Totally implantable venous access devices: retrospective analysis of different insertion techniques and predictors of complications in 796 devices implanted in a single institution

Inversion of Central Venous Ports in Children Under Six Years Old: A Retrospective Analysis of 154 Oncology Patients

Background Although some reports have evaluated the safety and efficacy of central venous port (CVP) placement in pediatric patients, the data about the inversion rate of the device and its risk factors are scarce. Therefore, this study aimed to evaluate the inversion rates of CVPs and their associated risk factors in pediatric patients. Methodology Between January 2010 and December 2021, 154 consecutive children (75 boys; median age, 28.5 months; range, 2-71 months) who underwent CVP placement at our center were included in this study. The primary outcome was the CVP inversion rate, and the secondary outcomes included technical success rate, intraoperative complications, and infectious complications. Intraoperative complications were evaluated according to the Society of Interventional Radiology guidelines. Patients under two years old were classified as the younger group and those aged ≥two years as the older group. Results The CVP inversion rate was 4.6% (n = 7/153), equivalent to 0.08 × 1,000 catheter-days. The inversion rate was significantly higher in the younger group (under two years old, 11.2%) than in the older group (≥two years old, 1.0%) according to the univariate analysis (p = 0.00576). The technical success rate was 99.4% (n = 153/154), and mild adverse events were observed during the procedure in three (1.9%) patients. Infectious complications were observed in 16 (10.5%) patients, equivalent to 0.19 × 1,000 catheter-days. Conclusions The CVP inversion rate was significantly higher in younger children (under two years old) than in older children (≥two years old).

Safety of non-cuffed tunneled central venous catheters in adults with cystic fibrosis

BACKGROUND

Peripherally inserted central catheters (PICCs) are the most common route of intravenous (I.V.) access for treatment of cystic fibrosis (CF) pulmonary exacerbations, but repeated PICC placement can result in upper extremity peripheral venous stenosis. Once peripheral stenosis develops, a non-cuffed tunneled central venous catheter (NcTCVC) is an alternative route for IV access. While these are regularly used at some CF centers, the safety and complication rate compared to PICCs in adults with CF has not been reported. This study aims to describe the safety of NcTCVCs in adults with CF.

METHODS

A retrospective cohort study was performed at a CF Foundation accredited institution including adults with CF who received NcTCVCs in interventional radiology from 7/19/2007 to 3/09/2020. Complications analyzed included catheter related deep venous thrombosis (DVT), central line associated blood stream infection (CLABSI), and catheter related central venous stenosis. Complications were considered attributable if they occurred while the catheter was in place or within 30 days of catheter removal.

RESULTS

During the study duration, 386 NcTCVCs were placed in 60 unique patients (55 % female) with a mean of 6.4 catheters per patient. Majority of NcTCVCs placed were 4 French (61.4 %). Average duration of indwelling NcTCVC was 16.2 days. No patients demonstrated catheter attributable symptomatic DVT. The incidence of DVT, CLABSI, and central venous stenosis was 0 (0 %), 4 (1 %), and 1 (0.3 %), respectively.

CONCLUSIONS

Many adults with CF have required insertion of numerous PICCs for the treatment of recurrent pulmonary exacerbations. In those adults that develop PICC-associated peripheral vein stenosis precluding PICC placement, these results indicate NcTCVCs are a safe alternative.

Evaluation of the position of the central venous catheter tip of implantable venous access devices in the occurrence of postoperative thrombotic and non-thrombotic complications

BACKGROUND

The position of the catheter tip of totally implantable venous access devices (TIVAD) is a risk factor for postoperative complications. The study aim was to assess the early and late complications (EC and LC) associated with the position of the catheter tip in cancer patients.

METHODS

We reviewed cancer patients who had a TIVAD placed in 2020. EC (≤ 90 days), LC (> 90 days) and risk factors for TIVAD-associated complications were assessed. The vertical mismatch of the catheter tip was compared to an "ideal position" (> 10 mm below the carina and ≥ 20 mm below the right main bronchus (RMB)) using chest x-ray, post-implantation.

RESULTS

301 patients were included. Median follow-up after TIVAD implantation was 9.4 months. All TIVAD catheters were inserted via the internal jugular vein (IJV). The mean distance between the catheter tip and the carina and the RMB was 21.3 mm and 6.63 mm respectively. In total, 11.3% patients developed EC and 5.6% had LC. An association was found between the position of the catheter tip from the carina (≤ 10 mm vs. > 10 mm) and the occurrence of EC (18.3% vs. 8.6%, p = 0.01) and for the catheter insertion side (left IJV vs. right IJV) (19.1% vs. 9.0% p = 0.02). Multivariate analysis showed that left IJV catheter insertion (OR 2.76), and a catheter tip located ≤ 10 mm below the carina (OR 2.71) are significant independent risk factors of EC.

CONCLUSIONS

TIVAD catheter tip located at ≤ 10 mm below the carina, and a left-side inserted catheter, are higher risk of EC.

Cephalic Vein Cut-Down Method for Totally Implantable Venous Access Ports: A Single-Institution Experience

BACKGROUND

The widespread use of chemotherapies has increased the need for totally implantable venous access ports (TIVAPs). Previously, the subclavian puncture approach with the landmark technique was the most used implantation method; however, it has been related to early complications such as pneumothorax, hemothorax, and arterial puncture. Therefore, a safer implantation method is required. This study aimed to assess the safety and efficacy of the cephalic vein cut-down method used in our institution.

METHODS

Patients who underwent TIVAPs implantation using the cephalic vein cut-down method as the first choice between January 1, 2018, and December 31, 2020, were included in this study. We retrospectively evaluated the technical success rates, operation times, and early complications.

RESULTS

This study included 221 adult patients (men, 129; women, 92), with a mean age of 68 ± 11 years. The mean body mass index (BMI) was 21 ± 4 kg/m2. A total of 213 patients (96.4%) had malignant tumors that required chemotherapy. The mean postoperative follow-up period was 659 ± 442 days (range, 5-1,698 days). A total of 127 patients (57.5%) died during the follow-up period. The technical success rate was 86.4% (191/221). There were 30 failures, 24 of which were converted to the subclavian vein puncture approach. The mean operation time was 53 ± 21 min. Early complications were observed in 4 (1.8%) patients, corresponding to an incidence of 0.028 complications/1,000 catheter days. One patient had an unintended arterial puncture; however, it was not a result of the cephalic vein cut-down method but a secondary result of the subclavian vein puncture. No complications of pneumothorax, hemothorax, or arterial puncture were observed with the cephalic vein cut-down method.

