Totally Implantable Venous Access Ports Implantation Research Articles

Application of pocket-first technique for implantation of totally implantable venous access ports.

While vascular puncture is always performed before making port pocket in the implantation of totally implantable venous access ports (TIVAP), some surgeons preferred to make port pocket first. This study seeks to verify the safety and feasibility for the pocket-first technique. The study retrospectively reviewed 447 patients who undergone TIVAP implantation from July 2017 to November 2022. All the patients were divided into two groups based on vascular puncture first or making port pocket first. The general information, operation information and post-operative complications were reviewed and analyzed. All the operations were performed successfully. No difference was observed in the sex, age, height, weight, BMI, port location and total complication rate between the two groups. The operation time of the Puncture Group and the Pocket Group were 46.9 ± 22.4min and 33.8 ± 13.6min ( P<0.00001 ). In the patients of SCV approach, the operation time between the two groups were 37.4 ± 14.8min and 33.5 ± 10.9min ( P<0.05 ). Multivariate analysis showed the variable BMI and first procedure were independent prognostic factors for operation time. In the cases using SCV/AxV approach the variable first procedure was the only independent prognostic factor for operation time (P = 0.002). The pocket-first technique can be considered as a safe, feasible and convenient technique for TIVAP implantation. The time consuming is significantly shortened compared with the puncture-first technique and this advantage may be more obvious when using SCV/AxV approach.

Cephalic Vein Cut-Down Method for Totally Implantable Venous Access Ports: A Single-Institution Experience

The widespread use of chemotherapies has increased the need for totally implantable venous access ports (TIVAPs). Previously, the subclavian puncture approach with the landmark technique was the most used implantation method; however, it has been related to early complications, such as pneumothorax, hemothorax, and arterial puncture. Therefore, a safer implantation method is required. This study aimed to assess the safety and efficacy of the cephalic vein cut-down method used in our institution. Patients who underwent TIVAPs implantation using the cephalic vein cut-down method as the first choice between January 1, 2018, and December 31, 2020, were included in this study. We retrospectively evaluated the technical success rates, operation times, and early complications. This study included 221 adult patients (men, 129; women, 92), with a mean age of 68±11 years. The mean body mass index (BMI) was 21±4 kg/m2. A total of 213 patients (96.4%) had malignant tumors that required chemotherapy. The mean postoperative follow-up period was 659±442 days (range, 5-1698 days). A total of 127 patients (57.5%) died during the follow-up period. The technical success rate was 86.4% (191/221). There were 30 failures, 24 of which were converted to the subclavian vein puncture approach. The mean operation time was 53±21 minutes. Early complications were observed in 4 (1.8%) patients, corresponding to an incidence of 0.028 complications/1,000 catheter-days. One patient had an unintended arterial puncture; however, it was not a result of the cephalic vein cut-down method, but a secondary result of the subclavian vein puncture. No complications of pneumothorax, hemothorax, or arterial puncture was observed with the cephalic vein cut-down method. This study showed that the cephalic vein cut-down method for TIVAPs had an acceptable success rate and fewer early complications than the conventional puncture techniques.

Standardized procedure prevents perioperative and early complications in totally implantable venous-access ports—a complication analysis of more than 1000 TIVAP implantations

PurposeSince their invention 40 years ago, totally implantable venous-access ports (TIVAPs) have become indispensable in cancer treatment. The aim of our study was to analyze complications under standardized operative and perioperative procedures and to identify risk factors for premature port catheter explantation.MethodsA total of 1008 consecutive TIVAP implantations were studied for success rate, perioperative, early, and late complications. Surgical, clinical, and demographic factors were analyzed as potential risk factors for emergency port catheter explantation.ResultsSuccessful surgical TIVAP implantation was achieved in 1005/1008 (99.7%) cases. No intraoperative or perioperative complications occurred. A total of 32 early complications and 88 late complications were observed leading to explantation in 11/32 (34.4%) and 34/88 (38.6%) cases, respectively. The most common complications were infections in 4.7% followed by thrombosis in 3.6%. Parameters that correlated with unplanned TIVAP explantation were gender (port in situ: female 95% vs. male 91%, p = 0.01), underlying disease (breast cancer 97% vs. gastrointestinal 89%, p = 0.004), indication (chemotherapy 95% vs. combination of chemotherapy and parenteral nutrition 64%, p < 0.0001), and type of complication (infection 13.4% vs. TIVAP-related complication 54% and thrombosis 95%, p < 0.0001).ConclusionStandardized operative and perioperative TIVAP implantation procedures provide excellent results and low explantation rate.

