Subcutaneous chest ports via the internal jugular vein. A retrospective study of 117 oncology patients

Internal jugular vein versus external jugular vein as the insertion site for totally implantable venous access ports in children: a randomized comparative study

BACKGROUND AND AIMS

Various venous approaches are possible during implanting a totally venous access port. In this study, we compare the result of venous access port implantation using external and internal jugular vein cut-down in young children to determine the safest method, associated with less complications and higher quality of life.

PATIENTS AND METHODS

January 2018 to January 2022 who received a TIVAP were included in the study and written informed consent was obtained from parents of all children at least 24 h prior to the intervention. One hundred and seven patients who needed TIVAP were randomly allocated into external jugular vein cut-down group (EJVCP) (n = 55) and internal jugular vein cut-down group (IJVCP) (n = 52) in this study.

RESULTS

Mean operative time was 32.5 ± 17.1 min in EJVCP group, and 63.6 ± 28.3 min in IJVCP group. The difference of operation time between the two groups was statistically significant (P < 0.05). The overall incidence of late complications found in this study was 14.5% in EJVCP group and 13.4% in IJVCP group, indicating that no statistical difference was observed.

CONCLUSIONS

Compared with internal jugular vein, external jugular vein access has obvious advantages: the location of external jugular vein is superficial and easy to find, the utilization of external jugular vein is easy to learn and master, and the external jugular vein is of little importance to the human body. Through our study, we found that the external jugular vein access does not increase complications. External jugular vein access can be used as the first choice.

Radiologic placement of totally implantable venous access devices: Outcomes and complications from a large oncology cohort

Introduction

Totally implantable venous access devices (TIVADs) or ports are increasingly used in oncology settings to provide long-term, easy venous access. This study reports our experience and results with 1180 cases in Singapore.

Method

Data from January 2019 to January 2022, obtained from a hospital-approved secure database application called the Research Electronic Data Capture registry, were reviewed and analysed retrospectively.

Results

A total of 1180 patients underwent TIVAD implantation with a 100% technical success rate. The mean age of the cohort was 61.9 years. The mean dwell duration was 342 days (standard deviation [SD] 223; range 3-1911). By 1 February 2022, 83% of patients were still using the TIVAD, 13.6 % underwent removal after completion of treatment, 2.1% were removed due to infection, 0.6% due to malfunction, 0.6% due to port extrusion and 0.1% at patient's request. The right internal jugular vein (IJV) was the most commonly accessed site (83.6%), followed by the left IJV (15.6%). The early post-procedure complications were pain (24.7%), bruising (9.2%), swelling (3.6%), bleeding (0.5%), fever (0.4%), itchiness (0.2%) and allergic dermatitis (0.1%). The delayed post-procedure complications were TIVAD site cellulitis (3.80%); discharge (1.10%); skin erosion with device extrusion (0.60%); malpositioned catheter (0.33%), which was successfully repositioned, catheter-related bloodstream infections (0.25%); migration of TIVAD leading to catheter dislodgement (0.25%); venous thrombosis (0.25%); fibrin sheath formation requiring stripping (0.10%) and TIVAD chamber inversion (0.10%).

Conclusion

TIVAD implantation via the jugular vein under radiological guidance provides a safe, reliable and convenient means of long-term venous access in oncology patients. By sharing our experience and acceptable outcomes from a large oncology cohort, we aim to increase the awareness and adoption of TIVAD usage in oncology patients, especially in Asia.

Case report: Extravascular catheter migration in a child: A rare complication of the totally implantable venous access device

BACKGROUND

Totally implantable venous access devices (TIVADs) are widely used to gain intermittent central venous access, such as in patients who need long-term chemotherapy, total parenteral nutrition, and long-term antibiotic treatment. At present, there are many complications associated with the use of these devices. Complete extravascular migration of TIVADs via the internal jugular vein is a very rare and potentially serious condition, especially in children.

CASE PRESENTATION

A 1-year-old girl needed palliative chemotherapy because of hepatoblastoma complicated by inferior vena cava thrombosis. A TIVAD was implanted through the right internal jugular vein with a routine heparin flushing tube. On the second day after the operation, a pale bloody liquid was drawn out from the device and the chest X-ray was checked to confirm that the position of the catheter was normal. On the third day after the operation, however, the patient's right respiratory sound was weakened on physical examination and auscultation. Fluoroscopy showed that the tip of the catheter was located in the right thoracic cavity, and there was a large amount of effusion in the right thoracic cavity. The pleural effusion was removed, the TIVAD was replaced again, and the child was discharged 2 days later.

CONCLUSIONS

Following TIVAD implantation, if abnormalities are found, in addition to chest X-ray, saline flush and echocardiography should be performed to determine the position of the catheter and rule out extravascular migration of the catheter to avoid irreparable consequences.

The role of routine chest radiography after implantable venous access port catheter insertion under the guide of ultrasonography and fluoroscopy

Background

The objective of this study is the evaluation of routine chest radiography following the placement of Implantable venous access port catheter (IVAPC) central lines using combined ultrasound and fluoroscopic guidance by a vascular surgeon in the operating room.

Material and method

A prospective study of 189 consecutive patients who underwent IVAPC central line insertion in the vascular surgery operating room from 2016 to 2019. Venipuncture was performed with an 18-gauge needle under the guidance of sonography in each case, and the access site was noted. The line position was confirmed by fluoroscopy following the procedure. Multiple tries for puncture and patients under 18 were excluded from our study. Routine radiography of chest was performed for all patients and pneumothorax, hemothorax, and catheter malposition were evaluated in each case.

Results

There were 2 cases of asymptomatic pneumothorax, no cases of hemothorax, and all catheter tip positions were optimal or acceptable. The annual cost of chest radiography was 33,000,000IRR, 220 h of hospital and staff time, and 1.1 mSv radiation.

