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

Comparison between arm port and chest port: A systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to compare the efficacy and safety of arm ports (APs) and chest ports (CPs) in clinical practice.

METHODS

Randomized controlled trials (RCTs), controlled clinical trials, and retrospective studies were searched in both English and Chinese databases, encompassing PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Database, and SinoMed up to November 27, 2023. Data analysis was performed using Stata 15.0.

RESULTS

Seventeen studies, including two RCTs, three cohort studies, and twelve case-control studies, were finally included, involving a total of 4168 participants, with 2151 participants in the CP group and 2017 in the AP group. The meta-analysis showed that there was no significant difference between CP and AP in the incidence rates of infections [OR = 0.98, 95% CI (0.68, 1.41)], catheter occlusion[OR = 0.95, 95% CI (0.55, 1.64)], thrombosis [OR = 0.85, 95% CI (0.60, 1.21)], exudation [OR = 1.32, 95% CI (0.52, 3.36)], fibrin sheath [OR = 1.68, 95% CI (0.46, 6.19)], catheter malposition [OR = 0.62, 95% CI (0.30, 1.29)], fracture[OR = 1.84, 95% CI (0.49, 6.96)], pneumothorax [OR = 5.73, 95% CI (0.94, 35.11)], and malfunction [OR = 1.87, 95% CI (0.65, 5.42)].

CONCLUSION

This study reveals no significant differences in the incidence of infections, catheter occlusion, thrombosis, exudation, fibrin sheath, catheter malposition, fracture, pneumothorax, and malfunction between the two implanted venous access ports. Thus, it can be concluded that AP is as safe as CP.

Quality of life in women with breast cancer undergoing neoadjuvant chemotherapy: comparison between PICC and PICC-port

BACKGROUND

Peripherally inserted central catheters (PICCs) and new type of arm-port, the PICC-port, are currently used for neoadjuvant chemotherapy treatment in patients with breast cancer. We aimed to compare Quality of Life (QoL) of patients receiving one of these two devices investigating overall satisfaction, psychological impact, as well as the impact on professional, social and sport activities, and local discomfort.

METHODS

We did a prospective observational before-after study of PICCs versus PICC-ports. Adult (aged ≥ 18 years) females with breast cancer candidate to neoadjuvant chemotherapy were included. The primary outcome was QoL according to the Quality-of-Life Assessment Venous Device Catheters (QLAVD) questionnaire assessed 12 months after device implantation.

RESULTS

Between May 2019 and November 2020, of 278 individuals screened for eligibility, 210 were enrolled. PICC-ports were preferred over PICCs with a QLAVD score of 29 [25; 32] vs 31 [26; 36.5] (p = 0.014). Specifically, most QLAVD constructs related to psychological impact, social aspects, and discomfort were in favor of PICC-ports vs PICC, especially in women under the age of 60. Overall, pain scores at insertion and during therapy administration were not significantly different between the two groups, as well as infection, secondary malpositioning, thrombosis, or obstruction of the device.

CONCLUSIONS

In women with breast cancer undergoing neoadjuvant chemotherapy, PICC-ports were overall better accepted than PICCs in terms of QoL, especially in those who were younger. Device-related complications were similar.

Development and Preliminary Validation of the Chinese Version of the Totally Implantable Venous Access Port Self-Management Behavior Scale (CPTSMBS) for Patients with Cancer

Objective

This study aimed to develop the Chinese version of the totally implantable venous access port (TIVAP) self-management behavior scale for patients with cancer to provide a reliable tool for medical staff to judge patients with TIVAP self-management behavior.

Methods

This study employed a mixed-method exploratory design. The initial scale was developed through a literature review, expert meetings, and two-round Delphi expert consultation. The reliability indicators included retest reliability and Cronbach's alpha coefficients. The validity indicators included content, construct, convergent, discriminant, and criterion validity. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were employed for the validity analysis; 22 venous therapy experts participated in the Delphi expert consultation. A total of 500 patients were recruited from two third-class A hospitals in Guangdong Province, China, between July 2020 and January 2021 to test reliability and validity. A convenience sampling method was adopted.

