Implantable Central Venous Access Devices Research Articles

Safety of Insertion of Percutaneous Totally Implantable Central Venous Access Devices by Surgical Residents.

To compare the outcomes of totally implantable central venous access device (TIVAD) insertions by surgical residents (SRs) with those by experienced surgeons (ESs) and establish the safety of percutaneous TIVAD insertion by SRs. A total of 700 insertions were successfully performed between January 2015 and December 2019 in our Department. The puncture site conversion and complication rates were compared, and risk factors related to complications were analysed. In total, 84 and 616 insertions were performed in the SR and ES groups, respectively. SRs mainly punctured the internal jugular vein (IJV), and ESs punctured the subclavian vein (SV). The conversion rate from the IJV to SV was similar, whereas that from the SV to IJV was higher by SRs than ESs. Overall, early, and delayed complications were similar between the two groups. Percutaneous TIVAD inserted into the IJV by an SR was demonstrated to be safe.

Detachment and embolization of totally implantable central venous access devices: diagnosis and management

Background Detachment and embolization (DE) is a rare complication of totally implantable central venous access devices (TIVADs). This study aimed to analyze clinical findings, etiology, and treatment options in DE of TIVADs. Methods Patients who experienced DE between 2010–2019 were included. Indications, implantation techniques, time to diagnosis, patient complaints, diagnostic methods, rupture site, location of embolization, treatment methods, and chest X-rays prior to detachment were analyzed retrospectively. Results DE of TIVAD was detected in 12(1.2%) patients. Eleven patients had breast cancer and one had colon cancer. Mean age at implantation was 45.3 ± 9.6(31–61.3) years. Seven (58%) patients were asymptomatic, four (33.3%) had TIVAD malfunction, and one (8.3%) had pain and swelling at port site after injection. Mean time from implantation to diagnosis was 1149.92(16–2795) days. The etiologies comprised Pinch-off Syndrome (POS) in eight (66%) patients, detachment directly adjacent to the lock mechanism in three (25%) patients, and probable iatrogenic injury during explantation in one (9%) patient. The most common site of embolism was the superior vena cava (25%). While the embolized fragment was removed percutaneously in 11 patients, medical follow-up was treatment choice for one patient. Conclusions DE is a rare complication with an incidence rate of 1.2% in this study. Since most patients were asymptomatic, chest radiography plays an important role in diagnosis. The most common cause was POS, and it can be prevented by inserting the catheter from lateral third of the clavicle during subclavian vein catheterization. The first-choice treatment was percutaneous femoral retrieval. However, if not technically possible, alternative treatment options are thoracotomy or follow-up with anticoagulant therapy.

Bactericidal and Antiproliferative Effects of Peripheral Parenteral Nutrition Solutions with Sodium Bisulfite on Pathogenic Microorganisms in Catheter Lumens.

Catheter-related bloodstream infections (CRBSIs) due to pathogenic microorganisms pose a major threat to patients requiring parenteral nutrition (PN). Additives contained in medicines and foods have antiproliferative and bacteriostatic effects on pathogenic microorganisms. Therefore, PN solutions containing additives may also have an antibacterial effect. However, so far, there have been no reports on or observations of a PN solution with bactericidal activity. In this study, we assessed several nutrition solutions with antimicrobial activities and investigated their effects on pathogenic microorganisms colonizing catheter lumens. We selected the highly acidic Plas-Amino® (PA), which contains a large amount of sodium bisulfite as a preservative and potentially has an antimicrobial effect. In this study, we used the following pathogenic bacteria as the main causatives of CRBSIs: Staphylococcus aureus, Staphylococcus epidermidis, Bacillus cereus, Serratia marcescens, Pseudomonas aeruginosa, and Candida albicans. We then created a catheter lumen microorganism contamination model and evaluated the antibacterial effect of PA; we found that all bacteria in the control group grew significantly in the catheter lumen in a time-dependent manner at 48 and 72 h. On the other hand, we demonstrated that PA has bactericidal effects on S. aureus, S. epidermidis, B. cereus, S. marcescens, and P. aeruginosa in the catheter lumen and confirmed that it has a remarkable antiproliferative effect on C. albicans. Hence, we concluded that highly acidic PN solutions that contain a preservative like sodium bisulfite have bactericidal and growth inhibition effects on microorganisms in the catheter lumens of patients with CRBSIs and patients with totally implantable central venous access devices, in whom it is difficult to remove the catheter.