CONCLUSIONS

This study showed that the cephalic vein cut-down method for TIVAPs had an acceptable success rate and fewer early complications than the conventional puncture techniques.

Very rare malposition of central venous catheter in cardiac surgery patients

Malposition of a catheter is found in approximately 7% of cases after central venous catheterisation. This may result in haemorrhage, venous thrombosis and functional impairment, depending on the injury to the vessel wall. Uncomplicated catheterisation, easy aspiration of blood and monitoring of catheterisation do not guarantee correct placement of the catheter. In our rare case series, we share our experience of four cases of malposition into the left internal mammary vein (LIMV) that we experienced in a three-year period. The thinness and fragility of the vessel wall, particularly, increases the probability of complications in malposition into the LIMV. Administration of a catheter through the right jugular vein is associated with the lowest incidence of malposition. Performing the procedure under the guidance of ultrasonography (USG) and confirmation of the catheter position after puncture using one of the USG techniques will minimise the probability of malposition. In addition, a lung X-ray should immediately be taken, and venography and fluoroscopy should be considered in the presence of suspicion.

Cephalic Vein Cut Down for Total Implantable Venous Access Ports: A Retrospective Review of a Single Institution Series

Objective

The aim of this work was to describe the early and late success rates of cephalic vein cut down (CVC) in the implantation of totally implantable venous access ports (TIVAP) for chemotherapy treatment in oncological patients.

Methods

This was a retrospective study of 1 047 TIVAP performed in a private institution between 2008 and 2021. The CVC with pre-operative ultrasound (PUS) was the initial approach. All cephalic veins (CVs) were mapped pre-operatively with Doppler ultrasound, measuring their diameter and course in oncological patients who required a TIVAP. With a CV diameter ≥ 3.2 mm TIVAP was carried out by CVC; with CV diameter < 3.2 mm, subclavian vein puncture (SVP) was performed.

Results

1 047 TIVAPs were implanted in 998 patients. The mean age was 61.5 ± 11.5 years, 624 were women (65.5%). Male patients were significantly older and with a higher incidence of colonic, digestive system, and laryngeal cancer. Initially, TIVAP was indicated in 858 cases (82%) by CVC and 189 (18%) by SVP. The success rate was 98.5% for CVC and 98.4% for SVP. There were no complications for CVC (0%) but five early complications (2.5%) in the SVP group. The rates of late complications were 4.4% in the CVC group and 5.0% in the SVP group, foreign body infection being the most frequent (57.5% of the cases) (p = .85).

Conclusion

The CVC or SVP using PUS for TIVAP deployment, performed through a single incision, is a safe and effective technique. This open but minimally invasive technique should be considered in oncological patients.

Outcome Comparison of Totally Implantable Venous Access Device Insertions Between Surgeons and Radiologists in Australia

Background

The need for chemotherapy treatment is increasing with the growing incidence of cancer worldwide. The insertion of totally implantable venous access devices (TIVADs) is commonly performed by surgeons and radiologists, but the procedures are not without complications. The primary outcome of this review outlines TIVAD insertion success and complication rates between general surgeons and radiologists. The secondary goal of this study is to help identify areas for improvement and consideration when performing TIVAD insertion.

Methodology

This was a descriptive, three-year, retrospective multicentre study of oncological patients who underwent TIVAD insertion by either general surgeons or radiologists at two peripheral Brisbane hospitals.

Results

Surgeons performed 61 percutaneous subclavian vein cannulations, 29 ultrasound-guided internal jugular veins, and seven open cephalic veins cut-down TIVAD insertions (n=97). Overall surgical success was 81.4%, with the internal jugular (89.7%) having the highest success rate followed by the open cut-down (85.7) and subclavian approaches (77.0%). The overall surgical complication rate was 16.4%, with five pneumothorax, five port malfunctions, three haemorrhages, two infections, one thrombus, and one mediastinal injury. Each pneumothorax was associated with subclavian cannulation attempts. Two haemorrhages were associated with both open cephalic and subclavian attempts. Radiologists performed 248 ultrasound-guided internal jugular vein TIVAD insertions (n=248) with 247 successful first attempts (99.5%). Within the radiology group, there was an overall complication rate of 15.3% with 22 infections, 14 port malfunctions, one haemorrhage, and 1 mediastinal injury.

Conclusion

Ultrasound-guided internal jugular vein TIVAD insertion had the highest first attempt success rate in both the surgical and radiology groups.

Totally Implantable Venous Access Devices: A Randomized Controlled Trial on the Effect of Psychological Support on Quality of Life and Body Image (BI-PORT)

Background: The presence of totally implantable venous access devices (TIVADs), as any permanent or semipermanent medical devices, has an impact on the quality of life (QoL) of patients. Therefore, the purpose of this trial was to evaluate the efficacy of psychological support for patients undergoing this procedure.

Methods: This randomized controlled trial (RCT) aimed to compare the efficacy of a psychological intervention vs. standard care on QoL in patients receiving TIVAD for chemotherapy treatment (ClinicalTrials.gov NCT02075580). The trial was conducted at the Veneto Institute of Oncology IOV-IRCCS (Padua, Italy) between October 2013 and September 2018. Participants were neoplastic adults receiving TIVAD for chemotherapy treatment for any cancer, not undergoing visible demolitive interventions, without psychopathological diagnosis and language understanding. The exclusion criteria were patients without a diagnosis of cancer, with psychopathological diagnosis, or with language misunderstanding.

Results: The variation of C30-QL2 and BR32-BI was not statistically different between intervention and control arms in men and women. However, the variation of C30-SF was statistically better in the intervention than control arm in men [mean difference (MD) 22.3, 95% CI 3.5 to 41.0] but not in women (MD −2.7, 95% CI −24.0 to 18.7). The variations of the other secondary outcome measures were not statistically different between intervention and control arms.

Conclusion: Psychological support did not show any clear advantages on global QoL and body image perception in patients at 15 days after TIVAD insertion for chemotherapy. In contrast, male patients might benefit from even a very short psychological counseling before or during chemotherapy even if they do not seem to ask for it.

