Radiology-assisted placement of implantable subcutaneous infusion ports for long-term venous access

Scarless totally implantable venous access port (TIVAP) implantation: Surgical technique, preliminary results, learning curve, and patients-reported outcome in 125 breast cancer patients

BACKGROUND

Minimal-access (endoscopic or robotic-assisted) breast surgery has been increasingly performed and shown better cosmetic results. However, location of totally implantable venous access port (TIVAP) for systemic treatment at anterior chest may compromise its aesthetic benefits. Therefore, we proposed a new scarless technique for TIVAP implantation, and reported the preliminary results, learning curve, and patients-surveyed outcome.

METHODS

Surgical technique of the new "scarless" TIVAP implantation was proposed. Patients receiving this procedure in a single institution were included. The preliminary results of the scarless TIVAP implantation, learning curve, and patient-reported outcome were analyzed and reported.

RESULTS

A total of 125 breast cancer patients received scarless TIVAP procedures were enrolled. The primary success rate of the scarless TIVAP implantation was 100%. Mean operative time was 46 ± 14 min. Mean amount of blood loss was 8.5 ± 3.2 ml. The cumulative sum plot showed operation time significantly decreased after 24th cases. In the initial learning phase, the mean operative time was 55 ± 17 min, and decreased to 43 ± 12 min in the later mature phase (P = 0.003). There were 5 (4%) complications detected, which included 1 (0.8%) seroma formation, 2 (1.6%) revisions, and 2 (1.6%) unplanned explantations. From patients-evaluated questionnaires, more than 90% of responders were satisfied with aesthetic results, experience during surgery, and application of scarless TIVAP for systemic therapy.

CONCLUSIONS

The scarless TIVAP implantation is a safe & reliable procedure with high patients-reported aesthetic satisfaction, and could be an alternative TIVAP procedure for patients requiring chemotherapy and desiring a less noticeable scar.

The risk of pocket infection or bloodstream infection following central venous port placement for the patients with Cetuximab therapy

OBJECTIVE

Cetuximab is a molecular targeted drug that targets epithelial growth factor receptors. The skin toxicity of cetuximab arising from epithelial growth factor inhibition is well known. Some patients with cetuximab therapy decided to make central venous port during the long-term intravenous treatments. Therefore, the author hypothesized that cetuximab administration might increase the risk of central venous port-related infection due to damage to skin barrier function. The main aim of the present study was to investigate the relationship between cetuximab administration and central venous port-related infection.

METHODS

A total of 83 patients had a central venous port placed from 2016 through 2021. We analyzed, retrospectively, the relationship between cetuximab therapy and the incidence of central venous port-related infection involving central line-associated bloodstream infection and pocket infection. Additionally, the risk factors of central venous port-related infection were examined in the population undergoing cetuximab therapy.

RESULTS

In total populations (83 cases), central line-associated bloodstream infection happened in five patients (6%) and pocket infection happened in six patients (7%) after central venous port placement. In the cetuximab therapy group (45 cases), there were four patients with central line-associated bloodstream infection (9%) and six with pocket infection (13%). The pocket infection happened more frequently in the cetuximab group than the other group with significant differences. Additionally, in the cetuximab group, the patients who had an interval of less than seven days between central venous port placement and cetuximab dosing, or central venous port placement preceded by cetuximab dosing had more pocket infection with significant differences.

CONCLUSION

Skin complications after the central venous port placement were related to cetuximab administration and the timing of cetuximab therapy.

Standardized procedure prevents perioperative and early complications in totally implantable venous-access ports-a complication analysis of more than 1000 TIVAP implantations

PURPOSE

Since their invention 40 years ago, totally implantable venous-access ports (TIVAPs) have become indispensable in cancer treatment. The aim of our study was to analyze complications under standardized operative and perioperative procedures and to identify risk factors for premature port catheter explantation.

METHODS

A total of 1008 consecutive TIVAP implantations were studied for success rate, perioperative, early, and late complications. Surgical, clinical, and demographic factors were analyzed as potential risk factors for emergency port catheter explantation.

RESULTS

Successful surgical TIVAP implantation was achieved in 1005/1008 (99.7%) cases. No intraoperative or perioperative complications occurred. A total of 32 early complications and 88 late complications were observed leading to explantation in 11/32 (34.4%) and 34/88 (38.6%) cases, respectively. The most common complications were infections in 4.7% followed by thrombosis in 3.6%. Parameters that correlated with unplanned TIVAP explantation were gender (port in situ: female 95% vs. male 91%, p = 0.01), underlying disease (breast cancer 97% vs. gastrointestinal 89%, p = 0.004), indication (chemotherapy 95% vs. combination of chemotherapy and parenteral nutrition 64%, p < 0.0001), and type of complication (infection 13.4% vs. TIVAP-related complication 54% and thrombosis 95%, p < 0.0001).

