Catheter fracture of intravenous ports and its management

Three-Dimensional Simulation Training for Oncology Nurses to Address Pitfalls in Current Irrigation Strategy for Intravenous Ports: Repeated Measurements Study

OBJECTIVE

We designed an interactive visual training course and three-dimensional (3-D) simulator for participants and used verified questionnaires as tool to evaluate the efficacy of the education course.

DATA SOURCES

From August 2020 to December 2021, 159 nursing staff who received the interactive visual training course and completed validated questionnaires before and after the course were included. The efficacy of the course was evaluated by comparing the pre- and post-course questionnaires.

CONCLUSION

The interactive visual training course, including maintenance lectures and practice with a 3-D simulator, improved consensus among the nursing staff and increased the willingness of oncology nurses to perform the proposed port irrigation procedure.

IMPLICATIONS FOR NURSING PRACTICE

An implanted intravenous port cannot be directly seen by nursing staff and can only be identified through manual palpation. This lack of visibility may result in individual variations in port identification during daily practice, potentially leading to malpractice. To minimize these individual variations, we have designed an interactive visual training course. We used validated questionnaires before and after the course to analyze its efficacy in practical education.

Case report: Extravascular catheter migration in a child: A rare complication of the totally implantable venous access device

BACKGROUND

Totally implantable venous access devices (TIVADs) are widely used to gain intermittent central venous access, such as in patients who need long-term chemotherapy, total parenteral nutrition, and long-term antibiotic treatment. At present, there are many complications associated with the use of these devices. Complete extravascular migration of TIVADs via the internal jugular vein is a very rare and potentially serious condition, especially in children.

CASE PRESENTATION

A 1-year-old girl needed palliative chemotherapy because of hepatoblastoma complicated by inferior vena cava thrombosis. A TIVAD was implanted through the right internal jugular vein with a routine heparin flushing tube. On the second day after the operation, a pale bloody liquid was drawn out from the device and the chest X-ray was checked to confirm that the position of the catheter was normal. On the third day after the operation, however, the patient's right respiratory sound was weakened on physical examination and auscultation. Fluoroscopy showed that the tip of the catheter was located in the right thoracic cavity, and there was a large amount of effusion in the right thoracic cavity. The pleural effusion was removed, the TIVAD was replaced again, and the child was discharged 2 days later.

CONCLUSIONS

Following TIVAD implantation, if abnormalities are found, in addition to chest X-ray, saline flush and echocardiography should be performed to determine the position of the catheter and rule out extravascular migration of the catheter to avoid irreparable consequences.

Catheter Lock Anchor Technique for Placement of Retrogradely Tunneled Implantable Ports

Objective Groshong valved catheters require retrograde tunneling and a port chamber needs to be attached to the catheter after trimming. During this process, working space constraints are generally faced by operators. We describe a novel technique to improve the comfort of the operator while working in a constrained space.

Materials and Method The port catheter with the distal valve is retrogradely tunneled and trimmed. Thread from absorbable surgical suture is used to anchor the catheter lock. Anchored catheter lock is comfortably pushed over the catheter into the subcutaneous tunnel without it being migrated proximally. Once the port chamber is attached to the catheter, the catheter lock is retrieved back and moved to the locking position. We retrospectively analyzed implantable ports for smoothness of curves and outcomes in terms of catheter days.

Results Technical success was achieved in all patients. There were no periprocedural complications. Clinical success was achieved in 27/29 cases. Early port removal was done due to infection in one patient and for nonhealing of the wound in one patient.

Conclusion The catheter lock anchor is a safe and useful technique for the placement of valved ports. A satisfactory catheter-nut angle can be achieved with this technique.

Does catheter material affect functional performance of intravenous ports via the superior vena cava?

Introduction

The catheter is the only intravascular portion of an implanted port and plays a crucial role in catheter related complications. Both polyurethane and silicone are biocompatible materials which are utilized for catheter manufacturing, but their correlation to complications remains controversial. The aim of this study was to try to analyze the relationship between catheter materials and complications.

Materials and methods

A total of 3144 patients who underwent intravenous port implantation between March 2012 and December 2018 at Chang Gung Memorial Hospital, Linkou, Taiwan were recruited. Of these, 1226 patients received silicone catheter port implantation and 1679 received polyurethane catheter ports. Case matching was done prior to analysis and catheter related complications and cumulative complication incidence for each group were compared.