Conclusion

In conclusion, when imaging guidance is used for IVAPC insertion by an experienced surgeon in a high-volume center, performing post-procedure routine chest radiography shows little benefit.

Complications After Implantation of Subcutaneous Central Venous Ports: Focus on Infection and Catheter Pinch-off

Objective

The objective of this study was to determine the causes of postoperative complications associated with subcutaneous central venous ports.

Summary of Background Data

Central venous ports were subcutaneously implanted in 523 patients between January 2005 and December 2013.

Methods

The purpose of port implantation was administration of chemotherapy in 439 patients and home central venous nutrition in 84 patients. The underlying disease was malignant in 481 patients and benign in 42.

Results

The median follow-up was 12 months (range, 1–99 months), and postoperative complications developed in 69 patients (13%). Infection occurred in 40 patients (7.6%) and catheter pinch-off in 11 patients (3%). Significant risk factors for infection were nutritional port placement (P &lt; 0.001) and use of a femoral vein approach (P = 0.001). A left subclavian approach was a significant risk factor for catheter pinch-off (P = 0.003).

Conclusions

Postoperative complications, mainly infections and catheter pinch-off, developed in 13% of the patients. As for measures against complications, a femoral vein approach should be avoided to prevent infection. Moreover, because ports for parenteral nutrition require multiple punctures, methods to reduce the number of punctures and techniques for disinfection and management should be reevaluated. To prevent catheter pinch-off, an internal jugular vein approach should be used instead of a left subclavian approach.

Contrast examination of central venous access port implanted through internal jugular vein for evaluation of suspected complications

PURPOSE

We summarized the findings, diagnosis, and outcomes of cases for which contrast examination of central venous access ports (CV-ports) were attempted to detect complications.

MATERIALS AND METHODS

Fifty-seven contrast examinations were attempted for 45 patients with 46 CV-ports (median, 162 days after implantation). Contrast examination was performed due to three suspicion catheter fractures or 54 CV-port dysfunctions (combinations of an absence of blood reflux on aspiration and 9 sufficient, 21 insufficient, or 24 impossible drip infusions).

RESULTS

Contrast examination was successfully performed in 52 cases and revealed 45 normal findings, 5 pericatheter fibrin sheath formations, and 2 partial catheter fractures. In 23 of 45 cases with normal findings, the resistance to injection was initially mild or moderate but resolved after the CV-port was flushed slowly with heparinized saline solution. Subsequent contrast examination demonstrated normal findings. All fibrin sheath formations disappeared after thrombolytic therapy. Five cases could not undergo contrast examination due to high resistance. After contrast examination, nine of 46 CV-ports were removed or exchanged, while the use of the remaining 37 continued.

CONCLUSION

Contrast examination of CV-port allowed the assessment of suspected complications and early treatment.

Meta-analysis of primary open versus closed cannulation strategy for totally implantable venous access port implantation

BACKGROUND

There is still no reference standard for the implantation of totally implantable venous access ports (TIVAPs). A recently published multicentre randomised controlled trial (RCT) revealed a significantly greater risk of pneumothorax after closed cannulation than after an open strategy. The aim of this meta-analysis was to provide an update of the available evidence for the safety and effectiveness of primary open versus closed cannulation strategy.

METHODS

RCTs comparing outcomes of open cut-down of the cephalic vein and closed cannulation of the subclavian vein were sought systematically in MEDLINE, Web of Science and CENTRAL. The primary outcome was the occurrence of pneumothorax. A beta-binominal model was applied to combine the respective outcomes, and results are presented as odds ratios (OR) with 95% confidence interval (CI).

RESULTS

Six RCTs with a total of 1831 patients were included in final analysis. Meta-analysis showed statistically significant superiority of the open cut-down technique regarding pneumothorax (OR 0.308, 95% CI 0.122 to 0.776), but a statistically significant higher failure of the primary technique for the open cut-down technique than for closed cannulation (OR 2.364, 95% CI 1.051 to 5.315). There were no significant differences between the two procedures regarding other morbidity endpoints.

CONCLUSION

This meta-analysis shows a general superiority of open cut-down of the cephalic vein over closed cannulation of the subclavian vein regarding the occurrence of pneumothorax. Open cut-down should be the first-line approach for TIVAP implantation. Closed cannulation should be performed with ultrasound as second-line procedure if the open technique fails.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005180.

Risk profile of subcutaneous port placement in small children

BACKGROUND/PURPOSE

Long-term central venous access is a safe and common procedure in children. However, complications with devices are a reality. Smaller children are thought to have a higher rate of complication after port placement, and some surgeons avoid placing ports with an arbitrary weight cutoff out of concern for surgical site morbidity.

METHODS

We performed a multi-institutional retrospective review of 500 patients less than 5 years of age undergoing port placement at three large volume children's hospitals from 2014 to 2018. Patients were divided by weight greater than or less than 10 kg at the time of insertion. Statistical analysis was performed to evaluate for differences in outcomes between the two groups.

RESULTS

The majority of ports were placed for chemotherapy access (71.8%). Other indications included long-term infusions (18.8%) and difficult chronic IV access (9.4%). Of the 500 charts reviewed, 110 (22%) experienced some documented complication (28.9% <10 kg, 20.6% >10 kg, p = 0.096). There were no differences between the two groups in terms of the type or timing of complications. Overall, 16.3% of ports required removal prior to the end of therapy owing to a complication. Complication rate per day with the port in place was not different between the two groups (<10 kg: 0.68 complications/1000 port-days vs >10 kg 0.44 complications/1000 port-days, p = 0.068).

