Trigger arrhythmia to confirm the position of totally implantable access ports (TIAP)

BACKGROUND: Totally implantable access ports (TIAP) with cutdown method has few complications, but needs assessment of fluoroscopic system. METHODS: We present a method to confirm the position of TIAP catheter without fluoroscopic assessment. We use the cutdown method and trigger arrhythmia while introducing the TIAP catheter. RESULTS: This method was applied in 54 patients and no complications were found. CONCLUSIONS: Checking the position by triggering arrhythmia while performing TIAP with cephalic vein cutdown in case of C-arm was not available is simple and safe.     

Efficacy and safety of ultrasound-guided totally implantable venous access ports via the right innominate vein in adult patients with cancer: Single-centre experience and protocol

BackgroundTotally implantable venous access ports (TIVAPs) are widely used and are an essential tool in the efficient delivery of chemotherapy. This study aimed to evaluate the feasibility and safety of implantation of ultrasound (US)-guided TIVAPs via the right innominate vein (INV) for adult patients with cancer.MethodsThis study retrospectively reviewed the medical records of 283 adult patients with cancer who underwent US-guided INV puncture for TIVAPs between September 2015 and September 2017. It also analysed the technical success rate, operation time, and short-term and long-term surgical complications.ResultsTechnical success was achieved in all patients (100%). The mean operation time was 28.31 ± 7.31 min (range: 23–39 min), and the puncture success rate for the first attempt was 99.30% (281/283). Minor complications included artery puncture during the operation in one patient, but no pneumothorax was encountered. The mean TIVAP time was 304.16 ± 42.54 days (range: 38–502 days). The rate of postoperative complications was 2.83% (8/283), including poor healing of the incision in one patient, catheter-related infections in three patients, port thrombosis in one patient, and fibrin sheath formation in three patients; no catheter malposition, pinch-off syndrome, catheter fracture, or other serious complications were observed.ConclusionsTIVAPs are widely employed for chemotherapy. The present study found that the novel approach of using US-guided INV puncture to implant TIVAPs in adult patients with cancer is both short-termly feasible and safe for long-term central venous access.     

Use of totally implantable central venous access port via the basilic vein in patients with thoracic malignancies

Background  For patients with a thoracic malignancy whose peripheral veins are not suitable for blood access for chemotherapy, we evaluated a totally implantable central venous access port, in which the port is implanted in the ulnar side of the arm and the catheter is introduced via the basilic vein into the superior vena cava (TIAP-BV). Methods  Twenty-five patients (21 with lung cancer, 2 with malignant pleural mesothelioma, and 2 with thymoma) receiving TIAP-BV were included. Indications, surgical complications, and long-term complications were analyzed. Results  Indications for TIAP-BV were: chemotherapy (17 patients) and chemotherapy with parenteral nutrition (8 patients). The following surgical complications occurred: arrhythmia due to misplacement of the tip of catheter (1 patient); intraoperative conversion from the left to right arm (2 patients); and hematoma at the implantation site (1 patient). Short-term problems were: death 1 week after implantation without the use of TIAP-BV (2 patients). Long-term complications were: skin ulcer at the port site (1 patient); early removal of TIAP-BV because of port site infection (1 patient); catheter occlusion (1 patient); and venous thrombosis of basilic vein (2 patients). In the 22 patients who did not die early or have the device withdrawn early, the median duration of TIAP-BV use was 7 months (range, 1 to 20 months) without any break to the port system, leakage of drugs, or catheter-related infections. Conclusion  TIAP-BV can be employed for long-term use for chemotherapy and parenteral nutrition. However, a patient’s expected prognosis and infectious disease status at the time of implantation surgery should be considered before the surgery proceeds.     

The mechanisms of failure of totally implantable central venous access system: Analysis of 73 cases with fracture of catheter

Background

Totally implantable access ports are often used for the administration of chemotherapy or prolonged intravenous infusions in patients with cancer. The technique has been well described. However, some complications would happen. The pinch-off-syndrome is one of these complications. We report another presentation of pinch-off-syndrome and how to prevent.

Methods

From January 2005 to December 2007, 73 patients of catheter fracture were collected. The duration of Port-A implantation ranged from January 2003 to October 2007. During this period, 3358 port-catheters were implanted. There were three brands of Port-A implanted included 46% BardPort™ (Bard, Salt Lake City, UT, USA), 42% A Port (Arrow international, Reading, PA, USA) and 12% PORT-A CATH (Deltec, St. Paul, MN, USA).