Results

Intergroup differences were identified in entry vessel (p = 0.0441), operation year (p < 0.0001), operation method (p = 0.0095), functional period (p < 0.0001), patient follow up status (p < 0.0001), operating time for vessel cutdown (p < 0.0001) and wire assisted approach (p = 0.0008). Stratified by specific entry vessel, no statistical difference was found in complication rate or incidence between the silicone and polyurethane groups. We further compared the cumulative complication incidence of the silicone and polyurethane groups, and also found no statistical difference (p = 0.4451).

Conclusion

As long as external stress forces generated by surrounding structures and focused on potential weak points are avoided, both silicone and polyurethane materials provide sufficient structural stability to serve as reliable vascular access for patients.

Successful recovery of central venous catheter fragment from coronary venous sinus and right ventricle: A case report

Catheter fracture with subsequent embolization is a well known but a potentially serious late complication of central venous catheter placement. Central venous catheters are frequently implanted for the purpose of chemotherapy and parenteral nutrition. Most common vein used for the placement of central venous catheter is subclavian vein. According to case reports, catheter placed in subclavian vein is vulnerable for fracture and is often preceded by the "pinch-off sign", first described by Aikten and Minton. It is due to shearing forces between the clavicle and first rib. Broken catheter frequently embolises to Right atrium, Right Ventricle, Inferior vena cava, Pulmonary arteries and rarely into Coronary sinus. Migration to Coronary sinus is very uncommon and only 5 cases are reported in the literature as of now. We are presenting an unusual case where chemoport catheter severed and lodged partly in coronary venous sinus and partly in right ventricle taking a "U "shape. Fragment was successfully retrieved percutaneously using a snare after straightening it with a pigtail catheter. Though majority of patients deny symptoms however, some do have symptoms or complications. Catheter fragment can lead to arrhythmias, thrombosis, infection and perforation. Thrombosis of coronary sinus is a life threatening complication. Regular follow up with Chest x ray may recognize the fracture and embolization much earlier. In almost all cases the migrated portion can be retrieved safely percutaneously without recourse to surgery.

Long-Term Results of a Standard Algorithm for Intravenous Port Implantation

Intravenous ports serve as vascular access and are indispensable in cancer treatment. Most studies are not based on a systematic and standardized approach. Hence, the aim of this study was to demonstrate long-term results of port implantation following a standard algorithm. A total of 2950 patients who underwent intravenous port implantation between March 2012 and December 2018 were included. Data of patients managed following a standard algorithm were analyzed for safety and long-term outcomes. The cephalic vein was the predominant choice of entry vessel. In female patients, wire assistance without use of puncture sheath was less likely and echo-guided puncture via internal jugular vein (IJV) with use of puncture sheath was more likely to be performed, compared to male patients (p < 0.0001). The procedure-related complication rate was 0.07%, and no pneumothorax, hematoma, catheter kinking, catheter fracture, or pocket erosion was reported. Catheter implantations by echo-guided puncture via IJV notably declined from 4.67% to 0.99% (p = 0.027). Mean operative time gradually declined from 37.88 min in 2012 to 23.20 min in 2018. The proposed standard algorithm for port implantation reduced the need for IJV echo-guided approach and eliminated procedure-related catastrophic complications. In addition, it shortened operative time and demonstrated good functional results.

Arm mobilization provokes deformity of long-term indwelling ports implanted via the jugular vein

BACKGROUND

The incidence of totally implantable catheter fracture ranges from 0.48% to 5.00%, and these fractures represent a potentially fatal complication. The fracture mechanism of catheters implanted via the jugular vein is unclear, and whether extreme arm movements represent an additional risk factor for repetitive stress of the material remains unknown. The aim of this study was to demonstrate and classify catheter deformations caused by extreme arm mobilization and associations with changes in catheter function and displacement.

METHODS

We analyzed the fluoroscopy images of 60 consecutive patients undergoing long-term indwelling port implantation via the jugular vein. Three images were taken: arm in maximal abduction, maximal frontal elevation, and maximal adduction. The images were compared with an image of the remainder of the arm. We analyzed three catheter regions to classify the deformity: A, connection between catheter and reservoir; B, the catheter's subcutaneous tunnel; and C, the catheter's entrance in the jugular vein. The deformations were classified in comparative manner as follows: 0 (no changes), 1 (minor changes, new slightly curvatures with an angle of >90°), and 2 (major changes, new severe curvatures with angles of ≤90°). In each position, catheter function (injection and aspiration) and displacement of the reservoir and tip were analyzed.