CONCLUSION

Weight less than 10 kg was not associated with a significantly higher incidence of any type of port complication in our cohort. This suggests that concern for complications should not exclude children less than 10 kg from port placement.

TYPE OF STUDY

Multi-institutional retrospective review.

LEVEL OF EVIDENCE

Level III.

Ultrasound guidance for Port-A-Cath insertion in children; a comparative study

Background

Gaining vascular access in children is challenging. Ultrasound-guided central line insertion in adults became the standard of care; however, its role in children is not clear. Our objective was to evaluate the ultrasound-guided Port-A-Cath or totally implanted long-term venous access device insertion in pediatric patients compared to the traditional approach.

Methods

This single-institution retrospective cohort study included 169 children who had port-A-catheters between May 2016 and Oct 2019. The patients were divided into two groups; group A included patients who had Port-A-Cath insertion using the landmark method (n = 117), and Group B included patients who had ultrasound-guided Port-A-Cath insertion (n = 52). Preoperative, operative, and postoperative data were collected and compared between the two groups. The study outcomes were operative time and catheter insertion-related complications.

Results

There was no significant difference in age or gender between both groups (P = .33 and .71, respectively). Eleven cases in group A and two cases in group B were converted to cut down technique because of difficulty in inserting the guidewire. There was no difference in the indication of the need for the port-A-Cath between both groups. The mean operative time for group A was 47 min and for group B was 41.7 min (P < .042). Two patients had intraoperative bleeding and hemothorax and required blood transfusion and chest tube insertion in group A. No statistically significant difference was found in the reported complications between the groups. However, the insertion-related complications were higher in group A (P = .053). No procedure-related mortality was reported.

Conclusions

Ultrasound-guided insertion of Port-A-Cath is an effective and safe technique with a reduction of failure rate. It should be considered the standard technique for Port-A-Cath insertion in the pediatric population.

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.

Local Anesthesia for Port Catheter Placement in Oncology Patients: An Alternative to Landmark Technique Using Ultrasound-Guided Superficial Cervical Plexus Block-A Prospective Randomized Study

Background/Objectives

Most patients that require port operation have experienced severe pain due to multiple surgeries in the past. Therefore, these patients have fear of pain before the procedure. This study aims to compare superficial cervical plexus block (SCPB) with local infiltration anesthesia in terms of comfort.

Methods

100 cancer-diagnosed patients were divided into two groups. The first group, the landmark technique with local infiltration anesthesia, was used for intravenous entry (Group LM, n = 50). The second group, USG, was used for venous entry with SCPB as anesthesia (Group US, n = 50). The type of local anesthesia, port placement technique, duration of the procedure, number of procedures, complications, visual analog scale (VAS) score, and surgeon's satisfaction with the procedure were recorded.

Results

It was established that an average of 1.7 and 1.1 attempts was conducted in Groups LM and US, respectively (P = 0.010). VAS scores were found to be 4.04 in Group LM and 2.62 in GroupUS (P = 0.001). Surgeon satisfaction was 1.96 in GroupLM and 2.38 in GroupUS (P = 0.014). The mean duration of the procedure was 22.10 minutes in GroupLM and 43.50 minutes in GroupUS (P = 0.001). Complication rates were observed in 1 patient in GroupLM and 9 patient in GroupUS (P = 0.040).

Conclusions

In the patient group with a high level of pain and anxiety port catheter placement using USG and SCPB, supported by routine sedation, provides better comfort for both patient and surgeon.

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.

Totally Implantable Central Venous Port Catheters: Radiation Exposure as a Function of Puncture Site and Operator Experience

BACKGROUND

Totally implantable central venous port systems provide a safe and effective, long-term means of access for administration of hyperosmolar, local irritant medication, such as chemotherapy, antibiotics and parenteral nutrition.

AIM

To evaluate the combination of access site and level of experience on fluoroscopy times (FT) and dose area products (DAP) during implantation of port catheters in a large patient population.

MATERIALS AND METHODS

A total of 1,870 patients (992 women, 878 men; age: 61±13.14 years) were reviewed investigating two groups of junior (≤50 implantations) and senior (>50) radiologists.

RESULTS

Senior radiologists required less FT/DAP (0.24 s/57.3 μGy m2 versus 0.43 s/68.2 μGy m2, respectively; p<0.001). Right jugular vein access required the least FT/DAP (0.25 s/56.15 μGy m2) and right-sided implantation lower FT/DAP (right: 0.26 s/56.4 μGy m2, left: 0.40 s/85.10 μGy m2, p<0.001).

CONCLUSION

Due to DAP/FT reductions, the right jugular vein seems to be the most favorable implantation side for port systems. For further dose reduction, residents should be well-trained.

Current situation regarding central venous port implantation procedures and complications: a questionnaire-based survey of 11,693 implantations in Japan

BACKGROUND

We conducted a nationwide questionnaire-based survey to understand the current situation regarding central venous port implantation in order to identify the ideal procedure.

METHODS

Questionnaire sheets concerning the number of implantation procedures and the incidence of complications for all procedures completed in 2012 were sent to 397 nationwide designated cancer care hospitals in Japan in June 2013. Venipuncture sites were categorized as chest, neck, upper arm, forearm, and others. Methods were categorized as landmark, cut-down, ultrasound-mark, real-time ultrasound guided, venography, and other groups.

RESULTS

We received 374 responses (11,693 procedures) from 153 centers (38.5 %). The overall complication rates were 7.4 % for the chest (598/8,097 cases); 6.8 % for the neck (157/2325); 5.2 % for the upper arm (54/1,033); 7.3 % for the forearm (9/124); and 6.1 % for the other groups (7/114). Compared to the chest group, only the upper arm group showed a significantly lower incidence of complications (P = 0.010), and multivariate logistic regression (odds ratio 0.69; 95 % confidence interval 0.51-0.91; P = 0.008) also showed similar findings. Real-time ultrasound-guided puncture was most commonly used in the upper arm group (83.8 %), followed by the neck (69.8 %), forearm (53.2 %), chest (41.8 %), and other groups (34.2 %).

