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 »  Abstract
 » Introduction
 » Subjects and Methods
 » Results
 » Discussion
 » Conclusion
 »  References
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  Table of Contents  
MINI SYMPOSIUM: SUPPORTIVE CARE
Year : 2012  |  Volume : 49  |  Issue : 1  |  Page : 114-118
 

Totally implantable venous access ports: Retrospective review of long-term complications in 81 patients


Department of Surgical Oncology, Rockland Hospital, Qutab Institutional Area, New Delhi, India

Date of Web Publication25-Jul-2012

Correspondence Address:
K K Bassi
Department of Surgical Oncology, Rockland Hospital, Qutab Institutional Area, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.98934

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 » Abstract 

Aim of The Study: A totally implantable venous access port (TIVAP) has become an essential prerequisite for many chemotherapy protocols. It is serving its purpose very well, but its use is not without complications. We are presenting our experience with these devices (TIVAPs). Subjects and Methods: We retrospectively reviewed the totally implantable venous access ports in 81 patients at our hospital between January 2009 and March 2011 for long-term problems which include postoperative and follow-up problems, excluding the immediate complications which occur at the time of insertion. Results: Catheter malfunction was the most common complication (9.87%, 0.40/1000 device-days of use/observation). Catheter-related bloodstream infections were present in 5 (6.17%) patients (0.25/1000 device-days of use/observation). The mean life of the catheter was 246 days. Only 11.1% ports required removal during the treatment period. Overall, patients either completed treatment (82.8%) or died (6.1%) while receiving treatment. Conclusion: TIVAPs provide safe and reliable vascular access for patients on chemotherapy but require utmost care by a dedicated team of trained medical professionals and paramedics experienced with the use of such ports, in order to minimize the complications and their continued use while administering treatment.


Keywords: Catheter-related infections, totally implantable venous access port, complications of totally implantable venous access port, pocket infection, thrombosis of catheter


How to cite this article:
Bassi K K, Giri A K, Pattanayak M, Abraham S W, Pandey K K. Totally implantable venous access ports: Retrospective review of long-term complications in 81 patients. Indian J Cancer 2012;49:114-8

How to cite this URL:
Bassi K K, Giri A K, Pattanayak M, Abraham S W, Pandey K K. Totally implantable venous access ports: Retrospective review of long-term complications in 81 patients. Indian J Cancer [serial online] 2012 [cited 2020 Jun 6];49:114-8. Available from: http://www.indianjcancer.com/text.asp?2012/49/1/114/98934



 » Introduction Top


A totally implantable venous access port (TIVAP), a subcutaneously implanted port made of titanium connected to a silicone central venous catheter, provides a simple, safe means of accessing the vascular system for intravenous delivery of chemotherapeutic drugs and fluids. [1] Implantable venous access systems [Figure 1] have become an essential prerequisite for many chemotherapy protocols for solid tumors and hematological malignancies. In addition to the perioperative problems, long-term complications can arise while in use; these can be catheter malfunction, catheter-related venous thrombosis/infection, injection port-related complications, and extravasation injury. [2] In a retrospective review, we present and discuss our long-term experience with TIVAPs at our hospital, excluding the immediate complications which occur at the time of insertion, e.g., pneumothorax, bleeding, failed cannulation of vein, hematoma formation, arrhythmias, etc.
Figure 1: Silicone catheter with an injectable subcutaneously implantable titanium port

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 » Subjects and Methods Top


Between January 2009 and March 2011, central venous access systems were implanted in 81 patients at the Department of Surgical Oncology at our tertiary care center. Of these patients, 66 were females and 15 males, with an average age at implantation of 57 years (35-77 years; [Table 1]). The indication for implantation was to administer intravenous chemotherapy in solid tumors and lymphomas. We used the Vortex® /Bard® port system for implantation consisting of a silicone catheter and titanium injection port [Figure 1].
Table 1: Patient characteristics

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We used Microsoft Excel (2003 version) for data entry and analysis. We evaluated the complications/problems per 100 devices implanted and 1000 device-days of use/observation [Table 2].
Table 2: Complications of TIVAP

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IDSA (Infectious Diseases Society of America) guidelines

Exit site infection


Clinical signs of infection (erythema, induration, tenderness, and/or pus formation) developing in the skin after the needle puncture or microbiological evidence of a micro-organism.

Tunnel infection

Clinical signs of infection along the subcutaneous tract of a catheter.

Pocket infection

Infected fluid collection in the subcutaneous pocket of a totally implanted intravascular device, often associated clinical signs of infection with or without spontaneous rupture and drainage.