RESULTS

Only 15% of patients did not show a deformity; 33.3% had a deformity in only one position, 47.7% in two positions, and 10% in three positions. Minor deformities were observed in 70% of patients and major deformities in 40%. Moreover, 25% of patients presented both major and minor deformities. Major deformities were observed in 25.0% of patients on maximal frontal elevation, in 23.3% on maximal adduction and in none on maximal abduction. Region B was the most affected, with 57.8% of all minor deformities and 78.1% of all major deformities. No change in function was noted in 91.7% of the catheters. Maximal arm adduction resulted in greater vertical and horizontal displacement of the catheter tip and horizontal displacement of the reservoir. Higher body mass index values were associated with major deformities.

CONCLUSIONS

Maximal frontal elevation and maximal adduction were associated with major catheter deformities, and the subcutaneous tunnel region was the most deformed catheter region. An association between major catheter deformity and high body mass index was noted; in contrast, no association between the severity of catheter deformity, tip or reservoir displacement, or worsened functioning was observed.

Current port maintenance strategies are insufficient: View based on actual presentations of implanted ports

Nursing staff play a crucial role in maintaining a functional port. Nursing guidelines recommend standard maintenance with 10 ml irrigation without consideration for variations among patients and individual nursing staff. The aim of this study is to identify the efficacy of the current maintenance strategy and analyze the correlation between complications and actual port presentations, based on disassembled intravenous ports after removal from patients. We attempt to organize the information and propose a definite maintenance strategy.After treatment completion, or due to complications, 434 implanted intravenous ports were removed from patients. All ports were deconstructed to observe their actual presentations and were then analyzed in conjunction with medical records. The correlation between complications and actual presentations was analyzed.From March 2012 to December 2017, 434 implanted intravenous ports were removed from oncology patients after completion of treatment or catheter related complications. From the view of maintenance related presentations, injection chamber blood clot was highly correlated with chemotherapy completion (P < .001) and malfunction (P = .005), while tip blood clot (P = .043) was related with chemotherapy completion and catheter fibrin (P = .015) was related to malfunction. From the view of structure related presentations, broken catheter integrity was correlated to chemotherapy completion (P = .007), fracture (P < .001), and malfunction (P = .008). Compression groove was related to chemotherapy completion (P = .03) and broken catheter at protruding stud was related to fracture (P = .04), while diaphragm rupture was correlated to chemotherapy completion (P = .048) and malfunction. (P < .001).Current port maintenance is insufficient for ideal port maintenance, whereby maintenance-related presentations, including tip clot, catheter fibrin, and injection chamber blood clot were identified. We propose a recommended maintenance strategy based on our findings. Structure-related presentations, including broken catheter integrity, broken catheter at protruding stud and diaphragm rupture were seen in patients with longer implantation period. Removal of the implanted port may be considered after 5 years if no disease relapse is noted.

Superior Vena Cava Port Catheter Tip Confirmation: Quantified Formula for Intravascular Catheter Length versus Anatomic Landmark Reference

BACKGROUND

Adequate tip location is crucial for intravenous port implantation because it can minimize catheter-related complications. Adequate tip location cannot be observed directly and needs to be confirmed by imaging tools. A quantified intravascular catheter length formula has been proposed and we attempt to compare its clinical effectiveness with anatomic landmark references.

METHODS

During the period from March 2012 to February 2013, 503 patients who received port implantation where implanted catheter length depended on carina level as confirmed by intraoperative fluoroscopy were assigned to Group A. From March 2013 to February 2014, 521 patients who received port implantation based on quantified intravascular catheter length formula were assigned to Group B. Clinical outcomes were compared.

RESULTS

Catheter tip location of Group A, as revealed by intraoperative fluoroscopy and postoperative chest film, was 1.18 ± 0.51 and 1.1 ± 1.3 cm below carina, respectively. Catheter tip location of Group B, as revealed by intraoperative fluoroscopy and postoperative chest film, was 1.25 ± 1.05 and 1.05 ± 1.32 cm below carina, respectively. Similar catheter tip location was identified in both groups. The functional period of implanted ports, complication rate (3.58% and 2.53%), and incidence (0.049 and 0.0506 episodes/1,000 catheter days) were similar in both groups.

