Permanent Venous Access Research Articles

Venous thromboembolitic complications in children and adults with permanent venous access (literature review)

Introduction. Over the past decades, permanent venous access devices, in particular port systems and peripherally implanted central catheters, has been increasingly introduced in adult and pediatric oncology. As far as central catheters and permanent access devices are foreign bodies in basic veins, quite naturally that they are one more risk factor for thrombosis.Material and methods. The authors searched literature data ( in Russian and English) for the period up to May 3, 2022 using public databases (Embase, Medline/PubMed, Researchgate, medrxiv.org, RSCI/eLibrary). The following keywords were used for the search: “port-system”, “peripherally implanted central catheter”, “totally implanted vascular access device”, “venous thromboembolism”, “VTE”, “venous thromboembolic complications”, “VTEC”, “catheter dysfunction”, “device malfunction”. Available preprints, articles with “in press” or “online first” status, and clinical cases were also included in the analysis.Conclusion. This review discusses prevention, diagnostics and treatment of venous thromboembolic complications in cancer patients using similar implantable devices. In patients with catheter-associated thromboses, of practical interest are various diagnostic and curative algorithms, recommendations on the choice of vascular access, medicamentous therapy as well as variants of surgical intervention.

ПРИМЕНЕНИЕ СИСТЕМ ПОСТОЯННОГО ВЕНОЗНОГО ДОСТУПА У ДЕТЕЙ С ГЕМОФИЛИЕЙ: ОПЫТ ОДНОГО ЦЕНТРА

To improve the results of treatment of severe hemophilia in children, the efficiency and safety of the use of venous catheter ports in patients of this group has been analyzed. The problem of optimizing vascular access in hemophilia, especially young patients, remains relevant, despite the emergence of drugs with a subcutaneous route of administration. In global clinical practice, implantable permanent venous access devices (IVAD) have been successfully used for a long time to initiate preventive therapy or to conduct immune tolerance therapy when detecting inhibitor to coagulation factor VIII as early as possible. In Russia, this experience is still local and not reflected in the literature. Materials and methods of research: a single-center retrospective uncontrolled non-randomized study was performed. In a total of 19 patients (100% boys) between the age of 1 and 8 years (median 2 years [1; 6]) have been installed 21 IVADs. The observation period ranged from 200 to 1,897 days, with a total number of 17,484 catheter days in the group. Results: a statistically significant decrease in the number of hemorrhages requiring treatment per year (p<0,001) has been observed in the general group of patients following the implantation of IVAD and the optimum treatment. The incidence of infectious complications was 0,22 per 1000 catheter days with no other complications recorded. Conclusion: the results of the presented case report demonstrate that the use of a port-type IVAD to ensure adequate vascular access in young children with severe hemophilia with a high degree of safety significantly increases the effectiveness of substitution/hemostatic therapy.

POS-593 ISN SISTER RENAL CENTRES PROGRAMME: ESTABLISHING AND SUSTAINING TUNNELLED VENOUS DIALYSIS LINE PLACEMENT IN PORT HARCOURT, NIGERIA

Under the auspices of the International Society of Nephrology Sisters Renal Centres programme, Renal centres from Port Harcourt, Nigeria and Salford UK have maintained collaboration in various aspects of kidney care. A key issue in sustaining dialysis care in a lower middle income economy is access for haemodialysis (HD). Before this project all HD access was via temporary femoral vein lines inserted for a single dialysis session. Pre-visit video conferencing provided educational and planning opportunities in the delivery of peritoneal dialysis for acute kidney injury (AKI). A Nigerian kidney doctor in training visited the UK centre to gain first-hand experience of line insertion techniques. An initial visit to the sister hospital was undertaken by UK nephrologists with special interests in dialysis and interventional nephrology. A pop-up dialysis access workshop was undertaken in the dialysis unit over 3 days for junior and senior doctors and members of the multi-disciplinary team: Didactic teaching on dialysis access methods Small group teaching on the basics of HD, PD and prescriptions Simple and sustainable training tools for basic surgical procedures, HD and PD catheter insertion and Seldinger technique Dialysis access ultrasound training with volunteers examining abdominal anatomy and vascular access imaging Hands on training with simple access phantoms, made from accessible materials for ongoing practice. Tunnelled haemodialysis line insertion was achieved by local and visiting nephrologists, unique to the dialysis centre which normally relies on temporary femoral venous access. All three patients achieved successful permanent venous line access without complication. The local nephrologist was able to place catheters with the visiting interventional nephrologist closely supervising. The procedures were recorded to allow analysis and reflection on the procedures. Since the 4 lines have been successfully inserted by the local nephrologist. This has been supported with ongoing video and telephone links. This has allowed continued updates on technique, difficulties and complications. One episode of local exit site bleeding was encountered and managed with follow up calls and advice. Covid 19 has precluded the planned follow up visits. This has highlighted the issues of keeping colleagues up to date and maintaining skills when practice is significantly altered. The collaboration is investing in more robust internet communication to facilitate teaching and mentorship while planning the next part of the project to establish a peritoneal dialysis programme. Significant gains have been made on our journey to establishing long term HD vascular access for the dialysis patients in Port Harcourt Teaching Hospital, despite the major obstacles faced.

