In-situ breakage of an implantable venous access system

A totally implantable system for venous access (Port-A-Cath, Pharmacia, Nu-tech) has now entered clinical use. This system consists of a silastic catheter secured to a stainless steel reservoir with a locking ring. The system has been shown to have several advantages when compared with earlier venous access systems. However, the advantages of total implantation have also disposed the system to new complications. Two cases are presented of patients who had this system placed and developed in-situ separation of the catheter from the reservoir. The catheter was removed surgically from the subcutaneous tissues in one patient and with a Dormain basket in the second because complete migration of the catheter into the central venous system had occurred. In neither patient could the precise cause for the separation be ascertained. However, it can be appreciated that if chemotherapeutic agents were infused in these patients the results would have been disastrous. It is recommended that if blood cannot be easily aspirated after gentle to and fro flushes with a 10 ml syringe, a chest radiograph be obtained prior to the infusion of any substance to check for continuity in the system. Any breaks in the system should be immediately repaired since migration of the catheter into the venous system can occur.     

Totally implantable central venous access ports for long-term chemotherapy

Background: A few data are available from analyses of the complications and costs of central venous access ports for chemotherapy. This prospective study deals with the complications and global costs of central venous ports connected to a Groshong catheter for deliverance of long-term chemotherapy.Patients and methods: Patients with a variety of solid neoplastic diseases requiring chemotherapy who were undergoing placement of implantable ports over a 30-month period (1 October 1994 to 31 March 1997) have been prospectively studied. Follow-up continued until the device was removed or the study was closed (30 September 1997); patients with uneventful implant experience and subsequent follow-ups of less than 180 days were not considered for this study.A single port, constructed of titanium and silicone rubber (Dome Port, Bard Inc., Salt Lake City, USA), was used, connected to an 8 F silastic Groshong catheter tubing (Bard Inc., Salt Lake City, USA). Two-hundred ninety-six devices were placed in the operating room under fluoroscopic control even in the patients treated and monitored in a day-hospital setting; 37 of them were in an angiographic suite. A central venous access form was filled in by the operator after the procedure and all ports were followed prospectively for device-related and overall complications.The average purchase cost of the device was obtained from the hospital charges, based on the costs applied during the 30-month period of the study. Insertion and maintenance costs were estimated by obtaining the charges for an average TIAP implant and its subsequent use; the costs of complication management were assessed analytically. The total cost of each device was defined as the purchase cost plus the insertion cost plus the maintenance cost plus the cost of treatment of the complications, if any. The cost of removing the TIAP was also included in the economic analysis when required by the treatment of the complication.Results: Three hundred thirty-three devices, for a total of 79,178 days in situ, were placed in 328 patients. Five patients received second devices after removal of the first. In all cases the follow-up was appropriate (median 237 days, range 180–732).Early complications included 10 pneumothoraxes (3.4%; six tube-thoracostomies were applied, 1.8%) and six revisions for port and/or catheter malfunction (overall early complications = 16, 4.48%). Late complications comprised five instances of catheter rupture and embolization (1.5%, 0.063 episodes/1000 days of use), five of venous thrombosis (1.5%, 0.063 episodes/1000 days of use), one of pocket infection (0.3%, 0.012 episodes/1000 days of use), and eight of port-related bacteremia (2.4%, 0.101 episodes/1000 days of use). The infections were caused by coagulase-negative Staphylococcus aureus (five cases), Bacillus subtilis (one case), Streptococcus lactaceae (one case) and an unknown agent (one case); port removal was necessary in six of eight cases.The total cost per patient treated for a six-month period, consisting of the costs of purchase and implantation, treatment of early and late complications, and of maintenance of the device, is US$1,970.Conclusions: This study represents the largest published series of patients with totally implantable access ports connected to a Groshong catheter. We have shown that US$2,000 are sufficient to cover six months of chemotherapy in one patient using the most expensive commercially available implantable port. According to the present study, totally implantable access ports connected to a Groshong catheter are associated with high purchase and insertion costs, a low complication rate and low maintenance costs. These data support their increasing use in current oncologic medical practice.     