CONCLUSION

Upper arm venipuncture with ultrasound guidance seems the most promising technique to prevent complications of central venous port implantation.

Spontaneous fracture and migration of catheter of a totally implantable venous access port via internal jugular vein--a case report

Background

The totally implantable venous access ports (TIVAPs) are indicated for patients undergoing chemotherapy, total parenteral nutrition and long-term antibiotic treatment. But, among their complications, the fracture and migration of the catheter of a TIVAP via internal jugular vein represents a very rare but potentially severe condition.

Case presentation

A 50-year-old woman indentified with a spontaneous fracture and migration of catheter of a TIVAP via right internal jugular vein after adjuvant chemotherapy for ovary cancer. She had been not evaluated and not managed with the heparin lock flush solution during three months after adjuvant chemotherapy. And then, she complained right neck bulging during saline infusion via a TIVAP and a chest radiography showed the fractured and migrated catheter of a TIVAP in right atrium. So, we emergently removed the catheter fragment by a goose neck snare via right femoral vein. After then, there was no problem.

Conclusions

If the fractured catheter of a TIVAP is detected, it is desirable to remove a fragment by an endovascular approach if it is possible.

A comparison of outcomes and complications of totally implantable access port through the internal jugular vein versus the subclavian vein

Totally implantable access ports (TIAPs) are generally used in oncology. Few studies have addressed complications associated with the insertion site. A total of 233 consecutive oncology patients were enrolled to receive TIAP inserts via internal jugular vein (IJV) or subclavian vein (SV). Data on clinicopathologic parameters and early/late complications were retrospectively collected. No differences were found early and late complication rates. Catheter injury was observed more frequently in the IJV group (2.9%) than in the SV group (1.0%) without statistical significance. Multivariate logistic regression analysis showed that age, switch to palliative use of TIAP, and the distribution of diseases (low risk in patients with colorectal cancer) were independent risk factors for determining complications. In conclusion, TIAP insertion site showed no impact on the early and late complication rates. Catheter injury appears to occur at the same frequency with both approaches. Therefore, medical doctors may choose their preferred puncture site when performing TIAP insertion.

1000 Port-A-Cath ® placements by subclavian vein approach: single surgeon experience

INTRODUCTION

Totally implantable venous access ports are widely used for the administration of chemotherapy in patients with cancer. Although there are several approaches to implantation, here we describe Port-A-Cath(®) (PAC) placement by percutaneous puncture of the subclavian vein with ultrasonographic guidance.

PATIENTS AND METHODS

Data on our vascular access service were collected prospectively from June 2004. This service included port-a-caths and Hickman lines. Once 1000 consecutive port-a-caths(®) had been reached the study was closed and data analysed for the port-a-caths(®) alone. The left subclavian vein was the preferred site for venous access, with the right subclavian and jugular veins being the alternative choices if the initial approach failed. Patients were followed up in the short-term, and all the procedures were carried out by a single surgeon at each one of two institutions.

RESULTS

Venous access by PAC was established in 100 % of the 1,000 cases. Of the 952 patients where the left subclavian vein was chosen for the first attempt of puncture, the success rate of PAC placement was 95 % (n = 904). Pneumothorax occurred in 12 patients (1.2 %), and a wound haematoma occurred in 4 (0.4 %) out of the total 1,000 patients. No infections were recorded during the immediate post-operative period but only in the long-term post-operative use with 8 patients requiring removal of the PAC due to infection following administration of chemotherapy.

CONCLUSION

This is a very large series of PAC placement with an ultrasound-guided approach for left subclavian vein and X-ray confirmation, performed by a single surgeon, demonstrating both the safety and effectiveness of the procedure.

Subcutaneous infusion ports via the internal jugular vein: single center experience

OBJECTIVE

Our purpose is to report and review the results and early complications of subcutaneous infusion port placement by our interventional radiology department.

MATERIALS AND METHODS

Three-hundred twenty-five subcutaneous infusion ports were placed in 320 patients between January 2005 and May 2010. Ports were placed under both general and local anesthesia. Five patients were catheterized twice. The internal jugular veins were used for access. Both ultrasono-graphic and fluoroscopic guidance were used in our interventions. Retrospectively, we evaluated the ports' duration time.

RESULTS

Our technical success rate was 100% and only five complications occurred during port placement. The common carotid arteries were punctured in three patients but bleeding stopped ten minutes following withdrawal of the needle and artery compression. An air embolism occurred in two patients and both were successfully treated with good positioning and suctioning. Early catheter removal was required in five patients. One patient had a right internal jugular vein thrombosis, three patients had catheter occlusions and two patients had catheter fractures. The mean duration of catheter usage was 354 days (range: 2 to 1,478 days).

CONCLUSION

Image guided placement of infusion ports has a greater success rate and lower early complication rate when compared with the unguided series. The right internal jugular vein is the first choice for infusion port access.

Upper arm central venous port implantation: a 6-year single institutional retrospective analysis and pictorial essay of procedures for insertion

Background

The requirement of central venous (CV) port implantation is increasing with the increase in the number of cancer patients and advancement in chemotherapy. In our division, medical oncologists have implanted all CV ports to save time and consultation costs to other departments. Recently, upper arm implantation has become the first choice as a safe and comfortable method in our unit. Here we report our experience and discuss the procedure and its potential advantages.