Antimicrobial Locks in Patients Receiving Home Parenteral Nutrition.

Catheter-related bloodstream infection (CRBSI) is one of the most common and potentially fatal complications in patients receiving home parenteral nutrition (HPN). In order to prevent permanent venous access loss, catheter locking with an antimicrobial solution has received significant interest and is often a favored approach as part of the treatment of CRBSI, but mainly for its prevention. Several agents have been used for treating and preventing CRBSI, for instance antibiotics, antiseptics (ethanol, taurolidine) and, historically, anticoagulants such as heparin. Nonetheless, current guidelines do not provide clear guidance on the use of catheter locks. Therefore, this review aims to provide a better understanding of the current use of antimicrobial locking in patients on HPN as well as reviewing the available data on novel compounds. Despite the fact that our current knowledge on catheter locking is still hampered by several gaps, taurolidine and ethanol solutions seem promising for prevention and potentially, but not proven, treatment of CRBSI. Additional studies are warranted to further characterize the efficacy and safety of these agents.

Venous access in cancer patients.

The most commonly used permanent venous access devices in cancer patients are the port, PICC port and PICC catheter (peripherally inserted central catheter). It is always necessary to consider the type of venous access needed for each individual cancer patient. Implantation should be performed using modern instruments to minimize the risk of early and late complications and thereby adelay in oncological treatment. The use of ultrasound is recommended at all stages of introduction. Precise tip placement of the central catheter in the sinoatrial junction region further reduces the number of thromboses arising in the catheter. Atrend towards the treatment of catheter infections is certainly to maintain the venous access without compromising the patientshealth. Permanent venous access devices allow the application of chemotherapy and repeated blood sample collections with minimal impact on the quality of life in cancer patients.

The peripheral portacath provides safe and convenient venous access in pediatric and adolescent patients

IntroductionAdolescent patients with chronic conditions rely on permanent venous access for safe treatment and supportive care. Traditionally this is provided by a central venous access device (CVAD) e.g. Hickmann catheter or totally implanted subcutaneous port or also called Port-a-Cath (PaC). We reviewed the patient experience, safety and feasibility of insertion of peripheral inserted implanted subcutaneous port (peripheral PaC). MethodsMedical records of patients who underwent insertion of peripheral PaC under ultrasound guidance at our institution since between 2012–2017 were reviewed to ascertain specific details including duration of insertion and complication rate. Short structured questionnaires were used to assess nursing and patient satisfaction. ResultsTwenty eight peripheral PaC were inserted at our institution. There were 17 female and 11 male patients aged between 12.3 and 18.7 years (median = 16.1). Six were inserted under local anesthetic (LA) in patients who were not fit for general owing to mediastinal mass or lung disease. At the time of analysis 2 PaCs remained in situ with a median duration of 8 months (range 3–48). Removal of 26 PaCs was under LA in 15 cases and under GA in 11. Complications were observed in 9 cases but only necessitated early removal or replacement in 3 cases (displacement and disconnection) and repositioning in 1 case. Thrombosis was seen in 2 patients who required systemic anticoagulation but had complete resolution. ConclusionThis study shows that the use of peripheral PaC is safe. The feedback from patients and nursing staff supports the use of the peripheral PaC. We are exploring additional patient groups that might benefit from this device.

