Hepatic migration of a catheter fragment followed by disconnection of a totally implantable venous access port

Totally implantable venous access ports (TIVAPs) are frequently used in oncology patients who require long-term courses of chemotherapy. We report a silent, but potentially hazardous complication of catheter fracture and hepatic migration in a 64-year-old male. The patient presented with a painful, rapid swelling of subcutaneous tissue around the port area during a saline flush. A chest radiograph showed that the disconnected catheter had separated from the port and was no longer in its original location. A chest CT scan revealed that the disconnected catheter was found to be embolized to the right atrium, inferior vena cava and right hepatic vein. The patient was treated successfully with percutaneous transfemoral retrieval of the catheter under fluoroscopic guidance. To our knowledge, there have been no previous reports of migration of the fractured catheter of a TIVAP into the right hepatic vein. This case highlights that the integrity of TIVAPs should be ascertained before chemotherapeutic drugs are administered.

The K-port concept: Proposal for optimising a fully implantable port system

Objective. Typical reasons for the malfunction of implantable central venous catheters involve obstructions caused by blood clots, perforation through the skin, and contamination of the device. The objective of introducing this new port concept is to reduce the incidence of complications by making alterations to the design.

Design. The main characteristics of this new port chamber are its drop-shaped interior, which opens into the catheter-connecting piece rather like a funnel, the lateral position of the puncture membrane, and the exchangeable catheter connection device. As a result, the following improvements with regard to conventional port catheters are feasible.

Results. The puncture is made laterally next to the port chamber in a large, previously unstressed area of skin. The subcutaneous puncture channel can be used for a greater length of time so as to avoid ascending infections. In the event of an occlusion of the catheter, a wire can be pushed through the cannula to clean it. The puncture cannula lies against the skin and can be attached more readily. Various port chamber sizes can be combined with different catheter thicknesses to best meet the individual requirements of the patient.

Current Status. The afore-mentioned port system is still at a conceptional stage of development. There are no data on practical experiences with the K-port, as licensing details have yet to be agreed upon with a manufacturer. We have applied for a patent for this device.

Pulmonary hypertension due to a retained totally implantable venous access device fragment

Pulmonary hypertension can occur from obstruction of the distal pulmonary arteries by thrombus, ova and parasites, and foreign material. We report a 62-year-old patient who had fatal pulmonary hypertension from an 8-cm fragment of a totally implantable venous access device (TIVAD) retained in the pulmonary artery. Despite long-term therapeutic anticoagulation, pulmonary angiography showed chronic occlusion of the posterior branch of the superior right pulmonary artery with paucity of distal vasculature consistent with an old right upper lobe pulmonary embolus. Retrieval of the fragment was attempted via pulmonary artery catheterization techniques but was unsuccessful. In conclusion, progressive pulmonary hypertension may result from retention of a TIVAD fragment in a central pulmonary artery despite therapeutic anticoagulation. Worsening pulmonary hypertension may have been due to partial obstruction of the main pulmonary arteries, resulting in recurrent thromboembolism or in situ thrombosis, and remodeling of small distal pulmonary arteries.

Protocol for the implantation of a venous access device (Port-A-Cath System). The complications and solutions found in 560 cases

INTRODUCTION

The cannulation of suitable peripheral veins may be a very painful experience. Implantable venous access systems have to some degree relieved this problem and help to provide an improvement in terms of quality of life.

MATERIAL AND METHODS

We have evaluated 560 patients during a follow up period of two years. A low overall complication percentage of 7.32% was seen when using the venous access device.

RESULTS

Complications and treatments were: pneumothorax; portal rotation or infection; catheter infection; embolism and migration; extravasation; partial or total obstruction of the device; rupture of the catheter or the membrane.

CONCLUSIONS

There is no other system that allows repeated venous access on such a long term basis. Placing the devices completely under the skin allows the patient to conduct a normal life style, and its maintenance does not need any special care, with the exception of the monthly heparinised serum infusion. The preferred option is to insert the catheter through the cephalic vein in the delto pectoral groove.

Comparisons of outcomes and survivals for two central venous access port systems

BACKGROUND

This study compares the outcomes and survivals between two central venous access port systems.

STUDY DESIGN

Medical records from 298 cancer patients who had received open-end (Deltec, N = 159) or closed-end (Groshong, N = 139) port catheter insertions were retrospectively reviewed.

METHODS

The infection, thrombosis, and surgical complication rates (chi-square test), as well as mean catheter-indwelling-days (t-test) were compared. Kaplan Meier analysis and stratified log rank test were used to compare actuarial survival rates. Cox proportion hazard model was applied to analyze the outcomes predictors.

RESULTS

The total catheter-indwelling-day was 116,603 days in general for this cohort. The Groshong catheters (569 +/- 386.1 days) had longer (P < 0.001) mean catheter-indwelling-day than did Deltec catheters (239 +/- 235.6 days). But the per 1,000 catheter day infection (Deltec 0.18, Groshong 0.16), thrombosis (Deltec 0.07, Groshong 0.06), and surgical complication rates (Deltec 0.07, Groshong 0.02) were equivalent (P > 0.05) between two groups. Patients with leukemia were at higher risk (odds ratio 13.4, P = 0.009) to develop adverse events. However, two types of catheters had similar actuarial survival rates at end of follow up (P > 0.05).

CONCLUSION

We found infection, thrombosis occlusion, surgical complication, and actuarial device survival rates were similar between Deltec and Groshong groups. Hematogenous malignancy was a risk factor for catheter failure.

Nonsurgical percutaneous retrieval of dislodged Port-A catheters from pulmonary artery in children

A total of 110 central venous access procedures using Port-A catheters were performed in our center for pediatric patients with oncologic or hematologic diseases over a period of 6 years from November 1994 to June 2000. Spontaneous dislodgement of the outlet catheters was noted in two cases. Both dislodged catheters were located in the left pulmonary artery and were successfully retrieved via the right femoral vein by nonsurgical transvenous snares. Awareness of the possibility of spontaneous catheter dislodgement and embolization of Port-A catheters is important as prompt retrieval will prevent further serious complications. When the procedure is performed by an open surgical method, to reduce the possibility of spontaneous catheter dislodgement, the use of a guidewire is recommended while a Port-A catheter is being inserted into the subclavian vein.

[Equipment surveillance of implantable catheter ports (1996-1998). Members of Sub-Commissions 4a and 4b for Equipment Surveillance]

We analyse all incident reports to the French Health Ministry over the 1996-1998 period, concerning implantable catheter ports. They represent 7% of all reports in the field of anaesthesia and intensive care. Two hundred eleven reports have been analysed. There were 93 catheter ruptures with 77 intravascular migrations. In more than 50% of cases, a pinch-off syndrome mechanism was responsible of these ruptures and a displacement of the O'ring was involved in 25%. Additional minor complications were reported and discussed in regard to literature. We conclude that implantable catheter ports may lead to serious incidents which are preventable in most cases.