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Original article
peer-reviewed

Complications of Totally Implantable Central Venous Catheters (Ports) Inserted via the Internal Jugular Vein Under Ultrasound and Fluoroscopy Guidance in Adult Oncology Patients: A Single-Center Experience



Abstract

Introduction

In this retrospective study, the safety and complication rates of port implantations via the internal jugular vein under ultrasound and fluoroscopy guidance in adult oncology patients were analyzed.

Material and methods

Eight hundred seven ports implanted in 799 adult oncology patients at a tertiary Oncology-Anticancer Hospital during a 36-month period from January 1, 2017 to December 31, 2019 were retrospectively reviewed. Data acquisition was obtained until December 31, 2020. All procedures were performed by two specialized interventional radiologists under ultrasound and fluoroscopy guidance. The vein access was via the internal jugular vein. Catheter days (the total number of days of maintenance of the port by all of the patients until removal, death, or December 31, 2020), technical success rates, and complication rates were evaluated based on the interventional radiological reports and patient medical records. Multivariate analysis regarding patients such as age, sex, body mass index (BMI), marital status, educational level, cancer type, side of insertion, diameter of internal jugular vein, diabetes, anticoagulants/antiplatelets, purpose of implantation, and catheter material as to the risk of complications was conducted.

Results

A total of 369,329 catheter maintenance days were observed (457.7±345.0). The technical success rate was 99.9%, and a total of 85 (10.5%) complications occurred, of which 24 (28.2%) occurred early (<30 days) and the remaining 61 (71.8%) were late (>30 days) complications. Specifically, 28 (3.5%) were catheter-related thrombosis (CRT), 27 (3.4%) related to infection, 17 (2.1%) were mechanical complications (16 fibrin sheath formation and one catheter occlusion), six (0.7%) related to catheter migration, four (0.5%) related to incision healing problems, and the remaining three (0.4%) related to ischemic skin necrosis. Forty-seven (5.8%) ports were removed due to complications. On multivariate analysis, cancer type was found as a risk factor for the development of a complication. Additionally, there was an indication that hematologic malignancy is related to infection.

Conclusion

Placement of ports via the internal jugular vein under ultrasound and fluoroscopy guidance is a safe procedure, with low rates of early and late complications.

Introduction

The first placement of a totally implantable central venous catheter (port) by Niederhuber in 1982 worthily represents an important milestone in the long history of venous puncture and catheterization [1]. Since then, the use of ports has been widely established and has prevailed in the management of oncology patients [2]. Ensuring permanent venous access is critical to the frequent and prolonged administration of chemotherapeutic agents, blood products, antibiotics, contrast media, parenteral nutrition, and blood samplings [3,4]. At the same time, the safety of the patient is preserved and the quality of life is improved [5]. Hence, there is an increase in the number of ports placed internationally on an annual basis.

Although different techniques and equipment have been developed and much experience is accumulated, the implantation and presence of ports are associated with complications. Some complications are life-threatening to the patients or cause discomfort, prolong hospital stay, delay treatment, and increase hospital cost. In the modern literature, it has been documented that the radiological placement of ports is associated with high rates of technical success and low rates of complications that range from 4.4% to 14% [6]. Under this prism, a retrospective study was conducted to investigate the safety of port insertion via the internal jugular vein under ultrasound and fluoroscopy guidance and the complications of the totally implantable venous catheters in adult oncology patients.

Materials & Methods

Study population’s demographic data were recorded. In addition, medical and technical information about patients was also recorded.