Results

The final scale comprised seven dimensions and 29 items. The content validity index (S-CVI) was 0.990. Cronbach's alpha coefficient and retest reliability of the scale were 0.931 and 0.900, respectively. The EFA results indicated a seven-factor structure, accounting for 65.68% of the total data variance. The results of the CFA showed that the CMIN/DF value was 2.348; the root mean square error of approximation value was 0.06; and the values of comparative fit index, incremental fit index, and Tucker-Lewis index were all >0.90. The factor loadings for all the items were >0.50, the composite reliability value was >0.70, and the average variance extracted (AVE) value was >0.50. Moreover, all absolute values of the correlation coefficients were less than the square root of the AVE for the seven dimensions. The total scores between the health promoting lifestyle profile-II revise (HPLP-IIR) and CPTSMBS were positively correlated (r = 0.465, p < 0.01).

Conclusion

The scale demonstrated good reliability and validity and can be applied in clinical practice to evaluate self-management behavior among patients using a TIVAP.

Vascular access device type for systemic anti-cancer therapies in cancer patients: A scoping review

BACKGROUND

Patients with cancer can expect to receive numerous invasive vascular access procedures for intravenous therapy and clinical diagnostics. Due to the increased incidence and prevalence of cancer globally there will be significantly more people who require first-line intravenous chemotherapy over the next ten years.

METHODS

Our objective was to determine the types of evidence that exist for the vascular access device (VAD) type for the delivery of systemic anti-cancer therapy (SACT) in cancer patients. We used JBI scoping review methodology to identify the types of VADs used for SACT and with a specific search strategy included articles from 2012-2022 published in the English language. We identify (i) type of VADs used for SACT delivery (ii) the type of insertion and post-insertion complications (iii) the geographical location and clinical environment (iv) and whether VAD choice impacts on quality of life (QOL). Findings were presented using the PAGER framework.

MAIN FINDINGS

Our search strategy identified 10,390 titles, of these, 5318 duplicates were removed. The remaining 5072 sources were screened for eligibility, 240 articles met the inclusion criteria. The most common design include retrospective study designs (n = 91) followed by prospective study designs (n = 31). We found 28 interventional studies with 21 registered in a clinical trial registry and identified no core outcome sets papers specific to VAD for SACT. The most prevalent publications were those that featured two or more VAD types (n = 70), followed by tunnelled intravenous VADs (n = 67). Of 38 unique complications identified, the most frequent catheter related complication was catheter related thrombosis (n = 178, 74%), followed by infection (n = 170, 71%). The county where the most publications originated from was China (n = 62) with one randomized controlled multicenter study from a comprehensive cancer centre. Of the thirty three studies that included QOL we found 4 which reported on body image. No QOL measurement tools specific to the process of SACT administration via VAD are available INTERPRETATION: Our findings suggest a systematic review and meta-analysis of VAD use for intravenous SACT can be considered. However, the development of a core outcome set for SACT should be prioritised. Funding for high quality programs of research for VAD in cancer are needed. Comprehensive cancer centres should lead this research agenda.

A novel incision technique of a totally implanted venous access port in the upper arm for patients with breast cancer

BACKGROUND

A totally implanted venous access port (TIVAP) in the upper arm is a safe and cost-effective vascular access device and is widely used in breast cancer patients. Traditional tunnelling technique increases the operation time and has an unsatisfied cosmetic effect, so we explored the feasibility, cosmetic effect and complications of an upper arm port with a novel incision in this retrospective study.

METHODS

We reviewed 489 cases of totally implantable venous access port implantation in the upper arm with two types of incisions in our centre from 1 January 2018 to 30 January 2022. The patients were divided into two different incision groups including the puncture site incision group (n = 282) and the conventional tunnelling group (n = 207). The comparison of the results was collected between the two groups, and contributing factors were analyzed for major complications.

