Complications of Blind Placement Technique in 980 Subcutaneous Infusion Ports

Risk of venous thromboembolism associated with totally implantable venous access ports in cancer patients: A systematic review and meta-analysis

BACKGROUND

Totally implantable venous access ports (TIVAPs) for chemotherapy are associated with venous thromboembolism (VTE). We aimed to quantify the incidence of TIVAP-associated VTE and compare it with external central venous catheters (CVCs) in cancer patients through a meta-analysis.

METHODS

Studies reporting on VTE risk associated with TIVAP were retrieved from medical literature databases. In publications without a comparison group, the pooled incidence of TIVAP-related VTE was calculated. For studies comparing TIVAPs with external CVCs, odds ratios (ORs) were calculated to assess the risk of VTE.

RESULTS

In total, 80 studies (11 with a comparison group and 69 without) including 39 148 patients were retrieved. In the noncomparison studies, the overall symptomatic VTE incidence was 2.76% (95% confidence interval [CI]: 2.24-3.28), and 0.08 (95 CI: 0.06-0.10) per 1000 catheter-days. This risk was highest when TIVAPs were inserted via the upper-extremity vein (3.54%, 95% CI: 2.94-4.76). Our meta-analysis of the case-control studies showed that TIVAPs were associated with a decreased risk of VTE compared with peripherally inserted central catheters (OR = 0.20, 95% CI: 0.09-0.43), and a trend for lower VTE risk compared with Hickman catheters (OR = 0.75, 95% CI: 0.37-1.50). Meta-regression models suggested that regional difference may significantly impact on the incidence of VTE associated with TIVAPs.

CONCLUSIONS

Current evidence suggests that the cancer patients with TIVAP are less likely to develop VTE compared with external CVCs. This should be considered when choosing the indwelling intravenous device for chemotherapy. However, more attention should be paid when choosing upper-extremity veins as the insertion site.

Totally Implantable Ports Connected to Valved Catheters for Chemotherapy: Experience from 350 Groshong Devices

Purpose

There are few studies regarding the use of totally implantable valved ports for chemotherapy. The objective of this study was to analyze the results obtained from consecutive implantation of 350 devices.

Methods

Adult patients submitted to port insertion in veins of the superior vena cava system over a 17-month period (July 2006 to December 2007) were considered. The device used was composed of a titanium and silicone rubber port (Dome Port™; Bard Inc, Salt Lake City, UT) connected to an 8.0 Fr silastic Groshong™ catheter tube. Follow-up was conducted on outpatient data and during clinical readmissions, until the device was removed or the patient died.

Results

Three hundred and fifty devices, total of 74,691 days in situ, were inserted, with a median follow-up of 176 days. There were 11 early complications (3.1%) and 49 late complications (14%), 21 of these (6%) were considered major ones. Early complications comprised four instances of phlebitis of the external jugular, three of pocket infection, two of technical failure and two of ecchymosis. Late complications comprised 33 instances of withdrawal difficulty, 12 of port-related bacteremia, two of deep venous thrombosis, one of occlusion and one of catheter fracture. Out of the 350 catheters implanted, 258 (73.5%) were still being used, 73 (21%) remained in use until the patient died, five (1.5%) were removed at the end of the treatment and 14 (4%) were removed because of complications.

Conclusions

There was a low rate of major complications associated with this valved system justifying its use.

Treatment of Pneumothorax as a Complication of Long-Term Central Venous Port Placement in Oncology Patients. An Observational Study

Background and Purpose

In percutaneous placement of central venous catheters an inadvertent, direct lesion of the lung parenchyma can occur. This is a cause of iatrogenic pneumothorax, whose incidence is approximately 1 to 4%, largely dependent on the experience of the operator, the site of venipuncture and probably the technique employed. Initial treatment currently ranges from observation alone to formal tube-thoracostomy. In an attempt to define the best initial treatment, if any, we reviewed our personal series and contributions from the literature. As a result we have produced a flow-chart proposing a rational treatment of this frequent complication.

Patients and Methods

One thousand four hundred twenty-one ports were placed in patients at the Department of Surgery of the European Institute of Oncology in Milan through an infraclavicular standardized percutaneous subclavian approach. They were placed during the 60-month period from January 1, 1996 to December 31, 2000 for long-term chemotherapy treatment of solid tumours. Chest upright X-rays were obtained post-operatively in all cases to check the correct position of the catheter tip and the presence of pneumothorax.

Results

Twenty-two patients out of 1421 (1.54%) experienced a radiologically-proven pneumothorax, ranging from 5 to 70% of the affected pleural space. Sixteen patients out of 22 (72.7%) with minor portions of affected pleural space received simple observation. In these patients the most common finding was an uncomplicated tachycardia (more than 100 beats/min); 8 of them did not complain of any symptoms. Six patients (27.2%) underwent an additional procedure (3 tube-thoracostomies and 3 aspirations of the pleural space), claiming symptoms of chest pain and various degrees of dyspnea. Tube thoracostomy was mainly adopted at the beginning of our experience, and in patients with a severe degree of pleural involvement (55 to 70% of the pleural space). Aspiration, instead, was used more recently and in patients with varying degrees of pleural space involved, ranging from 40 to 60%.

Conclusions

Looking at our own series and literature data, patients with iatrogenic pneumothorax following central venous cannulation who do not have a severe underlying pulmonary disease can be reassured, at the time of diagnosis, that surgery is usually unnecessary and tube thoracostomy is rarely needed. Simple aspiration of the pleural air by means of a central venous catheter inserted percutaneously into the pleural space under local anesthesia should be considered, even if the amount of affected pleural space is more than 50%, before opting for a formal tube-thoracostomy using small-bore tubes.