Methods

All CV port implantations (n = 599) performed in our unit from January 2006 to December 2011 were analyzed. Procedural success and complication rates between subclavian and upper arm groups were compared.

Results

Both groups had similar patient characteristics. Upper arm CV port and subclavian implantations were equivalently successful and safe. Although we only retrospectively analyzed data from a single center, the upper arm group had a significantly lower overall postprocedural complication rate than the subclavian group. No pneumothorax risk, less risk of arterial puncture by ultrasound, feasibility of stopping potential arterial bleeding, and prevention of accidental arterial cannulation by targeting the characteristic solitary basilic vein were the identified advantages of upper arm CV port implantation. In addition to the aforementioned advantages, there is no risk of “pinch-off syndrome,” possibly less patient fear of manipulation, no scars on the neck and chest, easier accessibility, and compatibility with the “peripherally inserted central catheter” technique.

Conclusions

Upper arm implantation may benefit clinicians and patients with respect to safety and comfort. We also introduce our methods for upper arm CV port implantation with the videos.

Is catheter rupture rare after totally implantable access port implantation via the right internal jugular vein? Report of a case

Catheter rupture after totally implantable access port (TIAP) implantation via the right internal jugular vein is thought to be very rare. We report a case of catheter rupture found 682 days after TIAP surgery in a 52-year-old woman with recurrent right breast cancer. It is possible that chronic stress at the flexure of the catheter induced by neck movements caused the catheter to rupture. Therefore, when inserting a TIAP via the right internal jugular vein, the site of venous puncture should be decided on carefully. Although a fracture of this type is rarely reported in the literature, the incidence of catheter injury of a TIAP inserted via the internal jugular vein at our institute is 1.8 %. This highlights the need to educate and caution medical staff and patients about preventing catheter fracture being caused by external factors.

Comparison of subcutaneous central venous port via jugular and subclavian access in 347 patients at a single center

The purpose of the present study was to examine whether patency times, including complications of subcutaneous venous chest port insertion using ultrasonography (US) guidance, differ between jugular and subclavian venous access. Between December 2008 and July 2010, subcutaneous venous chest ports were placed in 347 patients by an experienced team. All single-lumen port catheters were placed into jugular and subclavian veins under US and fluoroscopy guidance. Patency times and complication rates of ports via these routes were compared and the variables were age, gender, access, site of malignancy and coagulation parameters. The success of the jugular and subclavian groups was compared by univariate Kaplan-Meier survival analysis and the multivariable Cox regression test. A total of 15 patients underwent port removal due to complications. As a rate per 100 catheter days, ports were explanted in 7 (0.0092) due to thrombosis, 4 (0.0053) for catheter malposition, one each (0.0013) of port reservoir flip-over, bleeding, port pocket infection, skin necrosis and incision dehiscence, for a total of 15 patients (0.0197). Patency times were not different in the jugular and subclavian veins. Factors were not significant, with the exception of platelet count. There was no significant difference in patency times, including complications, between jugular vein access and subclavian vein access using US. This should be considered when selecting the access method.

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Long-term complications in totally implantable venous access devices: randomized study comparing subclavian and internal jugular vein puncture

BACKGROUND

This prospective randomized study evaluated complications related to long-term totally implantable catheters in oncologic children and adolescents by comparing venopunction performed either in the jugular or subclavian vein.

METHODS

A total of 83 catheters were implanted from January 2004 to April 2006 and followed-up until March 2008. Patients were randomly allocated to the subclavian or jugular vein group. The endpoint was complications that led to catheter revision or catheter removal.

RESULTS

Six patients were excluded, 43 had the catheter implanted in the subclavian and 34 in the jugular vein. Subclavian catheters were used for up to 12.6 months, while jugular catheters were kept in place for up to 14.8 months (P = 0.38). No statistical differences were found between the groups concerning age, sex, leukocyte count, platelet count, type of admission (in or outpatient), or previous chemotherapy regimens. When analyzed individually, long-term complications did not present statistically significant differences either. Infection occurred in 20 and 11% (P = 0.44), while catheter embolism took place in 23 and 8% (P = 0.11) of patients with subclavian and jugular catheters, respectively. A statistical difference was seen in the total number of complications, which occurred in 48 and 23% (P = 0.02) of patients in the subclavian and in the jugular groups, respectively.

CONCLUSIONS

Catheters implanted by puncture in the subclavian vein were more prone to late complications than those implanted in the jugular vein.

Central venous port systems as an integral part of chemotherapy

BACKGROUND

Port systems are easy to implant on an in- or outpatient basis and provide reliable, long-lasting central venous access. They are used mainly for cancer patients.

METHODS

This article is based on a selective literature review, the guidelines of the German Society for Nutrition Medicine and of the European Society for Clinical Nutrition and Metabolism, and the recommendations of the German Society for Pediatric Oncology and Hematology.

RESULTS

In modern oncology, central venous port systems are increasingly replacing short-term and permanently tunneled central venous catheters. They are indicated for patients who need long-term intravenous treatment involving, e.g., the repeated administration of chemotherapeutic drugs, parenteral nutrition, transfusions, infusions, injections, and/or blood sample collection. Port systems can markedly alleviate the burden of intravenous therapy and thereby improve these patients' quality of life. The planning, preparation, and performance of port system implantation require meticulous attention to detail. The rate of implantation-associated complications is less than 2% in experienced hands; overall complication rates have been reported from 4.3% to as high as 46%. The proper postoperative use and care of the port system are of decisive importance to the outcome. Reported infection rates during port system use range from 0.8% to 7.5% in current clinical studies.

CONCLUSION

The treatment, follow-up care, and rehabilitation of cancer patients are interdisciplinary tasks. Optimal treatment and complication avoidance require a collaborative effort of all of the involved specialists-not just the physician implanting the port system, but also the oncologists, nutritionists, visiting nurses, and other home health care providers. Continuing medical education, too, plays a role in improving outcomes.