RESULTS

A total of 489 patients were successfully implanted with arm ports using the puncture site incision technique (n = 282, 57.7%) and conventional tunnelling technique (n = 207, 42.3%). The average operation time of the two types of incisions was 36.5 ± 15 min in the puncture site incision group and 55 ± 18.1 min in the tunnel needle group (P < 0.05). In terms of complications, 33 catheter-related complications occurred (6.4%), including 9 cases of infection, 15 cases of catheter-related thrombosis and 7 cases of skin exposure. Fourteen patients in the puncture site incision group developed complications compared with 17 in the traditional incision group. There were no significant differences between the two groups in terms of overall complication events (5.0% and 8.2%, P = 0.145) while the same result was found in each complication event. Weight, total cholesterol and diabetes were found to be associated with device-related infections in the univariate Cox proportional hazard regression models. Diabetes was found to be associated with device-related infections in multivariate analysis while hypertension was associated with thrombosis.

CONCLUSIONS

The puncture site incision method is a novel technique with a better cosmetic appearance and less operation time than the traditional tunnelling technique, providing a comparable overall rate of complications. It offers a preferable choice for clinicians when dealing with different situations of patients. It is worthy of being used and promoted for patients requiring the totally implanted venous access port in the upper arm.

Chinese Society of Breast Surgery (CSBrS) Practice Guideline 2022

Background

The Chinese Society of Breast Surgery (CSBrS) Practice Guideline 2021 was published nearly one year ago. The new guideline was revised based on comprehensive feedback of the previous publication. The aim is to provide a better reference suitable for Chinese breast surgeons.

Methods

Referred to GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, evidences accepted by the Guideline were classified into four categories: I, II, III and IV, which reflected the reliability of the evidences quantitatively. The guideline also comprehensively considered the accessibility of the guideline in clinical practice in China and gave recommendations with different strengths.

Results

The guideline emphasized the basic idea that a curative surgical approach falls under the category of radical tumor surgery. Six chapters, including "Diagnosis and treatment of patients with invasive breast cancer", "Sentinel lymph node biopsy in patients with early-stage breast cancer", "Breast-conserving surgery in patients with early-stage breast cancer", "Modified radical mastectomy of breast cancer", "Central venous access for the systemic treatment of breast cancer", and "Breast cancer in pregnancy and postpartum breast cancer" were revised.

Conclusions

Compared with the 2021 edition, the new guideline has been revised in six chapters based on the latest research evidence and clinical needs.

Usefulness of peripherally inserted central catheter port system (PICC-PORT) implantation in the sitting position: a new technique for cases unsuitable for conventional implantation

PURPOSE

Totally implantable central venous access port implantation is typically performed in the supine position. However, some patients cannot adopt the supine position due to severe pain and/or dyspnea. The present study evaluated the technical feasibility of peripherally inserted central catheter port system (PICC-PORT) implantation in the sitting position in such cases.

MATERIALS AND METHODS

In the sitting position method, PICC-PORT implantation was performed with the patients seated on a videofluoroscopy chair positioned between the limbs of an angiographic C-arm and the operative upper arm positioned on an arm stand. From January 2019 to September 2021, eight patients underwent PICC-PORT implantations using this sitting method. We also evaluated 251 consecutive patients with conventional supine position PICC-PORT implantation as controls. Differences in technical success, procedure time and complications were retrospectively assessed between the two groups.

RESULTS

Procedural success rates were 100% in both groups. Median procedure times in the sitting and conventional groups were 42 and 44 min, respectively. No complications were observed in the sitting group. There were no significant differences between the two groups in procedure time (p = 0.674) and complications (p = 1.000).

CONCLUSION

Implantation of PICC-PORT in the sitting position is technically feasible and useful.

Infectious complications of radiologically placed upper arm ports: A single center analysis

OBJECTIVES

Infections are common complications in venous access ports. The presented analysis aimed to investigate the incidence, microbiological spectrum, and acquired resistances of pathogens in upper arm port associated infections to provide a decision aid in the choice of therapy.