CONCLUSION

Standardized operative and perioperative TIVAP implantation procedures provide excellent results and low explantation rate.

Complications from port-a-cath system implantation in adults with malignant tumors: A 10-year single-center retrospective study

Background

Methods

Results

Conclusions

Chinese expert consensus and practice guideline of totally implantable access port for digestive tract carcinomas

Totally implantable access port is a fully implantable drug delivery system that is implanted subcutaneously and can be retained for a long time. Advantages of ports include a simple nursing process, low risk of infection and embolism, and high patient comfort. In order to promote the standardized application of ports in the treatment of digestive tract tumors and reduce port-related complications, the Chinese Research Hospital Association Digestive Tumor Committee, the Chinese Association of Upper Gastrointestinal Surgeons, the Chinese Gastric Cancer Association, and the Gastrointestinal Surgical Group of Chinese Surgical Society Affiliated to Chinese Medical Association have organized multidisciplinary expert discussions at the General Hospital of the People’s Liberation Army and nation-wide expert letter reviews and on-site seminars, and formulated an expert consensus of the operation guidelines.

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.

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.

Implanted vascular access device options: a focused review on safety and outcomes

Implantable vascular access devices are frequently used in patients who have poor peripheral venous access. These devices can be partially implanted as tunneled and nontunneled central catheters, or they can be fully implanted as ports. Compared with long-term catheters, implanted ports have lower infection rates and improved perceptions of quality of life, but complications still occur in 2% to 18% of patients, frequently requiring removal of the device. Since the conception of implantable vascular access device ports, numerous advances in port design, materials, and techniques for implantation and care have been developed with the goal of overcoming frequent complications. We review the evidence related to these advances and their effect on the safety profile and complications of implantable vascular access device ports.

Totally Implantable Central Venous Port Catheters: Radiation Exposure as a Function of Puncture Site and Operator Experience

BACKGROUND

Totally implantable central venous port systems provide a safe and effective, long-term means of access for administration of hyperosmolar, local irritant medication, such as chemotherapy, antibiotics and parenteral nutrition.

AIM

To evaluate the combination of access site and level of experience on fluoroscopy times (FT) and dose area products (DAP) during implantation of port catheters in a large patient population.

MATERIALS AND METHODS

A total of 1,870 patients (992 women, 878 men; age: 61±13.14 years) were reviewed investigating two groups of junior (≤50 implantations) and senior (>50) radiologists.

RESULTS

Senior radiologists required less FT/DAP (0.24 s/57.3 μGy m2 versus 0.43 s/68.2 μGy m2, respectively; p<0.001). Right jugular vein access required the least FT/DAP (0.25 s/56.15 μGy m2) and right-sided implantation lower FT/DAP (right: 0.26 s/56.4 μGy m2, left: 0.40 s/85.10 μGy m2, p<0.001).

CONCLUSION

Due to DAP/FT reductions, the right jugular vein seems to be the most favorable implantation side for port systems. For further dose reduction, residents should be well-trained.

Performance of venous port catheter insertion by a general surgeon: a prospective study

As part of the vascular access procedures, venous ports, commonly referred to as catheters, are placed under the skin to enable safe and easy vascular access for administration of repeated drug treatments. 122 patients who had received a venous port catheter insertion procedure in the general surgery department between January 1012 and January 2014 were involved in this study. Patients were divided into two groups: those who had undergone a fluoroscopy (group 1) and those who had not undergone a fluoroscopy (group 2). Complications that emerged during and after the port catheter insertion procedure and successful insertion rates were recorded in the database. Data of these patients were presented in a prospective manner. There were 92 to 30 patients in groups 1 and 2, respectively. In group 1, the mean age was approximately 56.8, total catheter stay time was 20,631 days, and mean time of port use was 224.2 days. In group 2, the mean age was approximately 61.2, total catheter stay time was 13,575 days, and mean time of port use was 452.5 days. Successful insertion rate was 100% and 90% in groups 1 and 2, respectively (P < 0.05). The proper insertion of the port catheter accompanied by monitoring methods can decrease procedure-related complications. Statistical comparisons between the two groups in terms of malposition and successful insertion rates also support this view (P < 0.05). The findings support the view that in cancer patients, a venous port catheter insertion accompanied by a fluoroscopy can be safely performed by general surgeons.