Procedure

At the Interventional Radiology Department of our Anticancer and Oncology Hospital, ports were implanted in patients older than 18 years. The procedures were performed by two specialized interventional radiologists. Our equipment included an angiographic unit, Siemens Axiom Artis-Zee (Siemens Healthineers, Erlangen, Germany), and an ultrasound unit, Siemens Acuson NX3 (Siemens Healthineers, Erlangen, Germany). An eight-French (Fr) port with polyurethane Tita Jet Light II (PFM Medical, Inc., Cologne, Germany) and polyurethane Smart Port, Vortex (AngioDynamics, New York, United States), or silicone Nu port (PHS Medical GmbH, Fuldabrück, Germany) catheter was used. Upon the recommendation of the treating oncologist, a preoperative meeting was held. The patient's history and medication were recorded. Emphasis was given to anticoagulant-antiplatelet drugs, immunosuppression, previous deep vein thrombosis, reinsertion of central venous catheter, and known allergic reaction to contrast media. Recent imaging examinations and blood tests were evaluated, and an ultrasound examination of the cervical veins was performed to confirm the patency of the veins and reveal any anatomical variations or vein thrombosis. The patient was also physically examined for any anatomical or postoperation features and skin lesions on the chest. Then the patient was informed about the type and necessity of the operation as well as about any possible complications, and a written informed consent was obtained. Abnormal hemostatic function, bacteremia, or active infection that could lead to bacteremia was considered contraindications.

The procedure was performed under strict aseptic conditions and constant monitoring of the patient’s vital signs. Antibiotic prophylaxis, heparin, or sedation was not routinely used. In selected cases, 0.25-1 mg alprazolam per os (oral administration) and 1 g paracetamol intravenous (i.v.) were provided. The percutaneous approach to the right internal jugular vein was preferred because of its straight course. However, the left internal jugular vein was selected due to postmastectomy or postirradiation therapy status or when the right side was thrombosed. The chosen vein was punctured with an 18-gauge needle under ultrasound guidance. A 0.035-inch guidewire was advanced through the needle to the cavoatrial junction or inferior vena cava (ivc), under fluoroscopy guidance, using the Seldinger technique. Α micropuncture, using a 0.018-inch guidewire (Micro-Introducer Kit, (Galt Medical Corp., Garland, TX, USA)), was preferred instead when the jugular’s diameter was less than 6-7 mm, which was then exchanged through the sheath.

At the lateral thoracic area alongside and medial to the axillary skin fold and under local anesthesia, the port pocket was created. The incision’s length was about 2-3 cm, so that the chamber would precisely fit. Two absorbable sutures were passed through the pectoral fascia. The catheter was tunneled from the pocket to the puncture site and was connected to the chamber which was placed in the pocket and secured with the sutures. A nine-French peel-away sheath was then inserted over the guidewire into the vein. The catheter was twisted around the peel-away, and the correct length of the catheter was determined under fluoroscopy, so that it ended at the cavoatrial junction or 2-3 cm below in women with massive breast tissue.

The catheter was inserted through the peel-away, which was then removed. The port’s patency was confirmed by aspirating a small amount of blood and injecting a small amount of saline solution with pulsatile flow. A final fluoroscopic image documented the correct position of the catheter tip. A modified technique was employed in cases of left internal jugular vein catheterization, where the catheter was firstly placed at the cavoatrial junction and then connected to the chamber. In this setup, the catheter could be correctly guided using a hydrophilic guidewire and overcome the sharp angle at the point where the left innominate vein transits to the superior vena cava (svc). Patients remained in the hospital for 30-60 minutes, following the intervention, and were discharged having instructions about the care of the incisions. Regular visit every three to four months for the maintenance of the device regardless of its use and in cases of relevant problems was encouraged. In the department, electronic files were kept which were updated constantly. Port’s use for i.v therapy only was strongly recommended. Ports were not used systematically for blood sampling except in cases where bacteremia was investigated. For parenteral nutrition, a peripherally inserted central catheter (picc) line was inserted instead. In cases where patients had more than one complication, the most serious one was recorded in the corresponding variable.

Follow-up

A retrospective method was used for reviewing patients’ medical records between January 1, 2017 and December 31, 2020. The last date of follow-up was defined as the date December 31, 2020 or the death date by a death registry on medical records or the date of port removal. Catheter maintenance days were calculated as the number of days between implantation and the last date of follow-up.

