|Year : 2018 | Volume
| Issue : 3 | Page : 113-118
Cephalic vein cut down technique for chemoport implantantion and ease of chemoport access - A cohort study
Jency Mathews1, Seethal Abraham1, Rani Philip2
1 Division of Surgical Oncology, Pushpagiri Medical College, Tiruvalla, Kerala, India
2 Department of Oncology, Pushpagiri Medical College, Tiruvalla, Kerala, India
|Date of Web Publication||27-Sep-2019|
Dr. Jency Mathews
Division of Surgical Oncology, Flat No D2, Pushpagiri Hospital Quarters, Tiruvalla - 689 101, Kerala
Source of Support: None, Conflict of Interest: None
Background: Multiple techniques have been established for the insertion of totally implantable chemotherapy ports. Cephalic vein cut down technique is considered a safe technique with reasonable success. The surgical team implanting the chemoports and the nursing team handling them have a learning curve. This prospective observational cohort study aimed to document the techniques used for the implantation, the success and failure of cephalic vein cut down technique, the intraoperative and delayed complications of chemoport implantation, and the ease and difficulties of the nursing personnel in subsequent handling of the chemoports.
Patients and Methods: All consecutive patients undergoing surgical implantation of chemoports between September 2015 and December 2017 were included in this study. Chemoport implantation was first attempted in the cephalic vein by cut down technique followed by closed Seldinger method in the subclavian or internal jugular vein. Surgical details were recorded and further access of the chemoport by the nursing personnel was monitored. Any difficulty in access or use of the chemoports was noted and help sought. All data were collected prospectively and analysed.
Results: Thirty chemoport implantations and 280 chemoport cannulations were performed during the study period. Cephalic vein cut down technique was performed in 28 (96%) patients. Cephalic vein implantation of chemoport was successful in 14 (50%) patients. Obliterated vein, small luminal diameter and adverse anatomy were reasons for failure. Patients who had not previously received chemotherapy had a cephalic vein success rate higher than those who had, with an odds ratio of 2.4. Chemoport access by nursing personnel was easy in 92% patients. No blood return was seen in 7%.
Conclusion: Cephalic vein cut down technique was successful in 50% patients. It was less successful in patients who have previously been treated with chemotherapy. No blood return on access was the commonest cause for concern while handling chemoports. An algorithm for the preference of veins to be used and an institutional protocol for chemoport access and use increase safety and efficiency.
Keywords: Cephalic vein, chemoport access, chemoport cannulation, chemoport implantation
|How to cite this article:|
Mathews J, Abraham S, Philip R. Cephalic vein cut down technique for chemoport implantantion and ease of chemoport access - A cohort study. Arch Int Surg 2018;8:113-8
|How to cite this URL:|
Mathews J, Abraham S, Philip R. Cephalic vein cut down technique for chemoport implantantion and ease of chemoport access - A cohort study. Arch Int Surg [serial online] 2018 [cited 2020 Jan 18];8:113-8. Available from: http://www.archintsurg.org/text.asp?2018/8/3/113/268122
| Introduction|| |
Totally implantable devices for intermittent venous access, commonly known as port-a-cath or chemoports have improved the quality of life for patients receiving long-term chemotherapy. Although several methods have been established for the implantation of these devices, the surgical team has a learning curve with respect to the choice of vein and the choice of technique. Techniques for external cannulation of the subclavian and internal jugular veins were described by Broviac and Hickman in the 1970s. In 1982, Niederhuber et al. introduced the totally implantable access port. In 2008, Gallieni et al. have outlined the choice of the different devices suitable for different settings.
The cephalic vein cut down technique was described in the 1980s initially for placement of pacemakers and later used for implantation of chemoports. This technique is attractive for the beginner as the theoretical chances of complications are lesser. But no technique is flawless and the same patient may need multiple attempts and multiple vein punctures for the successful implantation of the chemoport. Patients who have received chemotherapy earlier may have extensively thrombosed veins causing further difficulties in implantation of chemoports.
The cephalic vein cut down technique was chosen to begin the implantation of the chemoports in our institution. The present study was done with the aim to observe the ease of chemoport implantation through the cephalic vein, and the ease and difficulties of the nursing personnel in accessing the chemoports.
| Patients and Methods|| |
Institutional ethical committee approval was obtained for the conduct of the study. All consecutive patients undergoing surgical implantation of chemoports in Pushpagiri Medical College Hospital, Tiruvalla, India between September 2015 and December 2017 were included in this prospective observational cohort study. Patients undergoing second time implantation of chemoport after failure or removal of the previously inserted port were excluded from the study. The demographic details of patients and surgical techniques were entered into a database and they were followed up at the chemotherapy units, where further follow-up details with respect to the chemoport access, usage and other outcomes were collected. Informed consent was obtained from all patients included in the study.
Chemoport insertion technique
The chemoports were implanted either during the time of primary cancer surgery under general anaesthesia or as a daycare procedure under local anaesthesia. Size of the chemoport was selected according to patient build and physique.