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.

Forty years after the first totally implantable venous access device (TIVAD) implant: the pure surgical cut-down technique only avoids immediate complications that can be fatal

Aim

Even though TIVADs have been implanted for a long time, immediate complications are still occurring. The aim of this work was to review different techniques of placing TIVAD implants to evaluate the aetiology of immediate complications.

Methods

A systematic literature review was performed using the PubMed, Cochrane and Google Scholar databases in accordance with the PRISMA guidelines. The patient numbers, number of implanted devices, specialists involved, implant techniques, implant sites and immediate complication onsets were studied.

Results

Of the 1256 manuscripts reviewed, 36 were eligible for inclusion in the study, for a total of 17,388 patients with equivalent TIVAD implantation. A total of 2745 patients (15.8%) were treated with a surgical technique and 14,643 patients (84.2%) were treated with a percutaneous technique. Of the 2745 devices (15.8%) implanted by a surgical technique, 1721 devices (62.7%) were placed in the cephalic vein (CFV). Of the 14,643 implants (84.2%) placed with a percutaneous technique, 5784 devices (39.5%) were placed in the internal jugular vein (IJV), and 5321 devices (36.3%) were placed in the subclavian vein (SCV). The number of immediate complications in patients undergoing surgical techniques was 32 (1.2%) HMMs. In patients treated with a percutaneous technique, the number of total complications were 333 (2.8%): 71 PNX (0.5%), 2 HMT (0.01%), 175 accidental artery punctures AAP (1.2%) and 85 HMM (0.6%). No mortality was reported with either technique.

Conclusion

The percutaneous approach is currently the most commonly used technique to implant a TIVAD, but despite specialist’s best efforts, immediate complications are still occurring. Surgical cut-down, 40 years after the first implant, is still the only technique that can avoid all of the immediate complications that can be fatal.

Complications and Management of Totally Implantable Central Venous Access Ports in Cancer Patients at a University Hospital in Oman

Objectives

Totally implantable central venous access ports (port-a-caths) are increasingly used for the safe administration of chemotherapy; however, their use is associated with complications. This study reviews patterns of complications, reasons for premature removal and the duration of the use of port-a-caths in patients receiving cancer treatment at Sultan Qaboos University Hospital (SQUH) and compares the infection rate with the literature and the researchers’ experiences.

Methods

This retrospective follow-up study included patients who had received cancer treatment through a port-a-cath and were admitted to SQUH between January 2007 and April 2019. Demographic features, underlying diagnosis, clinical stage, treatment, duration of use and the cause of premature removal of the port-a-cath were recorded.

Results

A total of 516 port-a-caths were inserted in 482 cancer patients. The majority of devices were implanted by interventional radiologists (n = 459; 89.0%) and the right internal jugular vein was most frequently accessed (n = 396; 76.7%). The mean indwelling time of a port-a-cath was 288 days (range: 3–1,872 days) for patients with complications and 550 days (range: 7–3,123 days) for patients without complications. Port-a-cath-related infection was the main complication (n = 63; 12.2%). Patient age, gender, treatment intent, underlying diagnosis, clinical stage, chemotherapy regimen, number of treatment courses, operator implanting the port, the type of micro-organism isolated from the port-a-cath and body mass index were significant factors affecting catheter indwelling time (P <0.05). On multivariate analysis, however, none of the factors was found to be significant.

Conclusion

Infection was the most common complication necessitating port-a-cath removal. The infection rate was much lower than the researchers’ previous experience and compares favorably with several published reports.

Chemoport-associated Complications and Its Management

Chemoport is being routinely used to administer chemotherapy, blood, blood products, total parenteral nutrition, and also to draw blood for investigations. We started using chemoport in our institute. We use it exclusively to administer chemotherapy. We analyzed our results of chemoport usage and confirm that the rate of complications associated with chemoport usage is at par with the available literature. We also conclude that with regular use, the intra-op and post-op complications will reduce further.

Risk of venous thromboembolism associated with totally implantable venous access ports in cancer patients: A systematic review and meta-analysis

BACKGROUND

Totally implantable venous access ports (TIVAPs) for chemotherapy are associated with venous thromboembolism (VTE). We aimed to quantify the incidence of TIVAP-associated VTE and compare it with external central venous catheters (CVCs) in cancer patients through a meta-analysis.

METHODS

Studies reporting on VTE risk associated with TIVAP were retrieved from medical literature databases. In publications without a comparison group, the pooled incidence of TIVAP-related VTE was calculated. For studies comparing TIVAPs with external CVCs, odds ratios (ORs) were calculated to assess the risk of VTE.

RESULTS

In total, 80 studies (11 with a comparison group and 69 without) including 39 148 patients were retrieved. In the noncomparison studies, the overall symptomatic VTE incidence was 2.76% (95% confidence interval [CI]: 2.24-3.28), and 0.08 (95 CI: 0.06-0.10) per 1000 catheter-days. This risk was highest when TIVAPs were inserted via the upper-extremity vein (3.54%, 95% CI: 2.94-4.76). Our meta-analysis of the case-control studies showed that TIVAPs were associated with a decreased risk of VTE compared with peripherally inserted central catheters (OR = 0.20, 95% CI: 0.09-0.43), and a trend for lower VTE risk compared with Hickman catheters (OR = 0.75, 95% CI: 0.37-1.50). Meta-regression models suggested that regional difference may significantly impact on the incidence of VTE associated with TIVAPs.

CONCLUSIONS

Current evidence suggests that the cancer patients with TIVAP are less likely to develop VTE compared with external CVCs. This should be considered when choosing the indwelling intravenous device for chemotherapy. However, more attention should be paid when choosing upper-extremity veins as the insertion site.

[Finger pain and personality changes after chemotherapy initiation via a central venous port system in a 67-year-old female patient]

Central venous port systems are an integral part of chemotherapy. Early recognition and management of arterial malposition are crucial to prevent further complications. A 67-year-old female with breast cancer underwent central venous port implantation for adjuvant chemotherapy. After administration of the first chemotherapy the patient developed acute bihemispheric cerebral infarction and myocardial ischemia due to arterio-arterial emboli with a toxic encephalopathic component. After systemic lysis and surgical removal of the central venous port system, the patient showed a complete recovery.

