Impact of insertion into the left internal jugular vein in chemoport-associated infections: a retrospective single-center study of 1690 cases

We analyzed chemoport insertion procedures to evaluate infectious morbidity and factors causing infection. This single-center retrospective study included 1690 cases of chemoport implantation between January 2017 and December 2020. Overall, chemoports were inserted in 1582 patients. The average duration of chemoport use was 481 days (range 1-1794, median 309). Infections occurred in 80 cases (4.7%), with 0.098 per 1000 catheter-days. Among the 80 cases in which chemoports were removed because of suspected infection, bacteria were identified in 48 (60%). Significantly more cases of left internal jugular vein punctures were noted in the infected group (15 [18.8%] vs. 147 [9.1%]; p = 0.004). Pulmonary embolism was significantly different between the infection groups (3 [3.8%] vs. 19 (1.2%), p = 0.048). The hazard ratio was 2.259 (95% confidence interval [CI] 1.288-3.962) for the left internal jugular vein, 3.393 (95% CI 1.069-10.765) for pulmonary embolism, and 0.488 (95% CI 0.244-0.977) for chronic obstructive pulmonary disease. Using the right internal jugular vein rather than the left internal jugular vein when performing chemoport insertion might reduce subsequent infections.

Vertebral Venous Congestion That May Mimic Vertebral Metastasis on Contrast-Enhanced Chest Computed Tomography in Chemoport Inserted Patients

OBJECTIVE

This study aimed to determine the prevalence of vertebral venous congestion (VVC) in patients with chemoport insertion, evaluate the imaging characteristics of nodular VVC, and identify the factors associated with VVC.

MATERIALS AND METHODS

This retrospective single-center study was based on follow-up contrast-enhanced chest computed tomography (CT) of 1412 adult patients who underwent chemoport insertion between January 2016 and December 2016. The prevalence of venous stenosis, reflux, and VVC were evaluated. The imaging features of nodular VVC, including specific locations within the vertebral body, were analyzed. To identify the factors associated with VVC, patients with VVC were compared with a subset of patients without VVC who had been followed up for > 3 years without developing VVC after chemoport insertion. Toward this, a multivariable logistic regression analysis was performed.

RESULTS

After excluding 333 patients, 1079 were analyzed (mean age ± standard deviation, 62.3 ± 11.6 years; 540 females). The prevalence of VVC was 5.8% (63/1079), with all patients (63/63) demonstrating vertebral venous reflux and 67% (42/63) with innominate vein stenosis. The median interval between chemoport insertion and VVC was 515 days (interquartile range, 204-881 days). The prevalence of nodular VVC was 1.5% (16/1079), with a mean size of 5.9 ± 3.1 mm and attenuation of 784 ± 162 HU. Nodular VVC tended to be located subcortically. Forty-four patients with VVC underwent CT examinations with contrast injections in both arms; the VVC disappeared in 70% (31/44) when the contrast was injected in the arm contralateral to the chemoport site. Bevacizumab use was independently associated with VVC (odds ratio, 3.45; P < 0.001).

CONCLUSION

The prevalence of VVC and nodular VVC was low in patients who underwent chemoport insertion. Nodular VVC was always accompanied by vertebral venous reflux and tended to be located subcortically. To avoid VVC, contrast injection in the arm contralateral to the chemoport site is preferred.

The External Jugular Vein Cut-Down Method for Chemoport Insertion from a Tertiary Cancer Treatment Center in Central India: A Prospective Study

INTRODUCTION

In the realm of oncology, the development of TIVAD (chemoport) has been a blessing for cancer patients, freeing them from having to undergo numerous recurrent venepunctures throughout their treatment. The External Jugular Vein cut-down has been the standard procedure for administering chemotherapy to cancer patients at our institution. Here, we discuss our experience with the External Jugular Vein cut-down Chemoport Insertion Technique and the outcomes it produced.

MATERIALS AND METHODS

We performed a prospective observational study and included all patients who underwent the open External Jugular Vein cut-down technique of Chemoport Insertion from January 2019 to January 2022 in the Department of Surgical Oncology at our hospital.

