniques, and complications

Central venous access is frequently essential for the management of many acute and chronic conditions in children. Millions of central venous access devices (CVADs) are placed each year. In this review article, we discuss the indications for long-term vascular access, the types of devices available, the state of the art of central venous cannulation and device placement, and the complications of long-term central venous access. We pay a special attention to the challenges of, and options for long-term central venous access, also those in developing countries, with limited financial, human, and material resources.

Fracture of the Port Catheter and Migration Into the Coronary Sinus: Case Report and Brief Review of the Literature

Introduction:

Totally implantable venous device has a good safety profile, although certain complications may occur. Late mechanical complications include catheter fracture and cardiac migration which are rarely occurring in approximately 0.1% to 1% of patients.

Case presentation:

A 33-year-old woman referred by the surgical oncologist for port catheter fragment extraction through endovascular approach. She was asymptomatic on presentation and has a history of hypertension and smoking. Chest X-ray showed a port catheter fragment previously thought to be in the right atrium at the level of 8-9 thoracic vertebrae (right heart catheterization showed that the port catheter fragment was in the coronary sinus). Angiography of the right outflow tract indicates that the fragment was not in the outflow tract or pulmonary arteries but posterior to it. It was concluded that the port catheter fragment had migrated deep into the coronary sinus and the snare was unable to pull the fragment. It was deemed unfeasible to remove the fragment through the endovascular approach.

Discussion:

The port catheter fracture had migrated entirely into the coronary sinus and to the deep of our knowledge; this was the fourth case reported in the current literature. We tried to do a review of previous similar case reports; interestingly, this was the only case where the fragmented catheter was situated deep within the coronary sinus without any part of the fragment projected to the right atrium. This made the retrieval of the fragment much more difficult with a high chance of failure.

Conclusions:

Migration of totally implantable venous device into coronary sinus is a rare but possible complication and might be difficult to remove if the position is unfavorable.