Differences in the Incidence of Sterile Inflammation After Trabectedin Infusion With Two Central Venous Port Systems: A Retrospective Study

Purpose Sterile inflammation along the tunneled catheter is a characteristic complication associated with trabectedin infusion via a central venous port (CVP). To date, no studies have evaluated the differences in sterile inflammation incidence according to the CVP system used. This study evaluated the differences in sterile inflammation incidence between two different CVP systems. Methods This study was conducted at The University of Tokyo Hospital, Bunkyo-Ku, Tokyo, Japan. Patients with trabectedin infusion using CVP via the internal jugular vein between April 2016 and February 2024 were retrospectively evaluated. Sterile inflammation was characterized as skin erythema, swelling, pain, or induration along the tunneled catheter after infusion of trabectedin from the CVP and negative for various infection tests. The incidence of sterile inflammation was compared using two different CVP systems: Anthron® polyurethane catheter with Celsite port (P-U Celsite; Toray Medical, Tokyo, Japan) and DewX Eterna (Terumo, Tokyo, Japan). Results Of the 21 patients, 12 and nine patients used P-U Celsite and DewX Eterna for trabectedin infusion, respectively. Sterile inflammation occurred in five patients; of these, four underwent CVP removal because of worsened pain, making trabectedin infusion difficult. Sterile inflammation occurred in 0 (0/12) and 56% (5/9) of patients using P-U Celsite and DewX Eterna, respectively, with a significantly lower incidence in patients using P-U Celsite (P = 0.006). Conclusion Sterile inflammation incidence was significantly lower in patients using P-U Celsite compared to those using DewX Eterna.

Technical Feasibility and Safety of Central Venous Ports for Intravenous Chemotherapy in Infants With Retinoblastoma: A Retrospective Study

PURPOSE

The central venous port (CVP) is widely used for intravenous chemotherapy (IVC) in adult patients because of its lower infection rates and easier management than that of a central venous catheter. However, the feasibility and safety of the CVP for IVC in infants remain unknown. This study evaluated the usefulness of CVP for IVC in infants with retinoblastoma.

METHODS

The usefulness of CVP was retrospectively evaluated using technical success rates, the safety of CVP placement, and postoperative procedure-related complications in 18 infants with retinoblastoma. This study was conducted at the National Cancer Center Hospital, Chuo-Ku, Tokyo, Japan.

RESULTS

The technical success rate was 100% (18/18) without any procedure-related complications. The sum duration of CVP implantation was 12,836 days (mean: 713 ± 453 days, range: 10-1,639 days). Postoperative complications were observed in two cases; one was a port reversal after 20 days, which was reversed by incisional surgery, and another was a catheter-related bloodstream infection after eight days, resulting in CVP removal. The total incidence of CVP-related infections was 5.6% (1/18) and 0.08/1000 catheter days. No other CVP-related complications were noted.

CONCLUSION

The use of the CVP for IVC in infants with retinoblastoma was feasible with few complications.

Accidental Detection of Persistent Left Superior Vena Cava During Central Venous Port Placement

Persistent left superior vena cava (PLSVC) is a rare abnormality of the thoracic vein that is often detected incidentally during central venous catheter insertion. We present the case of an 85-year-old female with PLSVC that was accidentally detected during central venous port placement. The left subclavian vein was punctured using the supraclavicular approach. Intraoperative fluoroscopy showed that the guidewire had descended through the left chest, suggesting PLSVC. Intraoperative computed tomography and venography confirmed that the PLSVC drained into the coronary sinus. In this case, the PLSVC and right superior vena cava (RSVC) coexisted, with no bridging veins. The diameter of the PLSVC was extremely small compared to that of the RSVC; therefore, catheter placement in the PLSVC was avoided considering the risk of venous thromboembolism, and a catheter was placed in the RSVC. When clinicians encounter cases where the PLSVC and RSVC coexist during central venous catheter insertion, the diameter of the PLSVC should be considered when deciding whether to place the catheter in the PLSVC. If the diameter of the PLSVC is narrow, it may be safer to avoid catheter placement in the PLSVC and instead place the catheter in the RSVC, considering the risk of venous thromboembolism after catheterization.

A Retrospective Analysis of Venographic Images of a Central Venous Port without Blood Return and Its Usable Period

Objective In routine practice, central venous ports without blood return (CVPWBRs) are common. However, very few studies have reported on the viable period of CVPWBR use. We therefore investigated this period by retrospectively analyzing the venographic images of CVPWBRs. Methods We examined patients' venography through the CVPs at the point when they became CVPWBRs for the first time and analyzed the reasons for becoming CVPWBRs. For patients with minor complications of CVPs or normal venographic findings, we used the Kaplan-Meier method to evaluate the period for which such CVPWBRs could be used. Patients Eighty-four patients with malignancy whose CVPs became CVPWBRs for the first time between July 31, 2015, and March 12, 2020, were included. Results Nine (10.7%) patients had major complications that made the CVPs unusable. Thirty-three (39.3%) patients had minor complications, and the remaining 42 (50.0%) had normal venographic findings. For the 75 patients with minor complications or normal venographic findings who continued to use their CVPWBRs, the Kaplan-Meier method estimated that 25% of complications that might make it unusable would occur within 1,273 days. Conclusion There are two learning points in our study. First, venography is needed when the CVP becomes a CVPWBR for the first time due to the high risk, and second, CVPWBRs can be used for a relatively long period in patients without major complications. It is necessary to develop an appropriate follow-up management method for CVPWBRs in prospective studies.

