Original Article |
Corresponding author: Martin Karamanliev ( martinkaramanliev@gmail.com ) © 2023 Martin Karamanliev, Tsanko Yotsov, Dobromir Dimitrov.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Karamanliev M, Yotsov T, Dimitrov D (2023) Success rate and safety of totally implantable access ports placed by the cephalic vein cutdown technique in oncological patients – a single-center study. Folia Medica 65(4): 577-581. https://doi.org/10.3897/folmed.65.e87401
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Introduction: Totally implantable access ports (TIAPs) are commonly used in oncologic patients undergoing ongoing chemotherapy. The methods of choice for implantation are the subclavian vein puncture approach and the cephalic vein cutdown technique, followed by internal jugular vein access and external jugular vein access.
Materials and methods: We analyzed all patients who had a central venous access implanted by a single surgeon at the University Hospital in Pleven between October 2018 and January 2022, with the aim of determining the success rate and safety of the cephalic cutdown technique for placing totally implantable access ports.
Results: 135 totally implantable access ports were inserted in the study period. Median age of patients was 69.2 years (range, 35-86 years). There were 71 (52.59%) women and 64 (47.41%) men. In 7 patients, the tip of the catheter was reported to go at the distal part of the subclavian vein and axillary vein on the ipsilateral side after initial placement and was repositioned under real-time fluoroscopic guidance. Successful placement of a totally implantable access port using the cephalic cutdown technique was reported in 127 patients (94.07%). No postoperative pneumothorax, hemothorax, or vessel injury were reported. One case of surgical site infection was seen on postoperative day (POD) 7. Late postoperative complications occurred in 3 patients with catheter-related bacteremia all after POD 30 (81, 95, and 172 days after the procedure). One patient died.
Conclusions: Totally implantable access ports placed using the cephalic vein cutdown technique can be used safely and with high success rates in oncological patients.
cancer, chemotherapy, port-a-cath
The totally implantable access ports (TIAPs) are commonly used devices in oncologic patients undergoing ongoing chemotherapy. In comparison to frequent vein puncture and cannulation, the main advantages of these devices are the quick, simple, and easy placement of a vein access for medication administration with minimal discomfort experienced by patients.[
In the present study, we aimed to determine the success rate and safety of the cephalic cutdown technique for placement of totally implantable access ports.
We analyzed all patients who underwent a surgery for placement of implantable central venous access performed by a single surgeon from October 2018 to January 2022 at our institution. The inclusion criteria were (1) patients >18 years old; (2) indications for totally implantable access port placement; and (3) histologically proven cancer. The exclusion criteria were (1) patients <18 years old and (2) indications for totally implantable access port placement other than cancer. The data, including patient demographics, operative time, success rate, oncological reason for insertion, complications, time and reason for removal, were collected and analyzed. All procedures were performed by a single surgeon and started as a cephalic cutdown technique.
The patients were positioned supine on the operating table. The surgical site was prepared and draped in the standard manner. All procedures were performed under 1% lidocaine anesthesia. A 4-cm long incision was made at the deltopectoral groove on the right side. After sharp and blunt dissection in the subcutaneous tissue and facial structures, the cephalic vein was exposed between the deltoid and pectoral major muscle. Two 3/0 vicryl sutures were placed around the vein proximally and distally, as the distal suture was tied. A transverse venotomy was done with Potts-scissors between the ligatures. Back-bleeding was controlled by applying traction on the proximal suture. Then, the catheter was inserted in the cephalic vein with the help of a vein pick and advanced until the tip reached the cranial part of the superior vena cava. The proximal suture was tied to prevent bleeding and catheter migration attached to the port and the port was sutured in a prepectoral pocket. A test for functionality was performed by attempting to aspirate blood and then flushing the system with a 20 cc saline solution. Layer-by-layer closure of skin and subcutaneous tissue was done with resorbable sutures.
A total of 135 totally implantable access ports were inserted in the study period at our institution. Median age of patients was 69.2 years (range, 35–86 years). There were 71 (52.59%) women and 64 (47.41%) men. Oncological reason for insertion was colorectal carcinoma in 115 patients (85.19%), ovarian cancer in 4 patients (2.96%), breast cancer in 11 patients (8.15%), and endometrial or cervical cancer in 5 patients (3.70%) (Fig.
No postoperative complications, such as pneumothorax, hemothorax, or a vessel injury were reported. One case of surgical site infection was seen on POD 7, treated locally for 5 days. Late postoperative complications occurred in 3 patients with catheter-related bacteremia all after POD 30 (81, 95, and 172 days after the procedure) and all 1-3 days after using the system for chemotherapy or routine flushing. One patient died at home after 48 hours of fever up to 40°C. The other two patients were septic, the port was removed and intravenous antibiotics were administered after antibiograms and were discharged on POD 5. Aseptic non-touch technique protocol for usage and flushing of ports was introduced after these cases. No other catheter-related bacteremia was seen 16 months after the introduction of the protocol.
Cancer patients benefit from totally implantable access ports because of the need for frequent and long-term i.v. drug administrations. Compared to the subclavian percutaneous approach, the cephalic cutdown technique has been reported to have fewer complications but lower success rates.[
Comparison between studies accessing the safety and feasibility of totally implantable access ports
Author | Year | Number of patients (n) | Success rate (%) | Pneumothorax (%) | Wound complications (%) | Long-term post-operative infections (%) |
Present study | 2022 | 135 | 94.07 | 0 | 0.74 | 2.22 |
Hashimoto et al.[ |
2019 | 212 | 95.8 | 0 | 1.9 | 5.5 |
Mudan et al.[ |
2015 | 1000 | 95 | 1.2 | 0.4 | 0.8 |
Palezny et al.[ |
2013 | 220 | 94.4 | 1.5 | not reported | not reported |
Lin et al.[ |
2013 | 758 | 92.6 | 0.13 | not reported | not reported |
Koketsu et al.[ |
2010 | 79 | 93.7 | 0 | not reported | not reported |
Ignatov et al.[ |
2008 | 550 | not reported | 0.36 | 0 | 7.63 |
Seiler et al.[ |
2006 | 400 | 79.5 | 0 | 0.75 | 3.5 |
Di Carlo et al.[ |
2001 | 344 | 100 | 0 | 0.52 | 1.7 |
Torramade et al.[ |
1993 | 234 | 70 | 0 | not reported | not reported |
The higher success rates and lower complication rates of the cephalic cutdown technique reported in the last few years suggest that it should be preferred over puncture techniques. When the cephalic cutdown technique fails, access via the internal or external jugular veins is usually used as an alternative. Reasons for failure were too small vessel or missing vessel, as reported in most of the studies. The percutaneous subclavian puncture method is associated with significantly higher rates of pneumothorax, hemothorax, and great vessel injuries.[
Totally implantable access ports placed by the cephalic vein cutdown technique can be used safely and with high success rates in oncological patients.
This work was supported by the European Regional Development Fund through the Operational Programme “Science and Education for Smart Growth” under contract No. BG05M2OP001-1.002-0010-C01(2018-2023).
All authors participated in the writing process, analysis of the results, and final revision of the article.
The authors have declared that no competing interests exist.