Cephalic Vein Cut-down for Totally Implantable Central Venous Access Devices With Preoperative Ultrasonography by Surgical Residents.

Cephalic vein (CV) cut-down for totally implantable central venous access devices (TICVADs) is not frequently used due to its low success rate. We compared the outcomes of CV cut-down using preoperative ultrasonography (US) performed by experienced surgeons versus surgical residents. From December 2015 to December 2017, 10 surgeons implanted 212 TICVADs using CV cut-down with preoperative US. The surgeons were divided into two groups of five each: surgical residents (Group A, n=124 procedures) and experienced surgeons (Group B, n=88 procedures). Duration of operation time, completion rate, and complications were retrospectively analyzed. The completion rate was significantly higher in Group A (98.4% versus 92.0%, p=0.04). Duration of operation time (45.2±14.5 versus 42.0±13.1 minutes, p=0.22), rates of early complications (1.6% versus 1.1%, p=0.77) and late complications (3.2% versus 2.3%, p=0.68) were equivalent between the two groups. No fatal complications occurred in either group. CV cut-down can be safely performed by surgical residents under the use of preoperative US.

Exceptional microorganisms on blood smear.

A 67-year-old woman with metastatic pancreatic adenocarcinoma was referred for acute respiratory distress syndrome and severe sepsis. She had a totally implantable central venous access device for chemotherapy administration and home parenteral nutrition. Laboratory workup at admission revealed increased C-reactive protein (209 mg/L), mild normocytic anemia (hemoglobin 8.6 g/dL), and severe acute thrombocytopenia (platelet count 3 × 109/L, as compared to 257 × 109/L 8 days before). White blood cell count, absolute neutrophil count, and blood smear were normal. Laboratory tests excluded disseminated intravascular coagulation. The patient was treated with cefotaxime and metronidazole. Forty-eight hours later, blood smear examination done on a sample taken through the intravenous line revealed yeasts (Image 1, panels A-E-B-D). Moreover, some bacilli were also observed (Image 1, panels C-E). Yeasts and budding yeasts in monocyte and neutrophil cytoplasm, extracellular branching pseudohyphae (arrow, respectively panels A-E-B-D May–Grünwald–Giemsa stain, original magnification 100× and 20×). Extra- and intracellular bacilli (arrowhead, respectively panels C-E, May–Grünwald–Giemsa stain, original magnification 100×) This exceptional observation of microorganisms on blood smear led to microbiological tests, identifying Candida albicans and Klebsiella pneumoniae. Severe thrombocytopenia was most likely related to severe sepsis. The patient was admitted to a palliative care unit. Nothing to report.

Usefulness of Totally Implantable Central Venous Access Devices in Elderly Patients: A Retrospective Study

Background/Aims: The need for totally implantable central venous access devices (TICVADs) has increased with increased opportunities in the use of chemotherapy and parenteral nutrition. This study aimed to determine the outcomes of TICVAD implantation and use in patients aged ≥85 years. Methods: Between January 2010 and August 2016, 117 patients underwent TICVAD implantation and their records were retrospectively reviewed. Results: Participants were divided into 2 groups (plus-85 and sub-85 groups). Fifty-five patients (47.0%) had solid organ cancer alone; 35 patients (29.9%) had cerebrovascular or cranial nerve disease. The average follow-up period was 201 (2–1,620) days. Major complications were identified in 6 (14.6%) plus-85 patients and 11 (14.5%) sub-85 patients (p = 0.9813). Catheter-related infections developed in 3 plus-85 (7.3%) and 4 sub-85 patients (5.3%; p = 0.6549). There were no significant group differences in hematoma, pneumothorax, occlusion, and removal rates. In plus-85 patients examined just before surgery and a month after surgery, increased rates of serum albumin and Onodera’s prognostic nutritional index were observed in 48% (14/39) and 41% (12/39), respectively. Conclusions: The use of TICVADs in the plus-85 group resulted in effective outcomes. The results of this retrospective study support the wider use of TICVADs in patients aged ≥85 years.

Investigating histological aspects of scars in children.