Ultrasound-Guided Radiological Placement of Central Venous Port via the Subclavian Vein: A Retrospective Analysis of 500 Cases at a Single Institute

The purpose of this study was to assess the technical success rate and adverse events (AEs) associated with ultrasound (US)-guided radiological placement (RP) of a central venous port (CVP) via the subclavian vein (SCV). Between April 2006 and May 2007, a total of 500 US-guided RPs of a CVP via the SCV were scheduled in 486 cancer patients (mean age +/- SD, 54.1 +/- 18.1 years) at our institute. Referring to the interventional radiology report database and patients' records, technical success rate and AEs relevant to CVP placement were evaluated retrospectively. The technical success rate was 98.6% (493/500). AEs occurred in 26 cases (5.2%) during follow-up (range, 1-1080 days; mean +/- SD, 304.0 +/- 292.1 days). AEs within 24 h postprocedure occurred in five patients: pneumothorax (n = 2), arterial puncture (n = 1), hematoma formation at the pocket site (n = 2), and catheter tip migration into the internal mammary vein (n = 1). There were seven early AEs: hematoma formation at the pocket site (n = 2), fibrin sheath formation around the indwelling catheter (n = 2), and catheter-related infections (n = 3). There were 13 delayed AEs: catheter-related infections (n = 7), catheter detachments (n = 3), catheter occlusion (n = 1), symptomatic thrombus in the SCV (n = 1), and catheter migration (n = 1). No major AEs, such as procedure-related death, air embolism, or events requiring surgical intervention, were observed. In conclusion, US-guided RP of a CVP via the SCV is highly appropriate, based on its high technical success rate and the limited number of AEs.

Ultrasonography-guided central venous port placement with subclavian vein access in pediatric oncology patients

BACKGROUND/PURPOSE

To evaluate the technical success and complications of image-guided central venous port (CVP) placement with subclavian vein (SCV) access in pediatric oncology population.

MATERIALS AND METHODS

Ninety-two children (52 boys, 40 girls; mean age, 8.5 years) underwent CVP implantation under local anesthesia with conscious sedation. SCV access was firstly attempted under ultrasonographic guidance and CVP implantation was performed under fluoroscopic guidance. Technical success, peri-procedural (<24h) complication, and post-procedural (>24h) complication were assessed.

RESULTS

In total, 102 CVPs were implanted in 92 children with a mean catheter time of 364 days (total, 38,224 days; range, 14-1911 days). In three small children, conversion of SCV access to internal jugular vein access yielded a primary technical success rate of 97.1% and overall technical success rate of 100%. Three minor peri-procedural complications were observed (2.9%) and seven post-procedural infectious complications occurred (infection rate, 6.7%; 0.18/1000 catheter days). No pneumothorax, catheter malposition, venous thrombosis, or mortality occurred.

CONCLUSION

Image-guided CVP placement with SCV access in a pediatric population was performed with high technical success and low complication rate without general anesthesia. This procedure can be taken into account as a choice of procedure when internal jugular venous access is not possible.

Iatrogenic percutaneous vascular injuries: clinical presentation, imaging, and management

Vascular interventional radiology procedures are relatively safe compared with analogous surgical procedures, with overall major complication rates of less than 1%. However, major vascular injuries resulting from these procedures may lead to significant morbidity and mortality. This review will discuss the etiology, clinical presentation, diagnosis, and management of vascular complications related to percutaneous vascular interventions. Early recognition of these complications and familiarity with treatment options are essential skills for the interventional radiologist.

Subcutaneous infusion ports via the internal jugular vein: single center experience

OBJECTIVE

Our purpose is to report and review the results and early complications of subcutaneous infusion port placement by our interventional radiology department.

MATERIALS AND METHODS

Three-hundred twenty-five subcutaneous infusion ports were placed in 320 patients between January 2005 and May 2010. Ports were placed under both general and local anesthesia. Five patients were catheterized twice. The internal jugular veins were used for access. Both ultrasono-graphic and fluoroscopic guidance were used in our interventions. Retrospectively, we evaluated the ports' duration time.

RESULTS

Our technical success rate was 100% and only five complications occurred during port placement. The common carotid arteries were punctured in three patients but bleeding stopped ten minutes following withdrawal of the needle and artery compression. An air embolism occurred in two patients and both were successfully treated with good positioning and suctioning. Early catheter removal was required in five patients. One patient had a right internal jugular vein thrombosis, three patients had catheter occlusions and two patients had catheter fractures. The mean duration of catheter usage was 354 days (range: 2 to 1,478 days).