Results

The most common clinical presentation was difficulty in injection in 32 cases (43.8%). The incidence of brand C was far lower than brand A and B. The most common site of fracture was at the proximal part (anastomosis between injection port and catheter) in 68 cases (93.2%). The incidence of fracture of Port-A was 6 in 738 (0.81%) in cut-down method; 67 in 2620 (2.56%) in percutaneous subclavian method. Most of thecases (34%) were no more than six months.

Conclusion

The most frequent location of fracture Port-A was in proximal part – anastomosis between injection port and catheter. The cause of easily fracture may be associated with pinch-off-syndrome and design of Port-A. This kind of fracture could be prevented by cut-down method and fixed one stitch in proximal part.     

An 11-year retrospective study of totally implanted central venous access ports: Complications and patient satisfaction

Aims

We wanted to assess the factors that predict complications and patient satisfaction of totally implanted central venous access ports (TIAP).

Methods

We reviewed 550 patients with breast or gynaecological malignancies who had initial port placement for chemotherapy between 1995 and 2006. We retrospectively assessed all TIAP complications, port duration and follow-up care until the TIAPs were removed (or the last known recorded documentation) or until the death of the patient. TIAP-related patient satisfaction was also assessed via a questionnaire-based survey of 356 patients.

Results

561 TIAPs were placed in 550 cancer patients (11 patients received 2 TIAPs during the study period); the median time of port duration was 22.5 months. There were 104 complications in this group. Of these, 81 occurred during chemotherapy treatment that lasted a median time of 182 days. Removal secondary to complication was observed in 48 cases. TIAPs placed on the left chest side, through the subclavian vein or with the catheter tip localized in the peripheral part of superior vena cava demonstrated the highest incidence of complications. Patients with a BMI >28.75 had an increased risk for developing complications. Our follow-up questionnaire revealed a 93% patient satisfaction rate with the TIAP.

Conclusions

Patients with left-sided ports, catheter tips lying in the upper part of the superior vena cava and implantation via the subclavian vein are at a higher risk for TIAP-associated complications. Being excessively overweight was assessed as another risk factor for developing complications. TIAPs are highly accepted and further recommended by patients.     

Ultrasound-assisted percutaneous catheterization of the axillary vein for totally implantable venous access device

Background

Placing a totally implantable venous access device (TIVAD) using the classical subclavian vein puncture method carries the risk of certain complications including hemothorax, pneumothorax and pinch-off syndrome. We set out to determine whether percutaneous axillary vein catheterization can decrease the incidence of these complications.

Method

This is a prospective, observational, uni-institutional study. We analyzed the outcome of 113 TIVADs performed by ultrasound-assisted percutaneous axillary vein catheterization from Jun. 2008 to Dec. 2008. Junior residents novice to subclavian and axillary vein catheterization performed the procedures. Insertion and indwelling catheter complications were recorded.

Result

In our study population, 100% of TIVAD placements were successful. 27 patients (23.9%) required 3 or more repeated punctures; only one patient (0.9%) had clinically insignificant pneumothorax. Neither arterial puncture nor brachial plexus injury was recorded in our study.

Conclusion

Ultrasound-assisted percutaneous axillary vein catheterization for TIVAD is a safe and relatively simple method for inexperienced operators.     

A comparative study between two central veins for the introduction of totally implantable venous access devices in 1201 cancer patients

Introduction and aims

The Subclavian vein has been traditionally the vein of choice for central venous catheterization by general surgeons. Alternative settings for the introduction of totally implantable venous access devices (TIVAD) and the search for lower rates of morbidity led to the choice of other central veins. This study compares two different venous accesses, the subclavian (SC) versus the internal jugular (IJ), in terms of early and late morbidity.

Patients and methods

This is a prospective, non-randomized, observational, uni-institutional (tertiary cancer centre) study. From March 2003 to March 2006, 1231 TIVADs were placed (1201 patients), in an ambulatory operating room, under vital signs and EKG monitoring, using local anaesthesia and without perioperative radiological control.