Bloodstream infection

Catheter-related bacteremia or fungemia in a patient who has an intravascular device and more than one positive result of culture of blood samples obtained from the peripheral vein, clinical manifestations of infection (e.g., fever, chills, and/or hypotension), and no apparent source for bloodstream infection (with the exception of the catheter). In a suspected CRBSI (catheter-related bloodstream infection), paired blood samples, drawn from the catheter and a peripheral vein, should be cultured before the initiation of antimicrobial therapy. A definitive diagnosis of CRBSI requires that the same organism grows from at least one percutaneous blood culture and from a culture of the catheter tip or that two blood samples be drawn, one from a catheter and the other from a peripheral vein. Quantitative blood cultures with a colony count of microbes grown from blood obtained through the catheter hub that is at least threefold greater than the colony count from blood obtained from a peripheral vein suggests CRBSI. [3],[4]

Implantation technique

All totally implantable venous access ports were inserted under fluoroscopic guidance using local anesthesia. A 70% propyl alcohol or 10% povidine iodine solution (allowed to dry/left at least for 2 min) was applied over the skin surface before the cannulation of the vein. The catheter tip was positioned in the superior vena cava. The injection port was placed over the chest wall in a subcutaneous pocket and was connected to the silicone catheter. The TIVAP was ready to be used after implantation. The care of the TIVAP was done in outpatient follow-up with four to six weekly heparin flushes by resident doctors only. Ports were kept for a maximum period of 2 years after the completion of chemotherapy treatment. Ports were removed electively in the event of persisting infection and nonfunctional blockage.

TIVAP care

All aseptic precautions were used while accessing the port before chemotherapetic drug infusion and while flushing of the TIVAP upon follow-up when not in use. A 70% propyl alcohol or 10% povidine iodine solution (allowed to dry/left at least for 2 minutes) was applied over the skin surface before accessing the port with a non-coring needle. We adopted the "no touch technique" and used sterile gloves to access the injection port.


 » Results Top


We reviewed the data of 81 patients who had the insertion of a TIVAP for chemotherapy for solid organ malignancies and lymphomas. The mean life of the catheter was 246 days (range 8-793 days, and standard deviation, 185). The total catheter life of all ports was 19,960 days [Table 1].

We evaluated the long-term complications per 100 devices implanted and 1000 device-days of use/observation [Table 2]. A total of 16.0% of the ports were removed due to infectious and noninfectious complications either during treatment or during follow-up after the completion of the primary chemotherapeutic treatment. Only 11.1% ports required removal during the treatment period. Overall, 82.8% patients completed treatment and 6.1% died (causes related to their disease process) while still on treatment with the functional port in situ.

The most common problem was catheter malfunction which hampered the use of a port in 8 (9.87%) patients with nonthrombotic occlusion in 3 (3.6%) patients and thrombotic occlusion in 5 (6.17%) patients, respectively (0.15/1000 and 0.25/1000 device-days of use/observation).

Infectious complications occurred in 7 (8.64%) patients; 5 had catheter-related bloodstream infections which required port removal (0.25/1000 device-days of use/observation). Two patients had pocket site infections of the TIVAP [Figure 2], of whom one could not be salvaged with treatment with antibiotics. One patient developed superior vena cava thrombosis with the port in situ [Figure 3]a and b. One patient had pressure necrosis of the overlying skin [Figure 4] which occurred 1-year after the completion of treatment.
Figure 2: Local infectious complication of injectable port site

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Figure 3: (a and b) CT scan showing superior vena cava thrombosis with the catheter in situ

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Figure 4: Pressure necrosis of the overlying skin

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 » Discussion Top


Permanent venous access devices are important tools of drug delivery in the fight against cancer. There have been comparisons between various external and totally implantable devices in the literature. [5],[6],[7],[8],[9] One of the studies reported 22.5% risk of blood steam infections (BSIs) originating from cuffed and tunneled central venous catheters. TIVAPs had a lesser risk of BSIs (0.1 vs. 1.6 BSIs per 1000 device days) as compared to cuffed or tunneled catheters. [6] TIVAPs are easy to use, concealed, easy to maintain, and convenient to the patient. Various studies have evaluated the efficacy of the totally implantable devices. [10],[11]