Definition

Complications were categorized according to the Society of Interventional Radiology (SIR) classification based on the time of onset: periprocedural (<24 hours), early (<30 days), and late (>30 days) [7]. Infection could be either bloodstream infection (bacteremia, sepsis) or local infection (pocket or tunnel infection) and was diagnosed according to Infectious Diseases Society of America Guidelines (IDSA). Catheter-related vein thrombosis (CRT) was documented with ultrasound examination or venography. Fibrin sheath formation, diagnosed with venography, and catheter lumen occlusion were encountered as mechanical complications. Catheter malfunction describes the inability for proper infusion or aspiration [8]. It can be the result of different conditions such as thrombotic causes, catheter migration twisting or kinking. Thus, it was not calculated as a different category of complications, in the present study. Catheter days were calculated as the total number of days of maintenance of the port by all of the patients until removal, death, or December 31, 2020. The purpose of implantation was characterized as adjuvant, when chemotherapy was administered after tumor excision, and as nonadjuvant, when chemotherapy was administered preoperatively or in metastatic disease, in settings where cancer lesions still exist.

Statistical methods

This study’s descriptive results are presented as i) absolute frequencies with the corresponding percentages in the case of nominal or ordinal variables and ii) mean and standard deviation in the case of quantitative continuous variables. For investigating the relationship between categorical variables, Chi-Square test was used [9]. In addition, t-test was performed to determine whether the means of two data sets were different [10]. For exploring whether there are factors influencing the occurrence of a complication, binary logistic regression was performed with a variable that expresses the occurrence of complication as the dependent one and several independent variables (such as age, sex, body mass index (BMI), marital status, educational level, cancer type, side of insertion, diameter of internal jugular vein, diabetes, anticoagulants/antiplatelets, purpose of implantation, and catheter material) in order to measure their effect as risk indicators [11]. The aforementioned logistic regression, using a stepwise method, aimed to distinguish patients reporting complications for the whole sample. The corresponding odds ratios for independent variables and p-values less than 0.05 were considered statistically significant, and 95% confidence intervals (CIs) are given for odds ratios (ORs) of the aforementioned logistic regression. Data analysis was performed using the statistical software of IBM Statistical Package for the Social Sciences (SPSS, IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp).

Results

Study population: data collection

In the period between January 1, 2017 and December 31, 2019, 807 ports were implanted in 799 adult patients (530 women and 269 men) at a tertiary Oncology-Anticancer Hospital. The average age of patients was 61.6±13.1 years (the corresponding range was from 18 to 88 years), and the total number of catheter maintenance days was 369,329 (457.7±345.0 catheter days).

The average BMI corresponded to the overweight category (27.2±18.8). In all patients, port placement was indicated for the administration of chemotherapy. Study population's demographic data (sex, education level, marital status), medical information (cancer type, diabetes, anticoagulants/antiplatelets, and implantation reason), and technical information (catheter material and side of insertion) about patients are included in Table 1.

Variable Categories Frequency Percent
Sex Male (M) 270 33.5
Female (F) 537 66.5
                                                -                                                                      - Total Male Female Total Male Female
Cancer type Breast cancer 213 1 212 26.4 0.4 39.5
Colorectal cancer 188 91 97 23.3 33.7 18.1
Pancreatic cancer 86 40 46 10.7 14.8 8.6
Sarcoma 68 38 30 8.4 14.1 5.6
Lung cancer 45 25 20 5.6 9.3 3.7
Ovarian cancer 40 0 40 5.0 - 7.4
Gastric cancer 39 24 15 4.8 8.9 2.8
Hematologic malignancy 6 0 6 0.7 0.0 1.1
Other types of cancer 122 51 71 15.1 18.9 13.2
Marital status Married 518 194 324 65.7 73.2 61.8
Unmarried 111 42 69 14.1 15.8 13.2
Widower/widow 74 7 67 9.4 2.6 12.8
Divorced 86 22 64 10.9 8.6 12.2
Educational level Primary school 274 92 182 34.6 34.7 34.5
High school 370 122 248 46.7 46.0 46.9
University 139 51 98 18.7 19.3 18.6
Diabetes (yes) 110 51 59 14.0 19.3 11.3
Anticoagulants/antiplatelets (yes) 150 64 86 19.0 24.2 16.4
Implantation reason Adjuvant 274 75 199 34.7 28.4 37.8
Nonadjuvant 516 189 327 65.3 71.6 62.2
Catheter material Silicone 133 47 86 16.5 17.4 16.0
Polyurethane 674 223 451 83.5 82.6 84.0
Side of insertion Right ijv 697 261 436 86.8 96.7 81.8
Left ijv 105 9 96 13.1 3.3 18.0