Introduction of a specialized consultation prior to insertion of totally implantable access venous devices: Impact on cancellation rate and patient satisfaction

OBJECTIVES

Preoperative consultation is usually not performed before insertion of a totally implantable venous access device (TIVAD). In our experience, an incomplete preoperative assessment, a predictable medical condition contraindicating surgery, or no-show patients the day of surgery led to several surgery cancellations. Therefore, we introduced a specific preoperative surgical consultation for TIVAD that took place shortly before surgery. The aim of the present study is to evaluate the patients' satisfaction and to establish the rate of cancellation after the adoption of this strategy.

METHODS

Two-hundred and four patients who benefited from the preoperative consultation before TIVAD insertion from August 2014 to August 2016 were included. Satisfaction of patients and cancellation rate were documented.

RESULTS

With that strategy, no TIVAD insertion was either delayed or cancelled. The overall level of satisfaction was high (91.8%); 184 patients (90.2%) judged the consultation useful in preparation for the surgery. The surgical procedure met their expectations in 92.2% of cases. Patients known for a psychiatric comorbidity were more likely to express dissatisfaction.

CONCLUSIONS

The introduction of a specific preoperative surgical consultation for TIVAD insertion led to a high level of patients' satisfaction. After the preoperative consultation, no cancellation was recorded. Special approaches have to be considered for patients with a psychiatric comorbidity.

Surface measurement, intracardiac electrocardiogram and tracheal bifurcation techniques for locating the catheter tips of totally implantable venous access port

BACKGROUND

The purpose of our study is to compare the reliability and consistency of three commonly used techniques, which are surface measurement, intracardiac electrocardiogram (IECG) and tracheal bifurcation methods in measuring the tip location of totally implantable venous access port (TIVAP) in the same patient.

METHODS

The thirty-five patients scheduled for implantation of TIVAP were included and right subclavian vein was selected for venous access. We used surface measurement method (Group L) to estimate the length and position of catheter before catheterization, and then we used IECG method (Group E) to confirm the position of catheter during catheterization and after catheterization used tracheal bifurcation method by CT (Group T) for measurement. The differences of catheter length measured by three methods were compared by non-parametric Kruskal-Wallis test. Intraclass correlation coefficient (ICC) was used to evaluate the reliability of three methods and Bland-Altman chart was used to evaluate consistency.

RESULTS

There are no difference in the length of TIVAP catheter between L and T groups (P > 0.05), but they have significant differences comparing with E group (P < 0.05). The three positioning methods have a good consistency (ICC = 0.886, P < 0.05).Through linear regression analysis, the regression equation are: catheter length (mm) = 77.32 + 0.66 × height (cm), 36.25 + 0.81 × height (cm) and 68.82 + 0.70 × height (cm). The distances from catheter tip to the junction of superior vena cava and right atrium measured by IECG (Group E) was closer to the target value.

CONCLUSIONS

All three methods can be used to measure the length of TIVAP catheter, and IECG method is the most accurate. And similar to most studies, returning the catheter 20 mm after positioning can avoid catheter entering the right atrium, but we found that 10 mm is a sufficient length to achieve this.

Cephalic Vein Cut-down for Totally Implantable Central Venous Access Devices With Preoperative Ultrasonography by Surgical Residents

BACKGROUND/AIM

Cephalic vein (CV) cut-down for totally implantable central venous access devices (TICVADs) is not frequently used due to its low success rate. We compared the outcomes of CV cut-down using preoperative ultrasonography (US) performed by experienced surgeons versus surgical residents.

PATIENTS AND METHODS

From December 2015 to December 2017, 10 surgeons implanted 212 TICVADs using CV cut-down with preoperative US. The surgeons were divided into two groups of five each: surgical residents (Group A, n=124 procedures) and experienced surgeons (Group B, n=88 procedures). Duration of operation time, completion rate, and complications were retrospectively analyzed.

RESULTS

The completion rate was significantly higher in Group A (98.4% versus 92.0%, p=0.04). Duration of operation time (45.2±14.5 versus 42.0±13.1 minutes, p=0.22), rates of early complications (1.6% versus 1.1%, p=0.77) and late complications (3.2% versus 2.3%, p=0.68) were equivalent between the two groups. No fatal complications occurred in either group.

CONCLUSION

CV cut-down can be safely performed by surgical residents under the use of preoperative US.

Cephalic vein approach for the implantable central venous access: A retrospective review of the single institution's experiences; Cohort Study

Long-term venous access is usually required in patients receiving chemotherapy. We hypothesized that, out of the various central line approach techniques, the cephalic vein cut-down technique can be a safe and simple alternative in terms of surgical safety, feasibility, cost-effectiveness, and functional outcomes.We retrospectively reviewed the medical records of 569 patients who underwent implantable central venous access between January 2012 and December 2014 at our hospital.We classified our cohort according to access routes, as follows: 230 patients underwent subclavian vein access, 134 patients underwent internal jugular vein access, 25 patients underwent external jugular vein access, and 119 patients underwent cephalic vein access. The cephalic vein group had a significantly longer operation time than the subclavian group (P < .01); however, there was no difference in operation time between the internal jugular vein and cephalic vein groups (P = .59). The procedure-related complications and functional outcomes of the implanted venous port during chemotherapy were comparable between the cephalic group and other groups. Additionally, body mass index, operation time, and age did not correlate with catheter dysfunction in the multivariate logistic regression analysis (P = .53; P = .66; P = .19, respectively).We suggest that a cut-down central venous catheter insertion through the cephalic vein can be performed easily and safely with no differences in surgical and clinical outcomes compared to those of conventional percutaneous approaches. Moreover, the cephalic vein approach requires no specialized equipment, including percutaneous vascular kits, tunneling instruments, and intraoperative ultrasonography. Therefore, this technique might incur less medical expenses than conventional approaches and would be helpful for both patients and surgeons.

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.

Superior Vena Cava Port Catheter Tip Confirmation: Quantified Formula for Intravascular Catheter Length versus Anatomic Landmark Reference

BACKGROUND

Adequate tip location is crucial for intravenous port implantation because it can minimize catheter-related complications. Adequate tip location cannot be observed directly and needs to be confirmed by imaging tools. A quantified intravascular catheter length formula has been proposed and we attempt to compare its clinical effectiveness with anatomic landmark references.