Very little is known about histological aspects of paediatric scars and the possible role of the immune system during their formation. In this study, the histology thoracic scars caused by the placement of an implantable central venous access device in children who underwent treatment for cancer was assessed. The amount and type of collagen, the collagen orientation, the type of elastic fibres, the vascularsation, and the count of neutrophils, macrophages, and lymphocytes were analysed. The severity of scarring was assessed using the Vancouver scar scale (VSS). To evaluate the role of the immune system on scar severity and histology, the scars of children suffering from acute lymphoblastic leukaemia (ALL) were compared with the scars of children suffering from other types of childhood cancer. Our results showed an extremely random orientation of the collagen fibres of the paediatric scars with a mean collagen orientation index of 0.22 (standard deviation (SD) 0.10, zero indicating a perfectly random orientation and a perfectly parallel orientation). A lower collagen orientation index was seen in scars with a lower VSS score (VSS score <3: 0.19 versus VSS score ≥3 0.29, p=0.037). A higher total VSS score, resembling a worse scar, was assessed to the scars in the non-ALL group compared with the children with ALL (mean ALL: 0.91 (0-3) versus mean non-ALL: 2.50 (0-6), p=0.037). To our knowledge, this is the first study investigating a wide array of histological aspects in paediatric scars. Compared with adult scars, an extremely random collagen orientation was found (0.22 in children versus 0.41 and 0.46 adult normotrophic and hypertrophic scars, respectively). A lower collagen orientation index was found in scars with a lower VSS score. In addition, less severe scarring was measured in children suffering from ALL compared with children suffering from other types of childhood cancer. This suggests that the immune system could play a role in the development of aberrant scarring and should be a target for future research.

Implantable central venous access device in infants: Long-term results.

The management of central venous access device (CVAD) is extremely difficult in babies and small infants (BSI). We therefore compared the long-term results and complications of CVAD in BSI with those in children. One hundred and twenty patients were divided into two groups as follows: age <1 year or weight <10 kg (group A; 25 patients); and age ≧1 year and weight ≧10 kg (group B; 95 patients). The clinical results were retrospectively compared between the groups. Mean age and weight were 12.5 ± 5.9 months and 8.2 ± 1.2 kg in group A, and 78.8 ± 58.9 months and 20.9 ± 13.6 kg in group B. Operation time was 57 ± 29 min in group A and 52 ± 21 min in group B (P = 0.38). The catheter was advanced with difficulty into the central vein in five and in 16 patients (P = 0.77), and surgical complications occurred in one and in seven patients in groups A and B, respectively (P > 0.99). The CVAD remained in place for 627 ± 494 and 550 ± 414 days (P = 0.47) and was removed before treatment completion in five and in 14 patients in groups A and B, respectively (P = 0.54). The clinical results for CVAD in BSI did not differ from those in children. CVAD are useful and safe for the treatment of BSI with serious diseases.

Safety and cost-effectiveness of port removal outside of the operating room among pediatric patients

PurposeThe current emphasis on fiscally responsible health spending in the era of the Affordable Care Act and other health care reform necessitates cost-conscious delivery of care. “Value” in health care is defined as the quality of care divided by the cost. As such, health systems optimize value by providing the most cost-effective care possible without sacrificing safety or outcomes. Elective, minimal risk surgical procedures in children may be value-enhanced by moving from an operating room (OR) to a more cost-efficient setting. The purpose of this study was to assess the safety and cost of performing the removal of implantable central venous access devices (“ports”) in locations other than the main OR. MethodsWe compared port removal at three sites: 1. Main OR, 2. Satellite OR, and 3. Clinic Procedure Room. This was a mixed-methods study including a retrospective review of medical records and prospective observation/interviewing. To calculate cost without the inherent biases of hospital charges, costs, and payments, we utilized the methodology of time-driven activity based costing. Specifically, we recorded time spent by the patient in hospital facilities and with health care personnel. This duration was then weighted with the hourly cost of each health care professional and hospital space. The Mann–Whitney U test compared time and cost across the three sites. Overall cost at each site was divided by overall cost at the referent site (Main OR) to obtain a ratio of cost savings. ResultsA total of 120 patients (40 per site) were included in the analysis. Demographic and clinical factors were not significantly different between sites. No complication occurred with port removal at any site. Time of the entire care episode was significantly decreased in the Clinic (median 161min, 95% confidence interval [CI] 134–188min), compared to the Main OR (median 235min, 95% confidence interval [CI] 209–251min) or Satellite OR (median 228min, 95% confidence interval [CI] 211–245min). Overall cost was decreased by 25% (95% CI: 13–34%) at the Clinic and by 6% (95% CI: −2–11%) at the Satellite OR, compared to the Main OR (referent, P<0.01). ConclusionIn our study, port removal in the Clinic Procedure Room was not associated with increased risk of negative outcomes. Shifting port removal from the Main OR to the Clinic may result in substantial cost savings.