MATERIALS AND METHODS

In total, 2667 implantations and 608 explantations were performed at a high-volume tertiary medical center between 2015 and 2019. In cases with infectious complications (n = 131, 4.9%), procedural conditions and results of microbiological testing were reviewed retrospectively.

RESULTS

Of 131 port associated infections (median dwell time 103 days, interquartile range 41-260), 49 (37.4%) were port pocket infections (PPI) and 82 (62.6%) were catheter infections (CI). Infectious complications occurred more often after implantation in inpatients compared to outpatients (P < 0.01). PPI were mainly caused by Staphylococcus aureus (S. aureus, 48.3%) and coagulase-negative staphylococci (CoNS, 31.0%). Other gram-positive and gram-negative species were encountered in 13.8% and 6.9%, respectively. CI were caused less frequently by S. aureus (8.6%) than CoNS (39.7%). Other gram-positive and gram-negative strains were isolated in 8.6% and 31.0%, respectively. Candida species were seen in 12.1% of CI. An acquired antibiotic resistance was detected in 36.0% of all significant isolates, occurring especially in CoNS (68.3%) and gram-negative species (24.0%).

CONCLUSIONS

Staphylococci comprised the largest group of pathogens in upper arm port associated infections. However, gram-negative strains and Candida species should also be considered as a cause of infection in CI. Due to the frequent detection of potential biofilm-forming pathogens, port explantation is an important therapeutic measure, especially in severely ill patients. Acquired resistances must be anticipated when choosing an empiric antibiotic treatment.

Effectiveness of a flow confirmation study of a central venous port of the upper arm versus the chest wall in patients with suspected system-related mechanical complications

Background

If mechanical complications associated with a central venous port (CVP) system are suspected, evaluation with a flow confirmation study (FCS) using fluorescence fluoroscopy or digital subtraction angiography should be performed. Evaluations of mechanical complications related to CVP of the chest wall using FCS performed via the subclavian vein have been reported. However, the delayed complications of a CVP placed in the upper arm have not been sufficiently evaluated in a large population. We evaluated the effectiveness of FCS of CVPs implanted following percutaneous cannulation of the subclavian (chest wall group) or brachial (upper arm group) vein.

Methods

A CVP was implanted in patients with advanced cancer requiring chemotherapy. FCS was performed if there were complaints suggestive of CVP dysfunction when initiating chemotherapy.

Results

CVPs were placed in the brachial vein in 390 patients and in the subclavian vein in 800 patients. FCS was performed in 26/390 (6.7%) patients in the upper arm group and 40/800 (5.0%) patients in the chest wall group. The clinical characteristics of the patients were similar in both groups. The duration of CVP implantation until FCS was significantly shorter in the upper arm group (136 ± 96.6 vs. 284 ± 260, p = 0.022). After FCS, the incidence of CVP removal/reimplantation being deemed unnecessary was higher in the upper arm group (21/26 [80.8%] vs. 26/40 [65.0%], p = 0.27). In the upper arm group, no cases of catheter kinking or catheter-related injury were observed, and the incidence of temporary obstruction because of blood clots that could be continued using CVP was significantly higher than that in the chest wall group (10/26 [38.5%] vs. 4/40 [10.0%], p = 0.012).

Conclusions

FCS was effective in evaluating CVP system-related mechanical complications and deciding whether removal and reimplantation were required in both groups.

Complications Associated With Totally Implanted Venous Access Devices in the Arm Versus the Chest: A Short-Term Retrospective Study

PURPOSE

To retrospectively compare complications for totally implanted venous access devices (TIVADs or ports) in the arm vs. the chest. One participating institution implanted all TIVADs in the arm, whereas the other institution implanted them in the chest.

METHODS

Subjects were consecutive patients > 18 years with a device inserted between July 2017 and January 2019 at either Hospital A, where all devices were implanted in the arm, or at Hospital B, where all devices were implanted in the chest. Complications (rates/1,000 catheter-days and frequencies) were compared between the arm and chest locations.

