Common and uncommon complications of totally implantable central venous ports: a pictorial essay

Malposition of subcutaneous central venous port system in a toddler with acute lymphoblastic leukemia: A case report

INTRODUCTION

Central venous port systems are essential for reliable and long-term venous access in children, mainly for cancer therapy, parenteral nutrition, administration of medications, blood transfusion, etc. However, complications either periprocedural, early, or delayed can be expected and may affect the venous port function, with occasional revision and even port removal.

CASE PRESENTATION

A central venous port device was implanted in a 2.5-year-old boy for chemotherapy administration in the treatment of acute lymphoblastic leukemia. After a month he presented again to our clinic due to a venous port device dysfunction, and inability to aspirate blood or infuse medications. A reoperation was done that revealed a port chamber in-place rotation. The chamber was repositioned in the pouch and suture-fixated. No port-related problems occurred in the follow-up period.

CLINICAL DISCUSSION AND CONCLUSION

Central venous port chamber rotation is among the rarest complications, which usually makes the port unusable. It should be quickly recognized, to avoid further damage, such as extravasation of the chemotherapeutic agent or mechanical chamber impairment. A reoperation is almost always needed with subsequent placement of the port in the correct position. This paper also emphasizes the key concepts of complication in implantable venous ports in children.

Complications of Totally Implantable Central Venous Catheters (Ports) Inserted via the Internal Jugular Vein Under Ultrasound and Fluoroscopy Guidance in Adult Oncology Patients: A Single-Center Experience

Introduction

In this retrospective study, the safety and complication rates of port implantations via the internal jugular vein under ultrasound and fluoroscopy guidance in adult oncology patients were analyzed.

Material and methods

Eight hundred seven ports implanted in 799 adult oncology patients at a tertiary Oncology-Anticancer Hospital during a 36-month period from January 1, 2017 to December 31, 2019 were retrospectively reviewed. Data acquisition was obtained until December 31, 2020. All procedures were performed by two specialized interventional radiologists under ultrasound and fluoroscopy guidance. The vein access was via the internal jugular vein. Catheter days (the total number of days of maintenance of the port by all of the patients until removal, death, or December 31, 2020), technical success rates, and complication rates were evaluated based on the interventional radiological reports and patient medical records. Multivariate analysis regarding patients such as age, sex, body mass index (BMI), marital status, educational level, cancer type, side of insertion, diameter of internal jugular vein, diabetes, anticoagulants/antiplatelets, purpose of implantation, and catheter material as to the risk of complications was conducted.

Results

A total of 369,329 catheter maintenance days were observed (457.7±345.0). The technical success rate was 99.9%, and a total of 85 (10.5%) complications occurred, of which 24 (28.2%) occurred early (<30 days) and the remaining 61 (71.8%) were late (>30 days) complications. Specifically, 28 (3.5%) were catheter-related thrombosis (CRT), 27 (3.4%) related to infection, 17 (2.1%) were mechanical complications (16 fibrin sheath formation and one catheter occlusion), six (0.7%) related to catheter migration, four (0.5%) related to incision healing problems, and the remaining three (0.4%) related to ischemic skin necrosis. Forty-seven (5.8%) ports were removed due to complications. On multivariate analysis, cancer type was found as a risk factor for the development of a complication. Additionally, there was an indication that hematologic malignancy is related to infection.

Conclusion

Placement of ports via the internal jugular vein under ultrasound and fluoroscopy guidance is a safe procedure, with low rates of early and late complications.

The “Arm-to-Chest Tunneling” technique: A modified technique for arm placement of implantable ports or central catheters

Purpose:

Central venous catheters or “venous access devices” include totally implantable venous access devices or “ports,” peripherally inserted central catheters, and tunneled lines. Venous access devices are now the standard of care in patients requiring long-term intravenous drug administration. Arm venous access device placement is a valuable option for vascular access yet often complicated or rendered practically impossible by the condition and size of peripheral veins. We describe a modification of the arm venous access device implantation technique that we use in our department in order to offer this option to our patients, regardless of their peripheral veins condition.

Methods:

After ultrasound guided venous access of a suitable neck vein, we create a port pouch—in case of a totally implantable vascular access device—or a skin nick—in case of a venous access device—in the inner aspect of the mid-arm. Using a straight metal tunneler, we tunnel the line from the neck to the arm in two stages, externalizing and re-inserting the line into a skin nick made on the deltopectoral groove. We call this technique “Arm-to-Chest Tunneling” and use it to place venous access devices in the arm using a neck venous access.

Results:

The Arm-to-Chest Tunneling technique allows us to use larger arm venous access device catheters irrespective of the arm veins condition. Thus, this technique has the advantages of arm venous access device placement, with the added benefit of saving the arm veins.

Conclusion:

The “Arm-to-Chest Tunneling” method offers the alternative to place a venous access device in a more discreet site in the arm, even in cases in which arm veins are inadequate.

The “L-shaped Tunneling Technique”: A Modified Technique Facilitating a more Discreet Implantable Port Positioning

Purpose

Venous port catheters, also known as “totally implantable venous access devices” (TIVADs), are now the standard of care in patients requiring long-term intermittent intravenous drug administration. We describe a modification of the implantation technique that we use in our department in order to improve the cosmetic result of a TIVAD.

Methods

After ultrasound-guided venous access in the internal jugular vein (IJV) or another appropriate vein has been obtained, we create a port pocket in the deltopectoral groove, in the upper-lateral chest wall, in a “far-lateral-oblique” orientation, respecting the individual patient's relaxed skin tension lines. Then we create a subcutaneous tunnel using a straight metal tunneler in two steps: first tunneling cranially and perpendicular to the port incision for a small distance, and then, after turning the tunneler at a right angle continuing in a straight line until we exit at the venous access site.

Results

This configuration not only prevents catheter kinking, to ensure uninhibited flow, but also allows us to place the port pocket in a more discreet position, in order to offer a better cosmetic result to our patients.

Conclusions

Adoption of a “far-lateral-oblique” port implantation site along with the “L-shaped tunneling technique” will offer doctors who are implanting TIVADs a useful alternative for a better cosmetic result.