CONCLUSION

Image guided placement of infusion ports has a greater success rate and lower early complication rate when compared with the unguided series. The right internal jugular vein is the first choice for infusion port access.

A single-incision technique for placement of implantable venous access ports via the axillary vein

PURPOSE

To evaluate the technical feasibility and safety of a single-incision technique for placement of implantable venous access ports via the axillary vein.

MATERIALS AND METHODS

Ports were placed in 216 patients between May and October 2012 using a single-incision technique via the axillary vein. Patients included 112 men and 104 women with a mean age of 58.2 years. After making a single vertical incision without subcutaneous tunneling, ports were placed via the left axillary vein in 172 patients and via the right axillary vein in 44 patients. Axillary vein punctures were directed medially at the incision site under ultrasound guidance. We retrospectively reviewed success rates, technical difficulties, procedure times, and immediate and delayed complications of the procedure.

RESULTS

All single-incision port placements were technically successful. Technical difficulties occurring during the procedure included advancement of the wire or catheter into an unintended vein (n = 33), kinking at the cuff-catheter junction (n = 13), bleeding via the puncture tract (n = 5), bending of the peel-away sheath (n = 3), and puncture of the axillary artery (n = 3). All technical problems were overcome with additional manipulation. The only immediate complication was puncture site hematoma in two patients. The mean follow-up period was 165.7 days, and there were no reports of port malfunction. Axillary vein thrombosis was observed in one patient.

CONCLUSIONS

The single-incision technique for placing ports via the axillary vein was a feasible and safe procedure with high technical success and low risk of complications.

Compact, power-efficient architectures using microvalves and microsensors, for intrathecal, insulin, and other drug delivery systems

This paper describes a valve-regulated architecture, for intrathecal, insulin and other drug delivery systems, that offers high performance and volume efficiency through the use of micromachined components. Multi-drug protocols can be accommodated by using a valve manifold to modulate and mix drug flows from individual reservoirs. A piezoelectrically-actuated silicon microvalve with embedded pressure sensors is used to regulate dosing by throttling flow from a mechanically-pressurized reservoir. A preliminary prototype system is demonstrated with two reservoirs, pressure sensors, and a control circuit board within a 130cm(3) metal casing. Different control modes of the programmable system have been evaluated to mimic clinical applications. Bolus and continuous flow deliveries have been demonstrated. A wide range of delivery rates can be achieved by adjusting the parameters of the manifold valves or reservoir springs. The capability to compensate for changes in delivery pressure has been experimentally verified. The pressure profiles can also be used to detect catheter occlusions and disconnects. The benefits of this architecture compared with alternative options are reviewed.

Severe neutropenia at time of port insertion is not a risk factor for catheter-associated infections in children with acute lymphoblastic leukemia

BACKGROUND

The objective of this study was to determine whether severe neutropenia on the day of port-a-catheter (PORT) insertion was a risk factor for catheter-associated infection (CAI) in children with acute lymphoblastic leukemia (ALL).

METHODS

This was a retrospective study of children with ALL who had a PORT insertion between January 2005 and August 2008. Early (≤ 30 days) and late (>30 days) postprocedure complications were reviewed. The length of follow-up ranged between 7 months and 42 months.

RESULTS

In total, 192 PORTs were inserted in 179 children. There were 43 CAIs (22%), and the infection rate was 0.35 per 1000 catheter-days. The CAI rate (15%) in children who had severe neutropenia on the day of the procedure did not differ statistically from the CAI rate (24%) in children who did not have severe neutropenia (P = .137). Conversely, patients with severe neutropenia who had a CAI were more likely to have their PORT removed (P = .019). The most common organisms to cause catheter removal were coagulase-negative Staphylococcus and Staphylococcus aureus. Patients with high-risk ALL had a statistically significant higher incidence of late CAI than patients with standard-risk ALL (P = .012). Age (P = .272), positive blood culture preprocedure (P = 1.0), and dexamethasone use (P = .201) were not risk factors for CAI. Patients who had an early CAI did not have a greater chance of having a late CAI. The catheter infection-free survival rate at 1 year was 88.6%.

CONCLUSIONS

The current results indicated that severe neutropenia on the day of PORT insertion does not increase the risk of CAI in children with ALL.

Increased use of percutaneous technique for totally implantable venous access devices. Is it real progress? A 27-year comprehensive review on early complications

BACKGROUND

First implantation of a totally implantable venous access device (TIVAD) was performed in 1982 with surgical technique. Since then, these devices have permitted infusion of total parenteral nutrition, antibiotics, blood products, and, above all, they have definitively changed the quality of life of patients with cancer. However, with the increase of percutaneous procedures, we have assisted with a concomitant raise of immediate postprocedural life-threatening complications. The aim of this study was to review the literature during a 27-year period, with regard to the changes of incidence of immediate complications after percutaneous or surgical cutdown for TIVAD's implant.

