Complications associated with an implantable vascular access device

Purpose

Implantable vascular access devices (ports) are well accepted in the management of many pediatric conditions. Modifications have improved port function, patient satisfaction, and enhanced compatibility with imaging studies. We reviewed our experience with a port system and identified unique mechanical complications.

Methods

From 1998 to the present, 301 patients underwent 296 port insertions and 175 port removals. We assessed medical records, radiographs, and operative findings. The 6.6F MRI Low-Profile Implanted Port (Bard Access Systems, Salt Lake City, Utah) was used almost exclusively and was assembled by the operating surgeon. Outcome measures included port reservoir leakage, catheter dislodgment, and number of device days until complication. Ports were implanted for multiple medical problems including 74.2% in hematology/oncology patients.

Results

For 296 port insertions, 15 complications (5.1%) were identified in 13 patients (mean age, 8.4 years). Eleven leaks (3.7%) in 9 patients were found, with 9 leaks resulting from needle perforation of the port base and 2 leaks seen at the catheter connection site. Average port duration was 425 days (range, 12-1266 days) before leakage. Four patients had catheter dislodgment (1.4%), with 3 of 4 catheters embolizing to the heart or pulmonary artery. Patients were asymptomatic, and catheters were retrieved by interventional radiology. Dislodgment at the catheter-port connection site was seen in 3 of 4 cases, and average port duration was 1075 days (range, 269-2657 days) until catheter separation. Twelve of 13 patients had successful implantation of a new port system.

Conclusions

This study identifies that (1) mechanical port complications (5.1%) are not rare for this device; (2) regardless of port age, the thin plastic base may result in a risk of perforation not seen in other devices; (3) the extended period before embolization likely indicates device wear rather than faulty assembly; and (4) complications could be successfully managed including retrieval of embolized catheters.     

Permanent access to the portal vein in rats: an experimental model

A safe and reproducible method for placement of indwelling catheters into the portal venous system is a prerequisite for improved delivery of anticancer drugs to experimental liver metastases. Due to the lack of tumor models in large animals and the difficulty in establishing permanent access to the portal vein in rodents, this type of model has rarely been described in the laboratory setting. We propose a simple, minimally invasive method for repeated portal vein injections in rats. A vascular access device was used, which remained patent for periods of up to 3 months. Placement and support of the catheter tip in the portal vein was performed with a technique designed to avoid portal thrombosis and infections. Permanent portal vein access in a rodent model of liver metastases will be invaluable for the development of novel therapeutic strategies.     

Insertion of an implantable venous access device in the groin using inferior epigastric vein

BACKGROUND: Patients with cystic fibrosis (CF) need reliable venous access that can be provided by implantable venous access devices (IVAD). Such IVADs usually are placed in the upper part of the body, but placing them in this area has 3 disadvantages: a suitable vein may not be available, the portal may be conspicuous, and there may be interference with chest physiotherapy. Positioning the IVAD in the groin by using the inferior epigastric vein (IEV) is an answer to these problems. METHODS: This is a review of 29 patients from a single surgeon's practice from 1984 to 1999. A groin incision was used to implant the IVAD and to introduce the catheter via the IEV to the inferior vena cava. RESULTS: A total of 33 IVAD were inserted in 29 patients (27 with CF). The average age at first operation was 12.4 years. Infection was seen in 5. Venous thrombosis was not seen in any patient. The average longevity of IVAD is 18.5 months. Total experience is 87 IVAD years. CONCLUSION: This is a useful route of first choice for CF patients, with an overall complication rate comparable with techniques in which IVADs are placed in the upper half of body. J Pediatr Surg 36:579-581.     

Technique for placement of an implantable venous access system

Increasingly complex programs of cancer chemotherapy have necessitated a system of reliable venous access that is relatively free of infectious complications. These criteria are met by the Porta-Cath, a totally implantable system consisting of an injection port and Silastic catheter. A technique for implantation of this device has been presented. It focuses on patient safety and comfort, ease of placement, and minimization of time and expense in the operating room.     

Long-term venous access using a subcutaneous implantable drug delivery system.