Severe neutropenia at time of port insertion is not a risk factor for catheter-associated infections in children with acute lymphoblastic leukemia

BACKGROUND

The objective of this study was to determine whether severe neutropenia on the day of port-a-catheter (PORT) insertion was a risk factor for catheter-associated infection (CAI) in children with acute lymphoblastic leukemia (ALL).

METHODS

This was a retrospective study of children with ALL who had a PORT insertion between January 2005 and August 2008. Early (≤ 30 days) and late (>30 days) postprocedure complications were reviewed. The length of follow-up ranged between 7 months and 42 months.

RESULTS

In total, 192 PORTs were inserted in 179 children. There were 43 CAIs (22%), and the infection rate was 0.35 per 1000 catheter-days. The CAI rate (15%) in children who had severe neutropenia on the day of the procedure did not differ statistically from the CAI rate (24%) in children who did not have severe neutropenia (P = .137). Conversely, patients with severe neutropenia who had a CAI were more likely to have their PORT removed (P = .019). The most common organisms to cause catheter removal were coagulase-negative Staphylococcus and Staphylococcus aureus. Patients with high-risk ALL had a statistically significant higher incidence of late CAI than patients with standard-risk ALL (P = .012). Age (P = .272), positive blood culture preprocedure (P = 1.0), and dexamethasone use (P = .201) were not risk factors for CAI. Patients who had an early CAI did not have a greater chance of having a late CAI. The catheter infection-free survival rate at 1 year was 88.6%.

CONCLUSIONS

The current results indicated that severe neutropenia on the day of PORT insertion does not increase the risk of CAI in children with ALL.

Indwelling central venous access port insertion during bevacizumab-based therapy

Indwelling central venous catheters and implantable port systems are widely used in the care of patients with cancer. Bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor, significantly prolongs survival when added to intravenous 5-fluorouracil-based chemotherapy as first-line treatment for metastatic colorectal cancer. It has also been shown to be of value in a range of other malignant diseases. Some elements of the toxicity profile of bevacizumab, however, such as bleeding and impaired wound healing, could interfere with surgical procedures involved in the treatment of the diseases. The aim of this study was to evaluate the possible effect of bevacizumab in increasing the morbidity associated with an indwelling central venous access port in patients currently receiving the drug, or those who had received it in the preoperative run-up to surgery. An analysis of the medical records of 57 patients with a variety of cancers, who had received an indwelling central venous access port, either during the course of treatment with bevacizumab or in the 4-week period before the commencement of therapy was carried out, with particular emphasis on periprocedural complications. Eight of the patients also had diabetes mellitus. There were no instances of delay in wound healing, abnormal bleeding, or wound infection in any of the patients and no episodes of skin ulceration during bevacizumab treatment. Although this is a relatively small study, and no definitive conclusions can be drawn at this stage, our data suggest that an indwelling central venous access port insertion may be carried out shortly before or during bevacizumab treatment without increasing periprocedural morbidity.

Complication rates and outcomes of 536 implanted subcutaneous chest ports: do rates differ based on the primary operator's level of training?

RATIONALE AND OBJECTIVES

Totally implanted subcutaneous central venous access devices (chest ports) are an attractive option for patients in need of intermittent, recurrent venous access. In our department, these are placed by different operator types including interventional radiology (IR) attending physicians, dedicated IR nurse practitioners (NP), and IR fellows/radiology residents. The purpose of our study is to assess the rate of complications of subcutaneous chest port placement among the different operator types.

MATERIALS AND METHODS

A retrospective review of all subcutaneous central venous access devices implanted in our department between October 8, 2004, and October 19, 2007, was undertaken. Total numbers of port days, overall complication rates for all operators, as well as complication rates for the various operator types were calculated and were compared using the chi square test.

RESULTS

A total of 558 patients had totally implanted subcutaneous central venous access devices placed during the period of study. Of these, 536 had documented follow-up and comprise the study population. A total of 89 were placed by attending physician alone, 133 by an NP, and 314 by an IR fellow or resident, with supervision by an attending physician. Mean duration of port usage was 341 days with 182,522 total port days. A total of 39 complications occurred (7.28%), including 27 infections (5%). There was no statistically significant difference in overall complication rates, including infection rates, among operator groups (P = .925).

CONCLUSIONS

Our results confirm that well-trained physician extenders and trainees can safely perform chest port placement and that these providers, under appropriate supervision, can help provide improved access to chest port placement for patients and referring clinicians.

Jugular versus subclavian totally implantable access ports: catheter position, complications and intrainterventional pain perception

PURPOSE

To determine the safest and most tolerable method for totally implantable access ports (TIAPs) particularly in regard to patient's pain perception and catheter-related complications.

MATERIALS AND METHODS

From January 2007 to October 2008 a subcutaneous TIAP (Bardport, Bard Access System, UT, USA) was implanted in 138 oncological patients (60 male, 78 female; 18-85 years old; mean age of 56 ± 6 years) by experienced interventional radiologists. 94 TIAP were implanted through the subclavian vein (subclavian group) and 44 TIAP were implanted through the internal jugular vein (jugular group). Intrainterventional pain perception (visual analogue scale from 1 to 10), postinterventional catheter tip migration and radiation dose were documented for each method and implantation side and differences were compared with Wilcoxon t-test. For ordinal variables, comparison of two groups was performed with the Fisher's exact test.