Evaluation of an implantable venous access system in a general oncology population.

Venous access has been a problem for the practicing oncologist. Previous approaches, such as arteriovenous fistulas, grafts, or percutaneous catheters, have not gained widespread acceptability. We report our experiences with 230 Port-a-Cath devices, a totally implantable venous access system. The catheters were placed in 218 general oncology patients for the administration of chemotherapy. One patient had three catheters placed and 10 patients had two catheters each. Most patients received standard bolus chemotherapy, while 25 patients were treated with continuous ambulatory infusions. The catheters were in place for an average of 271 days (range 2-1,427 days) for a total of 62,330 catheter days, representing the largest published experience with devices of this type in cancer patients. A total of 24 complications occurred in 22 patients. Catheter insertion was associated with four pneumothoraces, two of which required chest tube drainage. Five catheters were removed because of infection. There were 6 cases of venous thrombosis, but none resulted in pulmonary embolism. Other complications were manageable and included catheter occlusion, migration, and extravasation of chemotherapy agents. The Port-a-Cath is safe and is associated with a low rate of complications. Implantable venous access systems represent a significant advantage in the management of oncology patients with poor venous access.     

Exchanging dual‐lumen central venous catheters: How I do it

The management of a blocked long‐term central venous catheter has traditionally been removal and re‐siting, even when device failure is not associated with venous thrombosis or sepsis. It is not possible to ‘railroad’ a split dual‐lumen central venous catheter down a long tortuous s.c. tunnel. Our exchange technique was designed to salvage the tunnel and venous access site in a long‐term catheter that has had uncomplicated primary device failure. In this technique we divide the dual‐lumen catheter and secure the venous access site and the s.c. tunnel with separate peel‐away sheaths. The new catheter is then introduced in the conventional manner through the two peel‐away sheaths, which are then removed. The key advantage of the technique is that it preserves one of the few central venous access sites available. This article describes exchange of an internal jugular catheter, but the same technique is applicable to subclavian catheters.     

Spontaneous fracture of the catheter of a totally implantable venous access port: case report of a rare complication

A case of spontaneous fracture of the outlet catheter of a totally implantable venous access port (IVAP) is presented. Thirty-seven weeks after implantation, the outlet catheter was broken at the entrance into the left subclavian vein. The distal part was embolized in the left pulmonary artery. The embolized remnant was retrieved in an outpatient setting, using a grasping forcipal catheter through a 7 French longsheath. Experimental study of the catheter revealed that it had been broken due to a local cause, probably the long-standing compression at the narrow space between clavicle and first rib. It is emphasized to ascertain the position and intactness of an IVAP before using it to infuse cytostatic agents.     

Catheter design influences recurrence of catheter-related bloodstream infection in children with cancer.

PURPOSE: Multiple studies have demonstrated that catheter-related bloodstream infections (CRBI) can be successfully treated without catheter removal (in situ therapy), but there is insufficient information available to determine if catheter design can influence the eradication of bacteremia or recurrence. PATIENTS AND METHODS: Bacteremic episodes in patients at St Jude Children's Research Hospital between January 1996 and May 2001 were identified and patient records were reviewed. RESULTS: A total of 172 unique episodes of CRBI were identified. In situ therapy resulted in successful eradication of bacteremia in 87% of the episodes. Bacteremia recurred in 10% of the episodes. Although catheter design (Hickman and Broviac versus totally implantable central venous catheter) did not influence short-term eradication of bacteremia, totally implantable central venous catheters were significantly associated with recurrence of bacteremia (odds ratio, 10; 95% confidence interval, 3.1 to 33.3). In a multivariable analysis, this association between catheter design and recurrence remained statistically significant after adjustment for other factors that influenced recurrence in this study (isolation of coagulase-negative staphylococci and inadequate duration of initial antibiotic therapy). CONCLUSION: This study demonstrates that patients with CRBI with a totally implantable central venous catheter in place are more likely to develop recurrent bacteremia. Management strategies to prevent recurrence in this setting should be explored.     