RESULTS

201 arm devices (71% female, mean age 59.4 years) and 203 chest devices (66% female, mean age 61.5 years) were assessed. Overall complication rates did not differ between the arm and chest [arm: 30 complications per 56,938 catheter-days (0.530/1,000 catheter-days) vs. chest: 47 complications per 63,324 catheter-days (0.742/1,000 catheter-days), p-value 0.173]. Periprocedural complications and mechanical malfunction also did not differ. Although prophylactic antibiotic use was higher in the chest (79.3% vs. 1.50%, p-value < 0.0001), infection rates did not differ. Arm venous thrombosis was significantly higher in the arm cohort (0.205 vs. 0.017/1,000 catheter-days, p-value 0.003) and pulmonary thromboembolism in the chest cohort (0.269 vs 0.056/1,000 catheter-days, p-value 0.002).

CONCLUSIONS

While arm venous thrombosis was higher in the arm and pulmonary thromboembolism in the chest cohort, other complications were similar. Antibiotic use was more frequent in the chest cohort, while infection rates remained similar in both cohorts.

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.

PICC-PORT: Valid indication to placement in patient with results of extensive skin burns of the neck and chest in oncology. The first case in the scientific literature

INTRODUCTION

The management of patients with advanced gastric cancer requires a stable venous access required at different stages of disease (treatment phase, palliative phase). Totally implantable central venous access in the arm, named PICC-PORT, is used in a patient with results of extensive skin burns of the neck, chest and right arm and surgical outcomes of multiple skin grafts of chest. The described clinical case is the first event in the scientific literature.

PRESENTATION OF CASE

We report a case of a patient with results of extensive skin burns of the neck, chest and right arm and surgical outcomes of multiple skin grafts of chest that must perform chemotherapy with a port. In this patient, due to the difficulty of implanting a door in the cervico-thoracic district, we opt for the totally subcutaneous implantation of the vascular device (PICC-PORT 5 Fr) in the left arm.

DISCUSSION

In this patient for the difficulty of implanting a port in the cervico-thoracic district, we opt for the totally subcutaneous implantation of the vascular device (PICC-PORT) in the arm. The PICC-PORT is positioned with the same technique as the PICC (ultrasound-guided vein puncture, with modified Seldinger technique and tip location with ECG technique); presents all the functional and aesthetic advantages of a totally subcutaneous device.The case described is the first case in the scientific literature.

CONCLUSION

In Europe in recent years for the availability of the vascular device of small dimensions and materials increasingly compatible, the "PICC-PORT" is positioned in the veins of the arm with ultrasound-guidance without complications such as pneumothorax, arterial puncture, hematoma of the neck, Pinch-off syndrome, such as the clinical case presented with extensive scars on the chest and neck. Thoracic devices (chest port, tunnel venous catheter) are not indicated in thickened and inelastic skins, due to the high risk of dehiscence of the surgical wound.

Outcome analysis in 270 radiologically guided implantations of totally implantable venous access ports via basilic vein

BACKGROUND

Totally implantable venous access ports (TIVAPs) are widely applied in patients who require chemotherapy, parenteral nutrition, or frequent intravenous drug infusion. Although various venous access routes are possible for TIVAP insertion, the best method remains a topic of controversy. We present a single-center retrospective study of radiologically guided placement of TIVAPs through the basilic vein, with analysis of technical feasibility, patient safety, and device-related complications.

METHODS

We retrospectively reviewed 270 patients who received TIVAP implantation through the basilic vein from November 2013 to July 2016, under imaging guidance by an interventional radiology team at our institution. Fluoroscopic images, chest radiographs, computed tomography scans, and medical records were reviewed after port implantation. Catheter maintenance days were calculated and catheter-related complications were recorded.