MATERIALS AND METHODS

An extensive search of relevant literature was carried out by using MEDLINE (PubMed) and Google Scholar. We gathered articles from 1982 to 2009 that quoted patient's number, type of pathology, specialist involved, number of devices implanted, site and technique of implantation (surgical cutdown or percutaneous technique), and immediate complications occurrence.

RESULTS

A total of 952 reports were screened, and finally only 45 articles addressing all inclusion criteria were used for the present study. A total of 11,430 TIVADs implanted in 11,381 patients were analyzed. Pneumothorax, hemothorax, arterial puncture, and hemoptysis developed only after percutaneous procedures. Atrial fibrillation, hematomas, and malpositioning were more frequent after percutaneous approach. The total amount of immediate complications in patients submitted to percutaneous implant was 4.5%, compared with 0.9% subsequent to cutdown technique.

CONCLUSIONS

Despite the increased use of percutaneous technique for TIVADs' implantation, surgical cutdown, because of its safety, remains the best approach to avoid possible fatal immediate complications.

Central vein dilatation prior to concomitant port implantation

Implantation of subcutaneous port systems is routinely performed in patients requiring repeated long-term infusion therapy. Ultrasound- and fluoroscopy-guided implantation under local anesthesia is broadly established in interventional radiology and has decreased the rate of complications compared to the surgical approach. In addition, interventional radiology offers the unique possibility of simultaneous management of venous occlusion. We present a technique for recanalization of central venous occlusion and angioplasty combined with port placement in a single intervention which we performed in two patients. Surgical port placement was impossible owing to occlusion of the superior vena cava following placement of a cardiac pacemaker and occlusion of multiple central veins due to paraneoplastic coagulopathy, respectively. In both cases the affected vessel segments were dilated with balloon catheters and the port systems were placed thereafter. After successful dilatation, the venous access was secured with a 25-cm-long, 8-Fr introducer sheath, a subcutaneous pocket prepared, and the port catheter tunneled to the venipuncture site. The port catheter was introduced through the sheath with the proximal end connected to a 5-Fr catheter. This catheter was pulled through the tunnel in order to preserve the tunnel and, at the same time, allow safe removal of the long sheath over the wire. The port system functioned well in both cases. The combination of recanalization and port placement in a single intervention is a straightforward alternative for patients with central venous occlusion that can only be offered by interventional radiology.

Randomized clinical trial comparing venous cutdown with the Seldinger technique for placement of implantable venous access ports

Background

The aim of this randomized controlled study was to compare the primary success rate between venous cutdown and the Seldinger technique for placement of the totally implantable venous access port (TIVAP).

Methods

A total of 152 patients were randomized to receive TIVAP placement by either venous cutdown or the Seldinger technique. The main endpoint was the primary success rate. Secondary endpoints included overall success rate, procedure time and perioperative complication rates. Multiple logistic regression analysis was undertaken to assess the influence of different variables on primary success.

Results

The primary success rate was 71 per cent for venous cutdown and 90 per cent for the Seldinger technique (P = 0·007). The mean procedure time was significantly shorter for the Seldinger technique (48·9 versus 64·8 min; P &lt; 0·001). The overall success rate was 97·4 per cent. The rate of perioperative complications was similar for the two approaches (5 per cent), but was higher when a procedure was converted. The variables sex, body mass index, implantation side and surgeon experience had no impact on the primary success rate.

Conclusion

The Seldinger technique was more effective and quicker than venous cutdown, and should be regarded as the method of choice for TIVAP placement. Registration number: NCT00272623 (http://www.clinicaltrials.gov).

Peripherally inserted tunnelled catheters: a new option for venous access

We evaluated the feasibility and optimal technique for placing peripheral tunnelled central venous catheters. Fourteen peripherally inserted central catheters (PICC) were placed using a 2-3 cm subcutaneous tunnel created in the upper arm. An additional 29 PICC lines containing a cuff were placed, using a slight modification of the same technique. Indications for placement were the same as those for a conventional PICC line. All catheters were placed successfully. There were no procedural complications. The upper arm basilic vein was used in all cases. Catheters remained in place for 1-70 days. Catheters in place for only a short period of time were removed at the bedside, longer-term catheters required a minimal amount of blunt dissection for removal of the cuff portion. We conclude that tunnelled catheters can be safely placed in the upper arm with a reliable technique. The ease of placement and lack of procedural complications, suggests that follow-up studies are warranted, to determine if these catheters can be used for applications currently requiring tunnelled subclavian or internal jugular catheters.