Central venous catheter-related infections in patients receiving short-term hemodialysis therapy: incidence, associated factors, and microbiological aspects.

Bloodstream infections are the second most common cause of death among patients on hemodialysis. This study aimed to evaluate the incidence of and risk factors associated with central venous catheter-related infections in patients undergoing hemodialysis, and to identify and characterize the type and antimicrobial susceptibility profiles of the primary microorganisms isolated during one year of follow-up. A prospective cohort study was conducted in 2014 in a hemodialysis referral center. We included 200 outpatients with acute kidney injury who had no permanent venous access. A nurse assessed the patients for signs of infection three times per week during dressing changes. The clinicopathologic characteristics of patients with and without local or systemic infection were compared. Fifty-five episodes of catheter-related infections occurred in 43 (22%) patients; 38 (69%) were bloodstream infections and 17 (31%) were local infections. Thirty-two (75%) patients with infection had femoral vein catheter placement. In total, 6,240 hemodialysis sessions were performed; the rates of primary bloodstream and local infection were 6.1 and 2.7 episodes per 1,000 patients on daily dialysis, respectively. In the univariate analysis, diabetes was significantly associated with the development of infection, while level of education, ethnicity, age, and sex were not. Gram-negative bacteria were primarily isolated from blood culture specimens (55% of samples). Of the Gram-negative isolates, 56% were resistant to the carbapenems. We identified a high incidence of catheter-related infections caused by resistant microorganisms in patients undergoing hemodialysis via central venous catheters.

Psychological Aspects of Intravenous Treatment in Oncology andPermanent Venous Access Devices Tolerance

This paper deals with the psyche of patients during intravenous therapy. Since any intervention in the physical integrity of individuals are necessarily reflected in their mental level, we decided to conduct a survey dealing with tolerance of intravenous therapy in cancer patients. Especially, we focused on long-term venous access devices tolerance. The aim of this study was to evaluate descriptively patients´ awareness of the administration of parenteral drugs, risks in the application and the differences between the administration of drugs to the central and peripheral venous system. To collect data, own questionnaire containing 21 questions was compiled. It was distributed to patients in the oncology department and outpatient oncology ward at the hospital Novy Jicin. Patients signed an informed consent for data collection. One hundred valid questionnaires were evaluated in the analysis of the data. The results of the study generally indicate that patients do not tolerate venous sampling and intravenous therapy optimally. Patients who have some form of venous access device are mostly satisfied, as it fulfills its mandate of maximum patient comfort. The results indicate that most patients know alternatives to peripheral drugs application. However, awareness of this issue is inadequate. The vast majority of patients would recommend the introduction of long-term venous access device to other patients.

Incidents and complications of permanent venous central access systems: a series of 1,460 cases.

BackgroundImplanted venous access devices or permanent central venous access systems (PCVASs) are routinely used in oncologic patients. Complications can occur during the implantation or use of such devices. We describe such complications of the PCVAS and their management.MethodsOur retrospective study included 1,460 cases in which PCVAS was implanted in the 11 years between January 2002 and January 2013, including 810 women and 650 men with an average age of 45.2 years. We used polyurethane or silicone catheters. The site of insertion and the surgical or percutaneous procedure were selected on the basis of clinical data and disease information. The subclavian and cephalic veins were our most common sites of insertion.ResultsAbout 1,100 cases (75%) underwent surgery by training surgeons and 360 patients by expert surgeons. Perioperative incidents occurred in 33% and 12% of these patients, respectively. Incidents (28%) included technical difficulties (n=64), a subcutaneous hematoma (n=37), pneumothoraces (n=15), and an intrapleural catheter (n=1). Complications in the short and medium term were present in 14.2% of the cases. Distortion and rupture of the catheter (n=5) were noted in the costoclavicular area (pinch-off syndrome). There were 5 cases of catheter migration into the jugular vein (n=1), superior vena cava (n=1), and heart cavities (n=3). No patient died of PCVAS insertion or complication.ConclusionPCVAS complications should be diagnosed early and treated with probable removal of this material for preventing any life-threatening outcome associated with complicated PVCAS.