A total of 807 ports were implanted in 799 patients, i.e., in eight patients, a second port was reinserted. The technical success was achieved in 807 implantations from 808 cases that were admitted (technical success rate: 99.9%). A failure was reported in a case of svc thrombosis, where a port through the femoral vein was finally inserted. A total of 369,329 catheter maintenance days were recorded, and the mean catheter indwelling time was 457.7±345.0 days (range: 4-1,476 days). The right internal jugular vein was selected for the initial access catheterization route in 696 patients (87%). However, the left internal jugular was chosen in 104 patients (95 women and nine men). The internal jugular vein’s diameter was mostly greater than 10 mm (83.2%).

A total of 264 (32.7%) ports reached December 31, 2020 with an average number of catheter days 752.1±325.4 (range from 20 to 1,476 catheter days). From the remaining 543 (67.3%) ports, 441 (54.6%) patients did not reach the deadline due to death and 102 (12.6%) ports were removed. Among these, 54 (52.9%) ports were removed after completion of chemotherapy or in patients with no further treatment plan, 47 (46.1%) were removed due to complications, and one port was explanted upon patients’ demand. No periprocedural complication occurred. A total of 85 (10.5%) complications were observed during the follow-up period. Among them, 24 (28.2%) were early (18.1±6.8 catheter days) and the remaining 61 (71.8%) were late complications (241.6±221.1 catheter days). Bacteremia was associated mainly with sarcoma and secondarily with colorectal cancer, gastric cancer, and hematologic malignancy (Table 2).

Cancer Type Frequency Percent Cumulative Percent
Sarcoma 5 33.3 33.3
Colorectal cancer 2 13.3 46.6
Gastric cancer 2 13.3 59.9
Hematologic malignancy 2 13.3 73.2
Breast cancer 1 6.7 80.0
Pancreatic cancer 1 6.7 86.7
Other types of cancer 2 13.3 100.0
Total 15 100.0  

In addition, catheter-related thrombosis was associated mainly with colorectal cancer and breast cancer, as well as secondarily with pancreatic cancer and sarcoma (Table 3).

Cancer Type Frequency Percent Cumulative Percent
Colorectal cancer 8 26.7 26.7
Breast cancer 6 20.0 46.7
Pancreatic cancer 4 13.3 60.0
Sarcoma 4 13.3 73,3
Gastric cancer 3 10.0 83.3
Lung cancer 2 6.7 90.0
Other types of cancer 3 10.0 100.0
Total 30 100.0  

It was observed that as the number of catheter days increases, the incidence of complication decreases (Figure 1). Table 4 lists the frequencies and catheter days of complications that occurred early and late, respectively, as well as the mean days from insertion to complication.

Type of Complication No. of Early Complications (≤30 Days) No. of Late Complications (>30 Days) Total Complications  Mean Days From Insertion to Complication (Range)
n % /1,000 Catheter Days n % /1,000 Catheter Days n % /1,000 Catheter Days
Infection             27      
Port pocket infection 1 1.2 0.003 11 12.9 0.029 12 14.1 0.032 349.17
Blood stream infection 3 3.5 0.008 12 14.1 0.032 15 17.6 0.041 263.40
Catheter-related thrombosis (CRT) 11 12.9 0.029 17 17.6 0.046 28 33.0 0.076 106.58
Mechanical complications             17      
Fibrin sheath 4 4.7 0.011 12 14.1 0.032 16 18.8 0.043 106.12
Catheter occlusion 0 0.0 - 1 1.2 0.003 1 1.2 0.003 234.00
Catheter migration 2 2.4 0.005 4 4.7 0.011 6 7.1 0.016 94.33
Wound healing problem             4      
Pocket hematoma 1 1.2 0.003 0 0.0 0.000 1 1.2 0.003 15.00
Wound dehiscence  2 2.4 0.005 1 1.2 0.003 3 3.5 0.008 32.00
Skin necrosis 0 0.0 0.000 3 3.5 0.008 3 3.5 0.008 505.33

Twenty-eight cases of vein thrombosis included 26 internal jugular vein (ijv) thrombosis and two cases of innominate and svc vein thrombosis. Eight cases were asymptomatic and revealed during the scheduled follow-up, while the remaining 22 cases of suspected vein thromboses were diagnosed with ultrasound or venography (Figures 2a, 2b).