Wound dehiscence or failure to heal following venous access port placement in patients receiving bevacizumab therapy

PURPOSE

To determine the incidence of wound dehiscence or failure to heal after port placement in patients receiving bevacizumab therapy. A hypothesis was tested that the mean interval between bevacizumab administration and port placement was shorter in patients who had dehiscence than in those who did not.

MATERIALS AND METHODS

Medical records of all patients who had venous access ports placed from July 2006 through December 2007 were retrospectively reviewed. A total of 195 ports were placed in 189 patients (106 men) who were treated with bevacizumab within 120 days of port placement. The incidence of wound dehiscence and the significance of dose timing relative to port placement in these patients were calculated.

RESULTS

Six of 195 ports (3.1%) were associated with wound dehiscence requiring port removal. The mean interval between bevacizumab dosing and port placement in patients without dehiscence (n = 189) was 16.9 days. The mean interval in patients with dehiscence (n = 6) was 10.8 days. A two-tailed Wilcoxon test was performed, which yielded a P value of .0150. A statistically significant difference in the mean interval between bevacizumab dosing and port placement exists between patients with dehiscence and those without.

CONCLUSIONS

Wound dehiscence after port placement was related to timing of bevacizumab therapy. Patients receiving bevacizumab within 10 days of port placement had a higher incidence of wound dehiscence.

Randomized clinical trial of a modified Seldinger technique for open central venous cannulation for implantable access devices

INTRODUCTION

Totally implantable access ports (TIAPs) are often used for patients who need permanent venous access. The primary success rate using direct open insertion is about 80 per cent, so rescue strategies are needed. This study compared the primary success rates of standard open insertion and a modified Seldinger technique.

METHODS

This randomized trial recruited 164 patients scheduled for primary implantation of a TIAP and compared two interventions. The primary endpoint was the success rate of the implantation technique.

RESULTS

The primary success rates were similar: 66 (80 per cent) of 82 patients who had standard open insertion versus 69 (84 per cent) of 82 patients undergoing the modified Seldinger method (P = 0.686). A logistic mixed regression analysis including treatment group, age, Karnofsky index, body mass index and surgeon's experience showed no advantage for the Seldinger method: odds ratio 1.30 (95 per cent confidence interval 0.62 to 2.70). TIAPs were eventually implanted successfully in 163 (99.4 per cent) of 164 patients. In 11 patients randomized to standard surgery, the Seldinger method was a successful rescue strategy.

CONCLUSION

The primary success rate was similar for both open insertion methods. The modified Seldinger method is useful if standard open insertion fails.

REGISTRATION NUMBER

ISRCTN 52368201 (http://www.controlled-trials.com).

Protocol of an expertise based randomized trial comparing surgical Venae Sectio versus radiological puncture of Vena Subclavia for insertion of Totally Implantable Access Port in oncological patients

Background

Totally Implantable Access Ports (TIAP) are being extensively used world-wide and can be expected to gain further importance with the introduction of new neoadjuvant and adjuvant treatments in oncology. Two different techniques for the implantation can be selected: A direct puncture of a central vein and the utilization of a Seldinger device or the surgical Venae sectio. It is still unclear which technique has the optimal benefit/risk ratio for the patient.

Design

A single-center, expertise based randomized, controlled superiority trial to compare two different TIAP implantation techniques. 100 patients will be included and randomized pre-operatively. All patients aged 18 years or older scheduled for primary elective implantation of a TIAP under local anesthesia who signed the informed consent will be included. The primary endpoint is the primary success rate of the randomized technique. Control Intervention: Venae Sectio will be employed to insert a TIAP by a surgeon; Experimental intervention: Punction of V. Subclavia will be used to place a TIAP by a radiologist. Duration of study: Approximately 10 months, follow up time: 90 days.

Organisation/Responsibility

The PORTAS 2 – Trial will be conducted in accordance with the protocol and in compliance with the moral, ethical, and scientific principles governing clinical research as set out in the Declaration of Helsinki (1989) and Good Clinical Practice (GCP). The Center of Clinical Trials at the Department of Surgery, University Hospital Heidelberg is responsible for design and conduct of the trial including randomization and documentation of patients' data. Data management and statistical analysis will be performed by the independent Institute for Medical Biometry and Informatics (IMBI), University of Heidelberg.