Complications from long-term indwelling central venous catheters in hematologic patients with special reference to infection

Forty-three evaluable patients with hematologic malignancies, mainly acute leukemia, were prospectively randomized to receive a double lumen central venous catheter or a totally implantable venous access system. The mean catheter stay was 166 days (median, 104 days) for the 23 double lumen catheters and 164 days (median, 65 days) for implanted systems. Exit site infections were not encountered in double lumen catheters, but there were two proven infections around the injection port of implanted devices. Tunnel infections did not occur. Seven double lumen catheters and four implanted systems were removed because of infection. Staphylococcus epidermidis was the predominant microorganism cultured from these catheters. Five of nine patients with double lumen catheters and catheter-related S. epidermidis infection and the two patients with implanted systems in whom S. epidermidis was cultured were on selective gut decontamination. The pattern of infection did not seem to be influenced by this regimen. Totally implantable systems proved to be as safe as double lumen central venous lines.     

Catheter fracture: A rare complication of totally implantable subclavian venous access devices

Catheter fracture represents a rare problem among non-infectious complications following the insertion of totally implantable long-term central venous access systems for the application of chemotherapeutic agents. A literature survey revealed a total incidence of catheter fractures of 0–2.1%. Imminent catheter fracture can be identified radiologically, using different degrees of catheter narrowing between the clavicle and the first rib, called pinch-off sign. Two cases of catheter fracture are described and potential causes are discussed. Recommendations to avoid the pinch-off sign with the subsequent risk of catheter fracture and migration include a more lateral and direct puncture of the subclavian vein. In case of catheter narrowing in the clavicular-first rib angle, patients should be followed carefully by chest X-rays every 4 weeks. Whenever possible, the system should be removed within 6 months following insertion. © 1996 Wiley-Liss, Inc.     

Totally implantable venous access ports: Retrospective review of long-term complications in 81 patients

Aim of The Study: A totally implantable venous access port (TIVAP) has become an essential prerequisite for many chemotherapy protocols. It is serving its purpose very well, but its use is not without complications. We are presenting our experience with these devices (TIVAPs). Subjects and Methods: We retrospectively reviewed the totally implantable venous access ports in 81 patients at our hospital between January 2009 and March 2011 for long-term problems which include postoperative and follow-up problems, excluding the immediate complications which occur at the time of insertion. Results: Catheter malfunction was the most common complication (9.87%, 0.40/1000 device-days of use/observation). Catheter-related bloodstream infections were present in 5 (6.17%) patients (0.25/1000 device-days of use/observation). The mean life of the catheter was 246 days. Only 11.1% ports required removal during the treatment period. Overall, patients either completed treatment (82.8%) or died (6.1%) while receiving treatment. Conclusion: TIVAPs provide safe and reliable vascular access for patients on chemotherapy but require utmost care by a dedicated team of trained medical professionals and paramedics experienced with the use of such ports, in order to minimize the complications and their continued use while administering treatment.     

Implantofix vascular access system: an experience with 19 patients

The use of implantable vascular access devices has increased rapidly in recent years. We have placed the new Implantofix Implantable Drug Delivery System 7500 in 19 patients. The patients reported only minor discomfort. The majority of the nurses found the Implantofix port easier to access than other ports, and some reported less swelling and soreness at the port site. Some of the physicians had difficulty visualizing the radiopaque catheter on X-ray; Burron is currently developing a more radiopaque system. The Implantofix system offers several important benefits. Its compact size assures minimal discomfort for the patient. A new peel-away sheath offers a choice of insertion methods. The system is particularly economical because it can be implanted in an ambulatory care facility or an outpatient surgery room equipped with fluoroscopic capabilities.     