RESULTS

The procedural success rate was 99.3%. In total, 270 TIVAPs were implanted in 270 patients, of which 150 remained functional at the end of the study period. The total catheter maintenance days was 77 543 days, and the mean catheter indwelling duration was 287 ± 207 days. In 20 (7.4%) patients, TIVAP-related complications occurred during the follow-up period, resulting in a postprocedural complication rate of 0.26 incidences per 1000 catheter days. No significant relationship was observed between complications and gender (p = 0.188), age (p = 0.528), body mass index (p = 0.547), the type of primary malignancy (p = 0.914), or between the left and right basilic veins (p = 0.319).

CONCLUSION

Real-time ultrasound and fluoroscopic guidance provides a safe method for TIVAP implantation through the basilic vein, with a high technical success rate and few device-related complications.

Incidence of and risk factors for totally implantable vascular access device complications in patients with gastric cancer: A retrospective analysis

Totally implantable vascular access devices (TIVADs) are often used to administer chemotherapy by prolonged intravenous infusion. The objective of the present study was to investigate the incidence of long-term complications and identify risk factors associated with TIVAD placement in patients with gastric cancer. A total of 121 patients with gastric cancer who had undergone 150 TIVAD placement procedures for chemotherapy or supportive care were enrolled in the present retrospective cohort study. A number of risk factors were analyzed, including age, sex, hypertension, diabetes mellitus, history of thrombosis, body mass index, disease stage, and site and purpose of TIVAD. In total, 40 TIVADs (26.7%) developed long-term complications, of which 27 (18.0%) were infections, seven (4.7%) were catheter-related deep vein thrombosis (CR-DVT), and six (4.0%) were obstructions. Chemotherapy was associated with an increased rate of infectious adverse events (odds ratio 2.925; 95% CI, 1.104-7.750; P=0.031) according to the multivariate analysis. CR-DVT occurred more frequently in upper arm ports than in chest wall ports; however, this difference was not statistically significant (7.5 vs. 0.0%; P=0.084) according to the univariable analysis. All CR-DVTs developed in the upper arm sites. Chemotherapy and the upper arm site were associated with long-term complications in patients with TIVAD. However, further studies are needed to confirm the findings of the present study and to determine the reasons for the high incidence of long-term complications in these patients.

Arm port vs chest port: a systematic review and meta-analysis

Background

Two prevailing, totally implantable venous access ports are routinely utilized in oncology: chest port or arm port. This systematic review with meta-analysis was conducted to compare safety and efficiency of the two techniques.

Methods

We performed evidence acquisition intensively from PubMed, Embase, and Cochrane Library. Available comparative studies that evaluated both techniques were identified. The outcomes of interest included total complication events, procedure-related infections, thrombosis, intra-operative complications, mechanical complications, conversion rate, early port removal, and operating time.

Results

Thirteen comparative studies including 3,896 patients (2,176 for chest ports, and 1,720 for arm ports) were identified. The present study showed that arm port was associated with higher procedure conversion rate (2.51% in chest port group and 8.32% in arm port group; odd ratios [OR] 0.27, 95% confidence interval [CI] 0.15-0.46; p<0.001), but lower incidence of intra-operative complications (1.38% in chest port group and 0.41% in arm port group; OR 2.38, 95% CI 1.07-5.29; p=0.03). There were no between-group differences with respect to total complication events, procedure-related infections, thrombosis, mechanical complications, early port removal, and operating time. Subgroup analysis of patients under 60 years revealed that no significant difference was detected in intra-operative events (1.19% in chest port group and 0.02% in arm port group, OR 2.59, 95% CI 0.74-9.08; p<0.14), indicating that age may be a risk factor for intra-operative events. Sensitivity analysis did not change conclusions of all endpoints of interest.

Conclusion

Arm port is associated with higher procedure conversion rate, but lower incidence of intra-operative complications, and age may be a risk factor for intra-operative events.