Prevalence and Correlates of Frailty among Patients on Maintenance Hemodialysis

Background: Frailty has been recognized as a syndrome resulting from cumulative declines in multiple physiologic systems, leading to impaired homeostatic reserve and decreased capacity to withstand stress. Frailty is common in dialysis patients of all ages and is a more sensitive marker of morbidity and mortality than chronological age. Prevention of frailty in hemodialysis patients of all ages could form an active part of nephrology management. Objective: The aim of the current study was to determine the prevalence and correlates of frailty among hemodialysis patients Patients and methods: Cross section study was carried out from Oct 2013 to Nov 2014 in the hemodialysis unit of a Zagazig university hospital. The total number of the study was 165 hemodialysis patients, 25 were excluded from the study and thus the final included numbers became 140 hemodialysis patients. All participants were subjected to complete clinical examination. Routine laboratory investigations including corrected serum calcium (Ca) mg/dL, serum phosphate (P) mg/dL and serum intact PTH (i-PTH) (pg/mL) were performed. Anthropometric measurements, including mid arm circumference (MAC), mid-calf circumference (MCC) and body mass index (BMI). Frailty diagnoses and scoring by fried frailty criteria Results: The prevalence of frailty among hemodialysis patients in Zagazig university hospital was 60%, prefrail 15.7% and non-frail 24.3%. Frailty was started early at mean age of 44.11 ± 6.7 and significantly increase with aging P<0.05. Although gender, smoking, blood pressure, anthropometric measures, diabetes, serum albumin, Ca, P, iPTH, C-reactive protein (CRP), hemoglobin (Hb) % g/dl, RBCs χ106, Platelets χ103,WBCs χ103 and venous access line were assessed for correlation with frailty. Only female gender P<0.001, diabetes P<0.05, hypoalbuminemia P<0.001, severity of secondary hyperparathyroidism P<0.02, inflammatory state P<0.002, anemia P<0.001, and absence of permanent venous access P<0.001 were correlated with frailty. Administration of erythropoietin (EPO) and L.carnitine were negatively correlated with frailty Conclusion: The prevalence of frailty among hemodialysis patients in this study was an extremely high 60%, approximately 8-9 folds of the general population. Frailty increases with, female gender, diabetics, absence of permanent venous access for hemodialysis, anemia hypoalbuminemia and secondary hyperparathyroidism.

Abstract No. 287 - Ultrasound guided transhepatic permanent dialysis catheter: alternative approach for haemodialysis

Purpose Nonconventional image-guided percutaneous catheter placements are the exception and are requested only when traditional access sites are unavailable. They are good alternative routes for permanent venous access and haemodialysis, and with proper technique and care, will be associated with minimal post procedural complications This study highlights the technical aspects of ultrasound-guided transhepatic permanent dialysis catheter in vascular access management. Materials and Methods For patients dependent on permanent venous catheters for survival, the progressive loss of venous access sites should prompt a systematic approach to alternative sites and techniques to maximize patient survival and minimize complications. Results This study included 12 patients with exhausted all classical venous access for haemodialysis. They had normal coagulation profile. Conscious sedation was used for all patients. Ultrasound guided was used to access the hepatic vein ( right hepatic vein in 8 patients and middle hepatic vein in 4 patients), using a 16 G teflon coated needle. The subcostal approach was selected in 6 patients and the intercostal anterior axillary line in another 6 patients. Under fluoroscopy, the hydrophilic guide wire 0.0035 inch is introduced through the needle in hepatic vein to reach the superior vena cava. Gradual dilatation of the track was performed until peel away sheath was advanced to the cavo-atrial junction. A subcutaneous tunnel was formed and the permanent haemodialysis catheter was inserted with its tip at the right atrium. Mild right hypochondrial pain was noticed in three patients , with intercostal approach, for few days. Follow up for 6 -12 months, revealed normal functioning haemodialysis catheter in 11 patients and a single sepsis complication. Conclusion Transhepatic insertion of haemodialysis catheter is a good non-classical alternative access and has same patency rate and incidence of complications as that of classical chest haemodialysis catheter. Interventional radiologists should be familiar with the appropriate use of both conventional and unconventional types of venous access and their associated risks

Successful percutaneous retrieval of accidentally migrated hemodialysis catheter

Hemodialysis is done for end stage renal failure. It is often done through femoral or jugular venous access until a permanent venous access is constructed.1 Although infection and thrombosis of the access site are quite common, accidental migration of catheter is rare. Here we report a case of accidentally migrated hemodialysis catheter and the subsequent successful retrieval. It has avoided a major surgical intervention and the associated morbidity.