Long-term vascular access via the inferior vena cava

A prospective evaluation of long-term venous access catheters placed via the inferior vena cava was performed to determine their efficacy as well as short- and long-term morbidity. From June 1987 to May 1989, 31 catheters were placed in 26 patients, for a total of 3,503 catheter use days. All catheters were placed via an infraumbilical approach when the more conventional supraumbilical route was technically difficult, dangerous, or impossible to be used. There were a total of 14 complications in 12 episodes (one in every 701 catheter use days), six episodes of catheter occlusion or vessel thrombosis (one in every 583 catheter use days), one catheter malfunction, one episode of cuff erosion through the skin, and one catheter that migrated through the inferior vena cava into the retroperitoneum. These results compared favorably with our experience with long-term catheters of a similar type placed via a supraumbilical approach into the superior vena cava. We conclude that the infraumbilical route for long-term central venous access is safe and technically easy and should be strongly considered in patients in whom venous access via the supraumbilical approach will be technically difficult or have a high likelihood of failure.     

Clinical evaluation of a side entry access port: a novel dual-lumen venous access device

The initial clinical experience with a low-profile side entry access (SEA) dual-lumen implantable venous access port for cancer chemotherapy administration is summarized in this report. The catheter material is polyurethane. The overall experience in 35 patients in this study was a total of 6,224 patient days, with a mean of 178 days per patient. A variety of chemotherapeutic agents, biologic response modifiers, and antibiotics were administered. In 26% of the patients, the device chambers were in simultaneous use during the treatment period. A 6% incidence of clinical subclavian vein thrombosis was noted. There was no infectious complications. Inconsistencies in blood withdrawal and temporary catheter dysfunction were comparable to other access ports in clinical use. The novel design of this side entry port and the catheter material of low thrombogenicity make this device a good option in patients requiring a low-profile system and dual access. Nursing staff should be made aware of the side entry design and that in-service training for accessing the septum is required in centers where such devices are not routinely used.     

A totally implanted venous access system used in pediatric patients with cancer

A safe and effective method of venous access is important in the care and treatment of patients with malignancies. A recently available totally implantable venous access system offers advantages over traditional central vein catheters (Broviac and Hickman, Houston). We report our experience with the implanted venous access system used in 31 pediatric patients with malignancies. The mean age of the patients was 7 years (range, 6 months to 17 years), and the mean indwelling time of the catheters was 232 days (range, 14 to 607 days; total patient days, 7,198). The catheters were used to administer chemotherapy, drugs, blood products, and parenteral nutrition, as well as to draw blood. Clotting occurred in the catheters on four occasions, requiring removal of two catheters. Fever occurred in eight patients; one developed a local infection at the site of implantation and four developed bacteremia. Our use of the implanted venous access system in children resulted in a lower rate of infection compared with that when the traditional Broviac and Hickman catheters were used, and simplified patient management.     

Chemotherapy via tunneled central venous catheter left in place between drug courses. Prospective study in 98 ambulatory patients

Chemotherapy is normally given during several months and requires a good vascular access. Repeated injections of cytotoxic agents are harmful for peripheral veins. We report here a prospective study on 98 ambulatory patients provided with a tunneled central venous catheter left in situ between drug administration. The catheter is inserted either in the subclavian or the internal jugular vein. Between chemotherapy drugs injection, heparin is given once a week in the catheter. Among the several advantages reported with this technique: easiness of drug injection, comfort of patients, possibility of new insertions in an other site in case of occlusion and the low cost. This technique is a "routine" at the Institut Curie since 5 years. Advantages and side effects of this technique are compared with arterio-venous shunting or totally implantable devices used by other authors.     

