Chemotherapy drug extravasation in totally implantable venous access port systems: how effective is early surgical lavage?

Shape-Setting of Self-Expanding Nickel-Titanium Laser-Cut and Wire-Braided Stents to Introduce a Helical Ridge

PURPOSE

Altered hemodynamics caused by the presence of an endovascular device may undermine the success of peripheral stenting procedures. Flow-enhanced stent designs are under investigation to recover physiological blood flow patterns in the treated artery and reduce long-term complications. However, flow-enhanced designs require the development of customised manufacturing processes that consider the complex behaviour of Nickel-Titanium (Ni-Ti). While the manufacturing routes of traditional self-expanding Ni-Ti stents are well-established, the process to introduce alternative stent designs is rarely reported in the literature, with much of this information (especially related to shape-setting step) being commercially sensitive and not reaching the public domain, as yet.

METHODS

A reliable manufacturing method was developed and improved to induce a helical ridge onto laser-cut and wire-braided Nickel-Titanium self-expanding stents. The process consisted of fastening the stent into a custom-built fixture that provided the helical shape, which was followed by a shape-setting in air furnace and rapid quenching in cold water. The parameters employed for the shape-setting in air furnace were thoroughly explored, and their effects assessed in terms of the mechanical performance of the device, material transformation temperatures and surface finishing.

RESULTS

Both stents were successfully imparted with a helical ridge and the optimal heat treatment parameters combination was found. The settings of 500 °C/30 min provided mechanical properties comparable with the original design, and transformation temperatures suitable for stenting applications (Af = 23.5 °C). Microscopy analysis confirmed that the manufacturing process did not alter the surface finishing. Deliverability testing showed the helical device could be loaded onto a catheter delivery system and deployed with full recovery of the expanded helical configuration.

CONCLUSION

This demonstrates the feasibility of an additional heat treatment regime to allow for helical shape-setting of laser-cut and wire-braided devices that may be applied to further designs.

Surgical management after Oxaliplatin extravasation: A case report and literature review

This case report describes a unique case of chronic reaction after extravasation of oxaliplatin. The pain and extensive subcutaneous induration did not resolve after 9 months of conservative treatment. Surgical debridement with removal of the totally implantable venous access device (TIVAD) resulted in immediate resolution of the symptoms. Oxaliplatin has both irritant and vesicant properties that are difficult to distinguish at initial clinical presentation. In most literature cases complaints resolve within 3 months with conservative treatment yet surgical debridement should be considered if complaints persist beyond this period.

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.

Analysis of related complications of totally implantable venous access ports in children's chemotherapy: Single center experience

Totally implantable venous access port (TIVAP) has become an important infusion channel for children who need chemotherapy. With the popularization of TIVAP, its related complications have gradually received clinical attention. However, there are few studies on the complications of TIVAP in children. Therefore, this study intends to analyze the risk factors of complications in children's infusion port, so as to provide basis for guiding clinical prevention and intervention. This paper retrospectively analyzed 182 children who received TIVAP implantation in our hospital from January 2018 to January 2021. According to the demographic data, basic disease status and operation related data obtained through Hospital Information System and manual follow-up, the complications and related influencing factors after implantation and implantation were summarized and analyzed. SPSS software was used to analyze the influencing factors between the complication group and the control group. There were 182 cases of children implanted in intravenous infusion port, of which 71 cases had complications, infection was the most common complication in 50 cases, followed by catheter blockage in 23 cases. Among the infection factors, catheter-related blood stream infection accounted for the highest proportion in 31 cases (17.0%), and Staphylococcus epidermidis was the most common pathogen. A total of 19 cases were pulled out early, and the unplanned pullout rate of catheter-related blood stream infection was the highest. In the analysis of influencing factors, age had significant differences in catheter-related infection, all complications and no complications (P < .05). The overall incidence of complications in the use of TIVAP in children with chemotherapy is high, and infection is the most common complication, among which catheter-related blood stream infection is the most common cause of unplanned pullout. Lower age may be associated with a higher incidence of complications.

Cervical dissecting extravasation of oxaliplatin: A case report

Oxaliplatin is a chemotherapy drug considered to be an irritant and vesicant. Peripheral extravasation could happen following oxaliplatin chemotherapy administration, but mediastinal or cervical events are rare. The present study focused on the case of a 64-year-old female patient with KRAS-mutated colorectal adenocarcinoma. The patient was prescribed folinic acid, fluorouracil and oxaliplatin chemotherapy via a subcutaneous pump or port-a-cath device, which was inserted into the right subclavian vein. The patient reported a sudden throbbing pain in the chest wall and anterior cervical region. After performing a computed tomography scan, anterior cervical collection and jugular-subclavian venous confluence at the distal end was observed at the venous access site of the subcutaneous port-a-cath device, which extended cranially, dissected cervical planes and forming a hydro-aerial collection in the submaxillary region. Subsequently, the port-a-cath device was removed and a warm dry compress was applied. After 2 weeks, the patient had fully recovered without any sequelae at the cervical level. To the best of the authors' knowledge, this is the first case of cervical extravasation of oxaliplatin reported in the literature to date and will help to manage similar situations.