Guidelines for Central Venous Port Placement and Management (Abridged Translation of the Japanese Version)

The central venous port has been widely used for patients who require long-term intravenous treatments, and the number of palcement has been increasing. The Japanese Society of Interventional Radiology developed a guideline for central venous port placement and management to provide evidence-based recommendations to support healthcare providers in the decision-making process regarding the central venous port. The guideline consisted of two parts: (i) a comprehensive review of topics including preoperative preparation, techniques for placement or removal, complications, and maintenance methods and (ii) recommendations for the six clinical questions regarding blood vessels for central venous port placement, port implantation site, prophylactic antibiotic therapy, imaging guidance for puncture, disinfectant prior to accessing the central venous port, and the optimal procedure at the end of drug administration via the central venous port, generated on the basis of the rating quality of evidence by systematic review.

Safety of Early Bevacizumab Administration after Central Venous Port Placement for Patients with Colorectal Cancer

Bevacizumab (BEV) requires an adequate withdrawal period to avoid BEV-related complications during major surgery. However, the safety of BEV administration immediately after surgical placement of the central venous (CV) port, a minor surgery, is still unclear. This study aimed to investigate whether BEV is safe when administered early after CV port placement. We retrospectively evaluated 184 patients with advanced colorectal cancer (CRC) treated with a BEV-containing regimen and divided them into two groups according to the interval between CV port implantation and chemotherapy initiation, with the early administration group being ≤7 days and late administration group being >7 days. Complications were then compared between the two groups. The early-administration group was significantly older and had a higher rate of colon cancer than the late-administration group. Overall, 24 (13%) patients developed CV port-related complications. Male sex was a risk factor for complications (odds ratio [OR], 3.154; 95% CI, 1.19-8.36). The two groups showed no significant difference in the frequency of complications (p = 0.84) or patient characteristics (after the inverse probability of treatment weighting, p = 0.537). In conclusion, the frequency of complications is not affected by the timing of BEV initiation after CV port implantation. Thus, early BEV administration after CV port placement is safe.

Septic pulmonary embolism and subsequent bilateral pneumothorax in patients undergoing chemoradiotherapy for head angiosarcoma: An autopsy case report and literature review

RATIONALE

Septic pulmonary embolism (SPE) and subsequent pneumothorax are rare but serious conditions. We report a case of SPE and pneumothorax caused by central venous port (CV port) infection.

PATIENT CONCERNS

A 73-year-old woman, who underwent chemoradiotherapy for a head angiosarcoma and a CV port placement, presented with general malaise and myalgia.

DIAGNOSIS

A laboratory examination showed high levels of inflammatory markers. Chest computed tomography showed fluid collection around the CV port and multiple ground-glass opacities and nodular shadows in the bilateral lung field. She was admitted with a diagnosis of SPE due to CV port infection. The port was removed, and antibiotic administration was initiated; however, she was intubated because of refractory septic shock. Methicillin-susceptible Staphylococcus aureus was detected in the blood and pus around the port site.

INTERVENTIONS

Her respiratory status did not improve despite recovering from septic shock, and radiologic findings showed a left pneumothorax and exacerbation of SPE on day 9. Her condition was judged ineligible for surgery for pneumothorax, and chest tube thoracostomy was continued.

OUTCOMES

Air leaks persisted after chest tube thoracostomy, and her respiratory status did not improve despite ventilator management and recruitment maneuvers. Moreover, a right pneumothorax developed on day 19. Her respiratory status gradually worsened, and she died on day 21. Autopsy showed multiple cavitary lesions in the bilateral lungs and emboli containing organization and inflammatory cells that obstructed the pulmonary arterioles.

LESSONS

This case indicates that CV port-related infections are infrequent and difficult to diagnose; understanding the clinical features of SPE is important because of its high mortality rate; and pneumothorax secondary to SPE is a rare but serious condition and is difficult to treat during ventilator management.

Should we use a patient's port as the preferred intravenous route rather than inserting an additional venous access?