METHODS

During the period from March 2012 to February 2013, 503 patients who received port implantation where implanted catheter length depended on carina level as confirmed by intraoperative fluoroscopy were assigned to Group A. From March 2013 to February 2014, 521 patients who received port implantation based on quantified intravascular catheter length formula were assigned to Group B. Clinical outcomes were compared.

RESULTS

Catheter tip location of Group A, as revealed by intraoperative fluoroscopy and postoperative chest film, was 1.18 ± 0.51 and 1.1 ± 1.3 cm below carina, respectively. Catheter tip location of Group B, as revealed by intraoperative fluoroscopy and postoperative chest film, was 1.25 ± 1.05 and 1.05 ± 1.32 cm below carina, respectively. Similar catheter tip location was identified in both groups. The functional period of implanted ports, complication rate (3.58% and 2.53%), and incidence (0.049 and 0.0506 episodes/1,000 catheter days) were similar in both groups.

CONCLUSIONS

The quantified intravascular catheter length formula can predict an adequate catheter length just as well as carina do and results in good catheter tip location. The formula could replace the clinical use of anatomic landmarks and serve as an easy tool for practitioners.

Catheter-related Complications of Subcutaneous Implantable Venous Access Devices in Breast Cancer Patients

BACKGROUND/AIM

Totally implanted venous access devices (TIVAD) are increasingly used in the treatment of cancer patients. The aim of this study was to assess the incidence of early and late complications resulting from subcutaneous TIVADs in patients with breast cancer.

MATERIALS AND METHODS

Between 2004 and 2009, we reviewed patients with breast cancer who had a TIVAD placed. Early and late complications, as well as risk factors for TIVAD-associated thrombosis were retrospectively assessed.

RESULTS

A total of 281 patients were included. Complications occurred in 26% of patients, the majority of which were late complications (21.4%.) The development of TIVAD associated thrombosis was the most frequent late complication (16.4%). In the univariate analysis followed by a multivariate model, risk factors for TIVAD associated thrombosis were not identified. Only within the subgroup of metastatic breast cancer patients an increased risk of TIVAD-associated thrombosis of left compared to right venous access was detected (p=0.015).

CONCLUSION

TIVAD implantation done in a gynecological outpatient setting is feasible and safe.

Implanted vascular access device options: a focused review on safety and outcomes

Implantable vascular access devices are frequently used in patients who have poor peripheral venous access. These devices can be partially implanted as tunneled and nontunneled central catheters, or they can be fully implanted as ports. Compared with long-term catheters, implanted ports have lower infection rates and improved perceptions of quality of life, but complications still occur in 2% to 18% of patients, frequently requiring removal of the device. Since the conception of implantable vascular access device ports, numerous advances in port design, materials, and techniques for implantation and care have been developed with the goal of overcoming frequent complications. We review the evidence related to these advances and their effect on the safety profile and complications of implantable vascular access device ports.

Risks of long-term port use in enzyme replacement therapy for lysosomal storage disorders

Totally implantable vascular access devices (TIVADs) are commonly used in conjunction with enzyme replacement therapy (ERT) for lysosomal storage disorders (LSDs). This case series describes potential complications associated with long-term TIVAD use, such as compromise of skin integrity, infection, or port failures. Best practices and skilled specialists are essential for minimizing complications from long-term TIVAD use for ERT.

An unusual complication after placement of an inferior vena cava filter via right internal jugular vein access

INTRODUCTION:

Totally implantable venous access devices are used extensively worldwide in cancer patients for administration of venotoxic agents, blood sampling, and nutrition. Their tip is usually positioned at the junction of superior vena cava and right atrium. Inferior vena cava filters are usually used for deep venous thrombosis in cases where anticoagulation is contraindicated; they can be inserted either via internal jugular or femoral access depending on patient conditions and preference.

CASE DESCRIPTION:

We are describing here a case of totally implantable venous access device fracture following a right internal jugular approach for inferior vena cava filter placement as the patient had inferior vena cava thrombus below the renal veins, extending into the right common iliac vein prohibiting femoral approach.

CONCLUSION:

Iatrogenic fracture of totally implantable venous access device is a potential complication of accessing the internal jugular vein for other procedures such as insertion of inferior vena cava filter.

Programmatic change leads to enhanced resource utilization and efficiency in port placement

BACKGROUND

Central venous port (CVP) placement is performed by a variety of surgeons in different subspecialties, and our previous work suggests that individual surgeons-regardless of training-are the strongest predictor of outcomes. We sought to prospectively evaluate a programmatic shift toward a resource-conscious, patient-focused algorithm for this common and simple surgical procedure.

MATERIALS AND METHODS

After implementation of a systems-level program for efficient CVP placement, 78 CVPs were placed by a single surgeon. Primary outcomes were procedure time, total operating room (OR) time, total facility time, and procedure-related complications. These prospective data were compared with retrospective cohorts of surgically placed and interventional radiology-placed CVP. Demographic data were analyzed by chi-square analysis, whereas time data were analyzed by the Wilcoxon rank-sum test.

RESULTS

The programmatic delivery (prospective) set showed significantly shorter procedural (median 16 min versus 26-40, P <0.05), OR times (median 36 min versus 46-70, P <0.05), and facility times (median 235 min versus 299-319, P <0.05) except for the interventional radiology facility time (median 187 versus 235, P <0.05). The range of OR time savings with the prospective versus comparison groups was 10-34 min, representing 22%-49% reductions in OR time (P <0.05). Complication rates were not significantly different (P = 0.13).

CONCLUSIONS

Through a programmatic change emphasizing efficiency and patient-centered outcomes, procedural/OR/facility time can be reduced greatly without changing complication rates. These data provide compelling evidence that common and ostensibly simple operative procedures can be substantially improved upon with thoughtful, data-driven systems-level enhancements.

Radiation burden of pediatric ultrasound-guided percutaneous central venous access devices: A prospective cohort study

Permanent central venous access is essential for the management of many pediatric patients. Knowing the amount of ionizing radiation used during the insertion of these devices is important. Our aim was to identify the radiation used in percutaneous insertion of central venous access devices, and to correlate radiation exposure to patient weight.

METHODS

Data was prospectively collected during a 12-month period from August 2015 to August 2016 on all ultrasound-guided percutaneous central venous access device insertions. An image intensifier was used in all insertions with data on radiation dose and screening time extracted, when available. The total radiation dose was measured in mGym2 and the total radiation time in seconds. A p-value <0.05 was used to denote statistical significance.