Trial Registration

The trial is registered at ClinicalTrials.gov (NCT00600444).

Long-term outcomes of peripheral arm ports implanted in patients with colorectal cancer

BACKGROUND

Venous ports are mandatory for chemotherapy in cancer patients because prolonged infusions are required. The aim of this study was to assess the safety of peripheral arm ports for chemotherapy in patients with colorectal cancer.

METHODS

A peripheral venous access port was placed in the upper arm in 113 consecutive patients with metastatic colorectal cancer (MCRC). All patients received modified FOLFOX (5-fluorouracil [5-FU]/l-leucovorin [LV]/oxaliplatin [L-OHP]) 6 or FOLFIRI (5-FU/LV/irinotecan hydrochloride [CPT-11]) regimens at least once via the venous access port. All patients were followed up at least once every 2 weeks.

RESULTS

Puncture of the basilic veins was successfully completed under real-time sonographic guidance or radiographic guidance in all patients. The median operative time was 30 min. The cumulative follow-up period was 29 886 catheter days (range, 9-560 days; mean, 264 days). No procedural complications, such as pneumothorax, hemothorax, arterial puncture, or cardiovascular problems, occurred in our series. A total of nine patients (8.0%) had complications. Port-site infection occurred in six patients (5.3%; 0.20 infections per 1000 catheter-days). One patient (0.9%) had an episode of ultrasound-documented deep vein thrombosis in the ipsilateral upper extremity (0.03/1000 catheter-days). Dislocation or migration of the catheter tip occurred in two patients (0.07/1000 catheter-days). A second port was placed in six patients (5.3%) after removal of the fi rst port.

CONCLUSION

Peripheral arm ports can be maintained with excellent short-and long-term outcomes. Peripheral arm ports are considered to be a good alternative to central venous ports implanted in the chest in patients with MCRC.

Subcutaneous venous port implantation in patients with bilateral breast surgery

The purpose of this study was to evaluate the long-term follow-up results of subcutaneous venous ports implanted in patients with bilateral mastectomies. We retrospectively reviewed the hospital charts and the electronic database of 17 patients with bilateral mastectomies whom had venous port implantation in our interventional radiology suit. A total of 17 ports were implanted to the paramedian (n = 3) and anterolateral (standard; n = 12) chest wall, on the trapezius muscle (n = 1), and to the antecubital fossa (n = 1). The mean age was 48.29 years (range: 35-60 years). The mean time interval from time of surgery to port implantation was 34 months (range: 1-84 months). The mean follow-up time was 15 months (range: 7-39 months). Follow-up parameters and classification of the complications was defined according to the SIR guidelines. No procedure-related complication occurred. A single case of mild late infection was noted and the infection rate was 0.19/1000 catheter days. Infusion chemotherapy administration was still going on in eight patients. Two patients died during the follow-up and four patients were lost after 6 months. Port removal was performed in three patients at follow-up because of the end of treatment. One trapezius port and one paramedian port weres among the removed ports without any problem. Although we have a limited number of patients, port placement to the anterior chest wall, either paramedian or anterolateral, on the trapezius muscle or to the antecubital fossa depending on the extent of the bilateral breast surgeries that can be performed with low complication rates by a careful patient and anatomical location selection by involving the patients in the decision-making process. We believe that patient education and knowledge of possible complications have high importance in follow-up.

Evaluation of Catheter Loops in Central Venous Port Systems

OBJECTIVES

We sought to evaluate the cause for catheter loops of central venous ports.

MATERIAL AND METHODS

A total of 241 patients who received a central venous port via subclavian vein access were included in this retrospective study. Eighty of these patients had undergone a computed tomography of the chest, allowing retrospective evaluation of the course of central venous catheters. Complications were evaluated by review of the clinical data charts.

RESULTS

In 49 patients, the catheter penetrated only the major pectoralis muscle. Only one of these patients (2.0%) showed a loop. In 31 cases, the catheter went through both the major and minor pectoralis muscle, and in 26 of these patients (83.9%), a loop was seen. Complications after port implantation were catheter occlusion (n = 2), pneumothorax (n = 2), thrombosis (n = 2), infection (n = 1), and catheter dislocation (n = 1).

CONCLUSIONS

The loop of catheter of central venous ports is caused by catheter penetration through pectoralis major and minor.

Un épanchement pleural liquidien compliquant une chambre à cathéter implantable

INTRODUCTION

Totally implanted venous devices (TIVD) are an essential tool for repeated intravenous treatments such as chemotherapy for cancer and antibiotics for cystic fibrosis.