Results

Of the 1231 TIVAD, 617 were inserted via the SC and 614 via the IJ vein. The two groups (SC vs. IJ) were comparable as to general patient characteristics. Immediate complications were more frequent in the SC than in the IJ approach (respectively, 5.0% vs. 1.5%; p < 0.001); Catheter malposition occurred in 2.3% when using the SC vein and in 0.2% for the IJ (p = 0.001). Long term morbidity was also more frequent in the SC than in the IJ group (respectively, 15.8%, 87/551, vs. 7.6%, 39/512; p < 0.001). Venous thrombosis developed in 2.0% of patients with an SC TIVAD as compared to 0.6% with an IJ TIVAD (p = 0.044). Catheter malfunction was significantly dependent on the vein used: SC - 9.4% vs. IJ - 4.3% (p = 0.001).

Conclusions

Our results support the preferential use of the Internal Jugular vein for the insertion of TIVAD.     

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.     

Surgical technique for totally implantable access ports (TIAP) needs improvement: a multivariate analysis of 400 patients

BACKGROUND: The objective of this study was to analyze factors that may have an impact on the failure rate of the surgical implantation technique for totally implantable access ports (TIAP) and to assess whether morbidity rates differ between a primarily successful surgical and a secondary Seldinger approach. METHODS: Four hundred consecutive patients receiving a primary TIAP in local anesthesia were included into this retrospective cohort study. A logistic regression-model was used to evaluate reasons for failure of the TIAP method. RESULTS: Three hundred eighteen (79.5%) patients had a successful TIAP procedure, 82 patients were intraoperatively converted to a Seldinger technique. Reasons for failure were: correct positioning impossible n = 54, no or only an undersized vessel for insertion available n = 17, other reasons n = 11. Logistic regression analysis did not reveal any significant factor for failure of the primary surgical approach. In the group with primarily successful TIAP, 8 of 318 patients (3%) developed complications compared to 7 of 82 patients (9%) converted to a Seldinger technique. CONCLUSION: Failure of the surgical approach for implanting totally implantable access ports is related to insertion and positioning. Conversion to a Seldinger technique results in a higher complication rate. A modified approach for surgical port placement should be considered in order to reduce complications.     

完全植入式静脉输液港与经外周静脉穿刺中心静脉置管在儿童化疗中的个体化选择

目的:探讨恶性肿瘤患儿最合适的深静脉导管置管方式。方法:回顾性分析2013年1月至2019年8月收治的412例长期深静脉置管肿瘤患儿的临床资料。接受（totally implantable venous access port,TIVAP）患儿156例,男88例,女68例,为TIVAP组;接受经外周静脉穿刺中心静脉置管（peripherally inserted central catheter,PICC）患儿256例,男157例,女99例,为PICC组。对比两组患儿年龄、置管费用、一次性置管成功率及置管时间、置管操作中并发症发生率、留置时间、置管后并发症发生率及提前拔管发生率。结果:TIVAP组患儿年龄明显低于PICC组（P＜0.05）,但费用却明显高于PICC组（P＜0.05）;TIVAP组的一次性置管成功率略低于PICC组（P＜0.05）,两组置管时间及置管操作中并发症发生率无统计学差异（P＞0.05）;TIVAP组留置时间明显长于PICC组（P＜0.05）;PICC组患儿置管后并发症发生率及提前拔管发生率均随着时间的延长而逐渐增加（P＜0.05）;TIVAP组患儿置管后并发症发生率也随着时间延长而增加（P＜0.05）,但提前拔管发生率增加无统计学意义（P＞0.05）;置管后的前六个月,TIVAP组置管后并发症发生率及提前拔管发生率与PICC组无明显差异（P＞0.05）;而置管六个月后,TIVAP组发生率则明显低于PICC组（P＜0.05）。结论:TIVAP和PICC两种深静脉置管方式各有优缺点。对于低年龄儿童、化疗时间长于6月、患儿及家属依从性较差的的恶性肿瘤患儿,我们建议优先选择 TIVAP,但临床医生应综合考虑各方面因素,为患儿选择个体化深静脉导管留置方式。     