Fracture and atypical migration of an implantable central venous access device

Distal embolization of a fractured indwelling central catheter is a rare complication. The pinch-off syndrome (POS) should be known, prevented and early detected. We present a case in which further radiological exams were required to find the fragmented catheter with an atypical migration, requiring local surgery for removing. After chest and abdominal CT scan, neck X-ray, and heart echography, the catheter was found on the lower limbs X-ray on the internal side of right knee corresponding to a location of saphenous vein. Implanted catheters should be removed after completion of treatment and the integrity of the system should be monitored. To avoid POS, a catheter must be inserted into the subclavian vein as laterally as possible.

Insertion of totally implantable central venous access devices by surgeons.

PurposeThe aim of this study is to evaluate the results for the insertion of totally implantable central venous access devices (TICVADs) by surgeons.MethodsTotal 397 patients, in whom TICVADs had been inserted for intravenous chemotherapy between September 2008 and June 2014, were pooled. This procedure was performed under local anesthesia in an operation room. The insertion site for the TICVAD was mainly in the right-side subclavian vein. In the case of breast cancer patients, the subclavian vein opposite the surgical site was used for insertion.ResultsThe 397 patients included 73 males and 324 females. Primary malignant tumors were mainly colorectal and breast cancer. The mean operation time was 54 minutes (18-276 minutes). Operation-related complications occurred in 33 cases (8.3%). Early complications developed in 15 cases with catheter malposition and puncture failure. Late complications, which developed after 24 hours, included inflammation in 6 cases, skin necrosis in 6 cases, hematoma in 3 cases, port malfunction in 1 case, port migration in 1 case, and intractable pain at the port site in 1 case.Conclusion Insertion of a TICVAD under local anesthesia by a surgeon is a relatively safe procedure. Meticulous undermining of the skin and carefully managing the TICVAD could minimize complications.

Commentary on "Insertion of Totally Implantable Central Venous Access Devices by Surgeons" - What Is the Role of Surgeons When Implanting a Totally Implantable Venous Access Device to Prevent Immediate Complications?

To the editor: We have read with great interest the manuscript of An et al. [1], whose article focused on the safety of inserting a totally implantable central venous access device (TICVAD) by using a blind percutaneous approach. Although it is a method that has been used for many years and has been proven to be useful by many physicians familiar with this approach [2], risks remain. We offer some comments about the present article. In the section Procedure for the TICVAD insertion, the authors wrote that the venous was filled with about 10 mL of diluted heparin (50 IU/mL). Usually, the amount of saline mixed with heparin that can be placed in the of a TICVAD cannot be more than 2 mL. Also, the proportion of the mixed solution of saline and heparin was 9:1, meaning that for each 9 mL of saline, 1 mL of heparin (5,000 IU) was added. Thus, each milliliter contained 500 IU of heparin [3]-not 50 IU, as written by the authors. In the same paragraph, the authors wrote that they checked the tip of the after completing the procedure. The position of the should be checked during the procedure to avoid having to perform a second procedure, particularly in cancer patients who are already in an especially delicate state. In the RESULTS section, An et al. [1] differentiated the complications as early and late. This type of differentiation is not sufficiently precise. Generally, complications that appear within the first 24 hours are defined as immediate, between 24 hours and 30 days after the procedure as early, and after 30 days as late [4]. This classification is very important because the majority of the complications that occur during the first 24 hours are strictly related to the operator or to technical failures. Using this classification, late complications (e.g., pinch-off [5]) are fundamental and usually present after several months. In the same section, the authors wrote about a complication they called migration. Usually we hear of catheter migration. Perhaps the authors described port dislodgement as port migration [4]. This complication concerns a port that has been inserted into a subcutaneous space and is not well fixed to the fascia, causing it to become dislodged. In the DISCUSSION section, the authors focused on the differences in the incidence of pneumothorax in relation to the practitioner (surgeon or radiologist) who performed blind cannulation of the subclavian vein. In 2015, it is inconceivable that cannulation of a central vessel is performed in a blind manner. The fact that these authors did not experience any cases of pneumothorax or hemothorax is not a valid justification to continue to perform this technique without using an ultrasonography (US)-guided approach, which is currently recommended worldwide. Also, in the DISCUSSION section, the authors described the internal jugular vein as the safest access point for positioning a TIVAD catheter. We believe that the safest access remains the cephalic vein using the cutdown technique [6]. This technique is absolutely free of risk and immediate complications and does not require US support. Also, unless a skin incision is needed to position the port [7], surgeons should attempt the cutdown technique.