Infectious complications with TIVAPs in the range of 4.8-8.8% have been reported in the literature. [12],[13] In a prospective study of 680 patients between June 1987 and May 1989 at Memorial Sloan-Kettering Cancer Center, followed up until port removal, death, or a maximum of 1960 days, infectious complications were noted in 8.8% of patients, half of which were surgical site infections and rest were systemic sepsis. [12] Biffi et al. in a study of 376 patients found 3 patients who suffered from port-related bacteremia (0.8%, 0.016/1000 days of use). [14]

In our study, we observed 7 (8.64%) patients with infection with the port in situ, 5 of whom required the removal of the ports. The bloodstream infection rate was 0.25/1000 device-days of use/observation. Of these patients, four were neutropenic at the time of port removal. Long-term catheters should be explanted from patients with CRBSIs associated with any of the following conditions: severe sepsis, suppurative thrombophlebitis, endocarditis, bloodstream infection that continues despite >72 h of antimicrobial therapy to which the infecting microbes are susceptible, or infections due to Staphylococcus aureus, Pseudomonas aeruginosa, fungi, or mycobacteria. [3],[4]

Local complications (injection port site) include exit site infection (needle puncture site infection) and pocket infection. In our series, two patients had pocket infection (0.1/1000 days of device use; [Figure 2]). Even lower pocket and exit site infections rates (0.09/1000 and 0.03/1000 days of device observation, respectively) have been reported in an Italian multicenter study. This prospective observational study involved 1076 cancer patients with totally implanted central venous access ports from oncologic outpatient clinics. A total of 515 devices were observed in patients undergoing treatment and 561 in-patients were followed up in the outpatient clinic only for flushing. [10] Biffi et al. reported pocket infection rate of 0.53% (0.01 episodes/1000 days of use). [14]

The occlusion of a catheter is another common complication which is either due to a blood clot or due to abutting the catheter lumen to the venous side wall. An occlusion rate of 3.2-21.5% has been reported in various studies. [11],[13] We noted a 6.17% rate of occlusion, where neither fluid/blood can be pushed nor aspirated (0.25/1000 device days of use/observation). Two ports got blocked while patients were receiving treatment (0.1/1000 device days of use) and rest during the follow-up period (0.15/1000 device days of observation). The Italian multicenter study reported occlusion of 0.03/1000 device days of observation. [10]

Withdrawal occlusion is the inability to aspirate blood, but fluid can be pushed in. Various studies show a rate range of 0.9-2%. [15],[16] Biffi et al. in a randomized study of 302 patients noted the inability to draw blood in 2% cases where a standard open-ended catheter was used. [16] We had such difficulty in 2.4% of ports (0.10/1000 device days of use/observation).

The "pinch-off effect" is due to the impingement of the catheter between the clavicle and the first rib when the catheter is placed by subclavian vein access. One patient with a subclavian catheter in situ had such malfunction in our study. The pinch-off effect has also been the reported cause of catheter fracture. In order to prevent this complication, more lateral access of the subclavian vein is recommended. [17] We tried change in the posture and lifting the shoulder for partial/complete resolution of pinching.

One patient had necrosis of the overlying skin due to the injection port and another one patient had thrombosis of the superior vena cava; TIVAPs were removed in these patients. Pressure necrosis is caused by differential pressure exerted by the edge of injection port diaphragm on the overlying skin over the period of time. Asthenia and weight loss as the disease progresses lead to the loss of the subcutaneous fat contributing to this complication. The thrombotic occlusion of the great vessel is a serious complication associated with port use which requires the removal of the indwelling catheter and search for any other associated hypercoaguable state. Treatment involves the use of intravenous/subcutaneous heparin followed by the use of oral anticoagulant drugs for duration of 6 months to 1 year.

There have been rare complications reported in the literature like catheter fracture, migration/embolization, and disconnection. [17-19] We did not observe any such complications.


 » Conclusion Top


TIVAPs provide safe and reliable vascular access for patients on chemotherapy in general but are not without complications. A trained team of medical professionals and paramedics experienced with the use of such ports is needed in order to minimize complications. Recent guidelines for the prevention of CRBSIs recommend educating and training healthcare personnel who insert and maintain catheters, maximal sterile barrier precautions, and 0.5% chlorhexidine preparations with alcohol for skin antisepsis. Tincture iodine and 70% alcohol have been recommended as alternatives. [20] Neutropenia is a major risk factor for catheter-related infections necessitating their removal. Regular flushing of TIVAPs every 4-6 weeks, while not in use, can decrease the rate of thrombosis of catheters.