RESULTS

No severe periinterventional complication occurred. Inadvertent arterial punctures without serious consequences were reported in one case for the jugular group versus four cases in the subclavian group. Significantly (p<0.05) lower pain perception, radiation dose and tip migration rate were observed in the jugular group. Catheter occlusions occurred in 4% (n=4) of the subclavian group versus 2% (n=1) of the jugular group. The corresponding values for vein thrombosis and catheter dislocation were 3% (n=3) and 1% (n=1) in the subclavian group, while none of those complications occurred in the jugular group.

CONCLUSION

Both techniques, the TIAP implantation via fluoroscopy-guided subclavian vein puncture and via ultrasound-guided jugular vein puncture, are feasible and safe. Regarding intrainterventional pain perception, radiation dose, postinterventional catheter tip position and port function the jugular vein puncture under ultrasound guidance seems to be advantageous.

Increased use of percutaneous technique for totally implantable venous access devices. Is it real progress? A 27-year comprehensive review on early complications

BACKGROUND

First implantation of a totally implantable venous access device (TIVAD) was performed in 1982 with surgical technique. Since then, these devices have permitted infusion of total parenteral nutrition, antibiotics, blood products, and, above all, they have definitively changed the quality of life of patients with cancer. However, with the increase of percutaneous procedures, we have assisted with a concomitant raise of immediate postprocedural life-threatening complications. The aim of this study was to review the literature during a 27-year period, with regard to the changes of incidence of immediate complications after percutaneous or surgical cutdown for TIVAD's implant.

MATERIALS AND METHODS

An extensive search of relevant literature was carried out by using MEDLINE (PubMed) and Google Scholar. We gathered articles from 1982 to 2009 that quoted patient's number, type of pathology, specialist involved, number of devices implanted, site and technique of implantation (surgical cutdown or percutaneous technique), and immediate complications occurrence.

RESULTS

A total of 952 reports were screened, and finally only 45 articles addressing all inclusion criteria were used for the present study. A total of 11,430 TIVADs implanted in 11,381 patients were analyzed. Pneumothorax, hemothorax, arterial puncture, and hemoptysis developed only after percutaneous procedures. Atrial fibrillation, hematomas, and malpositioning were more frequent after percutaneous approach. The total amount of immediate complications in patients submitted to percutaneous implant was 4.5%, compared with 0.9% subsequent to cutdown technique.

CONCLUSIONS

Despite the increased use of percutaneous technique for TIVADs' implantation, surgical cutdown, because of its safety, remains the best approach to avoid possible fatal immediate complications.

Skin erosion over totally implanted vascular access devices in children

Erosion of the skin over a totally implanted vascular access device (TIVAD) is a rare event that may lead to life-threatening sequelae. From 1994 to 2007, we reviewed the medical records and central line database of 960 central line insertions for the complication of skin erosion over the TIVAD. Outcome measures included age, gender, and nutritional status, number of days until complication, insertion site, and attending surgeon. A total of 540 of the 960 central lines were TIVAD. Skin erosion occurred in 9 patients for an incidence of 1.67%. Average age at insertion was 51 months (range 25-116.5 months). The average catheter duration use in days was 335 with a range of 39-1575 days. Malnutrition defined as BMI <5% or a decrease in BMI percentiles occurred in 2 and 4 patients, respectively, and contributed to the thinning of the subcutaneous fat. Skin erosion over TIVAD is a rare complication. Most cases can be prevented by inserting the device in a subfacial location in the very young child or in the child with expected weight loss. Furthermore, the device should be placed at a fair distance from the skin incision to prevent early skin erosion through the wound.

Totally implantable venous access ports via the external jugular vein: safety and effectiveness for young pediatric patients

BACKGROUND AND AIMS

Various venous approaches are possible during implanting a totally venous access port. The veins, which are commonly used in pediatric patients are internal and external jugular veins. Comparison of different venous approaches has been discussed in a few reports only. The present study reviews the complication rate, operation time of implanting the port via different veins in children.

PATIENTS AND METHODS

From January 2003 to December 2005, 94 venous access ports were implanted in 88 consecutive patients in the Pediatric Surgical section of the Taipei Veterans General Hospital. The patients were classified according to the vein used. Group A (n=45), the external jugular vein access group; and group B (n=43), the internal jugular vein access group.

RESULTS

The operation time in group A and B were 38.4+/-11.1 and 57.6+/-20.3 min, respectively. The mean operation time of group A was significantly shorter than that of group B (P<0.001). The overall complication rates in group A and B were 8.5%, and 19.1%, respectively. These differences, however, were not significant (P>0.05).

CONCLUSIONS

The external jugular vein approach has a shorter operation time and a lower complication rate than the internal jugular vein approach. This approach may be a method of choice in selected pediatric patients.

Radiological Interventions for Correction of Central Venous Port Catheter Migrations

PURPOSE

The purpose of this study was to evaluate radiological-interventional central venous port catheter corrections in migrated/malpositioned catheter tips.

MATERIALS AND METHODS

Thirty patients with migrated/malpositioned port catheter tips were included in this retrospective analysis. To visualize the catheter patency a contrast-enhanced port catheter series was performed, followed by transfemoral port catheter correction with various 5-F angiographic catheters (pigtail; Sos Omni), gooseneck snares, or combinations thereof.

RESULTS

One patient showed spontaneous reposition of the catheter tip. In 27 of 29 patients (93%), radiological-interventional port catheter correction was successful. In two patients port catheter malposition correction was not possible, because of the inability to catch either the catheter tip or the catheter in its course, possibly due to fibrin sheath formation with attachment of the catheter to the vessel wall. No disconnection or port catheter dysfunction was observed after correction.

CONCLUSIONS

We conclude that in migrated catheter tips radiological-interventional port catheter correction is a minimally invasive alternative to port extraction and reimplantation. In patients with a fibrin sheath and/or thrombosis port catheter correction is often more challenging.