Reply on "What Is the Role of Surgeons When Implanting a Totally Implantable Venous Access Device to Prevent Immediate Complications?".

To the editor: We appreciate your great interest in our article [1]. First of all, I agree with the comments concerning the risk of a blind technique and the need to check the catheter's position during the procedure. In terms of safety, a surgical cut-down procedure on the cephalic vein or the external jugular vein is excellent, especially for avoiding fatal complications such as a pneumo- or a hemothorax [2,3,4]. Also, ultrasonography guidance makes the procedure safer [5,6]. I think that the main issue is whether or not ultrasonography or fluoroscopy is available in the operation room. In fact, in the past, neither ultrasonography nor fluoroscopy was freely available in the operation rooms at Konkuk University Medical Center. However, recently with the availability of these medical devices, ultrasonography is routinely used to insert the totally implantable central venous access devices (TICVAD) and to check the position of the catheter tip during the procedure, as you recommended. As to the terminology of migration, your comment is correct, and changing port migration to dislocation/dislodgement of chamber would be much clearer, as you mentioned [7]. Additionally, I would like to comment on the classification of complication according to the period. The standard of early and late complications is different in different reports in the literature. Knebel et al. [7] classified complications as perioperative and postoperative. You have classified them as immediate, early and late complications or as early and late complications [2,4]. As you have indicated in your comments, complications within 24 hours after the procedure are important because they are related to the surgeon or to technical failures. We were interested in the surgeon's influence on the complications. Therefore, we wanted to focus on complications within 24 hours after the surgery, which we defined as early complications. As to your comment on heparin usage, we indicated the usage of 10 mL of diluted heparin. This means that a total of 10 mL of diluted heparin solution was used to flush and fill the catheter before and after TICVAD insertion into the central vein. Also, we used a solution of heparin sodium (500 IU of heparin in 10 mL of isotonic saline) for flushing.

Prone positioning induced tachyarrhythmias from an implantable central venous access device

SummaryWe present a case report of position‐dependent tachyarrhythmia following prone positioning for surgery in a 42‐yr‐old female with a left‐sided totally implantable venous access system (TIVAS) in‐situ. TIVASs are becoming increasingly popular for cancer patients receiving chemotherapy and who may present for either elective or emergency surgery.

Totally implantable vascular access devices 30 years after the first procedure. What has changed and what is still unsolved?

The first placement of a totally implantable central venous access device (TIVAD) was performed in 1982 at the MD Anderson Cancer Center in Houston by John Niederhuber, using the cephalic vein—exposed by surgical cut-down—as route of access to central veins. After that, TIVADs proved to be safe and effective for repeated administration of drugs, blood, nutrients,and blood drawing for testing in many clinical settings, especially in the oncologic applications. They allow for administration of hyperosmolar solutions, extreme pH drugs, and vescicant chemotherapeutic agents,thus improving venous access reliability and overall patients’ quality of life. Despite the availability of a variety of devices, each showing different features and performances, many issues are still unsolved. The aim of this review article is to point out what has changed since the first implant of a TIVAD, and what it is still matter of debate, thus needing more investigation. Topics analyzed here include materials, choice of the veins and techniques of implantation, role of ultrasound (US) guidance in central venous access, position of catheter tip assessment, TIVAD-related infection and thrombosis, and quality of life issues.

Percutaneous treatment of superior vena cava syndrome caused by chronic thrombosis

Chronic upper extremity deep vein thrombosis (UEDVT) and superior vena cava syndrome (SVCS) are becoming increasingly common due to the use of indwelling catheters and implantable central venous access devices. Hypercoagulable syndromes, malignancy, extrinsic compression, and tumor invasion are other causes. Endovascular management of chronic UEDVT and SVCS is accepted as an important first-line treatment given its high overall success rate and low morbidity as compared with medical and surgical treatments. In this case, we present successful management with stenting of superior vena cava obstruction syndrome as a result of chronic thrombosis. A 48-year-old woman was diagnosed with SVCS one year ago. Despite the use of warfarin therapy, her symptoms (swelling of the face and both upper extremities) progressively increased. It was thus decided to treat the patient with percutaneous angioplasty and stenting. Details of the occlusion were evaluated with computed tomography and venography. The right femoral vein and right jugular vein were used for the intervention. The occlusion was passed with a Miracle 12-g guidewire. After balloon pre-dilatation, two self-expandable stents were implanted. After stent placement, her clinical symptoms improved and she was discharged without complication.