To facilitate long-term venous access in patients receiving chemotherapy, a subcutaneous totally implantable system (Port-a-Cath, Phamacia) has been used in 14 patients. The method of implantation and the advantages over conventional central venous catheters are discussed. The expense of the system necessitates careful patient selection.     

植入式静脉输液港相关感染管理执行单的设计及应用

目的 开发植入式静脉输液港相关感染管理执行单,并探索其在肿瘤患者中的应用效果。方法 通过文献回顾、小组会议、半结构化访谈、专家咨询等方法设计植入式静脉输液港相关感染管理执行单。将住院患者按照病区随机分为研究组（n=160）和对照组（n=148）。对照组执行植入式静脉输液港常规护理,研究组应用执行单实施植入式静脉输液港相关感染管理。结果 干预后,研究组植入式静脉输液港相关感染发生率及感染处理耗时显著低于和短于对照组（均P＜0.05）;研究组护士植入式静脉输液港相关感染管理知信行问卷得分显著高于对照组（均P＜0.05）。结论 实施清单管理可有效降低植入式静脉输液港相关感染发生率,缩短感染控制耗时,同时提高护士相关感染控制的知识、信念和行为水平。     

植入式静脉输液港肩关节受限患者的康复训练

目的 探讨康复训练方案在植入式静脉输液港肩关节受限患者中的应用效果。方法 选取植入式静脉输液港肩部活动受限患者,按入院时间先后将69例设为对照组,采用常规握力球进行训练;72例设为干预组,采用康复训练方案进行干预。3个月后,比较两组患者肩关节活动度、日常生活活动能力及并发症发生情况。结果 两组干预后肩关节活动度前屈、外展、外旋、内旋、后伸活动度及日常生活活动能力评分显著优于本组干预前,干预后干预组关节活动度及日常生活活动能力评分显著优于对照组,血栓发生率显著低于对照组（均P＜0.05）;两组导管堵塞、异位发生率比较,差异无统计学意义（均P＞0.05）。结论 康复训练方案简单易学,容易掌握,不受场地与时间限制,能改善静脉输液港肩关节受限患者肩关节活动度、日常生活活动能力,降低患者血栓发生率。     

Fungal septicaemia in patients with cystic fibrosis associated with totally implantable venous access device system.

Fungal septicaemia is a serious and potentially fatal condition. We report 4 cases in patients with Cystic Fibrosis (CF) associated with totally implantable venous access device system (TIVADS).     

Permanent ventricular assist device support versus cardiac transplantation.

BACKGROUND: Although cardiac transplantation provides excellent therapy for some patients with terminal heart failure, the results are limited by the scarcity of donor organs, reduced long-term survival, and comorbid conditions. Current experience with temporary left ventricular assist devices suggest that a permanent, totally, or near totally implantable device may be a viable alternative. METHODS: We analyzed data from the 1997 International Society for Heart and Lung Transplantation (ISHLT) Registry and other literature on heart transplantation and compared survival and complication rates with our experience and that of others with temporary ventricular assist devices. From these data, we attempted to identify those patients who would benefit most from permanent left ventricular assist systems (LVASs). RESULTS: Among heart transplant candidates, United Network for Organ Sharing (UNOS) status II, O blood type, weight >180 lb, older age, and preformed antibodies are negative factors for receipt of donor hearts. Of patients transplanted, women and nonwhites have poorer outcomes. Success with wearable LVAS's suggest some of these patients might be better served with an LVAS than with cardiac transplantation. CONCLUSIONS: Because LVAS's could be made readily available without the need for a waiting list, they might compete well with the strategy of cardiac transplantation.     

In vivo evaluation of an implantable portal pump system for augmenting liver perfusion