RESULTS

Out of 136 patients, 3 (2.2%) had failed external jugular vein (EJV) cannulation, and alternative access (Internal Jugular Vein) was chosen for cannulation. The most common indication for chemoport insertion in our study was carcinoma of the breast, around 72.93% (97/133), and hence the majority of patients were females, about 84.21% (112/133). Only 18.04% (24/133) were male patients. The age distribution ranged from 2 years to 84 years. Out of 133 patients, complications were observed in 14 patients (10.52%). Around 6 patients (4.5%) had problems with catheter blockage after one cycle of chemotherapy. 4 patients (3%) had port infections at the chamber region (pectoral region). 3 patients (2.2%) had catheter tip displacement into the brachiocephalic vein. 1 patient (0.75%) had extravasation of chemotherapy.

CONCLUSION

In conclusion, our study demonstrates that the External Jugular Vein cut-down technique offers several advantages in the realm of oncology, as it is a safe, efficient, and straightforward technique for chemoport insertion. With its minimal learning curve and simplicity, this technique represents a favorable initial option for successfully implanting chemoports in cancer patients. Further research and comparative studies are needed to validate and further explore the benefits of this technique in diverse patient populations and healthcare settings.

External Jugular Venous Cutdown versus Percutaneous Technique for Chemoport Insertion in Children: A Comparative Study

Aims

We aimed to compare the external jugular vein (EJV) cutdown technique with the percutaneous technique for difficulties in insertion, maintenance, and other complications of chemoport placement in children.

Materials and Methods

A retrospective study was carried out in children who underwent chemoport insertion between January 2007 and December 2019 either by EJV cutdown or percutaneous technique in the department of pediatric surgery at a tertiary center. All children aged <18 years undergoing chemoport insertion by EJV cutdown or percutaneous technique were included in the study. Data collected included the indication, procedure time, early and late complications, and the time to removal of chemoport.

Results

There was no significant difference between the EJV group and the percutaneous group in terms of the time taken for chemoport placement (40.9 ± 7.6 min vs. 37.6 ± 18.9 min; P = 0.14), failure to cannulate (one vs. six; P = 0.05), and the mean chemoport indwelling days (816.8 ± 729.2 days vs. 854.5 ± 705.1 days; P = 0.73). The chemoport placement by EJV cutdown method was found to have significantly fewer overall complications (4 vs. 14; P = 0.01) and a lesser rate of premature chemoport removal (4 vs. 12; P = 0.04) compared to the percutaneous group.

Conclusions

Chemoport placement by the EJV cutdown was found to have fewer port-related complications and a lesser rate of premature chemoport removal compared to the percutaneous technique. The time taken for port placement and the mean chemoport-indwelling days were similar in both techniques.

Chemoport Insertion-Less Is More

Implantable chemoport is a very useful device for long-term venous access for infusion of chemotherapeutic drugs and other agents. There are few studies from resource poor countries reporting complications of chemoport. The aim of the present study is to evaluate the feasibility of chemoport insertion without image guidance and by closed technique without direct visualisation of a major vein (mainly IJV) and to study the complications associated with the procedure. This was a prospective observational study which analysed 263 patients who underwent chemoport insertion. The medical records of these patients were analysed for the patient characteristics, diagnosis, port-related complications, and their management. A total of 263 patients who were harbouring either locoregionally advanced or metastatic tumour requiring either chemotherapy or targeted treatment or both were included in the study. In total, 133 (50.57%) were female patients and 130 were male patients (49.43%). A total of 236 patients (89.73%) underwent port insertion procedures under local anaesthesia. None of the patients had any major intra-operative complications. Postoperatively, 4 patients (1.52%) were found to have port catheter malposition; 3 out of this 4 were corrected under IITV guidance as a second procedure under local anaesthesia only. One patient (0.38%) required formal removal and replacement of port. Four patients (1.52%) developed IJV thrombosis requiring port removal and anti-coagulation. One patient (0.38%) developed thrombus in the right atrium. There were 2 port site infections (0.74%) requiring port removal (SSI cat. 5). Low complication rates of port insertion were observed in the present, large, prospective study. Complication rates may be further reduced by using a well-designed procedure, experienced surgeons, an aseptic environment, ultrasound-guided puncture, and fluoroscopy with contrast media.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-020-01265-6.