The case for using implanted ports

Uses of central venous access devices (CVADs) include the administration of vital fluids and medications. Implanted ports are a type of CVAD that is used when long-term vascular access is required. The device is discreet and associated with a low risk of catheter-related bloodstream infection. This article describes the different types and components of ports and how to select them. It explains how to insert ports, and provides guidance on accessing and de-accessing them

Peripherally inserted central catheter ports: A vascular access specialist's systematic approach

Implanted ports are an important vascular access device for patients with malignancies requiring long-term chemotherapy. Peripherally placed ports are increasing in use as they are a safe, cost-effective alternative to chest-placed ports. Most peripheral ports can be placed bedside by specialist nurses in designated clinical areas rather than costly operating rooms or interventional radiology suites. Peripheral ports are considered less invasive compared with chest port placement because of reduced procedural risk. To enhance the success rate of peripheral port placement and minimize risks, we provide vascular access specialists with a systematic approach along with some technical advice tips and tricks to help avoid mechanical complications such as repeated puncture of the vein, excessive bleeding, thrombosis or skin dehiscence, as well as latent complications such as catheter migration and catheter-related blood stream infection.

A Comparison of 2 Venous Puncture Sites for Peripheral Implanted Ports

The use of peripheral implanted ports to administer parenteral nutrition in a number of patient cohorts is increasingly seen as a safe alternative to chest ports with equivalence in long-term outcomes. Two insertion sites on the upper arm were compared using the zone insertion method (ZIM), which was developed as an approach to optimize and reduce catheter-related exit site complications. The ZIM divides the medial upper arm into 3 main colors, red, green, and yellow, which are based on musculoskeletal, skin, and vessel characteristics. The optimal exit site is considered to be the green zone, the middle third of the upper arm. Thirty-five patients were allocated to vein puncture at the yellow/green zone (group A) and 35 patients at the yellow zone near the axilla (group B). All devices were implanted in the distal green zone. Successful peripheral port implantation was 91.4% (n = 35) for group A and 100.0% (n = 35) for group B (P = .07). No procedural or postprocedural complications were observed.

Trapezius Port Placement in Patients with Breast Cancer: Long-Term Follow-up and Quality-of-Life Assessment

PURPOSE

To evaluate the long-term results of and patient satisfaction with trapezius ports in breast cancer patients, as an alternative to chest ports.

PATIENTS AND METHODS

This retrospective study included all patients who underwent trapezius port placement from December 2007 to January 2017. Seventy female patients with breast cancer, with a mean age of 54 ± 9.9 years (range, 29-76 years), were included. Indications for trapezius implantation were bilateral breast surgery or unilateral breast surgery and contralateral breast involvement. Sixty-eight of 70 patients had long-term follow-up. A retrospective, questionnaire-based survey was conducted to assess satisfaction and the trapezius port's effect on the daily life of the patient.

RESULTS

All implantations were technically successful. Total catheter service time for 68 patients was 65,952 days (2 patients were lost to follow-up). Mean catheter service time was 969.8 days (range 7-3,458 days; median 570 days; 95% confidence interval, 739-1199; standard deviation, 947.7). No immediate procedural complications occurred. Port complications developed in 4 patients (5.9%); port infection developed in 2 patients (0.03/1,000 days); skin dehiscence developed in 1 patient (0.02/1,000 days); and port malfunction developed in 1 patient (0.02/1,000 days). The overall infection rate was 2.9% (2/68). All patients (n = 44) or a close relative (n = 17) who were interviewed with a phone call reported satisfaction regarding their ports.

CONCLUSIONS

Trapezius ports offer a safe and feasible option to patients with breast cancer who need an alternative site to chest ports. It is also associated with high overall patient satisfaction.

Comparison of complications between peripheral arm ports and central chest ports: A meta-analysis

AIM

The aim of this study was to compare peripheral arm ports versus central chest ports in complication rates.

BACKGROUND

Late complications of arm ports versus chest ports, including catheter-related infection, venous thrombosis and catheter obstruction, remain controversial.

DESIGN

A meta-analysis conducted following the Cochrane handbook.