Anticoagulants were prescribed, while none of the ports was removed due to vein thrombosis. The 16 cases of fibrin sheath formation, suspected of catheter malfunction, were documented with venography (Figures 3a-3d).

Two cases of fibrin sheath formation were successfully treated with catheter stripping. Nine cases had to be removed, while in five cases, ports were used under precaution. The totally occluded catheter was removed (Figure 4).

The 27 cases of infection included 15 cases of bacteremia and 12 cases of local infection in the pocket. The pathogen microorganisms in bacteremia were Gram-positive cocci in eight cases, Gram-negative cocci in five cases, and fungus in two cases. The most common Gram-positive cocci was Staphylococcus spp. especially Staphylococcus epidermidis, while most often Gram-negative cocci was Enterobacter and Pseudomonas aeruginosa. Candida spp. was isolated in fungus category. Twenty-six ports were removed due to infection, while one case with local infection regressed with antibiotic therapy. One case of catheter migration was corrected with a snare catheter (Figures 5a-5c). The other five cases had to be removed. Three ports were removed due to healing problems and three due to skin necrosis.

In the present study, five out of six patients with hematologic malignancy had complications. Three cases were categorized as infection, one as catheter-related thrombosis, and the last one as healing problem. Therefore, there is an indication that hematologic malignancy could be associated with infection. In addition, catheter-related thrombosis was not associated with anticoagulants (χ2=0.653 p=0.634) or placement reason (χ2=3.229, p=0.080). Comorbidity of diabetes was not associated with catheter-related thrombosis (χ2=0.011 p=0.999) and bacteremia (χ2=0.680, p=0.708), and age <65 years was not associated with the occurrence of complication (χ2=3.025, p=0.085). The catheter’s material did not affect the appearance of catheter-related thrombosis (χ2=0.951, p=0.454) or the appearance of infection (χ2=0.056, p=0.999). In addition, no correlation was observed between the occurrence of catheter-related thrombosis and the diameter of the jugular vein (χ2=0.386, p=0.463). The movement of the catheter was not related to the body mass index (t=0.356, p=0.722). The average number of catheter days for patients with placement reason "adjuvant" (589.10) was statistically significantly higher than the average number of catheter days for patients with placement reason "nonadjuvant " (373.99) (t=8.291, p<0.01).

Binary logistic regression (BLR) was conducted with “occurrence of complication” as the dependent variable (Table 5). For the whole sample, the only independent variable reflecting factors that affect the occurrence of complication was cancer type (reference category: sarcoma, rest categories: breast cancer, pancreatic cancer, colorectal cancer, gastric cancer, lung cancer, ovarian cancer, hematologic malignancy, other types of cancer). Specifically, patients with breast cancer (OR=0.487, p=0.060), pancreatic cancer (OR=0.317, p=0.028), colorectal cancer (OR=0.421, p=0.030), and lung cancer (OR=0.197, p=0.039) were associated with a reduced probability of complication’s occurrence compared to sarcoma. On the contrary, patients with hematologic malignancy (OR=21.154, p=0.007) were associated with a higher probability of complication’s occurrence compared to sarcoma. The selected BLR model is considered statistically significant (χ2=28.814, p<0.01) with a relatively satisfactory predictive accuracy (90.0%) (Table 6).