Chemoport-associated Complications and Its Management

Chemoport is being routinely used to administer chemotherapy, blood, blood products, total parenteral nutrition, and also to draw blood for investigations. We started using chemoport in our institute. We use it exclusively to administer chemotherapy. We analyzed our results of chemoport usage and confirm that the rate of complications associated with chemoport usage is at par with the available literature. We also conclude that with regular use, the intra-op and post-op complications will reduce further.

Implantable Venous Access Devices in Pediatric Malignancies - Institutional Experience in a Developing Nation

Background

Implantable venous access devices (IVAD) are preferred over long term external catheters in children due to less infection rates and better patient compliance in pediatric malignancies. Use of IVAD is a routine practice in developed part of the world. However it needs more emphasis for its widespread use in developing nation in order to improve the quality of care in children with malignancy.

Aims and Objectives

We aimed at analyzing the outcome of IVAD in pediatric malignancies in a tertiary care set up of developing nation. Our objective is to enlighten the importance and feasibility of IVAD in childhood malignancies with review of literature.

Materials and Methods

There were 152 children who underwent IVAD insertion in the study period. The parameters analyzed were indications, patient demography, size of the port, laterality of insertion, method of access to internal jugular vein (IJV), duration of surgery, time for access, complications, indication for removal and the parental satisfaction.

Results

Mean age was 48 months. 112/152 patients had hematological malignancies. Right sided IJV was used by default in 97.4% patients, while remaining 2.6% had their left IJV cannulated. Open venotomy was used in 14 cases and 138 underwent ultrasound guided IJV access. The position of the catheter was reconfirmed in the X-ray, 6-8 hours after surgery. 149/152 ports were accessed 12 hours after surgery, whereas remaining 3 had a delay in access for 24 hours. Post operative complications were divided into early and late. 141 ports were removed after completion of chemotherapy, 4 were removed due to complications. 93 of parents gave the response as "satisfied".

Conclusion

With proper training and expertise, insertion and care of IVAD is safe in pediatric malignancies without significant complications.

External Jugular Cutdown Technique for Totally Implantable Venous Access Devices: a Single-Centre Study

Chemotherapy drugs are the integral part of cancer treatment. Their administration is optimized by central venous access devices. We present our prospective study of chemoport implantation by external jugular vein cutdown technique. We studied 100 patients who underwent chemoport insertion over a span of 3 years for various solid and haematological malignancies via external jugular vein cutdown method. Outcomes such as type of disease, anaesthesia, choice of venous access, catheter tip position, length of the procedure, time to start chemotherapy and morbidity data were analysed. The Hundred /100 intravenous devices were implanted in 66% females and 33% males. Most common indication was breast cancer (64% of patients). A total of 80% of patients underwent procedure under local anaesthesia. Chemoports were inserted on the right side in 84 and left side in the remaining 16. The average surgical time was 32 min. The overall success rate was 97% with no intraoperative complications. Three postoperative complications were encountered due to displacement of catheter or wound infection. External jugular vein cutdown approach is a safe, reliable method for venous access device implantation. This approach has a high success rate and has minimal complications and can be easily learnt.

Bacteremia due to Rahnella aquatilis in a Patient with a Chemoport

Rahnella aquatilis, a saprophytic organism, is a member of the Enterobacteriaceae family. The natural habitat of this organism is fresh water, and it is rarely found in clinical specimens. Clinical conditions ascribed to this organism include bacteremia, respiratory infection, urinary tract infection, wound infection in an immunocompromised host, and infective endocarditis in patients with congenital heart diseases. Here, we report a case of bacteremia due to R. aquatilis in a woman with breast cancer who had received chemotherapy through a chemoport. To our knowledge, this is the second case of bacteremia caused by this organism in a patient with cancer in Korea.