CASE REPORT

A woman of 76 years was treated for bronchiectasis, colonised by Pseudomonas aeruginosa, with courses of intravenous antibiotics. On account of poor peripheral veins a TIVD was implanted. The implantation and subsequent antibiotic injections were uncomplicated. Three years later a further course of antibiotics was prescribed. As no reflux of blood was obtained on puncturing the device the position of the catheter was checked radiologically. The patient complained of right shoulder pain following each infusion. The chest x-ray showed a pleural effusion. The sudden onset of the effusion, the absence of signs of infection and the patient's good clinical condition suggested pleural extravasation of the antibiotic infusion from the TIVD. Pleural aspiration yielded 1400 mls of watery fluid. Injection of contrast into the TIVD confirmed intra-pleural extravasation.

CONCLUSION

When using a TIVD it is important to bear in mind the possibility of late pleural complications.

Implantation of central venous ports with catheter insertion via the right internal jugular vein in oncology patients: single center experience

AIM OF WORK

Evaluation of suitability and safety of venous port implantation with catheter insertion via the right internal jugular vein in oncology patients.

PATIENTS AND METHODS

One hundred one totally implantable venous ports were placed in 100 patients with malignancies from January 1, 2003 until March 31, 2005. Catheter of venous port was preferably inserted via the right internal jugular vein. We recorded a number of successful implantations using this venous approach and the rate of complications during the procedure and follow-up.

MAIN RESULTS

Ninety-seven catheters (96%) of totally implantable venous ports were inserted via the right internal jugular vein in 96 patients, and only in four cases were we not able to access this vein. We had no complications related to catheter insertion via the right internal jugular vein. Follow-up was made in all 96 patients with a total access days of 41 in 151 days (mean: 407 days). Premature catheter removal was required in six (6.2%, 0.144 per 1,000 access days) due to complications: three catheter dislocations/malfunctions (3.1%, 0.072 per 1,000 access days), one port-related sepsis, one pocket port infection, and one decubitus over port (1%, 0.024 per 1,000 access days). Six venous ports were removed after completion of the treatment at the patient's request.

CONCLUSION

The placement of totally implantable venous ports with catheter insertion via the right internal jugular vein has a high success rate without any early complications. Follow-up also demonstrates a low incidence of late complications requiring port removal.

Managing peripherally inserted central catheter-related venous thrombosis: How I do it

Imaging-guided insertion of central venous catheters, either in the form of a peripherally inserted central catheter (PICC) or through a subclavian or a jugular approach, is becoming the preferred method of acquiring long-term venous access for a variety of therapeutic purposes. The most significant complication from central venous catheters is thrombosis of the catheterized vein. Venous thrombosis related to the insertion of PICC lines is conventionally treated with line removal followed by anticoagulation. Direct thrombolysis with urokinase, using the lumen of the PICC line to facilitate the insertion of the infusion catheter is a simple, safe and effective treatment option. In this article, we describe our experience with this procedure and the technique used.

Radiological and surgical placement of port devices: a 4-year institutional analysis of procedure performance, quality of life and cost in breast cancer patients

PURPOSE

The present study is designed to evaluate and compare percutaneous radiologic arm port (R) and surgical subclavian port (S) devices in two homogeneous sets of breast cancer patients in terms of safety, efficacy, quality of life (QoL) and cost analysis.

MATERIAL AND METHODS

This study involved a retrospective review of a prospective databank including 200 consecutive port device implantation attempted procedures performed over a 4-year period, in two similar groups of 100 breast cancer women who underwent either the surgical cephalic vein cutdown approach or the percutaneous basilic vein catheterization for intravenous adjuvant chemotherapy. Parameters analyzed included technical success, procedure duration, complications, QoL and cost evaluation for both techniques.

RESULTS

The success rate for port implantation was higher for R than for S placement (96% versus 91%). Mean implant duration time was 5.6 and 7.6 months for R and S, respectively. The overall complication rate was 10 and 16% for R and S, respectively. Mean implant duration time, without any complication or death, was 6.4 and 7.8 months for R and S, respectively. Six and seven percent for R and S, respectively, had to be removed prematurely. Both techniques exhibited very good QoL. Direct costs were respectively euro 230.8 and 219.1 for R and S, respectively.

CONCLUSION

The significant advantages of R over S include higher success rate, higher cosmetic results despite a 15% relative overcost for R placement. Both are indicated for breast cancer chemotherapy treatment, nevertheless R placement is mandatory in anxious patients who fear surgery, in case of previous cervico-thoracic irradiation or upper extremity venous thrombosis, or in patients at risk of respiratory insufficiency.