Explanatory Variables B SE Wald df Sig. Exp(B) 95% CI for EXP(B)
Sarcoma     23.212 8 0.003    
Breast cancer -0.719 0.382 3.544 1 0.060 0.487 (0.231, 1.030)
Pancreatic cancer -1.148 0.524 4.804 1 0.028 0.317 (0.114, 0.886)
Colorectal cancer -0.866 0.400 4.695 1 0.030 0.421 (0.192, 0.921)
Gastric cancer -0.077 0.519 0.022 1 0.881 0.925 (0.335, 2.559)
Lung cancer -1.626 0.786 4.274 1 0.039 0.197 (0.042, 0.919)
Ovarian cancer -1.070 0.675 2.513 1 0.113 0.343 (0.091, 1.288)
Hematologic malignancy  3.052 1.138 7.191 1 0.007 21.154 (2.274, 196.825)
Other types of cancer -0.974 0.452 4.645 1 0.031 0.378 (0.156, 0.916)
Constant -1.442 0.308 21.876 1 <0.001 0.236  
Sample Omnibus Tests of Model Coefficients Model Summary Classification Table (Cut Value=0.50)
Chi-Square p-value -2 Log Likelihood Cox and Snell R Square Nagelkerke R Square Accuracy
Total 28.814 <0.01 514.515 0.035 0.072 90.0%

Discussion

It is documented in the literature that the placement of a port under ultrasound and fluoroscopy guidance using the Seldinger technique ensures low complication rates and high technical success rates [12,13]. The Seldinger technique when performed under ultrasound guidance has almost 100% success even from the first attempt, avoiding the possibility of hematoma and trauma that increases the chance for thromboses [14,15]. It is also associated with a total complication rate of 6.6%-14%, while for anatomical landmark-guided surgical insertion, the reported complication rates range from 5% to 24.6% [16]. On the other hand, the complication rates of the cut-down technique via the cephalic vein range from 16% to 21% [17]. The internal jugular vein (ijv) is considered superior to subclavian vein (scv) catheterization regarding the technical success, complication rates, and procedure time, due to its direct visualization, its distance from the lung apex, and its straight course, concerning the right side [18]. Some studies support that ijv catheterization carries a lower incidence of thrombosis than scv catheterization [19,20]. In a meta-analysis by Wu et al., the authors identified the superiority of the ijv regarding the incidence of major mechanical complications, but they did not reveal any statistically significant difference in infections and thrombotic complications [21]. At the same time, the fluoroscopy guidance is necessary not only to verify the correct length of the catheter but also to correct any unsuitable course of the guidewire or the catheter. The overall complication rate of radiological placement of a port has been reported in a study from 4.4% to 14% [6].

In our study, the technical success rate was 99.9%, while no periprocedural complication was recorded. The overall complication rate was 10.5% (incidence: 0.23 complications/1,000 catheter days). Teichgraber et al. also reported 99.8% technical success, while total complication rate was 11.8%, (incidence: 0.41 complications/1,000 catheter days) in 3,160 port implantations [22], while Maureau et al. reported total complication incidence 0.52%/1,000 catheter days [23]

Also, cancer type was found as a risk factor for the development of a complication, while hematologic malignancy and sarcoma were associated with high rates of complications. Several other studies have identified that certain cancer types, such as pancreatic and gastric cancers [24], hematologic malignancy [25], or breast and lung cancer [26], are associated with an increased risk of complications. Regarding the distribution of complications in correlation to catheter days, it was observed that as the number of catheter days increases, the incidence of complication decreases, but no clear threshold was documented, although Voog et al. reported that complications were extremely rare after one year [27]. Although the number of catheter days for patients with adjuvant placement (589.10) was higher than the number of catheter days for patients with nonadjuvant placement (373.99), surprisingly the first group, having zero tumor burden at the time of insertion, had more complications. We hypothesize that other factors interfere like cancer type and performance status.

Catheter-related thrombosis rates were 3.5% (incidence: 0.076/1,000 catheter days). Catheter-associated thrombosis has a reported incidence of 0.3%-28.3% [28]. Luciani et al. observed that the upper extremity catheter-related vein thrombosis is not a rare occurrence (11.7%) and is usually asymptomatic [29]. In a large series of 51,049 patients, 1.8% developed an upper extremity thrombosis [30], and in a systematic review where the incidence of symptomatic vein thromboses varied from 0.3% to 28.3%, the incidence of venography (mostly asymptomatic) ranged from 27% to 66% [31]. Our numbers of vein thrombosis include some asymptomatic cases (8/28) that were revealed during the scheduled follow-up. Nevertheless, no patients needed hospitalization or removal of the device and all of them were treated with heparin. Fibrin sheath formation rate was 1.98% (incidence: 0.044/1,000 catheter days). It represents a common problem that can be restored with flushing, thrombolysis, or catheter stripping, but it may also lead to port removal. Anticoagulants did not affect the occurrence of vein thrombosis or fibrin sheath formation, and this is in accordance with the clinical practice guidelines, where routine prophylaxis with anticoagulants to prevent thrombotic events is not recommended [32,33]. Risk factors such as vessel diameter (<10 mm), left jugular vein catheterization, obesity, age, ovarian cancer, and diabetes were not documented in our study. Also, right jugular vein catheterization was not associated with lower rates of vein thrombosis.