 
 » References Top

1.Brothers TE, Von Moll LK, Niederhuber JE, Roberts JA, Walker-Andrews S, Ensminger WD. Experience with subcutaneous infusion ports in three hundred patients. Surg Gynecol Obstet 1988;166:295-301.  Back to cited text no. 1
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2.Kurul S, Saip P, Aydin T. Totally implantable venous-access ports: Local problems and extravasation injury. Lancet Oncol 2002;3:684-92.  Back to cited text no. 2
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3.Mermel LA, Farr BM, Sherertz RJ, Raad II, O'Grady N, Harris JS, et al. Guidelines for the Management of Intravascular Catheter-Related Infections. Clin Infect Dis 2001;32:1249-72.  Back to cited text no. 3
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4.Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1-45.  Back to cited text no. 4
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5.Johansson E, Engervall P, Björvell H, Hast R, Björkholm M. Patients' perceptions of having a central venous catheter or a totally implantable subcutaneous port system-results from a randomised study in acute leukaemia. Support Care Cancer 2009;17:137-43.  Back to cited text no. 5
    
6.Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: A systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81:1159-71.  Back to cited text no. 6
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7.Carde P, Cosset-Delaigue MF, Laplanche A, Chareau I. Classical external indwelling central venous catheter versus totally implanted venous access systems for chemotherapy administration: A randomized trial in 100 patients with solid tumors. Eur J Cancer Clin Oncol 1989;25:939-44.  Back to cited text no. 7
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8.Mueller BU, Skelton J, Callender DP, Marshall D, Gress J, Longo D, et al. A prospective randomized trial comparing the infectious and noninfectious complications of an externalized catheter versus a subcutaneously implanted device in cancer patients. J Clin Oncol 1992;10:1943-8.  Back to cited text no. 8
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9.Hooda B, Lalani G, Fadoo Z, Billoo G. Implantable port devices are catheters of choice for administration of chemotherapy in pediatric oncology patients-a clinical experience in Pakistan. Ann N Y Acad Sci 2008;1138:43-6.  Back to cited text no. 9
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10.Dal Molin A, Rasero L, Guerretta L, Perfetti E, Clerico M. The late complications of totally implantable central venous access ports: The results from an Italian multicenter prospective observation study. Eur J Oncol Nurs 2010;15:377-81.  Back to cited text no. 10
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11.Strum S, McDermed J, Korn A, Joseph C. Improved Methods for Venous Access: The Port-A-Cath, A Totally Implanted Catheter System. J Clin Oncol 1986;4:596-603.  Back to cited text no. 11
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12.Schwarz RE, Groeger J, Coit DG. Subcutaneously implanted central venous access devices in cancer patients: A prospective analysis. Cancer 1997;79:1635-40.  Back to cited text no. 12
    
13.Kock HJ, Pietsch M, Krause U, Wilke H, Eigler FW. Implantable venous access system: Experience in 1500 patients with totally implanted central venous port system. World J Surg 1998;22:12-6.  Back to cited text no. 13
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14.Biffi R, Pozzi S, Agazzi A, Pace U, Floridi A, Cenciarelli S, et al. Use of totally implantable central venous access ports for high-dose chemotherapy and peripheral blood stem cell transplantation: Results of a monocentre series of 376 patients. Ann Oncol 2004;15:296-300.  Back to cited text no. 14
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15.Di Carlo I, Cordio S, La Greca G, Privitera G, Russello D, Puleo S, et al. Totally implantable venous access devices implanted surgically: A retrospective study on early and late complications. Arch Surg 2001;136:1050-3.  Back to cited text no. 15
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16.Biffi R, De Braud F, Orsi F, Pozzi S, Arnaldi P, Goldhirsch A, et al. A randomized, prospective trial of central venous ports connected to standard open-ended or Groshong catheters in adult oncology patients. Cancer 2001;92:1204-12.  Back to cited text no. 16
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17.Klotz HP, Schöpke W, Kohler A, Pestalozzi B, Largiadèr F. Catheter fracture: A rare complication of totally implantable subclavian venous access devices. J Surg Oncol 1996;62:222-5.  Back to cited text no. 17
    
18.Di Carlo I, Fisichella P, Russello D, Puleo S, Latteri F. Catheter fracture and cardiac migration: A rare complication of totally implantable venous access devices. J Surg Oncol 2000;73:172-3.  Back to cited text no. 18
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19.Lam AW, Chen YM, Yang KY, Tsai CM, Perng RP. Disconnection of a venous Port-A-Cath followed by embolization after saline flush: Rare case report. J Clin Oncol 1999;29:643-5.  Back to cited text no. 19
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20.O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011; 52:e162-93.  Back to cited text no. 20
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]

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