RESULTS

A total of 145 central venous access devices were inserted (82 portacaths, 43 double lumen lines, 16 single lumen lines and 4 hemocaths) in 127 patients (Median Age: 5.5years (Range 0-17); Median Weight 21kg (Range 1.9-100)) with 15 patients requiring multiple insertions over the course of the study. Of these, 88 had data captured for total radiation dose and time used and a further 23 had screening time only recorded. Median radiation dose was 0.00599 mGym2 (range 0.000543-0.148) with a median fluoroscopic screening time of 18s (range 2-479). Median dose was higher for children <10kg compared to larger children, 0.00661 mGym2 (range 0.00202-0.0468) versus 0.005715 mGym2 (range 0.000543-0.148) respectively. Left-sided internal jugular vein (IJV) insertions also had a higher median radiation dose of 0.0091 mGym2 (range 0.00142-0.148 mGym2) versus 0.005245 mGym2 (range 0.000543-0.0285 mGym2) for right-sided IJV insertions.

CONCLUSION

The radiation burden to children from percutaneous ultrasound-guided central venous access device insertions is small, in the order of that received during a chest radiograph. Weight<10kg and access of the left IJV are associated with receiving higher doses.

STUDY TYPE

Cohort Study (Level of Evidence: II).

Usefulness of Totally Implantable Central Venous Access Devices in Elderly Patients: A Retrospective Study

BACKGROUND/AIMS

The need for totally implantable central venous access devices (TICVADs) has increased with increased opportunities in the use of chemotherapy and parenteral nutrition. This study aimed to determine the outcomes of TICVAD implantation and use in patients aged ≥85 years.

METHODS

Between January 2010 and August 2016, 117 patients underwent TICVAD implantation and their records were retrospectively reviewed.

RESULTS

Participants were divided into 2 groups (plus-85 and sub-85 groups). Fifty-five patients (47.0%) had solid organ cancer alone; 35 patients (29.9%) had cerebrovascular or cranial nerve disease. The average follow-up period was 201 (2-1,620) days. Major complications were identified in 6 (14.6%) plus-85 patients and 11 (14.5%) sub-85 patients (p = 0.9813). Catheter-related infections developed in 3 plus-85 (7.3%) and 4 sub-85 patients (5.3%; p = 0.6549). There were no significant group differences in hematoma, pneumothorax, occlusion, and removal rates. In plus-85 patients examined just before surgery and a month after surgery, increased rates of serum albumin and Onodera's prognostic nutritional index were observed in 48% (14/39) and 41% (12/39), respectively.

CONCLUSIONS

The use of TICVADs in the plus-85 group resulted in effective outcomes. The results of this retrospective study support the wider use of TICVADs in patients aged ≥85 years.

Usefulness of Percutaneous Puncture in Insertion of Totally Implantable Venous Access Devices in Pediatric Patients

Purpose

Totally implantable venous access devices (TIVADs) are commonly used in pediatrics for the administration of chemotherapy, antibiotics, or parenteral nutrition. TIVADs can be implanted using various techniques, including surgical cutdown (SC) and percutaneous puncture (PP). Recently, percutaneous TIVAD became popular in adults, but studies comparing between PP and SC group in pediatric patients are rare.

Materials and Methods

Data were collected and analyzed retrospectively from 23 patients who underwent TIVAD at a single institution between January 2013 and December 2015. We examined the clinical characteristics, insertion techniques, and clinical outcome. We divided the patients into 2 groups and compared PP with ultrasonography and SC using the insertion technique. We compared success rate, procedural time, and the patency rate between the 2 groups.

Results

Eleven TIVADS were inserted using PP, and 12 TIVADs were inserted using SC. No statistically significant difference in characteristics was found between the 2 groups. The procedural time in the PP group was shorter than that in the SC group, but the difference was not statistically significant (P=0.685). During follow-up, 1 patient in the SC group had an occlusion, and 1 patient in the PP group had an infection.

Conclusion

PP of the internal jugular vein with ultrasonography appears to be the method of choice for TIVAD insertion owing to its similar success rate in terms of implantation and complication rate to that in SC, with shorter procedural times in pediatric patients.

Transitioning from anatomic landmarks to ultrasound guided central venous catheterizations: guidelines applied to clinical practice

Introduction

Centrally inserted central catheter (CICC) insertion is a commonly performed procedure that may give rise to different complications. Despite the suggestion of guidelines to use ultrasound guidance (USG) for vascular access, not all centers use it systematically. The aim of this study is to illustrate the experience with ultrasound in CICC placement at a high-volume oncological center, in a country where the landmark technique is standard.

Methods

Retrospective analysis of a prospective database was performed on CICC placement under USG in the Central Venous Catheter Unit of Instituto Português de Oncologia de Lisboa Francisco Gentil, from 2012 to 2015.

Results

Three thousand five hundred and seventy-two procedures were recorded. From 2728 CICC placements, 1187 (43.5%) were done using USG. The majority of CICC placements were successful without immediate complications (96.1%). In 55 cases (4.6%), more than three attempts were necessary to puncture the vein. Pneumothorax occurred in 5 cases (0.4%) and arterial puncture was registered in 41 cases (3.5%). An increasing use of USG for placing CICCs was planned and observed over the years and, in the last year of the study, 67.3% of the CICC placements were with USG.

Conclusions

CICC placement with USG is a safe and effective technique. Despite some resistance that is observed, these results support that it is worth following the guidelines that advocate the use of the USG in the placement of CICC.

Comparison of Inversion ("flipping") Rates Among Different Port Designs: A Single-Center Experience

PURPOSE

To compare incidence of port inversion among different types of implantable venous access devices.

MATERIALS AND METHODS

Records of patients who underwent imaging-guided subcutaneous port placement without port fixation between July 2001 and April 2015 were reviewed with use of a quality assurance database. 1930 patients with complete follow-up (death or explant) were included in the study. Collected data included date and indication for port placement, port type, venous access site, immediate and long-term complications, indication for removal, and total number of catheter days. BMI of patients with inverted ports was also calculated.

