Computed tomography (CT) venography using a multidetector CT prior to the percutaneous external jugular vein approach for an implantable venous-access port

ACR Appropriateness Criteria® Central Venous Access Device and Site Selection

The use of central venous access devices is ubiquitous in both inpatient and outpatient settings, whether for critical care, oncology, hemodialysis, parenteral nutrition, or diagnostic purposes. Radiology has a well-established role in the placement of these devices due to demonstrated benefits of radiologic placement in multiple clinical settings. A wide variety of devices are available for central venous access and optimal device selection is a common clinical challenge. Central venous access devices may be nontunneled, tunneled, or implantable. They may be centrally or peripherally inserted by way of veins in the neck, extremities, or elsewhere. Each device and access site presents specific risks that should be considered in each clinical scenario to minimize the risk of harm. The risk of infection and mechanical injury should be minimized in all patients. In hemodialysis patients, preservation of future access is an additional important consideration. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

External Jugular Cutdown Technique for Totally Implantable Venous Access Devices: a Single-Centre Study

Chemotherapy drugs are the integral part of cancer treatment. Their administration is optimized by central venous access devices. We present our prospective study of chemoport implantation by external jugular vein cutdown technique. We studied 100 patients who underwent chemoport insertion over a span of 3 years for various solid and haematological malignancies via external jugular vein cutdown method. Outcomes such as type of disease, anaesthesia, choice of venous access, catheter tip position, length of the procedure, time to start chemotherapy and morbidity data were analysed. The Hundred /100 intravenous devices were implanted in 66% females and 33% males. Most common indication was breast cancer (64% of patients). A total of 80% of patients underwent procedure under local anaesthesia. Chemoports were inserted on the right side in 84 and left side in the remaining 16. The average surgical time was 32 min. The overall success rate was 97% with no intraoperative complications. Three postoperative complications were encountered due to displacement of catheter or wound infection. External jugular vein cutdown approach is a safe, reliable method for venous access device implantation. This approach has a high success rate and has minimal complications and can be easily learnt.

Ultrasound-guided central venous tip confirmation via right external jugular vein using a right supraclavicular fossa view

Introduction:

Ultrasound-guided central venous catheter tip confirmation has a potential to precisely locate the central venous catheter, preventing its misplacement, using real-time guidance. This observational study sought to determine the accuracy of central venous catheter tip positioning via the external jugular vein via a supraclavicular fossa view under ultrasound guidance.

Methods:

In total, 77 patients scheduled for central venous catheter insertion via the right external jugular vein were enrolled. The depth of central venous catheter insertion was determined by advancing the tip of the guidewire to the junction of the superior vena cava and right pulmonary artery, using a right supraclavicular fossa view ultrasound method. We determined the reference insertion depth to the carina using a postoperative chest x-ray photograph method. We then compared insertion depths obtained by the ultrasound and x-ray photograph methods and body-height formula.

Results:

In total, 62 patients were able to advance the guidewire and underwent ultrasound-guided central venous catheter insertion. In four patients, we corrected for misplaced guidewires. According to Bland–Altman plots, the insertion depth was 0.88 cm shorter for the ultrasound method (95% limits of agreement, −1.66 to 3.41 cm) and 0.90 cm shorter for the formulaic method (95% limits of agreement, −2.77 to 4.56 cm), compared with the x-ray photograph method. The x-ray photograph method had significantly positive correlations with the ultrasound (r = 0.73) and formulaic methods (r = 0.27).

Conclusion:

A right supraclavicular fossa view improves the accuracy of central venous catheter tip positioning and prevents central venous catheter misplacement via the right external jugular vein.

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.

Totally implantable venous access port via the femoral vein in a femoral port position with CT-venography

BACKGROUND AND PURPOSE

We aimed to determine the success rate and any complications using a percutaneous approach to the femoral vein (FV) for placement of a totally implantable access port (TIVAP), with a preoperative assessment of the femoral and iliac veins using computed tomography-venography (CT-V).

METHODS

A prospective study of 72 patients was conducted where placement of a TIVAP was attempted via the right FV, with the port placed in the anterior thigh, when subclavian vein or jugular vein access was contraindicated. Preoperative assessment of the femoral venous plexus was performed with CT-V in 72 patients.

RESULTS

CT-V success was achieved in 72 of 72 patients (100%). The average distance between the inguinal ligament and the saphenofeomral (FV-GSV) junction was 42.8 ± 12.9 mm. The FV approach had a 97% successful cannulation rate. Two patients had a thrombosis in either the femoral vein or the great saphenous vein. One procedural complication (1.4%) and one initial complication (1.4%) occurred. Late complications occurred in four patients (5.7%).

CONCLUSIONS

The percutaneous FV approach with CT-V guidance is an option for patients with multiple central venous cannulations, as well as those with bilateral breast cancer, or those undergoing hemodialysis. J. Surg. Oncol. 2016;114:1024-1028. © 2016 Wiley Periodicals, Inc.

A prospective evaluation on external jugular vein cut-down approach for TIVAD implantation

Background

Totally implantable venous access devices can be implanted both by percutaneous approaches and by surgical approaches with cephalic vein or external jugular vein cut-down techniques that are related to low intraoperative complication rates. The authors report a prospective evaluation of 83 consecutive external jugular vein cut-down approaches for totally implantable venous access devices implantation.

Methods

Eighty three consecutive patients (28 M, 55 F, mean age 54.2) suffering from solid tumors (58) or hematologic diseases (25) were consecutively submitted to totally implantable venous access devices insertion through external jugular vein cut-down approach (75 on right side, 8 on left side).

Results

All devices were surgically implanted; no instances of intraoperative complications were detected. After a minimum follow-up of 150 days, only one case of wound hematoma and one case of device malfunction due to incorrect catheter angulation were noted.

Postoperative patient satisfaction was evaluated by the use of specific questionnaire that demonstrated a good satisfaction and compliance (92.8 %) of patients with implanted devices.

Conclusions

Despite the lack of controlled studies comparing external jugular vein cut-down approach vs other approaches, this approach should be considered as a tool for long-term central vein catheters positioning, both as an alternative and for primary approach.

External jugular vein approach for TIVAD implantation: first choice or only an alternative? A review of the literature

PURPOSE

Totally implantable venous access devices (TIVADs) can be implanted by percutaneous approach (to the subclavian or internal jugular vein) or by surgical approach, through cephalic vein or external jugular vein (EJV). The authors present a review of the literature about EJV approach for TIVAD implantation.

METHODS

A review of articles indexed in MEDLINE (PubMed) and Cochrane Central Register on "EJV access," "EJV cut-down," and "TIVADs" was performed, even matching the terms.We gathered articles from papers quoting patient number, specialist involved, number of devices implanted, site and technique of implantation and complications.

RESULTS

A total of 1,308 TIVAD implantations through EJV have been reported, with a success rate ranging from 73.7% to 100% and a complication rate up to 13%. Only in 4 on 10 series reported (with more than 15 procedures) the EJV approach was the first choice, while in the other 6 series this approach was the alternative after failure of other approaches.

CONCLUSIONS

Despite the lack of consistent series and prospective studies comparing EJV with other approaches, data present in the literature may support the evidence that EJV approach for TIVAD implantation is safe and effective, and may be considered as the first approach in selected patients.