Choosing an appropriate implantable device for long-term venous access

A variety of devices is now available for venous access in patients requiring long-term infusions of chemotherapeutic agents, hyperalimentation solutions, blood products or antibiotics. All have advantages and disadvantages which may make the selection of one type of device appropriate under a given set of circumstances but inappropriate in another. Experience has shown that patients needing intensive therapy for hematologic malignancies are best served by lines that require minimal dissection for insertion, such as the Hickman catheter. Patients who are unlikely to hemorrhage at the time of insertion and who need only intermittent therapy can take advantage of the greater convenience and cosmetic appearance of a totally implantable port. Peripheral vein cannulation by means of fine silicone rubber cathethers can be performed by trained intravenous nurses to provide access of intermediate duration without the expense and inconvenience of surgical insertion in an operating room.     

三种不同囊袋切口的胸壁完全性植入式输液港#br# 术式对比#br#

目的比较几种不同囊袋切口的胸壁完全性植入式输液港的手术效果。方法回顾性分析2018年1月至2019年7月期间158例于广州市第一人民医院接受输液港植入术的患者资料。根据术式不同分为3组,隧道针 横切口组(n=47)、穿刺点 纵切口组(n=60)、穿刺点 横切口组(n=51),对3种术式的手术时间、术后并发症进行对比。结果3种术式中平均手术时间,隧道针 横切口组最长为(3136±110)min,其次为穿刺点 横切口组(2865±107)min,穿刺点 纵切口组最短为(2670±093)min,差异具有统计学意义(P<005)。并发症方面,隧道针 横切口组5例(104％),穿刺点 纵切口组10例(167％),穿刺点 横切口组7例(137％),差异无统计学意义(P>005)。结论穿刺点 纵切口、穿刺点 横切口两种术式操作更为简便,是锁骨下静脉胸壁完全性植入式输液港的理想术式。     

Venous access ports: frequency and management of complications in oncology patients

Totally implantable venous access ports have been in use now for over 20 years. They are valuable instruments for long-term intravenous treatment of patients with cancer. Apart from perioperative difficulties, the typical complications associated with venous access ports are venous thrombosis, port infection, extravasation, pinch off syndrome, dislocation, occlusion and catheter leakages. The vast majority of these complications are avoidable, or at least the complication rate can be reduced with health care personnel training and education of patients. This review will give a broad overview on the frequency and possible complications related to port devices. Furthermore, this review suggests strategies for management including proposals to avoid such complications.     

Cytostatic extravasation. A serious complication of long-term venous access

Totally implantable ports have gained popularity as venous access in the treatment of cancer. A case is reported with an uncommon but very serious complication, i.e., cytostatic extravasation secondary to a broken implanted catheter. Guidelines for implantation and remedies are recommended.     

Comparing normal saline versus diluted heparin to lock non-valved totally implantable venous access devices in cancer patients: a randomised,non-inferiority,open trial

BackgroundHeparin has been used for years as a locking solution in totally implantable venous access devices. Normal saline (NS) might be a safe alternative for heparin. However, evidence of non-inferiority of NS versus heparin is lacking.Patients and methodsWe randomly allocated 802 cancer patients with a newly inserted port either to heparin lock (300 U/3 ml) or to NS lock groups in a 1:1 assignment ratio. The primary outcome was the number of functional complications, which was defined as ‘easy injection, impossible aspiration’ at port access. Secondary outcomes included all functional problems and catheter-related bacteraemia. We hypothesised that NS locks do not cause more functional problems and catheter-related bacteraemia than heparin locks. Non-inferiority is established if the upper limit of the confidence interval (CI) for the relative risk of NS versus heparin is <1.4.ResultsThree hundred and eighty-two patients from the NS group and 383 from the heparin lock group were included in the analysis. The incidence rate of our primary outcome (easy injection, impossible aspiration) was 3.70% (95% CI 2.91%–4.69%) and 3.92% (95% CI 3.09%–4.96%) of accesses in the NS and heparin groups, respectively. The relative risk was 0.94% (95% CI 0.67%–1.32%). Catheter-related bloodstream infection was 0.03 per 1000 catheter days in the NS group and 0.10 per 1000 catheter days in the heparin group.ConclusionNS is a safe and effective locking solution in implantable ports if combined with a strict protocol for device insertion and maintenance.     

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.