Ultrasound-guided totally implantable venous access ports placement via right brachiocephalic vein in pediatric population: A clinical debut.

To investigate the feasibility and safety of ultrasound-guided totally implantable venous access ports (TIVAPs) via the right brachiocephalic vein (BCV) in pediatric patients. A single-institute retrospective review was performed on 35 pediatric patients with predominantly hematological malignancies (88.6%) who underwent TIVAP implantation via ultrasound-guided right BCV approach from July 2018 to June 2021. The catheter tip was adjusted to be positioned at the cavoatrial junction under pulsed fluoroscopic guidance. Technical success rate, procedural information, and TIVAP-related complications were evaluated. All the pediatric TIVAP devices were successfully implanted via right BCV access. Venous access was successful by first attempt in 32 children (91%), two cases (5.7%) required a second attempt, and one patient (2.9%) required a third attempt. The mean procedural time was 44.6 ± 6.4minutes (range: 34-62minutes). No intraoperative complications occurred. The average TIVAP indwelling time was 564 ± 208days (range: 193-1014days), with a cumulative 19,723catheter-days. Overall, three patients (8.6%) experienced four postoperative complications (two cases of local hematoma and two catheter dysfunctions) at a rate of 0.2 per 1000catheter-days. No other complications such as wound dehiscence, delayed incision healing, catheter-related thrombosis (CRT), catheter malposition/fracture, surgical site infection, catheter-related bloodstream infection (CRBSI), pinch-off syndrome, and drug extravasation were observed during follow-up. Ultrasound-guided right BCV access for TIVAP placement in pediatric patients appears to be technically feasible, safe, and effective. Further large-sample, prospective studies are warranted.

Incidence and risk factor for infection of totally implantable venous access port.

Totally implantable venous access ports (TIVAP) have been widely used in cancer patients for many years. The early infection (within 30days after TIVAP implantation) rate of TIVAP accounts for about one-third of all TIVAP infections, and early infection often causes port removal and affects subsequent cancer treatment. This study investigated the incidence and risk factors for early and late infection after TIVAP implantation. From January 2013 to December 2018, all adult cancer patients who received TIVAP implantation in Taipei Medical University Shuang-Ho Hospital were reviewed. We evaluated the incidence of TIVAP-related infection, patient characteristics, and bacteriologic data. Univariable analysis and multiple logistic regression analysis were used to evaluate the risk factors of TIVAP-related infection. A total of 3001 TIVAPs were implanted in 2897 patients, and the median follow-up time was 424days (range: 1-2492days), achieving a combined total of 1,648,731 catheter days. Thirty-one patients (1.0%) had early infection and 167 (5.6%) patients had late infection. In multivariate analysis, TIVAP combined with other surgeries (p = 0.03) and inpatient setting (p < 0.001) was the risk factor of early infection, and TIVAP combined with other surgeries (p = 0.007), hematological cancer (p = 0.03), and inpatient setting (p < 0.001) was the risk factor of late infection. Inpatient TIVAP implantation and TIVAP implantation combined with other surgeries are associated with high rates of TIVAP-related early and late infections.