Mediastinal infusion with tracheal necrosis: an unusual complication of Port-a-cath devices

The Port-a-cath (PAC) is a catheter totally implanted under the skin. It is commonly used in oncology for permanent venous access. It provides a more simple way to infuse chemotherapies, antibiotics or parenteral nutrition, while offering improved comfort to patients. The usual complications of these devices (infections and catheter obstructions) are well documented. More exceptional events are catheter fractures with systemic migration, and endopleural perfusions due to a wrong positioning of the catheter. Since 1998, 10 cases of mediastinal infusion of cytotoxics have been reported. Surgical management was necessary in only two cases. We are reporting the case of a 57-year-old female suffering from a multimetastatic sigmoid adenocarcinoma. A mediastinal infusion of Folfiri and bevacizumab with a tracheal necrosis complicated the PAC use and required a latissimus dorsi myoplasty to fill up the tracheo-bronchial defect.

Randomized clinical trial of a modified Seldinger technique for open central venous cannulation for implantable access devices

Totally implantable access ports (TIAPs) are often used for patients who need permanent venous access. The primary success rate using direct open insertion is about 80 per cent, so rescue strategies are needed. This study compared the primary success rates of standard open insertion and a modified Seldinger technique. This randomized trial recruited 164 patients scheduled for primary implantation of a TIAP and compared two interventions. The primary endpoint was the success rate of the implantation technique. The primary success rates were similar: 66 (80 per cent) of 82 patients who had standard open insertion versus 69 (84 per cent) of 82 patients undergoing the modified Seldinger method (P = 0.686). A logistic mixed regression analysis including treatment group, age, Karnofsky index, body mass index and surgeon's experience showed no advantage for the Seldinger method: odds ratio 1.30 (95 per cent confidence interval 0.62 to 2.70). TIAPs were eventually implanted successfully in 163 (99.4 per cent) of 164 patients. In 11 patients randomized to standard surgery, the Seldinger method was a successful rescue strategy. The primary success rate was similar for both open insertion methods. The modified Seldinger method is useful if standard open insertion fails. ISRCTN 52368201 (http://www.controlled-trials.com).

Prolonged venous access for chemotherapy by means of the Hickman catheter.

One hundred and six long-term right atrial (Hickman) catheters have been used to establish permanent venous access in 99 patients undergoing prolonged chemotherapy for leukemia and other malignancies at the University of Maryland/Baltimore Cancer Research Center over the 30-month period from November 1978 to May 1981. A uniform technique for insertion, using cannulation of the external or internal jugular vein and atraumatic dissection of the subcutaneous tunnel, has resulted in no episodes of hemorrhage or tunnel infection in the last 55 placements in these high-risk granulocytopenic, thrombocytopenic patients. Twelve catheters have now been in place for over one year, and two catheters have been in place for over two years without apparent ill effects. A low catheter related infection rate is attributed to meticulous adherence to catheter care guidelines, supervised by a single trained and interested nurse.

Comparison of Venae Sectio vs. modified Seldinger Technique for Totally Implantable Access Ports; Portas-trial [ISRCTN:52368201