Radiological Interventions for Correction of Central Venous Port Catheter Migrations

The purpose of the study is to evaluate radiological-interventional central venous port catheter corrections in migrated/malpositioned catheter tips. Thirty patients with migrated/malpositioned port catheter tips were included in this retrospective analysis. To visualize the catheter patency, a contrast-enhanced port catheter series was performed, followed by transfemoral port catheter correction with various 5F angiographic catheters (pigtail, Sos Omni), goose-neck snare, or combinations thereof. One patient showed spontaneous reposition of the catheter tip. In 27 of 29 patients (93%), radiological-interventional port catheter correction was successful. In two patients, port catheter malposition correction was not possible because of the inability to catch either the catheter tip or the catheter in its course, possibly due to fibrin sheath formation with attachment of the catheter to the vessel wall. No disconnection or port catheter dysfunction was observed after correction. In migrated catheter tips, radiological-interventional port catheter correction is a minimally invasive alternative to port extraction and reimplantation. In patients with a fibrin sheath and/or thrombosis, port catheter correction is often more challenging.

Evaluation of Catheter Loops in Central Venous Port Systems

OBJECTIVES

We sought to evaluate the cause for catheter loops of central venous ports.

MATERIAL AND METHODS

A total of 241 patients who received a central venous port via subclavian vein access were included in this retrospective study. Eighty of these patients had undergone a computed tomography of the chest, allowing retrospective evaluation of the course of central venous catheters. Complications were evaluated by review of the clinical data charts.

RESULTS

In 49 patients, the catheter penetrated only the major pectoralis muscle. Only one of these patients (2.0%) showed a loop. In 31 cases, the catheter went through both the major and minor pectoralis muscle, and in 26 of these patients (83.9%), a loop was seen. Complications after port implantation were catheter occlusion (n = 2), pneumothorax (n = 2), thrombosis (n = 2), infection (n = 1), and catheter dislocation (n = 1).

CONCLUSIONS

The loop of catheter of central venous ports is caused by catheter penetration through pectoralis major and minor.

Implantation of central venous ports with catheter insertion via the right internal jugular vein in oncology patients: single center experience

AIM OF WORK

Evaluation of suitability and safety of venous port implantation with catheter insertion via the right internal jugular vein in oncology patients.

PATIENTS AND METHODS

One hundred one totally implantable venous ports were placed in 100 patients with malignancies from January 1, 2003 until March 31, 2005. Catheter of venous port was preferably inserted via the right internal jugular vein. We recorded a number of successful implantations using this venous approach and the rate of complications during the procedure and follow-up.

MAIN RESULTS

Ninety-seven catheters (96%) of totally implantable venous ports were inserted via the right internal jugular vein in 96 patients, and only in four cases were we not able to access this vein. We had no complications related to catheter insertion via the right internal jugular vein. Follow-up was made in all 96 patients with a total access days of 41 in 151 days (mean: 407 days). Premature catheter removal was required in six (6.2%, 0.144 per 1,000 access days) due to complications: three catheter dislocations/malfunctions (3.1%, 0.072 per 1,000 access days), one port-related sepsis, one pocket port infection, and one decubitus over port (1%, 0.024 per 1,000 access days). Six venous ports were removed after completion of the treatment at the patient's request.

CONCLUSION

The placement of totally implantable venous ports with catheter insertion via the right internal jugular vein has a high success rate without any early complications. Follow-up also demonstrates a low incidence of late complications requiring port removal.

Relationship between Chest Port Catheter Tip Position and Port Malfunction after Interventional Radiologic Placement

PURPOSE

The relationship between catheter tip position of implanted subcutaneous chest ports and subsequent port malfunction was investigated. Tip movement from initial supine position to subsequent erect position was also evaluated.

MATERIALS AND METHODS

Patients who underwent imaging-guided internal jugular chest port placement between July 2001 and May 2003 were identified with use of a quality-assurance database. Sixty-two patients were included in the study (22 men and 40 women), with a mean age of 58 years (range, 27-81 years). Catheter tip location on the intraprocedural chest radiograph was determined with use of two methods. First, the distance from the right tracheobronchial angle (TBA) was recorded (TBA distance). Second, tip location was classified into six anatomic regions: 1, internal jugular veins; 2, brachiocephalic veins; 3, superior vena cava (SVC; n = 11); 4, SVC/right atrial junction (n = 22); 5, upper half of right atrium (n = 25); and 6, lower half of right atrium (n = 4). For the duration of follow-up, catheter tip location was documented, as were all episodes of catheter malfunction.

RESULTS

Patients with catheter tips initially placed in position 3 had a higher risk of port malfunction (four of 11; 36%) than patients with catheter tips located in position 5 (two of 25; 8%). This difference narrowly fell short of statistical significance (P =.057). When comparing intraprocedural chest radiographs to the first erect chest radiographs, significant upward tip movement was noted. The tips migrated cephalad an average of 20 mm (P =.003) and 1.0 position units (P =.001).

DISCUSSION

Catheter tips placed in the SVC tended to have a greater risk of port malfunction compared with those positioned in the right atrium. Chest ports migrated cephalad between the supine and erect positions.

Radiologic diagnosis and management of complications related to central venous access

Central venous access is an important aspect of medical treatment. There are different designs of access devices for different purposes. In essence, they can be classified as short- and long-term devices. Insertion procedures vary for different devices. There is a risk for both acute and delayed complications. Radiology plays a central role both in placement and in device management. Image-guided insertion increases technical success and reduces the rate of acute complications. The diagnostic approach to long-term complications includes radiography, fluoroscopy, CT, and ultrasound. Treatment by interventional procedures is possible for a number of these conditions. These interventions increase device lifespan and reduce the number of necessary reinsertions.