CONCLUSIONS

The quantified intravascular catheter length formula can predict an adequate catheter length just as well as carina do and results in good catheter tip location. The formula could replace the clinical use of anatomic landmarks and serve as an easy tool for practitioners.

Influence of venipuncture point and port chamber site on the risk of catheter fracture in right internal jugular port placements

BACKGROUND

For subcutaneously implanted central venous ports, some complications due to prolonged placement have been reported. We investigated the appropriate puncture points and port placement sites to prevent catheter fracture in right internal jugular port placement.

METHODS

This retrospective study included 709 patients who underwent right internal jugular vein puncture and port implantation in the right precordium between 1 May 2012 and 31 March 2018. The cases were divided into undamaged catheter group and damaged catheter group comprising normal and fracture cases, respectively. The catheter angle, distance from the clavicle, tip position, and curvature radius were measured from fluoroscopic images obtained at the time of implantation. The t-test was used in statistical analysis.

RESULTS

Median angles were 91.6° in the undamaged catheter group and 58.0° in the damaged catheter group. Median distances were 26.0 mm in the undamaged catheter group and 36.6 mm in the damaged catheter group. Median tip positions were 51.6 mm in the undamaged catheter group and 37.5 mm in the damaged catheter group. Median curvature radii were 9.2 R in the undamaged catheter group and 7.1 R in the damaged catheter group. Significant differences were found in the angle, height, and curvature radius between the two groups.

CONCLUSION

Our results indicate that a venipuncture as close to the clavicle as possible (less than 3 cm) and a gentle catheter curve (close to 90° angle) are associated with a lower risk of catheter fracture.

Test method for mechanical properties of implantable catheters according to DIN 10555-3

To enable causal analysis of port catheter failure, this study aimed to develop an experimental setup for uniaxial tensile tests that addresses the specific requirements of highly elastic medical catheters; and to quantify parameters of the catheters' mechanical competence with respect to effects of artificial aging. Segments of 6F-polyurethane catheters were tested in their native status, after chemical and after mechanical aging. Tension experiments were performed with a rate of 220 mm/min until catheter failure. Material behavior was analyzed based on load cell measurements of the universal test system and an additional optical distance registration. The Young's modulus, the ultimate stress and the ultimate strain were determined. Chemical aging significantly decreased Young's modulus (84%; p = 0.001) and ultimate stress (83%; p < 0.001), whereas mechanical aged samples demonstrated similar results for the Young's modulus (p = 0.772) and a non-significant rise of ultimate stress (13%; p = 0.128). Ultimate strain did not differ significantly regardless of the pretreatment. The results proof reliability, reproducibility and sensitivity to quantify artificial aging induced variations and also promise to detect deviations in material features caused by long-term clinical usage of catheters.

Percutaneous transvenous retrieval of fractured catheter in cancer patients receiving chemotherapy

OBJECTIVE

To explore the clinical efficacy and safety of percutaneous transvenous retrieval of intravascular fractured catheter and to evaluate the possible reasons and final results in cancer patients.

METHODS

A dataset of 19 patients was used. Percutaneous transvenous retrieval of intravascular fractured catheter was performed in each patients. Clinical data was retrospectively analyzed with respect to the efficacy, safety and outcome, and chest radiography was performed to verify that no catheter fragments were left.

RESULTS

Two cases had peripherally inserted central catheter and 17 had subcutaneous implanted port catheter. The catheter fragments were located in the brachiocephalic vein-superior vena cava (n = 1), superior vena cava (n = 1), superior and inferior vena cava (n = 1), superior vena cava-right atrium (n = 2), brachiocephalic vein-superior vena cava-right atrium (n = 1), superior vena cava-right atrium-right ventricle (n = 6), brachiocephalic vein-superior vena cava-right atrium and right ventricle (n = 1) and pulmonary artery (n = 6), respectively. All of these catheter fragments were retrieved successfully. No complications such as bleeding and thrombosis were found.

CONCLUSION

Percutaneous transvenous retrieval is a safe, minimally invasive and relatively simple procedure for the patients with fractured catheter and should be recommended as the first choice.