Meta-analysis of primary open versus closed cannulation strategy for totally implantable venous access port implantation

BackgroundThere is still no reference standard for the implantation of totally implantable venous access ports (TIVAPs). A recently published multicentre randomised controlled trial (RCT) revealed a significantly greater risk of pneumothorax after closed cannulation than after an open strategy. The aim of this meta-analysis was to provide an update of the available evidence for the safety and effectiveness of primary open versus closed cannulation strategy.MethodsRCTs comparing outcomes of open cut-down of the cephalic vein and closed cannulation of the subclavian vein were sought systematically in MEDLINE, Web of Science and CENTRAL. The primary outcome was the occurrence of pneumothorax. A beta-binominal model was applied to combine the respective outcomes, and results are presented as odds ratios (OR) with 95% confidence interval (CI).ResultsSix RCTs with a total of 1831 patients were included in final analysis. Meta-analysis showed statistically significant superiority of the open cut-down technique regarding pneumothorax (OR 0.308, 95% CI 0.122 to 0.776), but a statistically significant higher failure of the primary technique for the open cut-down technique than for closed cannulation (OR 2.364, 95% CI 1.051 to 5.315). There were no significant differences between the two procedures regarding other morbidity endpoints.ConclusionThis meta-analysis shows a general superiority of open cut-down of the cephalic vein over closed cannulation of the subclavian vein regarding the occurrence of pneumothorax. Open cut-down should be the first-line approach for TIVAP implantation. Closed cannulation should be performed with ultrasound as second-line procedure if the open technique fails.Systematic review registrationPROSPERO CRD42013005180

Outcome analysis in 270 radiologically guided implantations of totally implantable venous access ports via basilic vein.

Totally implantable venous access ports (TIVAPs) are widely applied in patients who require chemotherapy, parenteral nutrition, or frequent intravenous drug infusion. Although various venous access routes are possible for TIVAP insertion, the best method remains a topic of controversy. We present a single-center retrospective study of radiologically guided placement of TIVAPs through the basilic vein, with analysis of technical feasibility, patient safety, and device-related complications. We retrospectively reviewed 270 patients who received TIVAP implantation through the basilic vein from November 2013 to July 2016, under imaging guidance by an interventional radiology team at our institution. Fluoroscopic images, chest radiographs, computed tomography scans, and medical records were reviewed after port implantation. Catheter maintenance days were calculated and catheter-related complications were recorded. The procedural success rate was 99.3%. In total, 270 TIVAPs were implanted in 270 patients, of which 150 remained functional at the end of the study period. The total catheter maintenance days was 77 543 days, and the mean catheter indwelling duration was 287 ± 207 days. In 20 (7.4%) patients, TIVAP-related complications occurred during the follow-up period, resulting in a postprocedural complication rate of 0.26 incidences per 1000 catheter days. No significant relationship was observed between complications and gender (p = 0.188), age (p = 0.528), body mass index (p = 0.547), the type of primary malignancy (p = 0.914), or between the left and right basilic veins (p = 0.319). Real-time ultrasound and fluoroscopic guidance provides a safe method for TIVAP implantation through the basilic vein, with a high technical success rate and few device-related complications.

Late complications associated with totally implantable venous access port implantation via the internal jugular vein.

Several studies have analyzed late complications associated with totally implantable venous access ports (TIVAP) implantation via the internal jugular vein (IJV); however, the reported results are inconclusive. The aim of the study is to elucidate the characteristics and risk factors of late complications associated with TIVAP implantation via the IJV. The study included 482 patients who underwent TIVAP implantation for long-term chemotherapy and/or nutritional support between April 2012 and December 2017. Most patients (95.2%) had malignant diseases. Events requiring TIVAP removal were defined as TIVAP-related complications. The median TIVAP and global follow-ups were 319 days (IQR 152-661) and 218,971 catheter days, respectively. The 3-year cumulative TIVAP availability rate was 70%. There were 44 complications (incidence of 9.1%; 0.201 complications/1000 catheter days). Infectious, catheter-related, and port-related complications occurred in 21, 14, and 9 patients, respectively with infectious complications occurring earlier and more frequently than catheter- and port-related complications. Multivariate analysis revealed that age < 65 years and presence of non-gastrointestinal diseases were significant unfavorable factors for TIVAP-related complications. Patients with 1 and 2 of these factors had an elevated risk (2.2 and 5.4 times, respectively) compared with those without. Among the late complications associated with TIVAP implantation via the IJV, infectious complications occur earlier and more frequently than catheter- and port-related complications. Patients with an age < 65 years and having non-gastrointestinal diseases have a significantly high risk of TIVAP-related complications.