BACKGROUND: Increasing portal inflow in cirrhosis using a mechanical pump reduces portal venous pressure and improves liver function. A pump has been developed for portal vein implantation in human cirrhosis. This study describes the initial in vivo evaluation in a porcine model. METHODS: Five Large White pigs underwent laparotomy and exposure of the liver. Flow in the hepatic artery, portal vein and hepatic microcirculation was monitored continuously. Hepatic tissue oxygenation was measured by near-infrared spectroscopy. After baseline measurements the pump was inserted into the portal vein. Pump flow rate was then increased stepwise to 50 per cent over the baseline value for a period of 2 h. The pump was then stopped for 20 min and left in situ while continuing to collect systemic and hepatic haemodynamic data. The animal was killed and biopsies for histological examination were taken from the liver, small intestine and spleen. RESULTS: The baseline total hepatic blood flow was 626(39) ml/min; the hepatic artery supplied 18.4(2.1) per cent and the portal vein 81.6(2.1) per cent. The pump was inserted successfully in all animals without surgical complications. During surgical insertion of the pump, the temporary portal vein occlusion resulted in a significant rise in hepatic artery blood flow (22(3) per cent; P < 0.01 versus baseline). Portal vein flow was augmented by pumping; there was a significant correlation between the pump motor speed and portal vein flow (P < 0.0001). This inflow correlated directly with flow in the hepatic microcirculation and hepatic tissue oxygenation (P < 0.001). The pump ran satisfactorily throughout the study. Histological examination revealed no evidence of structural damage to the liver or ischaemic changes in the small intestine or spleen. CONCLUSION: It is technically possible and safe to insert an implantable pump in the portal vein. Portal venous blood flow can be increased up to 50 per cent with a resultant increase in flow in the hepatic microcirculation and hepatic oxygenation and without adverse effects on either hepatic or systemic haemodynamics.     

Fibrin sleeve formation after long term brachial catheterisation with an implantable port device. A prospective venographic study.

OBJECTIVE--To evaluate the risk of thrombosis after long term venous access with an implantable port device (PAS-Port system). DESIGN--Open study. SETTING--University Hospital, Link?ping, Sweden. SUBJECTS--Sixteen patients who required central venous catheters for long term chemotherapy were prospectively followed for 218 patient months (median 12.5 months/patient, range 3-34). INTERVENTIONS--Venogram taken while the catheters were being withdrawn. Venography was also done in 10 patients 1-29 months after the catheter had been removed. RESULTS--The venograms showed that fibrin sleeves had developed along the route of the catheter in all cases (cubital vein to the superior vena cava n = 7; to subclavian vein alone n = 8; and basilic vein alone n = 1). One of the 10 patients who underwent venography 1-29 months later had developed an occlusive subclavian vein thrombosis with well developed collateral vessels 10 months after the catheter had been removed. CONCLUSION--Because of the high incidence of formation of extensive fibrin sleeves, implantable port devices should be removed as soon as they have served their purpose. If catheters malfunction they should be evaluated radiographically.     

Long-term follow-up of patients treated with an implantable left ventricular assist device as an extended bridge to heart transplantation.

Four patients were given the TCI implantable left ventricular assist device as a bridge to heart transplantation. The median treatment time was 541 days (range 462 to 873 days), with a total of 2,417 treatment days. The patients were followed with exercise tests and echocardiography 3 to 18 months after implantation. An invasive method was used for quantification of inflow valve incompetence.     

出院护理指导模式在肿瘤患者植入式静脉输液港的运用

目的观察出院护理指导在肿瘤患者植入式静脉输液港的运用效果。方法筛选我院100例使用植入式静脉输液港的肿瘤患者,按照不同护理方法将其分为常规组(50例)与观察组(50例),常规组运用常规护理,观察组强化出院护理指导,对比两组的护理效果。结果两组均未见皮下气肿、血肿及气胸等并发症,而导管堵塞、感染并发症中,常规组发生率是14.0%,观察组是6.0%,观察组低于常规组,对比差异有统计学意义(P0.05);常规组的护理满意度是86.0%,观察组是98.0%,观察组高于常规组,对比差异有统计学意义(P0.05)。结论出院护理指导在肿瘤患者植入式静脉输液港的运用效果显著,可有效降低导管堵塞、感染等并发症,显著提升护理满意度。     

蝶翼无损伤针在植入式静脉输液港应用中的常见问题及对策

目的探讨蝶翼无损伤针在植入式静脉输液港应用中的常见问题及对策,旨在提高护理技能。方法对14例应用植入式静脉输液港患者采用蝶翼无损伤针穿刺658次。结果 658次操作中,遇到问题50次,包括针刺伤、重复穿刺、患者自行拔针和输液不畅等。结论目前蝶翼无损伤针配合静脉输液港使用的临床护理经验尚不足,通过总结护理经验有助于提高护理技能。