Four-dimensional CT-guided transcatheter removal of a fractured migrated catheter of a totally implantable venous access port

Patients undergoing chemotherapy usually undergo placement of a totally implantable venous access port (TIVAP), but TIVAP catheter fracture is rare. We encountered a case where flushing the TIVAP catheter became impossible because of resistance. A 61-year-old-woman underwent TIVAP placement. Although a chest X-ray revealed the fractured catheter had migrated into the right hilar area, the timing of the fracture was unclear. Four-dimensional computed tomography (4D-CT) showed that the tip of the fractured catheter was located at the anterior segmental artery of the right upper lobe and was immobile, with the remaining portion flapping with the blood flow. Transcatheter removal of the migrated catheter was judged to be possible and was performed successfully. 4D-CT may be useful as an appropriate approach in transcatheter removal of a migrated fractured catheter.

Spontaneous arterial catheter fracture and embolisation: Unpredicted complication

Arterial cannulation is a common procedure in the care and management of critically ill patients. Blood pressure measurement, arterial blood sampling and cardiac output determinations are a few primary reasons for arterial cannulation. This invasive catheter placement also imposes certain risks and clinical management problems like bleeding, thrombosis and hematoma formation. Fracture and embolisation of arterial catheters placed in the femoral region is a rare and serious complication that may result in arterial occlusion and thrombosis. Percutaneous retrieval of the foreign body is frequently reported to be the technique of choice, leaving the surgical option to a small group. We report two consecutive cases of catheter fracture that was successfully retrieved by a combination of surgery and balloon tip retrieval device.

Initial experiences with a new design for a preattached intravenous port device

All available conventional ports share a common design, including catheter, locking nut, and port body, and all share two sites of structural weakness. One site is the junction between the locking nut and the proximal end of the catheter. The other site is the catheter fixation site between the locking nut and the protruding stud of the connecting tube. To overcome these shortcomings, we designed a new type of intravenous port which combines the connecting tube into one piece. The aims of this study were to test the mechanical characteristics of the new design and assess its safety in animal study. The prototype of the preattached port was manufactured from biocompatible materials, including PEEK, silicone and polyurethane. All components were assembled with biocompatible glue and mechanical and safety tests were performed to determine the mechanical strength, and tissue reaction of surrounding soft tissue and entry vessels. The mechanical tests showed the new design would not lead to catheter fracture in the oscillation test. The traction test showed significant peak load (18.75 ± 3.29 vs. 26.61 ± 1.75 N; p = 0.036) because of the difference in catheter extension capacity (26.57 ± 4.28 vs. 47.93 ± 2.45 mm; p = 0.012). Significantly smaller endurable injection pressure was identified in the prototype. (90 ± 20 vs. 177.5± 9.48 psi; p = 0.01) The safety test showed good tolerance in beagle dogs and led to no intravascular thrombus and minimal reaction in surrounding tissues. The new prototype preattached port showed good mechanical strength and overcame two potential structural weakness points. The integrated fixation design not only reduced the dimensions of the port device but also provided a greater injection area compared to current designs. It did not cause intravascular thrombosis and produced minimal tissue reaction in surrounding soft tissue, as identified by autopsy. The new design of the fixation device could serve as the basis for the next generation of intravenous ports. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1017-1027, 2018.

Fracture of Totally Implanted Central Venous Access Devices: A Propensity-Score-Matched Comparison of Risks for Groshong Silicone versus Polyurethane Catheters

Purpose

To evaluate retrospectively the fracture risk of totally implanted venous access devices connected to Groshong silicone (SC) versus polyurethane (PU) catheters, inserted via the internal jugular vein.

Materials and methods

The study population comprised 384 SC and 221 PU central venous catheters implanted via the internal jugular vein. The presence of catheter fracture was evaluated. Variables possibly related to catheter fracture were evaluated. First, in order to determine the factors associated with fracture, fracture rates were compared with the log-rank test between the two groups divided by each of the variables. Then, in order to adjust for potential confounders, propensity-score matching of the variables was employed in the two catheter groups. Finally, the rates of fracture were compared between the two propensity-score-matched catheter groups.

Results

There were 16 cases of catheter fracture, for an overall fracture percentage of 2.6% (16/605). All 16 cases of fracture occurred in the SC catheter group. Smaller patient body mass index (p = 0.039), deeper catheter tip position (p = 0.022), and SC catheters (p = 0.019) were significantly associated with fracture. With the propensity-score-matching method, 180 cases were selected in each catheter group. Comparison of the two propensity-score-matched groups showed that fracture rates for SC catheters remained significantly (p = 0.018) higher than those for PU catheters.

Conclusions

Ports connected to Groshong SC catheters – when implanted via the internal jugular vein – posed a higher risk of fracture than did ports connected to PU catheters.

Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices: a meta-analysis of comparative studies

Background

A totally implantable venous access device (TIVAD) provides reliable, long-term vascular access and improves patients’ quality of life. The wide use of TIVADs is associated with important complications. A meta-analysis was undertaken to compare the internal jugular vein (IJV) with the subclavian vein (SCV) as the percutaneous access site for TIVAD to determine whether IJV has any advantages.

Methods

All randomized controlled trials (RCTs) and cohort studies assessing the two access sites, IJV and SCV, were retrieved from PubMed, Web of Science, Embase, and OVID EMB Reviews from their inception to December 2015. Random-effects models were used in all analyses. The endpoints evaluated included TIVAD-related infections, catheter-related thrombotic complications, and major mechanical complications.

Results

Twelve studies including 3905 patients published between 2008 and 2015, were included. Our meta-analysis showed that incidences of TIVAD-related infections (odds ratio [OR] 0.71, 95 % confidence interval [CI] 0.48–1.04, P = 0.081) and catheter-related thrombotic complications (OR 0.76, 95 % CI 0.38–1.51, P = 0.433) were not significantly different between the two groups. However, compared with SCV, IJV was associated with reduced risks of total major mechanical complications (OR 0.38, 95 % CI 0.24–0.61, P < 0.001). More specifically, catheter dislocation (OR 0.43, 95 % CI 0.22–0.84, P = 0.013) and malfunction (OR 0.42, 95 % CI 0.28–0.62, P < 0.001) were more prevalent in the SCV than in the IJV group; however, the risk of catheter fracture (OR 0.47, 95 % CI 0.21–1.05, P = 0.065) were not significantly different between the two groups. Sensitivity analyses using fixed-effects models showed a decreased risk of catheter fracture in the IJV group.

Conclusion

The IJV seems to be a safer alternative to the SCV with lower risks of total major mechanical complications, catheter dislocation, and malfunction. However, a large-scale and well-designed RCT comparing the complications of each access site is warranted before the IJV site can be unequivocally recommended as a first choice for percutaneous implantation of a TIVAD.

Association of Anaesthetists of Great Britain and Ireland: Safe vascular access 2016

Safe vascular access is integral to anaesthetic and critical care practice, but procedures are a frequent source of patient adverse events. Ensuring safe and effective approaches to vascular catheter insertion should be a priority for all practitioners. New technology such as ultrasound and other imaging has increased the number of tools available. This guidance was created using review of current practice and literature, as well as expert opinion. The result is a consensus document which provides practical advice on the safe insertion and removal of vascular access devices.

Spontaneous fracture and migration of catheter of a totally implantable venous access port via internal jugular vein--a case report

Background

The totally implantable venous access ports (TIVAPs) are indicated for patients undergoing chemotherapy, total parenteral nutrition and long-term antibiotic treatment. But, among their complications, the fracture and migration of the catheter of a TIVAP via internal jugular vein represents a very rare but potentially severe condition.

Case presentation

A 50-year-old woman indentified with a spontaneous fracture and migration of catheter of a TIVAP via right internal jugular vein after adjuvant chemotherapy for ovary cancer. She had been not evaluated and not managed with the heparin lock flush solution during three months after adjuvant chemotherapy. And then, she complained right neck bulging during saline infusion via a TIVAP and a chest radiography showed the fractured and migrated catheter of a TIVAP in right atrium. So, we emergently removed the catheter fragment by a goose neck snare via right femoral vein. After then, there was no problem.

Conclusions

If the fractured catheter of a TIVAP is detected, it is desirable to remove a fragment by an endovascular approach if it is possible.

The Treatment Results of a Standard Algorithm for Choosing the Best Entry Vessel for Intravenous Port Implantation

Vascular cutdown and echo guide puncture methods have its own limitations under certain conditions. There was no available algorithm for choosing entry vessel. A standard algorithm was introduced to help choose the entry vessel location according to our clinical experience and review of the literature. The goal of this study is to analyze the treatment results of the standard algorithm used to choose the entry vessel for intravenous port implantation.During the period between March 2012 and March 2013, 507 patients who received intravenous port implantation due to advanced chemotherapy were included into this study. Choice of entry vessel was according to standard algorithm. All clinical characteristic factors were collected and complication rate and incidence were further analyzed.Compared with our clinical experience in 2006, procedure-related complication rate declined from 1.09% to 0.4%, whereas the late complication rate decreased from 19.97% to 3.55%. No more pneumothorax, hematoma, catheter kinking, fractures, and pocket erosion were identified after using the standard algorithm. In alive oncology patients, 98% implanted port could serve a functional vascular access to fit therapeutic needs.This standard algorithm for choosing the best entry vessel is a simple guideline that is easy to follow. The algorithm has excellent efficiency and can minimize complication rates and incidence.