RESULTS

Port inversion within the pocket was observed in 18 patients (0.9%) including 7/82 (9%) of Dignity ports, 4/126 (3%) of Vaxcel plastic arm ports, 3/142 (2%) of Smartports, 2/100 (2%) of Powerports, 1/14 (7%) of Vaccess ports, and 1/1421 (0.07%) of Vortex LP ports. Among these designs, the inversion rate was significantly lower in Vortex LP ports (0.1%) (P < 0.05). There was a trend toward higher inversion rate of Dignity ports, which have a rectangular design with a relatively narrow base. Mean dwell in inverted ports was 114 days (7-580).

CONCLUSION

The incidence of port inversion without suture fixation of the port base to the pocket is extremely low. The present study shows differences in inversion incidence based on port design.

LEVEL OF EVIDENCE

Case Series, Level IV.

Surgeon, not technique, defines outcomes after central venous port insertion

BACKGROUND

Although central venous access for port placement is common and relatively safe, complications and poor resource utilization occur. We hypothesized that despite the simplicity of port placement, surgeon and/or resident performance-rather than technique-is associated with clinical outcomes and operating room efficiency.

MATERIALS AND METHODS

Medical records of 1200 patients who underwent port placement between 2012 and 2015 at our institution were retrospectively reviewed. Insertion route (subclavian, internal jugular, cephalic cutdown), individual surgeon (A-G), surgeon volume, body mass index, patient age, and resident presence were evaluated to determine their association with operating room time, complications, and need for alternate insertion route.

RESULTS

On univariate analysis, operating room times were significantly different among individual surgeons, with surgeons E and F having the longest operating room times (50 and 63 versus 31-40 min; P < 0.01) and switching to an alternate method more frequently (13.5% and 21.3%, versus 0%-10.3%, P < 0.01). On multivariate analyses, operating time was increased with elevated body mass index, resident presence, and switching to an alternate method. Individual surgeons had varied effects on operating time with two surgeons found to be the predominant drivers (OR 19 and 27; P < 0.01). With residents excluded, these two surgeons continued to increase operating times (OR 15 and 29; P < 0.01) and procedural complications (OR 3.2 and 5.9; P < 0.05).

CONCLUSIONS

Although port placement is ostensibly simple, individual surgeon performance is the primary driver of patient outcome and operative efficiency. In an era requiring optimized resource utilization and outcomes, these data demonstrate potential for enhanced programmatic organization and case distribution.

A novel "shrug technique" for totally implantable venous access devices via the external jugular vein: A consecutive series of 254 patients

BACKGROUND

The external jugular vein (EJV) approach for totally implantable venous access devices (TIVADs) is safe. However, the success rate is unsatisfactory because of the difficulty in catheterization due to the acute angle between the EJV and the subclavian vein (SCV). A novel "shrug technique" to overcome this difficulty was developed, and its efficacy was assessed in a consecutive case series.

METHODS

TIVAD placement was performed via the EJV cut-down approach. "Shrug technique," a simple way to straighten the EJV-SVC angle by shrugging the patient's shoulder, was applied to facilitate the passage of the guidewire and sheath-introducer when there was acute angulation between the EJV and SCV.

RESULTS

A total of 254 patients underwent TIVAD implantation by the EJV cut-down approach. The "shrug technique" was applied in 51 cases (20%), and catheterization was successful in all cases. Thus, TIVAD implantation was successfully completed in all 254 cases (100%) in a single operative setting. The median operating time was 38 [IQR 30-45] min. Eleven complications (4%) were observed, but none of them were EJV-specific.

CONCLUSION

The "shrug technique" is simple but very useful to achieve a higher success rate and safer insertion of TIVADs from the EJV. J. Surg. Oncol. 2017;115:291-295. © 2016 Wiley Periodicals, Inc.

Phase II Trial on Extending the Maintenance Flushing Interval of Implanted Ports

PURPOSE

Retrospective studies suggest that it may be safe to extend the maintenance flushing interval of implanted ports from once every month, as recommended by the manufacturer, to once every 3 months, but no prospective cohort studies have been done specifically assessing the safety and feasibility of this intervention.

METHODS

This was a phase II study in oncologic patients who retained a functional port after completion of systemic chemotherapy. Patients enrolled in the study had their port flushed once every 3 months and were observed until completion of five scheduled flushes (one on enrollment and four additional flushes, one every 3 months) or development of any port-related complication, including infections, thrombosis, and occlusions. The primary end points were frequency of port-related complications and port failure requiring removal.

RESULTS

A total of 87 patients were enrolled in the study. The median follow-up time was 308 days, accounting for a total of 24,202 catheter-days. There were 10 port-related complications (11.49%; 95% CI, 4.85% to 18.14%). No infection or symptomatic thrombosis occurred. The mean time to port-related complication was 184 days. No patients developed port failure while on protocol, but on subsequent medical record review, four patients developed a complication that required port removal or port revision within 30 days of being removed from the trial (4.6%; 95% CI, 0.4% to 8.8%; 0.17/1,000 catheter-days).

CONCLUSION

Extending the maintenance flushes of implanted ports in adult oncologic patients to once every 3 months is safe, effective, and likely to increase patient adherence and satisfaction while decreasing the associated cost.

Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices: a meta-analysis of comparative studies

Background

A totally implantable venous access device (TIVAD) provides reliable, long-term vascular access and improves patients’ quality of life. The wide use of TIVADs is associated with important complications. A meta-analysis was undertaken to compare the internal jugular vein (IJV) with the subclavian vein (SCV) as the percutaneous access site for TIVAD to determine whether IJV has any advantages.

Methods

All randomized controlled trials (RCTs) and cohort studies assessing the two access sites, IJV and SCV, were retrieved from PubMed, Web of Science, Embase, and OVID EMB Reviews from their inception to December 2015. Random-effects models were used in all analyses. The endpoints evaluated included TIVAD-related infections, catheter-related thrombotic complications, and major mechanical complications.