The cephalic vein was the initial vein of choice for all patients except in patients with severe truncal obesity. Right-sided veins were preferred for insertion unless the disease (breast cancer) or patient preference for non-dominant arm dictated left side insertion. No. 8 Fr. Groshong tip BARD Catheter (MRI compatible) was used in all patients. Catheter placement was guided by fluoroscopy. The tip of the catheter was placed at the superior vena cava–right atrial junction. The ports were implanted in a subcutaneous pocket created in the infraclavicular region. The open cut down technique was used to access the cephalic vein. In case of failure of cannulation of cephalic vein, the second vein attempted was either the subclavian or the internal jugular vein by Seldinger technique. All surgical details including vein of insertion, sequence of veins used, and reason for failure were duly recorded. Any attempts in contralateral vein were recorded. Prior chemotherapy status was noted.
Chemoport cannulation method
Chemoports were accessed by senior staff trained in oncology nursing using 22G/20G winged infusion set (Huber needle). Maximum two attempts were tried before seeking help. The number of attempts, the ease of access and the difficulties encountered were recorded in a log book. If the personnel were not able to access the chemoport or no blood return was seen on accessing the port, the surgeon was notified and radiological confirmation (chest X-ray [CXR] or contrast studies) for catheter position was done before further use of the chemoport. Any port site swelling, pain, arm oedema and infection were noted. Any delay in starting chemotherapy due to port-related complications was also noted.
| Results|| |
Thirty chemoport implantations and 280 chemoport cannulations were available for analysis. Demographic details of the cohort and the insertion techniques details are outlined in [Table 1].
The cephalic vein cut down technique was attempted in 28 (96%) patients and successful in 14 patients (50%). Two patients were not considered candidates for cephalic vein exploration due to severe truncal obesity. Closed Seldinger technique was employed in both patients to cannulate the internal jugular vein. The causes for failure of cephalic vein cannulation are listed in [Table 2]. There were no intraoperative complications.
Cephalic vein cannulation was more successful in patients who had not received prior chemotherapy than those who had received chemotherapy with an odds ratio of 2.4 [Table 3]. The first vein of insertion was successful in 16 (53%) patients, 14 in the cephalic vein and 2 in internal jugular vein. The second vein attempted was the subclavian vein in 6 patients (43%) and the IJV in 8 patients (57%). It was successful in 12 (40%) patients (5 in subclavian and 7 in IJV). Two patients (7%) required a third vein to be cannulated for successful implantation of the catheter. Subclavian vein was not used as first vein of attempt in any patient.
Two patients (6%) developed post-operative hematoma at the port pocket. One patient was treated conservatively and the other required aspiration and compressive dressing. None of the patients developed immediate post-operative infection at the implantation site. Long-term complications included shoulder pain which was the most frequent subjective complaint of the patients (46%). None of the patients required any intervention for pain. No arm oedema was observed in any patient [Table 4].
There was no delay to start chemotherapy due to port-related complications. One patient had a catheter malposition (port base turned sideways) which was corrected by repositioning by palpation. Catheter migration, breakage, catheter pinch syndrome and kinking were not observed in our study cohort. Port site infection was suspected in two patients presenting with complaints of fever, 120 and 710 days after chemoport insertion. Blood collected from the chemoport and simultaneous peripheral blood culture had shown a differential positivity in both patients. Chemoport was removed in both the patients. But final implant culture was negative in one patient and positive in the other.
Chemoports were accessed 280 times. It was easy 258 times. Help was sought by the nursing personnel 22 times (8%). The details are outlined in [Table 4]. No blood return on aspiration of the chemoport was encountered in six patients (20 aspirations). The patients whose catheter had no blood return presented with the same problem again during the next chemotherapy or flushing schedule. CXR confirmation of catheter position was done in five patients when no blood return was encountered. One patient required contrast study of the chemoport for confirming port position. There were no untoward consequences of using the chemoport, albeit no blood returned on aspiration. One patient had air on aspiration from the chemoport. Fistulous tracts were ruled out by doing CT scan. The Huber needle (puncture needle) was found to be faulty and rectified after changing the needle. Further chemotherapy and intravenous fluids infusions were, however, uneventful.
| Discussion|| |
The success rate of cephalic vein chemoport implantation was only 50% in this cohort. The literature describes both high and low success rates of cephalic vein cut down technique.,, Koketsu et al. attributed failure to small lumen (<3 mm), absent cephalic vein and inability to traverse the cephalic vein into the subclavian vein. In our study, we report similar difficulties with obliterated vein, absent vein and <3 mm lumen. In patients with severe truncal obesity, the depth of the deltopectoral groove is too deep to negotiate the catheter. Hence, the cephalic vein cut down was not attempted for the two patients with severe obesity.
The different methods of chemoport implantation and choice of veins for insertion have been studied and compared in randomised controlled trials and meta-analysis with no difference in complication rates. No method has been shown to be superior to another., A Cochrane review of the methods used to insert the catheter such as Seldinger technique for the subclavian vein compared to the venous cut down technique had a higher implantation rate with the Seldinger technique.