A comparison of outcomes and complications of totally implantable access port through the internal jugular vein versus the subclavian vein

Totally implantable access ports (TIAPs) are generally used in oncology. Few studies have addressed complications associated with the insertion site. A total of 233 consecutive oncology patients were enrolled to receive TIAP inserts via internal jugular vein (IJV) or subclavian vein (SV). Data on clinicopathologic parameters and early/late complications were retrospectively collected. No differences were found early and late complication rates. Catheter injury was observed more frequently in the IJV group (2.9%) than in the SV group (1.0%) without statistical significance. Multivariate logistic regression analysis showed that age, switch to palliative use of TIAP, and the distribution of diseases (low risk in patients with colorectal cancer) were independent risk factors for determining complications. In conclusion, TIAP insertion site showed no impact on the early and late complication rates. Catheter injury appears to occur at the same frequency with both approaches. Therefore, medical doctors may choose their preferred puncture site when performing TIAP insertion.

Deltoid branch of thoracoacromial vein: a safe alternative entry vessel for intravenous port implantation

An entry vessel is crucial for intravenous port implantation. A safe alternative entry vessel that can be easily explored is crucial for patients without feasible cephalic vein or for those who need port reimplantation because of disease relapse. In this study, we tried to analyze the safety and feasibility of catheter implantation via the deltoid branch of the thoracoacromial vein.From March 2012 to November 2013, 802 consecutive oncology patients who had received intravenous port implantation via the superior vena cava were enrolled in this study. The functional results and complications of different entry vessels were compared.The majority of patients (93.6%) could be identified as thoracoacromial vessel. The deltoid branch of the thoracoacromial vein is located on the medial aspect of the deltopectoral groove beneath the pectoralis major muscle (85.8%) and in the deep part of the deltopectoral groove (14.2%). Due to the various calibers employed and tortuous routes followed, we utilized 3 different methods for catheter implantation, including vessel cutdown (47.4%), wire assisted (17.9%), and modified puncture method (34.6%). The functional results and complication rate were similar to other entry vessels.The deltoid branch of the thoracoacromial vein is located in the neighborhood of the cephalic vein. The functional results of intravenous port implantation via the deltoid branch of the thoracoacromial vein are similar to other entry vessels. It is a safe alternative entry vessel for intravenous port implantation.

Fractures of Totally Implantable Central venous Ports: More than Fortuity. A Three-Year Single Center Experience

Purpose

Totally implantable venous access devices (Ports) represent the mainstay for infusion therapy in patients undergoing chemotherapy, total parenteral nutrition and/or long-term antibiotic treatment. Amongst mechanical complications, lesions of the catheter wall represent a rare but potentially severe condition. We report our experience with the accidental detection of catheter ruptures in a series of ports removed for complication or for end of use.

Methods

All ports removed from January 2011 to June 2013 were considered. All removed ports had been inserted according to a standardized protocol including ultrasound-guided percutaneous venipuncture (out-of-plane or in-plane approaches) and electrocardiogram-guided positioning of the tip. Once removed, each catheter was checked by inspection and saline instillation in order to evaluate the integrity of the device itself and rule out possible ruptures.

Results

In over 338 removed ports, 12 Groshong catheters out of 65 (18.5%) had evidence of partial rupture of the catheter wall. Amongst considered variables, “out-of-plane” approach and type of port (silicon, closed tip with Groshong valve) were the only ones significantly associated with catheter ruptures (p=0.0003 and 0.0008, respectively). We could detect no evidence of rupture in any silicon open-ended catheter (Celsite ports) or in any catheter inserted by “in-plane” approach to the vein.

Conclusions

The actual advantage of using port connected with Groshong silicon catheters should be questioned, since apparently they are more fragile than standard catheters. Furthermore, ultrasound-guided “out-of-plane” puncture of the internal jugular vein should be discouraged.

Embolization of a fractured central venous catheter placed using the internal jugular approach

INTRODUCTION

Fracture and embolization of central venous catheters placed via the subclavian approach is well recognized, but fractured catheters placed via the internal jugular vein are extremely rare.