BackgroundThe insertion of a Totally Implantable Access Port (TIAP) is a routinely employed technique in patients who need a safe and permanent venous access. The number of TIAP implantations is increasing constantly mainly due to advanced treatment options for malignant diseases. Therefore it is important to identify the implantation technique which has the optimal benefit/risk ratio for the patient.Study designA single-centre, randomized, controlled superiority trial to compare two different TIAP implantation techniques. Sample size: 160 patients will be included and randomized intra-operatively. Eligibility criteria: Age equal or older than 18 years, patients scheduled for primary elective implantation of a TIAP in local anaesthesia and a signed informed consent. Primary endpoint: Primary success rate of the randomized technique. Intervention: Venae Sectio in combination with the Seldinger Technique (guide wire and a peel away sheath) will be used to place a TIAP. Reference treatment: Conventional Venae Sectio will be used with a direct insertion of the TIAP without guide wire or peel away sheath. Duration of study: Approximately 20 months.Organisation/ResponsibilityThe trial will be conducted in compliance with the protocol and in accordance with the moral, ethical, and scientific principles governing clinical research as set out in the Declaration of Helsinki (1989) and Good Clinical Practice (GCP). The trial will also be carried out in keeping with local and regulatory requirements. The Klinisches Studienzentrum Chirurgie (KSC) – Centre of Clinical Trials in Surgery at the Department of Surgery, University Hospital Heidelberg is responsible for planning and conduction of the trial. Documentation of patient's data will be accomplished via electronical Case Report Files (eCRF) with MACRO®-Software by the KSC. Randomization, data management, monitoring and biometry are provided by the independent Koordinierungszentrum für Klinische Studien (KKS) – Coordination Centre for Clinical Trails at the University of Heidelberg.

Saphenous Vein Eversion: A Novel Technique for Hickman® Catheter Insertion

Saphenous eversion Hickman catheter insertion can provide an alternative technique for venous access in patients in whom upper body access is not feasible. The technique is simple and obviates many of the complications of upper body permanent venous access catheter insertion. Further experience is required to assess whether this technique can become one of the standard Hickman insertion techniques.

Mediastinoscopy and permanent venous access device positioning through the same incision

We report herein our technique for positioning of permanent venous access device in patients undergoing mediastinoscopy for diagnosis and/or staging of thoracic malignancies. Through the same 3-cm skin incision employed for mediastinoscopy, access to right internal jugular vein is obtained and the prepectoral pocket for chamber positioning is prepared. The technique is simple, safe and provides increased patient acceptability.

Use of a peripherally implanted subcutaneous permanent central venous access device for chemotherapy--the Singapore General Hospital experience.

Venous access for chemotherapy patients at the Singapore General Hospital has conventionally been via an externalised (Hickman) catheter. A peripherally implanted permanent subcutaneous central venous access device (P.A.S.Port) was introduced in 1996. We review its use, complications and cost competitiveness with other chemotherapy delivery systems. A retrospective study of clinical records was conducted with follow up interviews of patients and nursing staff. Twelve patients had the P.A.S.Port inserted for administration of chemotherapy as an outpatient procedure. Immediate complications were pain (8%) and bruising (8%). One port-related infection (8%) one week following insertion was reported and one patient complained of interference with elbow movement as a late complication. Cost analysis was favourable for P.A.S.Port over an externalised Hickman catheter or chest-placed port at one year. Patient and nursing staff acceptance was high. P.A.S.Port insertion is a safe outpatient procedure and is an alternative for permanent venous access.

Safety and complications of central venous catheters in AIDS patients

Objective To investigate and compare the incidence and type of complications related to central venous catheters in AIDS patients and in two control groups of non-AIDS patients. Methods Three groups of patients requiring permanent venous access were investigated retrospectively between January 1988 and January 1994. The indication for Port-A-Cath system implantation in AIDS patients was administration of virustatics and/or total parenteral nutrition (TPN) (group A, n =71), in non-AIDS immunocompromised patients it was chemotherapy (group B, n = 65) and in immunocompetent patients it was home TPN (group C, n = 14). Complications were categorized into infectious complications and non-infectious complications, and related to patient characteristics, degree of immunosuppression, type of therapeutic medium, insertion technique and catheter survival time. Results Type of complications could not be related to type of insertion procedure or length of operation. Catheter-related mortality was low in all groups (0–1%). Type of complications could be related to catheter survival time in all groups. Infectious complications could not be related to degree of immunosuppression (CD4 + lymphocyte counts or white blood cell count). Unexpectedly, the incidence of both infectious and non-infectious complications was significantly higher for group C than for groups A and B, probably because of type of medium and/or differences in handling of the catheter. Conclusion In this retrospective study, central venous catheters appear to be safe and are well tolerated by AIDS patients, as compared to non-AIDS immunocompromised patients receiving chemotherapy and immunocompetent home-TPN patients.