Results

Twelve studies including 3905 patients published between 2008 and 2015, were included. Our meta-analysis showed that incidences of TIVAD-related infections (odds ratio [OR] 0.71, 95 % confidence interval [CI] 0.48–1.04, P = 0.081) and catheter-related thrombotic complications (OR 0.76, 95 % CI 0.38–1.51, P = 0.433) were not significantly different between the two groups. However, compared with SCV, IJV was associated with reduced risks of total major mechanical complications (OR 0.38, 95 % CI 0.24–0.61, P < 0.001). More specifically, catheter dislocation (OR 0.43, 95 % CI 0.22–0.84, P = 0.013) and malfunction (OR 0.42, 95 % CI 0.28–0.62, P < 0.001) were more prevalent in the SCV than in the IJV group; however, the risk of catheter fracture (OR 0.47, 95 % CI 0.21–1.05, P = 0.065) were not significantly different between the two groups. Sensitivity analyses using fixed-effects models showed a decreased risk of catheter fracture in the IJV group.

Conclusion

The IJV seems to be a safer alternative to the SCV with lower risks of total major mechanical complications, catheter dislocation, and malfunction. However, a large-scale and well-designed RCT comparing the complications of each access site is warranted before the IJV site can be unequivocally recommended as a first choice for percutaneous implantation of a TIVAD.

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.

Central Venous Access in the Pediatric Population With Emphasis on Complications and Prevention Strategies

Central venous catheters are often necessary in the pediatric population. Access may be challenging, and each vessel presents its own unique set of risks and complications. Central venous catheterization is useful for hemodynamic monitoring, rapid fluid infusion, and administration of hyperosmolar medications, including vasopressors, antibiotics, chemotherapy, and parenteral nutrition. Recent advances have improved the catheters used as well as techniques for insertion. A serious complication of central access is infection, which is associated with morbidity, mortality, and significant financial costs. Reduction of catheter-related bloodstream infections is realized with use of ethanol locks, single lumens when appropriate, and prudent adherence to insertion and maintenance bundles. Ultrasound guidance used for central venous catheter placement improves accuracy of placement, reducing time and unsuccessful insertion and complication rates. Patients with central venous catheters are best served by multidisciplinary team involvement.

Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction

Despite the level of skill of the operator and the use of ultrasound guidance, central venous catheter (CVC) placement can result in CVC malpositioning, an unintended placement of the catheter tip in an inadequate vessel. CVC malpositioning is not a complication of central line insertion; however, undiagnosed CVC malpositioning can be associated with significant morbidity and mortality. The objectives of this review were to describe factors associated with intravascular malpositioning of CVCs inserted via the neck and chest and to offer ways of preventing, identifying, and correcting such malpositioning. A literature search of PubMed, Cochrane Library, and MD Consult was performed in June 2014. By searching for “Central line malposition” and then for “Central venous catheters intravascular malposition,” we found 178 articles written in English. Of those, we found that 39 were relevant to our objectives and included them in our review. According to those articles, intravascular CVC malpositioning is associated with the presence of congenital and acquired anatomical variants, catheter insertion in left thoracic venous system, inappropriate bevel orientation upon needle insertion, and patient’s body habitus variants. Although plain chest radiography is the standard imaging modality for confirming catheter tip location, signs and symptoms of CVC malpositioning even in presence of normal or inconclusive conventional radiography findings should prompt the use of additional diagnostic methods to confirm or rule out CVC malpositioning. With very few exceptions, the recommendation in cases of intravascular CVC malpositioning is to remove and relocate the catheter. Knowing the mechanisms of CVC malpositioning and how to prevent, identify, and correct CVC malpositioning could decrease harm to patients with this condition.

The Treatment Results of a Standard Algorithm for Choosing the Best Entry Vessel for Intravenous Port Implantation

Vascular cutdown and echo guide puncture methods have its own limitations under certain conditions. There was no available algorithm for choosing entry vessel. A standard algorithm was introduced to help choose the entry vessel location according to our clinical experience and review of the literature. The goal of this study is to analyze the treatment results of the standard algorithm used to choose the entry vessel for intravenous port implantation.During the period between March 2012 and March 2013, 507 patients who received intravenous port implantation due to advanced chemotherapy were included into this study. Choice of entry vessel was according to standard algorithm. All clinical characteristic factors were collected and complication rate and incidence were further analyzed.Compared with our clinical experience in 2006, procedure-related complication rate declined from 1.09% to 0.4%, whereas the late complication rate decreased from 19.97% to 3.55%. No more pneumothorax, hematoma, catheter kinking, fractures, and pocket erosion were identified after using the standard algorithm. In alive oncology patients, 98% implanted port could serve a functional vascular access to fit therapeutic needs.This standard algorithm for choosing the best entry vessel is a simple guideline that is easy to follow. The algorithm has excellent efficiency and can minimize complication rates and incidence.

Review of the radiation exposure during screening of surgically implanted central venous access devices

PURPOSE

Ionizing radiation is used for the insertion of surgically implanted venous access devices (SIVADs) with children at the highest risk of cumulative radiation effects from these procedures. This study examines the radiation dose in a pediatric population during intraoperative radiological screening.

METHODS

A retrospective study looked at all pediatric patients in a tertiary hospital between January 2008 and January 2014 who had a surgically implanted venous access device inserted using intraoperative fluoroscopy. Patient demographics, reason for SIVAD insertion, the type and method of insertion, fluoroscopy time and radiation dose area product were determined.

RESULTS

A total of 505 patients had 682 SIVADs inserted, with 123 patients receiving multiple SIVAD over the six year period. There were two types of SIVAD inserted, 492 were totally implanted venous access devices (TIVAD) and 190 were tunneled central venous catheters (cuffed central line). Five hundred seven of the SIVAD inserted recorded the dose area product and fluoroscopy time. The median time for screening was 5seconds (range 1 to 275seconds) and the median dose area product was 0.00352mGym(2) (range 0.000001mGym(2) to 0.28mGym(2)). Of the 507 SIVAD that recorded the radiation data, 479 were open surgical cut-down insertion and 27 were percutaneous insertion. Percutaneously inserted surgically implanted venous access devices (mean 0.0060mGym(2)) had a longer dose area product than open insertion (mean 0.0034mGym(2); p=0.05).

CONCLUSION

Screening of SIVAD involves low levels of radiation exposure and is comparable to a chest x-ray or a transatlantic flight. The excess lifetime cancer risk to patients is estimated to be very low and is considered to be outweighed by the benefits of insertion. Open surgical cut-down insertion has a significantly reduced radiation exposure compared to percutaneous techniques. Although radiation dose is higher with percutaneous procedures, the clinical effects are considered minimal, and the resultant radiation risk is estimated to be very low. Radiation dose should not determine technique of insertion of SIVAD.