PRESENTATION OF CASE

A 65-year-old man presented with a catheter embolus after placement of a central venous port using the internal jugular approach undertaken to administer adjuvant chemotherapy for colon cancer with lung metastases. Goose neck and conformational loop snares were successfully used to percutaneously retrieve the severed catheter, which had migrated to the right ventricle.

DISCUSSION

Catheter fracture may occur even after placement via the internal jugular approach and may be underestimated because it is often asymptomatic. Interventional radiology techniques using goose-neck and conformational loop snares may be useful to retract an intravascular foreign body.

CONCLUSION

Imaging studies such as a chest X-ray are mandatory to check that the catheter tip is in the appropriate position during the entire follow-up period even if it was placed through the internal jugular vein.

Is Ultrasound-guided Central Venous Port Placement Effective to Avoid Pinch-off Syndrome?

Purpose

Ultrasound (US)-guided internal jugular vein access has been the standard practice of central venous port (CVP) placement. The subclavian vein (SCV) access has also been preferred, but has potential risk of pinch-off syndrome (POS). The purpose of this study was to examine the effect of US-guided SCV access to avoid POS in patients with CVP.

Methods

Included in this study were patients who had undergone CVP placement via the SCV. We mainly assessed the computed tomography (CT) findings from two different placement techniques of a CVP via the SCV: (i) venipuncture point described by the ratio between the distance from the venipuncture point to the sternoclavicular joint and the clavicular length; and (ii) presence of direct attachment of the catheter to the clavicle. Secondary outcome was POS rate associated with two different placement techniques of CVP via the SCV.

Results

A total of 237 patients were included in this study between August 2007 and January 2011. A total of 100 patients (42.2%) underwent CVP placement using the landmark technique while 137 patients (57.8%) underwent CVP placement by US guidance. CT revealed that the US-guided technique tended to be lateral SCV approach compared with the landmark technique (p<0.001). A total of four patients (1.7%) experienced POS, all of them in the landmark group.

Conclusion

Our results showed that the US-guided technique determines a more lateral SCV approach, with a reduced POS risk than the landmark venipuncture technique.

Dislodgement of port-A catheters in pediatric oncology patients: 11 years of experience

BACKGROUND

Port-A catheters are frequently used in pediatric cancer patients. Their dislodgement is potentially seriously risky although the incidence is not high. We analyzed our 11 years of data to address this important problem.

METHODS

From January 2001 to December 2011, 330 port-A catheters of different brands were implanted in pediatric cancer patients. In total, eight children suffered a dislodgement of their catheter. Their ages ranged from four to thirteen years, with a median age of ten. Five patients presented with catheter dysfunction, two presented with a cough and one was identified incidentally during surgery to remove his port.

RESULTS

The downstream ends of the dislodged catheters were located in the right atrium (three patients), left pulmonary artery (three) and inferior vena cava (two). Six of the eight catheters were broken at the site of anastomosis to the port and the other two were broken halfway in between. All episodes of dislodgement happened after the chemotherapy regimen was completed. The dislodged catheters were successfully retrieved without complications by transcatheter retrieval using a gooseneck snare.

CONCLUSIONS

The dislodgment rate of port-A catheter in our series was 2.4%. Chest X-rays can rapidly detect the problem. Most of the catheters were broken at the site of anastomosis. Earlier explantation of port-A catheters after completing chemotherapy may be considered to avoid the dislodgement of catheters, but this needs to be weighed against the possibility of underlying disease recurrence. However, we should re-examine how long port-A catheters need to be retained after chemotherapy considering the improved cure rate of pediatric cancer.

Is catheter rupture rare after totally implantable access port implantation via the right internal jugular vein? Report of a case

Catheter rupture after totally implantable access port (TIAP) implantation via the right internal jugular vein is thought to be very rare. We report a case of catheter rupture found 682 days after TIAP surgery in a 52-year-old woman with recurrent right breast cancer. It is possible that chronic stress at the flexure of the catheter induced by neck movements caused the catheter to rupture. Therefore, when inserting a TIAP via the right internal jugular vein, the site of venous puncture should be decided on carefully. Although a fracture of this type is rarely reported in the literature, the incidence of catheter injury of a TIAP inserted via the internal jugular vein at our institute is 1.8 %. This highlights the need to educate and caution medical staff and patients about preventing catheter fracture being caused by external factors.