3 380例乳腺癌患者放置完全植入式静脉输液港化疗的并发症分析

目的探讨乳腺癌患者放置完全植入式静脉输液港(TIVAP)进行化疗时发生并发症的情况。 方法回顾性分析2013年7月至2018年4月在重庆医科大学附属第一医院成功置入TIVAP进行化疗的3 380例乳腺癌患者临床资料。统计患者并发症的发生率,并分析不同植入路径发生血栓的情况。运用拟合优度检验比较各类并发症(回抽无回血、无症状导管相关性血栓、有症状导管相关性血栓、导管相关性感染、港体外露、导管异位、药物外渗、导管破裂或脱落)构成比的差异,采用χ²检验比较不同植入路径血栓发生率的差异。 结果3 380例患者中,经颈内静脉置港3 255例、贵要静脉置港77例、腋静脉置港40例、锁骨下静脉和股静脉置港各4例;其中经左侧置港1 491例,右侧1 889例。患者留置导管时间为(136.6±39.1) d,时间范围为51.0～940.0 d。本组患者中共有1 588例发生并发症,总的并发症发生率为47.0%(1 588/3 380)。拟合优度检验结果显示,各类并发症不服从等比例分布,其中无症状导管相关性血栓占比最高(73.3%,1 164/1 588)(χ²＝5 590.217,P<0.001)。颈内静脉植入路径的血栓发生率为36.7%(1 195/3 255),贵要静脉和腋静脉植入路径的血栓发生率分别为3.9%(3/77)和2.5%(1/40),股静脉(n＝4)和锁骨下静脉(n＝4)植入路径均无血栓发生。不同植入路径血栓发生率的差异具有统计学意义(χ²＝74.460,P<0.001),其中颈内静脉植入路径血栓发生率明显高于贵要静脉和腋静脉植入路径(P均<0.050)。左、右颈内静脉植入路径血栓发生率分别为41.5%(594/1 433)和33.0%(601/1 822),两者对比,差异有统计学意义(χ²＝24.742,P<0.001)。 结论使用TIVAP进行化疗时导管相关性血栓并发症所占比例最高。为了降低导管相关性血栓的发生风险,若无禁忌证,可优先考虑贵要静脉和腋静脉植入路径。其次,经颈内静脉置入TIVAP进行化疗时植入路径优选右侧颈内静脉,且要警惕导管相关性血栓的发生。     

Outcome of cephalic vein cut-down approach: A safe and feasible approach for totally implantable venous access device placement

This study aimed to evaluate the safety and feasibility of the venous access via the cephalic vein cut-down (CVCD) approach for totally implantable venous access device (TIVAD) placements. A total of 79 patients who received TIVAD for the treatment of unresectable or recurrent colorectal carcinomas were recruited. The operation time and the complications were evaluated. Results showed the TIVAD placement via the CVCD approach was successful in 74 patients. A total of 5 patients required conversion to a percutaneous puncture approach. The mean operation time was 34.7 min. No intraoperative or postoperative complications were observed. Therefore, the CVCD approach is a safe and feasible method for TIVAD placement.     

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。     

Use of totally implantable central venous access ports for high-dose chemotherapy and peripheral blood stem cell transplantation: results of a monocentre series of 376 patients.

BACKGROUND: The complication rate of central venous totally implantable access ports (TIAP), used for high-dose chemotherapy with autologous stem cell transplantation support, has not been fully investigated to date, due to the almost exclusive use of externalised, tunnelled devices in this clinical setting. PATIENTS AND METHODS: During a 66-month period (from 1 January 1997 to 30 June 2002), 376 patients suffering from breast cancer, ovarian cancer, lymphoma or multiple myeloma were treated with high-dose chemotherapy and autologous stem cell transplantation at the European Institute of Oncology (Milan, Italy). A single type of port was used, constructed from titanium and silicone rubber, connected to a 7.8 F polyurethane catheter (Port-A-Cath; SIMS Deltec, Inc., St Paul, MN, USA) inserted into the subclavian vein. They were followed prospectively for device-related complications until the device was removed, the patient died or the study was closed (30 June 2002). RESULTS: No TIAP-related deaths were observed in this series. Seven pneumothoraxes (1.8%) occurred as a complication of TIAP placement, one patient only (0.2%) requiring a tube thoracostomy. Port pocket infection occurred twice in this series (0.53%, 0.01 episodes/1000 days of use), whereas three patients suffered from port-related bacteraemia (0.8%, 0.016/1000 days of use). Infections were successfully treated with antibiotics; all three cases had the ports removed at programme completion. Four cases of deep vein thrombosis were detected (1.06%, 0.022/1000 days of use); low molecular weight heparin was given, followed by oral anticoagulants. Finally, one case of extravasation occurred (0.26%, 0.005/1000 days of use), requiring port removal and local medical therapy. CONCLUSIONS: The use of TIAPs has resulted in a safe and effective option for high-dose chemotherapy deliverance and stem cell transplantation, in spite of inducing severe neutropenia and increasing the risk of sepsis in this category of oncology patient.