DATA SOURCES

Studies published between 1950-August 2017 were searched through Pubmed, Embase, Web of science and Cochrane library.

REVIEW METHODS

Two authors independently searched the eligible studies and extracted the data. Studies reporting complications of arm ports compared with chest ports, published in full texts and abstracts, were included. The quality of the studies was assessed with the Newcastle-Ottawa Scale. We did subgroup analyses according to cancer type, age, follow-up and anticoagulant. Relative ratios were calculated with different models.

RESULTS

A total of 15 articles covering 3,524 tumour patients met the eligibility criteria. There was no difference in catheter-related infection and catheter obstruction between arm ports and chest ports. After reducing the high heterogeneity, no difference was observed in thrombosis overall; however, arm ports had a lower thrombosis rate than chest ports in patients with head and neck cancer, while a higher thrombosis rate was observed in patients <60 years old or follow up ≥1 year. Further studies are needed in venous thrombosis.

CONCLUSIONS

Arm ports are a safe option beside chest ports for adult patients with malignancy, especially in patients with head-neck cancer or breast cancer. Patients should be well informed of the advantages and disadvantages of different vascular access devices and provided a choice.

Impact of port site scar on perception of patients with breast cancer: patient-reported outcomes

PURPOSE

As the number of survivors continues to increase with improvements in breast cancer treatment, greater emphasis has been placed on the aesthetic outcome following breast surgery. Effort is made to minimize scarring on the breast, yet patients who require a port for treatment inevitably have a scar on the upper chest from the port itself. We hypothesized that patients with breast cancer are conscious of their port scars, and if given a choice would prefer placement of the port in the arm rather than the chest.

METHODS

Female breast cancer patients treated at our Breast Center who had a port placed from 2009 to 2015 were asked to complete a 20-question, anonymous survey via SurveyMonkey® reporting demographics and treatment information, and a validated Patient Scar Assessment Questionnaire (PSAQ).

RESULTS

Of 139 identified, 105 had email information available for contact, and 67 (64%) patients responded. Of the 67, 37 (55%) had undergone arm placement and 30 (45%), chest. Sixty (92%) patients report noticing their scars; 44 (69%) believed that their scar was noticeable to others; and 22 of the 44 (50%) made an effort to hide their scar. Thirty-seven patients were offered options for port site placement, and 24 (65%) chose placement in the arm (p = 0.057).

CONCLUSION

Most patients are conscious of their port scars and if offered the choice choose placement in the arm rather than the chest. Upper extremity port placement should be further explored as an alternative approach for patients with breast cancer to improve port scar consciousness.

Health-Related Quality of Life of Cancer Patients with Peripherally Inserted Central Catheter: A Pilot Study

Introduction

This pilot exploratory study aimed to compare the health-related quality of life (HRQOL) among patients diagnosed with different types of cancer receiving peripherally inserted central catheters (PICCs).

Methods

A multicenter cross-section study of cancer patients with PICCs was performed from February 1, 2013 to April 24, 2014. The primary objective of this study was to compare HRQOL in different cancer type patients with PICC. HRQOL was examined based on European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core 30 (EORTC QLQ-C30). Multiple linear regression models were conducted for coping with potential confounding variables. We also examined PICC-related quality of daily life with a self-made questionnaire.

Results

Three hundred and fifty-seven cancer patients with PICC completed the survey in nine teaching hospitals. Lung cancer patients with PICC reported the worst dyspnea. Digestive tract cancer patients reported the worst appetite loss. Patients with hematologic malignancy reported the worst emotional, social function, fatigue and financial impact. Breast cancer patients reported better HRQOL. Baseline variables were proven not significant predictors of EORTC QLQ-C30 global health status. In self-made survey, pain after PICC insertion was null or a little in 98.6% of cancer patients. Limitation of upper extremity activity was null or a little in 94.1% of patients.

Conclusions

HRQOL varies in different types of cancer patients with PICC. PICC may have a low impact on cancer patients’ HRQOL. Further large sample studies are needed.

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.