Port Implantation in Patients with Severe Thrombocytopenia is Safe with Interventional Radiology.

Platelet counts <50/nl are often considered a contraindication for surgical and interventional radiology procedures. Yet, there are patients requiring totally implantable venous access ports (TIVAP) in whom normalization of the coagulation state is not feasible. This retrospective study evaluates the safety of interventional radiological TIVAP implantation in patients with severe thrombocytopenia. From 12/2010 to 12/2014, a total 1200 consecutive radiological TIVAP implantations were performed and retrospectively analyzed. Among those 181 patients had platelet counts (PC) below the reference value of 150-350 thrombocytes/nl: 55 patients with mild (PC: 100-150/nl), 58 patients with moderate (PC: 50-100/nl) and 68 patients with severe thrombocytopenia (PC <50/nl). All patients diagnosed with severe thrombocytopenia received platelet concentrates before or during the procedure according to a fixed preparation protocol. All patients were assessed at least 2weeks before and up to 12months after intervention. Outcome parameters were recorded with a particular focus on bleeding complications. Data were statistically analyzed with a p value <0.05 considered statistically significant. The technical success rate for TIVAP implantation was 100%. Patients were followed for a mean of 833 indwelling catheter days in patients with thrombocytopenia (total: 150.923days) and for 936 indwelling catheter days in patients with normal platelet counts (total: 953.760days). No significant differences in complication rates between patients with normal platelet counts and patients with mild to severe thrombocytopenia under platelet substitution were found (p>0.05), especially no bleeding complications occurred during acute, early or late phase. With individualized platelet substitution, patients with severe thrombocytopenia may receive radiological TIVAP implantation without an increased risk of bleeding complications. IV.

Long-term clinical outcomes of the single-incision technique for implantation of implantable venous access ports via the axillary vein.

To evaluate long-term clinical outcomes and complications of the single-incision technique for implantation of totally implantable venous access ports (TIVAPs) via the axillary vein. A total of 932 TIVAPs were placed in 927 patients between May 2012 and October 2014 using a single-incision technique. Patients included 620 men and 307 women with a mean age of 60.0 years. TIVAPs were placed via the left (n = 475) and right (n = 457) axillary veins after making a single oblique vertical incision and medial side pocket without subcutaneous tunneling. We retrospectively reviewed medical records to evaluate status of the patients and TIVAPs, complications, and reasons for explantation. In patients who still had a TIVAP in place, we calculated the duration of TIVAP use from the cut-off day of November 1, 2015. Clinical follow-up was obtained for a total device service period of 311,069 days with a median indwelling time of 467 days (range: 3-1097 days). A total of 37 (4.0%) complications developed. Early complications (n = 4) were one case each of stenosis of the brachiocephalic vein by tumor growth, thrombosis of axillary vein, intravascular migration, and malfunction depending on patient's position. Late complications (n = 33) were suspected catheter-related blood stream infection (n = 23), local infection of the pocket (n = 4), symptomatic stenosis and thrombosis of central vein (n = 4), malfunction by fibrin sleeve (n = 1), and intravascular migration (n = 1). A single-incision technique for TIVAP implantation via the axillary vein seems to be safe with a low risk of complication.

Study of in vivo catheter biofilm infections using pediatric central venous catheter implanted in rat.