Early in 2021, the Infusion Nursing Society has released the latest version of the Infusion Therapy Standards of Practice. In the last two decades, these Standards have been representing one of the most important evidence-based documents available in the world of venous access. Nevertheless, we were quite concerned reading a recommendation included in chapter 26 (Vascular Access Device Planning: practice recommendation I, C): "Use a patient's port, unless contraindicated (e.g. existing complication) as the preferred IV route in preference to insertion of an additional VAD." Such recommendation is offered not on the basis of evidence, but as experts' opinion ("Committee Consensus"). This Editorial deals with the opinion of GAVeCeLT (The Italian Study Group for Long Term Central Venous Access) that strongly discourage the use of ports for intravenous treatment different from chemotherapy (or from the therapy that specifically required that long term, infrequent access). The rationale for this choice is based on the consideration that the patient's port-if used in a non-specialty ward-would be at high risk of complications, some of them potentially leading to the loss of the device, and that such complications might be particularly difficult to manage in this setting. The continuous or frequent use of a port transforms it into an external device, thus cancelling the main advantage of a totally subcutaneous location, while adding a significant disadvantage (need for repeated percutaneous punctures and risk of extravasation/infiltration due to improper insertion or dislocation of the non-coring needle). One exception is the possible use of port for radio-diagnostic purposes (as long as the port is power injectable). This strategy may be associated with advantages for the patient, and imaging quality improvement, but requires the adoption of specific protocols for prevention of infective and mechanical complications.

Safety and feasibility of 3-month interval access and flushing for maintenance of totally implantable central venous port system in colorectal cancer patients after completion of curative intended treatments

Patients with colorectal cancer (CRC) treated with curative intent surgery undergo continuous fluorouracil (5-FU) infusion-based chemotherapy using totally implantable central venous port system (TICVPS) in cases with high risk of recurrence. Approximately 30% of patients relapse after therapy completion, especially within 2 years. Hence, many patients with high risk CRC keep the TICVPS for 6 to 24 months after treatment with regular intervals of TICVPS flushing. However, little is known about the proper interval duration of the port. The aim of this study is to investigate whether a 3 months extended interval is safe and if port maintenance is feasible.A retrospective cohort was compiled of patients with CRC who underwent curative intent surgery and perioperative chemotherapy using TICVPS between 2010 and 2017. The primary end point was TICVPS maintenance rate, including maintenance of TICVPS for at least 6 months, planned TICVPS removal after 6 months, and regaining the use of TICVPS at the time of recurrence.A total of 214 patients with CRC underwent curative intent treatments during the study period. Among them, 60 patients were excluded, including 6 patients for early recurrence within 3 months and 54 patients with violation of flushing interval. Finally, 154 patients were analyzed. Mean flushing interval was 98.4 days (95% confidence interval [CI], 96.2-100.6; range, 60-120). In December 2018, 35 patients kept the TICVPS, 92 patients had planned removal, 25 patients reused the TICVPS, and 2 patients had to unexpectedly remove the TICVPS due to site infection and pain. Thus, the functional TICVPS maintenance rate was 98.8% (152/154). Thirty-eight patients relapsed, and 30 patients were treated with intravenous chemotherapy. Among them, 25 patients (83.3%) reused the maintained TICVPS without a reinsertion procedures.Our study demonstrated that 3-month interval access and flushing is safe and feasible for maintaining TICVPS during surveillance of patients with CRC. An extended interval up to 3 months can be considered because it is compatible with CRC surveillance visit schedules.

Deep vein thrombosis of the upper extremity caused by central venous port in a patient with soft tissue sarcoma: A case report

Deep vein thrombosis (DVT) more commonly occurs in the lower extremities, whereas involvement of the upper extremities is rare. The present case report describes the clinical course of the development and treatment of upper extremity DVT (UEDVT) following insertion of an indwelling central venous (CV) port in a patient with soft tissue sarcoma (STS) of the thigh. A 66-year-old man was referred to our hospital for STS treatment. The indwelling CV port was placed via the left subclavian vein, and two courses of neoadjuvant chemotherapy were administered. Two months after the catheter placement, DVT was detected from the left upper arm to the left internal jugular vein. Anticoagulation therapy with warfarin was started and DVT was undetectable at 5 months after surgery. In conclusion, DVT may occur in cancer patients who undergo treatment with indwelling CV ports. Therefore, screening should be conducted concurrently with surgical resection and chemotherapy for STS.

[Totally implantable central venous port: analysis of complications and their prevention]

OBJECTIVE

To analyze postoperative complications of totally implantable central venous port system (TIPCVP) deployment and develop methods of their prevention.

MATERIAL AND METHODS

The study involved 43 patients who underwent TIPCVP implantation through right-sided jugular access and 3 patients with migration of the catheter transferred to the Domodedovo Central City Hospital.

RESULTS

There were four perioperative and one early postoperative complication. None of the complications was the reason for removal of TIPCVP. Pinch-off syndrome occurred in two patients who were operated in other hospitals and a catheter was inserted through the right subclavian vein.

CONCLUSION

Injury of the carotid artery and pneumothorax can be avoided by ultrasound navigation during internal jugular vein puncture. Catheterization of the internal jugular vein is useful to avoid pinch-off syndrome. Migration of the catheter is successfully cured by endovascular methods.