Catheter Fracture of Subclavian Venous Chemoport Device at Costoclavicular Junction: Pinch-off Syndrome

Chemoport is most commonly used venous access devices for instillation of chemotherapeutic drugs in cancer care. Mechanical complications like catheter fracture can lead to serious morbidity, albeit occurring rarely. We present a case of a 35-year-old lady, a case of carcinoma breast, who had spontaneous fracture of chemoport access device in subclavian vein at the level of clavicle after four successful cycles of chemotherapy. The fracture was suspected on chest x-ray and was subsequently confirmed on contrast linogram. The patient was successfully managed with endovascular interventional technique without suffering any ill effects. It is a rare presentation of pinch-off syndrome.

Endovascular retrieval of foreign body in persistent left-sided superior vena cava

Endovascular retrieval of a foreign body is becoming an increasingly common procedure in the management of complications resulting from more frequent endovascular procedures. Many procedures are performed on a regular basis in assessment of vascular anatomy, endovascular-guided therapy, and catheter placement. This case report depicts a complication of a chemoport placement resulting in a foreign body. Evaluation of the foreign body raised attention to aberrant anatomy, a persistent left-sided superior vena cava. We further discuss briefly the embryology behind a persistent left-sided superior vena cava, technical errors leading to the foreign body, and assessing the nature of the foreign body through different imaging modalities. This is followed by the subsequent endovascular retrieval by Interventional Radiology and a literature review and individual case assessment of endovascular foreign body retrieval. We discuss considerations for practice based upon our literature review.

Totally Implantable Venous Access Devices in Children Requiring Long-Term Chemotherapy: Analysis of Outcome in 122 Children from a Single Institution

Children with malignancy require venous access that is reliable, safe and compliant on a long-term basis. There is little data available on utilization of totally implantable venous access devices (TIVAD) for long term chemotherapy in children in an Indian setting [1]. We report our long-term follow-up results of utilization of totally implantable venous access devices for long-term chemotherapy in children. This was a retrospective analysis of 122 children requiring long-term chemotherapy done between January 2008 and December 2013. Data collected included primary disease process, type of port, site of insertion, intraoperative events, early and late postoperative complications, and issues with utilization, maintenance and removal. 127 ports were placed in 122 children. The follow up ranged from 16 to 50 months. Internal jugular vein was accessed in 96.8 % of cases (123/127). Majority of children (61 %) had hematological malignancy. Early complications occurred in 5 children. Late complications occurred in 18 children which included port pocket infection in 3, port site skin issues in 5, catheter related issues in 3, venous thrombosis in 2 and catheter related bacteremia in 5 children respectively. Only 10 children have been lost to follow-up either due to death or discontinuation of treatment and rest are on follow up. Totally implantable venous access devices usage is safe and reliable for access needs in children for long-term chemotherapy. Their low complication and low cost maintenance should increase their utilization in children requiring long-term chemotherapy. Chemoport placement in children with hematological malignancy can be carried out safely without much impact on complication rates. Though management and compliance of children with malignancy has improved; critical analysis and standardization of port system care through prospective trials are necessary to reduce the morbidity and for cost analysis in these children.

"Difficult to flush chemoport: an important clinical sign"

A central venous access device is an intravenous device whose internal tip lies in a large central vein. Chemoport is a central venous device which serves various purposes in oncology practice apart from optimum delivery of chemotherapy. Various early and late complications have been frequently reported with the use of these devices. Fracture-embolization of the port catheter is an uncommon but life-threatening complication. Timely recognition and management is important to minimize the morbidity and mortality.

Spontaneous chemoport fracture and cardiac migration

Central venous access devices are routinely used in oncology for delivering chemotherapy of which implantable chemoports are the most common. Spontaneous breakage and migration of the catheters is a very rare but known complication of the procedure. Patients will usually present with cardiac manifestations in form of chest pain or arrythmias. Herein we report a case of spontaneous breakage and cardiac migration in which the patient was asymptomatic. Patient was successfully managed by an interventional cardiologist.