Venous access catheters used in clinics are prone to biofilm contamination, contributing to chronic and nosocomial infections. Although several animal models for studying device-associated biofilms were previously described, only a few detailed protocols are currently available. Here we provide a protocol using totally implantable venous access ports (TIVAPs) implanted in rats. This model recapitulates all phenomena observed in the clinic, and it allows bacterial biofilm development and physiology to be studied. After TIVAP implantation and inoculation with luminescent pathogens, in vivo biofilm formation can be monitored in situ, and biofilm biomass can be recovered from contaminated TIVAP and organs. We used this protocol to study host responses to biofilm infection, to evaluate preventive and curative antibiofilm strategies and to study fundamental biofilm properties. For this procedure, one should expect ∼3 h of hands-on time, including the implantation in one rat followed by in situ luminescence monitoring and bacterial load estimation.

Short-term and long-term outcome of radiological-guided insertion of central venous access port devices implanted at the forearm: a retrospective monocenter analysis in 1704 patients.

The objectives are to analyze the technical success rate as well as the short-term and long-term complications of totally implantable venous access ports (TIVAPs) at the forearm. Retrospective analysis of 1,704 consecutively implanted TIVAPs was performed. Primary endpoints were defined as technical success rate, clinical outcome, device service interval, and rates of major complications. Minor complications not requiring port explantation were defined as secondary endpoints. The technical success rate was 99.2 % with no major complications. During follow-up, a total of 643,200 catheter-days were documented, the mean device service interval was 380.6 days/patient. A total of 243 complications (14.4 %) in 226 patients were observed (0.4/1000 catheter-days), in 140 patients (8.3 %) the port device had to be explanted. Disconnection between the port device and the catheter (1.6 %) was more frequent than fracture (0.8 %) and leakage (0.6 %) of the catheter, which occurred more frequently when the catheter was inserted via the cephalic versus the brachial vein. TIVAP implantation at the forearm is a simple and safe procedure with a low rate of early and late complications.

Subclavian vein puncture vs. surgical cut-down to the cephalic vein for insertion of totally implantable venous access ports

Totally implantable venous access ports (TIAP) are commonly used in oncology, but which insertion modality should be preferred is still discussed controversially. We present a retrospective survey of the two main approaches for central venous cannulation from a single surgical department. All TIAP procedures between January 2004 and December 2010 were included. Direct puncture of the subclavian vein (DP) represented the standard approach for port insertion until 2007, when surgical cut-down to the cephalic vein (CD) was introduced as a reliable alternative at our department. Primary success rate, procedure time and postoperative complications within 30 days were analysed. In 301 (64.9 %) cases, DP was performed, and CD was done 163 times. Primary success rate for DP and CD was 94.4 and 87.1 %, respectively (p = 0.012). Mean procedure time was significantly longer in the CD group (38 vs. 32 min; p = 0.008). On routine postoperative chest X-ray, pneumothoraces were seen only following DP (10/301; 3.3 %), twice (2/301; 0.7 %) necessitating drainage. Early port infection (n = 6), haematoma (n = 2) and inadvertent arterial placement (n = 1) were seen following DP only. Complication rate for DP and CD procedures accounted for 7 and 1.2 %, respectively (p = 0.006). Surgical CD is associated with a minimal risk for (severe) early complications and should be favoured over DP for TIAP implantation even if it takes longer and is associated with a lower primary success rate

Identification of Risk Factors for Catheter-Related Thrombosis in Patients with Totally Implantable Venous Access Ports in the Forearm