Drug Extravasation in a Large General Hospital in Hunan, China: A Retrospective Survey

Background and Aim

Drug extravasation is one of the most common complications of intravenous therapy, which can lead to severe tissue injury if inappropriately treated. This study analyzes the current situation of extravasation and the risk factors affecting the severity of extravasation to provide a theoretical basis for carrying out prospective research, reducing the severity of drug extravasation, and strengthening the management of drug extravasation.

Materials and Methods

We retrieved the data on extravasation from January 2016 to December 2020 from the hospital’s safe infusion management system. We used nonparametric tests to assess the differences in the severity of drug extravasation among each variable and performed a multivariate analysis using multivariate ordered logistic regression.

Results

Extravasation occurred in 0.038% (263/694,043) of patients, including 203 cases of mild extravasation (77.2%), 57 cases of moderate extravasation (21.7%), and 3 cases of severe extravasation (1.1%). The main diseases of the patients with extravasation were cancer (24.7%), neurological-related diseases (19.4%), circulatory-related diseases (14.8%), and digestive-related diseases (14.1%); the main extravasated drugs were hypotonic or hypertonic drugs (31.9%) and contrast media (27.8%); the infusion tools of extravasation were indwelling needles (92.0%) and steel needles (8.0%). The multi-factor analysis showed that close to joints, patients’ age ≤6 or age >65, cancer, neurological-related diseases, circulatory-related diseases, antineoplastic agents, hypotonic or hypertonic drugs and strong acid or alkali drugs were independent risk factors for more severe extravasation. The nurses’ age and first identified by nurse were nurse-related factors that influenced the severity of drug extravasation.

Conclusion

To prevent the occurrence of drug extravasation and reduce its severity, the nurses should strengthen the learning of emergency plans related drug extravasation, strengthen inspections of high-risk patients. Besides, the managers should strengthen the risk warning management of high-risk extravasated drugs.

Extravasation of chemotherapeutic drug from an implantable intravenous infusion port in a child: A case report

BACKGROUND

Drug extravasation is a complication of totally implantable access port (TIAP) use and could cause tissue injury and sustained organ dysfunction. Therefore, the clinical management of children with TIAP is challenging.

CASE SUMMARY

This was a case of extravasation of a chemotherapeutic drug (paclitaxel) from an implantable infusion port in a 23-mo old child. After fully evaluating the skin at the site of extravasation, the nurse continued to use the infusion port to complete the follow-up chemotherapeutic course. The skin around the infusion port was red, and showed no ulceration, swelling, or induration at discharge.

CONCLUSION

Since children are more active and often noncompliant, it is necessary to appropriately train pediatric nurses caring for individuals with TIAPs, and any abnormal situation should be timely addressed.

Difference in Computed Tomography Image Quality between Central Vein and Peripheral Vein Enhancement in Treatment Naive Esophageal Cancer Patients

Simple Summary

A chest CT via central vein enhancement not only eliminates peripheral vein regurgitation but also provides better image quality that facilitates precise clinical staging. A chest CT via central vein enhancement may be considered after tissue proof in order to better discriminate disease severity.

Abstract

The differences in chest computed tomography (CT) image quality may affect the tumor stage. The aim of this study was to compare the image quality and accuracy of chest CT via central vein and peripheral vein enhancement. Fifty consecutive patients were enrolled from a tertiary medical center in Taiwan from May 2016 to March 2019. All the patients received a chest CT via central vein enhancement prior to neoadjuvant concurrent chemoradiation in order to compare the chest CT that was obtained via the peripheral vein. In addition, blind independent central reviews of chest CT via central vein and peripheral vein enhancement were conducted. For T and N stage, chest CT via central vein enhancement had a greater consistency with endoscopic ultrasonography and positron-emission tomography-computed tomography findings (kappa coefficients 0.4471 and 0.5564, respectively). In addition, chest CT via central vein enhancement also showed excellent agreement in the blind independent central review (kappa coefficient 0.9157). The changes in the T and N stage resulted in stage migration in 16 patients. Chest CT via central vein enhancement eliminated peripheral vein regurgitation and also provided more precise clinical staging. This study is registered under the registered NCT number 02887261.

Assessing the Quality of Existing Clinical Practice Guidelines for Chemotherapy Drug Extravasation by Appraisal of Guidelines for Research and Evaluation II

Background:

Extravasation is a potentially hazardous event that may occur during chemotherapy. The aim of this study is to assess the quality of existing Clinical Practice Guidelines (CPGs) for chemotherapy drug extravasation by Appraisal of Guidelines for Research and Evaluation II (AGREE II).