The mystery of the occluded port that allowed blood withdrawal: Is it safe to use standard needles to access ports? A case report and literature review

A frequent complication of totally implantable central venous access devices (TIVADs) is withdrawal occlusion. We describe a case of rare dysfunction of TIVADs: blood withdrawal was possible, whereas infusion was not. A further investigation demonstrated that during infusion, a silicone core, probably produced by hypodermic needle puncture, occluded the reservoir outlet hole. The silicone septum puncture by standard needles instead of non-coring ones may reduce the device effectiveness and expose patients to serious complications.

Infection Related to Implantable Central Venous Access Devices in Cancer Patients: Epidemiology and Risk Factors

To describe the epidemiology of infections related to the use of implantable central venous access devices (CVADs) in cancer patients and to evaluate measures aimed at reducing the rates of such infections. Prospective cohort study. Referral hospital for cancer in São Paulo, Brazil. We prospectively evaluated all implantable CVADs employed between January 2009 and December 2011. Inpatients and outpatients were followed until catheter removal, transfer to another facility, or death. Outcome measures were bloodstream infection and pocket infection. We also evaluated the effects that the creation of a multidisciplinary team for CVAD care, avoiding in-hospital implantation of CVADs, and limiting CVAD insertion in neutropenic patients have on the rates of such infections. During the study period, 966 CVADs (mostly venous ports) were implanted in 933 patients, for a combined total of 243,792 catheter-days. We identified 184 episodes of infection: 154 (84%) were bloodstream infections, 21 (11%) were pocket infections, and 9 (5%) were surgical site infections. During the study period, the rate of CVAD-related infection dropped from 2.2 to 0.24 per 1,000 catheter-days ([Formula: see text]). Multivariate analysis revealed that relevant risk factors for such infection include surgical reintervention, implantation in a neutropenic patient, in-hospital implantation, use of a cuffed catheter, and nonchemotherapy indication for catheter use. Establishing a multidisciplinary team specifically focused on CVAD care, together with systematic reporting of infections, appears to reduce the rates of infection related to the use of these devices.

Totally implantable venous access devices in surgical patients: Our 3-year experience

Aim-Background Totally implantable central venous access devices (TIVADs) are commonly used in patients to administer chemotherapy or long-term parenteral nutrition. In the present article, we report our experience with TIVADs.

Successful treatment of central venous catheter induced superior vena cava syndrome with ultrasound accelerated catheter‐directed thrombolysis

Superior vena cava (SVC) syndrome results from obstruction of flow through the vessel either by external compression or thrombosis. External compression by intrathoracic neoplasms is the most common etiology, especially lung cancer and lymphoma. Thrombosis is becoming increasingly common due to the use of indwelling catheters and implantable central venous access devices. Most patients are unresponsive to anticoagulation alone which appears to be effective only in the mildest cases. However, recent advances in catheter-based interventions have led to the development of a variety of minimally invasive endovascular strategies to remove venous thrombus and accepted as an important first-line treatment given its high overall success rate and low morbidity as compared with medical and surgical treatments. Ultrasound accelerated catheter-directed thrombolysis (UACDT) has been developed to rapidly and completely resolve the existing thrombus. This technique integrates high frequency, low intensity ultrasound (US) with standard CDT in order to accelerate clot dissolution, reducing treatment time and the incidence of thrombolysis-related complications. An US wave enhances drug permeation through thrombus by disaggregating the fibrin matrix, exposing additional plasminogen receptor sites to the thrombolytic agent. The US energy affects thrombus in the entire venous segment, increasing the probability of complete thrombus clearing. We report the case of a 56-year-old man who presented with a 5 days history of SVC syndrome symptoms who had been receiving chemotherapy for colon cancer through a right subclavian vein port catheter. The patient successfully treated with UACDT with EkoSonic(®) Mach4e Endovascular device with an overnight infusion. © 2013 Wiley Periodicals, Inc.