In most institutions, the chemoport is implanted at the beginning of the chemotherapy treatment. This theoretically leads to higher success rates and with the first vein of attempt itself. In lower resource populations, chemoports are implanted only in the setting of recurrence or palliation when all the peripheral venous access options are emptied. Chemotherapy causes thrombosis/obliteration of the vein lumen along the entire length of the vein. Our cohort had 53% patients previously treated with chemotherapy and this probably is the cause for the lower cephalic vein success rate. A thorough literature search did not reveal any study correlating the success rate of cephalic vein cut down with prior chemotherapy status.
The side of insertion was chosen on the right side for the majority. Left side was used only in patients who had breast cancer on the right side and in one patient who specifically wanted it on the non-dominant side. Right side catheter implantation is preferred as it decreases length of implanted catheter and the angulation between the catheter axis and the axis of the superior vena cava is lesser. In this study, the side planned was successful in all patients and there was no contralateral attempt. In a randomised study done on the preference of the side of implantation of a chemoport, there was no significant difference in the implantation rate or complications.
To improve the success rate of cephalic vein cut down technique in pacemaker wire implantation, the literature describes the use of preoperative ultrasonography and Doppler to identify the cephalic vein, its luminal diameter and depth of the vein in the deltopectoral groove. A similar practice of preoperative identification of cephalic vein, luminal patency and diameter can increase the success rate of cephalic vein catheter implantation.
Most surgical units performing the chemoport insertion have a preferred technique. In a study by Wei et al., an established algorithm helps to choose the best entry vessel for the catheter insertion. We have tried a similar approach in this study attempting the cephalic vein first, but the Internal jugular vein and subclavian vein have been equally preferred for the subsequent percutaneous approach following failure of the cephalic vein attempt. The algorithm by Wei et al. does not include the subclavian vein at all due to worry about “iatrogenesis”. While some authors completely avoid the subclavian vein, Harish et al. describe some additional manoeuvres such as bending the sheath for the natural curvature of the vein. In this study, the subclavian approach was equally successful as the Internal jugular vein and no additional complications were noted. We suggest the subclavian vein may be equally placed in the algorithm.
Early complications of chemoport implantation such as hematoma, pneumothorax, and port site infection were not seen in this study. The two cases of fluid collection around the port in the immediate post-operative period were managed conservatively and resolved with extended antiobiotic therapy. Kinking of the catheter (catheter pinch-off), displacement, breakage, catheter migration are known delayed complications of chemoport placement. However, these complications are decreasing with better port design and better insertion techniques and they were not seen in this study. Catheter-related blood stream infection is a lesser but significant complication in patients with indwelling chemoports. This necessitates surgical removal of the implanted device. Differential time to positivity is considered the best method to diagnose catheter related bacteraemia. In this study, two patients needed surgical removal of the chemoport for catheter-related bacteraemia. One patient had exhibited the “port flush form” with fever and chills immediately after saline flush of the chemoport.
The guidelines for indwelling catheters mandates that blood return on aspiration when cannulating the chemoport is necessary for administration of the drugs or heparin flushes. Absence of blood return (partial occlusion) was the cause for concern in 7% of the cannulations in this study. This was seen in patients who had completed chemotherapy and were undergoing flushing of the port to maintain patency. A standard Chest x-ray can detect catheter dislocation or migration. However, the gold standard for diagnosis is radiographic visualization with contrast injection via the chemoport. This is not a routine procedure before each cycle of chemotherapy as it is associated with the risk of contrast–medium-related complications, need for radiological facilities, and higher costs. Chest x-ray was adequate to confirm port position in majority of the patients in this study. These patients continued to have heparin saline flushing of the chemoport 2 monthly until the ports were removed. None of these patients had any untoward effect.
The patients who had no blood return detected during the course of the chemotherapy schedule underwent radiological imaging including CT scans to ensure port position and had the rest of the chemotherapy without any complications using the chemoport, although blood could not be aspirated at any subsequent port cannulation. Fibrin sheath formation is said to be the commonest cause of this problem acting as a one-way valve preventing aspiration of blood while allowing infusion of fluids. The Groshong tip catheter used in all patients in this study is designed to decrease the risk of thrombus formation; however, fibrin film formation in the tips of the catheters can still occur.
The literature does not mention air on aspiration as a known difficulty encountered during cannulation of the chemoports. In this study cohort, one patient had this particular problem and CT scan was done to rule out migration or fracture of the catheter. With no evidence of any abnormalities in the port or the catheter, the problem was identified to be a faulty Huber needle, which was rectified after changing the Huber needle. Port rotation was encountered in one patient and this was managed by simple manipulation.
While several studies on chemoport implantation have included patients suffering from one type of cancer only, the cohort in the present study included patients suffering from a variety of cancers. Majority of patients were females in this cohort, explained by the fact that most patients were breast or ovarian cancers who were counselled about the need for chemoports.
| Conclusion|| |
Cephalic vein cannulation was successful in 50% of patients. Chemoports once implanted could be used successfully in all patients without any major complications. There were no untoward consequences of using the chemoport despite no blood return on aspiration. An algorithm for the preference of veins to be used depending on prior chemotherapy status and preoperative vascular sonography can increase the success rate of insertion. Safety and efficiency of chemoport access can be increased by developing institutional protocols.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]