Materials and Methods:

Valid electronic databases and CPGs from 2007 to August 2018 were searched by keywords of CPGs, extravasation, chemotherapy, and cancer. CPGs were evaluated independently by five experts through AGREE II tool, and the consensus among evaluators was calculated by ICC (Intra-class Correlation Coefficient).

Results:

Five of the 111 CPGs matched the inclusion criteria. The methodological quality of CPGs in domains of “scope and purpose,“ “stakeholder involvement,“ “clarity of presentation,“ and “applicability“ were good, in the domain of “rigor of development,“ was acceptable, and in “editorial independence“ domain, it needed more attention of developers of CPGs. The range of assessors' consensus was within a range of moderate to very good (0.55--0.93).

Conclusions:

The methodological quality of existing CPGs of chemotherapy drugs extravasation assessed by AGREE II tool is appropriate. Four CPGs had high level while one had moderate level of quality. Therefore, their use is recommended in the clinic to reduce the risk of chemotherapy extravasation to the entire treatment team and the nurses working in the oncology departments.

Negative-pressure wound therapy and early pedicle flap reconstruction of the chest wall after epirubicin extravasation

PURPOSE

Accidental extravasation is a serious iatrogenic injury among patients receiving anthracycline-containing chemotherapy. The aim of this work is to present a combination therapy for chest wall reconstruction following epirubicin extravasation.

METHODS

Herein, we report a 68-year-old woman with massive soft tissue necrosis of the anterolateral chest wall after epirubicin extravasation from a port implanted in the subclavicular area.

RESULTS

The necrotic tissue was resected, the port was removed, and negative-pressure wound therapy was applied. Three weeks later, a latissimus dorsi pedicle flap was successfully used to cover the defect.

CONCLUSIONS

To the best of the authors' knowledge, this is the first report of a strategy comprising the combination of negative-pressure wound therapy and a latissimus pedicle flap for reconstruction of the chest wall after soft tissue necrosis following epirubicin extravasation.

Plastic Surgery in the Multimodal Treatment Concept of Soft Tissue Sarcoma: Influence of Radiation, Chemotherapy, and Isolated Limb Perfusion on Plastic Surgery Techniques

Surgical intervention is the mainstay treatment for soft tissue sarcomas (STSs). The significance of adjuvant and neoadjuvant therapies, such as chemotherapy, radiation, and isolated limb perfusion, remains under controversial discussion. The goal of this review is to discuss the effects of the aforementioned treatment modalities and their timing of application in plastic surgery techniques. Furthermore, options of reconstruction in cases of complications caused by adjuvant and neoadjuvant therapies are discussed. When compared with adjuvant radiation, neoadjuvant treatment can reduce negative side effects such as fibrosis and edema because radioderma can be removed during the subsequent surgical procedure. Furthermore, there have not been any reports of negative effects of neoadjuvant radiation on microsurgical procedures. However, the dose of neoadjuvant radiation correlates with increased risks of impaired wound healing postoperatively. Thus, a patient-specific approach to decide whether radiation should be performed adjuvant or neoadjuvant is necessary. Preoperative irradiation should be considered in cases where functional structures are exposed after tumor resection, in order to ensure the best possible functionality. Adjuvant radiation should be considered in all other cases because of its known superior wound healing. As for chemotherapy, no negative influence of its use adjuvant or neoadjuvant to reconstructive procedures, such as local or free flaps, has been reported. Lastly, small sample size studies have not shown increased risks of microsurgical failure or wound complications after isolated limb perfusion. The findings of this review suggest that the chronological order of the discussed therapeutic approaches is not a decisive factor in the surgical outcome of reconstructive procedures for STS.

Haemodynamics and Flow Modification Stents for Peripheral Arterial Disease: A Review

Endovascular stents are widely used for the treatment of peripheral arterial disease (PAD). However, the development of in-stent restenosis and downstream PAD progression remain a challenge. Stent revascularisation of PAD causes arterial trauma and introduces abnormal haemodynamics, which initiate complicated biological processes detrimental to the arterial wall. The interaction between stent struts and arterial cells in contact, and the blood flow field created in a stented region, are highly affected by stent design. Spiral flow is known as a normal physiologic characteristic of arterial circulation and is believed to prevent the development of flow disturbances. This secondary flow motion is lost in atheromatous disease and its re-introduction after endovascular treatment of PAD has been suggested as a method to induce stabilised and coherent haemodynamics. Stent designs able to generate spiral flow may support endothelial function and therefore increase patency rates. This review is focused on secondary flow phenomena in arteries and the development of flow modification stent technologies for the treatment of PAD.