To identify risk factors for the development of catheter-related thrombosis (CRT) in patients with totally implantable venous access ports (TIVAP) in the forearm, and to analyze the effect of prophylaxis and treatment. We retrospectively identified 200 patients (94 men, 106 women, mean age 57.7 +/-14 y) with TIVAP implantation in the forearm between 3/2010 and 11/2010. Type, number of punctures and sonographically defined diameter of the accessed vein were analyzed. Chemotherapy administered prior to the implantation procedure and history of thrombo-embolic events were assessed. Thrombo-embolic prophylaxis (TEP) following port implantation and treatment as well as course of CRT were analyzed. Twenty-one patients (10.5%) were diagnosed with CRT. Accessed vessels and mean diameter were basilic (n=150, 3.7 mm), brachial (n=39, 3.5 mm) and cephalic (n=11, 3.5 mm) vein. Neither type nor vessel diameter had effect on CRT development (P>.05). Implantation in the left forearm resulted in a significantly higher rate of CRT (P=.04). Ninety-five patients (47.5%) received chemotherapy and 30 patients (15.0%) had a history of thrombosis prior to implantation; both had no effect on development of CRT. Low molecular weight heparin (LMWH) was prescribed in 94/200 patients (47.0%) and had no effect on development of CRT (P>.05). Therapeutic anticoagulation with LMWH resulted in clinical improvement in 12/21 patients (57.4%). TIVAPs of the forearm may be associated with a certain rate of early and late CRT. The simplest vein to puncture should be selected for vascular access. Thrombo-embolic prophylaxis appears to be rather ineffective for prevention of CRT.

Reply to Letter: Further Data About Upper Extremity Ports

To the Editor: We thank Marcy et al. [1] for their interest and detailed comments on our manuscript evaluating the performance of totally implantable venous access ports (TIVAPs) placed in the forearm [2]. Literature on arm-port placement is rare, and in most of the published studies, patients received antibiotic prophylaxis before implantation as a routine, although arguments for this strategy seem weak: A meta-analysis found no statistically significant benefit from antibiotic prophylaxis before insertion of long-term tunnelled central venous catheters [3]. The Centers For Disease Control and Prevention does not recommend administration of oral or parenteral antibacterial drugs to prevent catheter-related blood stream infection [4]. Insofar the study of Marcy et al. aims at the lack of evidence regarding infectious prophylaxis in patients undergoing port implantation. There is obvious disagreement about what is believed to be the right way to prevent infections and what is proposed by evidence-based medicine [5]. Nevertheless, in patients undergoing TIVAP implantation, one should differentiate between those with normal risk of device infection and those with increased risk of device infection. In addition to the groups mentioned by Marcy et al. (i.e., immunocompromised and diabetic patients), we would also consider systemic prophylaxis for haematological patients receiving induction chemotherapy, for those who are neutropenic at the time of catheterinsertion, and for those undergoing bone marrow transplantation. It would be useful to evaluate whether systemic antibiotic prophylaxis would be of value for this subgroup of high-risk patients. Furthermore, it would be beneficial to have guidelines, based on additional published data, for interventional radiologists regarding systemic infectious prophylaxis in patients undergoing TIVAP implantation. Own experience coincides with that of Marcy et al. regarding the predominance of Staphylococcus aureus and Candida species as being the most common pathogens among infected TIVAPs demanding explantation, and any peri-interventional prophylaxis should cover these pathogens [6]. With interest we noted Marcy’s statement regarding mechanical complications in the arm-port subgroup: They found a mechanical complication rate of 7.3%, which is much higher than our own experience (0.9% mechanical complication). To our knowledge, Marcy et al. implanted the TIVAPs in the upper arm, whereas we implanted these devices in the proximal third of the forearm. We use a tunnelling device, which is included in the device set, to create a small tunnel for the port catheter to cross the elbow joint. As described earlier by Yamamoto et al., this technique has a low rate of mechanical complications [7]. We believe that compared with upper-arm placement, the location of the port chamber in the forearm is the reason for the lower rate of mechanical complications in our study. Implantation in the forearm facilitates a longer and more harmonic course of the tunnelled port catheter, thus resulting in less flexibility and lower rates of catheter fractures, slits, and disconnections as well as preventing malrotation of the port chamber. In addition, the forearm has less subcutaneous fat tissue than the location used for implantation in the upper arm; this allows more accurate sizing of the port pocket, which therefore appears less extendable. Furthermore, it is our subjective impression that a forearm port is easier to access because it can be felt, J. P. Goltz (&) R. Kickuth Institute of Radiology, University of Wurzburg, 97080 Wurzburg, Germany e-mail: goltz@roentgen.uni-wuerzburg.de