[Protocol for use of subcutaneous reservoir in a gynecological oncology unit]

Use of subcutaneous reservoir has been extended in recent years in response to the need of chronic intravenous treatments. Some cancer patients and need to have a venous access maintained. In them is not advisable to use a peripheral vein, the sclerosing effect and/or irritating on the endothelium have many of the drugs administered, and the numerous venous punctures to which are often subjected. In this regard, the establishment of a permanent subcutaneous reservoir at the central level can obtain blood samples and administer all types of intravenous therapies. Although it also has the advantage of a low incidence of infections, the possibility of outpatient use and well accepted by patients. The system consists of a silicone venous catheter that is placed below the subcutaneous tissue and provides a vascular access, easy to find, secure and durable. Despite its frequent use today, this technique is not completely without risk, and among the possible complications of infectious diseases, thrombosis, catheter migration, occlusion, pneumothorax or vascular erosion. The aim of this study was to describe the protocol using the subcutaneous reservoir held in the unit of gynecologic oncology, University Hospital Virgen de las Nieves in Granada.

Jugular versus subclavian totally implantable access ports: catheter position, complications and intrainterventional pain perception

PURPOSE

To determine the safest and most tolerable method for totally implantable access ports (TIAPs) particularly in regard to patient's pain perception and catheter-related complications.

MATERIALS AND METHODS

From January 2007 to October 2008 a subcutaneous TIAP (Bardport, Bard Access System, UT, USA) was implanted in 138 oncological patients (60 male, 78 female; 18-85 years old; mean age of 56 ± 6 years) by experienced interventional radiologists. 94 TIAP were implanted through the subclavian vein (subclavian group) and 44 TIAP were implanted through the internal jugular vein (jugular group). Intrainterventional pain perception (visual analogue scale from 1 to 10), postinterventional catheter tip migration and radiation dose were documented for each method and implantation side and differences were compared with Wilcoxon t-test. For ordinal variables, comparison of two groups was performed with the Fisher's exact test.

RESULTS

No severe periinterventional complication occurred. Inadvertent arterial punctures without serious consequences were reported in one case for the jugular group versus four cases in the subclavian group. Significantly (p<0.05) lower pain perception, radiation dose and tip migration rate were observed in the jugular group. Catheter occlusions occurred in 4% (n=4) of the subclavian group versus 2% (n=1) of the jugular group. The corresponding values for vein thrombosis and catheter dislocation were 3% (n=3) and 1% (n=1) in the subclavian group, while none of those complications occurred in the jugular group.

CONCLUSION

Both techniques, the TIAP implantation via fluoroscopy-guided subclavian vein puncture and via ultrasound-guided jugular vein puncture, are feasible and safe. Regarding intrainterventional pain perception, radiation dose, postinterventional catheter tip position and port function the jugular vein puncture under ultrasound guidance seems to be advantageous.

[Femoral venous catheterization. Does it really need to be avoided?]

The guidelines to prevent central venous catheter related bloodstream infections (CVCBSI) of the Centers for Disease Control and Prevention (CDC) of 2002, Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias/ Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEMICYUC/SEIMC) of 2004, and the recently published guidelines of the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA(IDSA) of 2008 have recommended using the subclavian vein and avoiding the use of the femoral vein. They also recommend considering the use of antiseptic- or antimicrobial-impregnated CVCs for hospital units or groups of patients with a high incidence of CVCBSI. When implementing these guidelines, two questions could be asked: 1) Could the abuse of the subclavian vein and avoiding the use of the femoral vein imply a decrease in the incidence of CVCBSI, but an increase in the rate of mechanical complications as pneumothorax and/or hemothorax? 2) Couldn't antimicrobial-impregnated CVCs be used to prevent CVCBSI when the femoral venous access is used?

[Pneumothorax in human immunodeficiency virus infected patients]

INTRODUCTION

The respiratory system still continues to be a common place which deteriorates in HIV patients. Among the signs and symptoms, is the occurrence of a pneumothorax due to trauma and infections and is a cause of aggravation for these patients. The present study attempts to identify and characterise the behaviour of a group of variables in HIV patients with this complication.

MATERIAL AND METHOD

An observational, descriptive case series study was carried out. The desired variables were obtained from clinical records.

RESULTS

Of the total number, 91.67% were males, and the mean age was 32.17 years. The main causes of pneumothorax were infections, particularly due to Pneumocystis jirovecii and deep venous catheterisation. A persistent statistically significant air leak was present in 33.3% of patients and two cases of pleural sepsis. Four patients died, all with acute respiratory failure and bacterial bronchopneumonia.

CONCLUSIONS

The majority were males in the third decade of life, AIDS patients. The main causes of the pneumothorax were infections and catheterisation of the subclavian vein. Immunodepression played a significant prognostic role in the progression and outcome of the patient. Minimum pleurotomy continues to be the first treatment option in these patients, due to their precarious general state which contraindicates a major procedure. The most frequent complication was the persistent air leak, being a significant indicator of a poor prognosis in the progress of these patients. Causes of death such as acute respiratory failure and bilateral bronchopneumonia prevailed.

Central venous access: techniques and indications in oncology

Long lines can be inserted centrally or peripherally through patent veins into the central venous system down to the atrial caval junction. Traditionally surgeons, anesthetists, cardiologists and more recently interventional radiologists have been placing them using vein cutdown or percutaneous needle puncture techniques. Typical candidates for implanted venous catheters are cancer patients undergoing long-term chemotherapy. The most important issues, in addition to the patency of central veins and the history of previous indwelling catheters, pacewires or venous thrombosis, are the patient's performance status, body mass index, medical history and respiratory status, and the relevant technique. The present article will give an overview of the radiological and surgical implantation techniques and will highlight the impact of imaging means on the technical feasibility, assessment and treatment of device-related complications.