Infection rate was 3.4% (incidence: 0.073/1,000 catheter days) which was the most serious complication leading to prolonged hospitalization in some cases and removal of the device. Incidence of port-associated infection ranges from 0.6% to 27% [34]. Most guidelines recommend 0.3 infections/1,000 catheter days as an appropriate upper threshold for port implantation [35]. Few studies have shown that hematogenous malignancy is better associated with infections than solid tumors [36-38], a fact that is observed as well in our study, although the number of cases is relatively small. Impaired patient immunity may be responsible for the development of this complication. There was no association between infection and diabetes, a fact that is supported by other investigators [39,40]. The most common microorganism identified on blood and/or catheter cultures was Staphylococcus epidermidis, followed by Enterobacter, Pseudomonas aeruginosa, and Candida spp. The same results are reported in several studies [41,42]. These microorganisms which are isolated on the skin, gastrointestinal tract, urinary system, and environment can contaminate the port and lead to infection. It is very crucial for the aseptic technique to be applied meticulously not only during the implantation but also during the incision’s healing and in every use.

In our study, 25 ports out of 807 (3%) were removed due to infection, which reaches the percentage reported in the study of Shim et al., where 45 out of 1,747 (2.6%) implanted ports were explanted due to infection [43]. Vidal et al. reported that 81% of infections required port removal, while conservative treatment and port salvage were feasible only in a few cases [44]. It is documented in the literature that infection is the most frequent indication for port removal [5]. The catheter material did not affect the appearance of thrombosis or infection. Some investigators report that some types of polyurethane may be associated with a higher incidence of thrombosis, while silicone may be associated with better biocompatibility [45]. Wildgruber et al. concluded that polyurethane catheters are more susceptible to catheter-related infections and exhibited a higher thrombogenicity, compared to silicone catheters [46]. Busch et al. reported more thrombotic catheter occlusions in silicone catheters and more venous thromboses in polyurethane catheters [47]. However, Biffi et al. reported that there is no specific recommendation regarding materials for clinical practice [48].

Catheter migration can lead to cardiovascular, neurologic, thrombotic, and infectious complications [49]. The increase of intrathoracic pressure due to coughing, sneezing, weight lifting, changes in body position, or physical movements and a high infusion flow rate are considered as possible mechanisms [50]. It is restricted when the procedure is performed under fluoroscopy guidance and the catheter tip is located at the cavoatrial junction or in the proximal right atrium. It is not clear in the literature whether catheter migration is correlated with BMI [51-53]. In our study, where six cases (0.7%, incidence: 0.016/1,000 catheter days) were recorded in women only, no association was revealed. It is important that catheter migration may be corrected with a snare catheter; otherwise, it has to be removed. Healing problem rate was 0.4% (incidence: 0.011/1,000 catheter days). Pocket hematoma occurs with an incidence ranging between 0% and 4.5% [54]. A small hematoma is a relatively common event which gradually resorbs, but a severe hematoma needs drainage and may lead to port removal. It is reported that intravenous heparin initiation six hours or 24 hours after pocket creation is associated with 20% prevalence of pocket hematoma formation, while warfarin therapy or no anticoagulation is associated with only 2%-4% risk of pocket hematoma formation [55]. Wound dehiscence may be restored, although there is a high probability of local infection. Anticoagulants did not affect the probability of hematoma or diabetes in the occurrence of wound dehiscence.

Skin necrosis rate was 0.4% (incidence: 0.008/1,000 catheter days) and occurred in patients who had severe weight loss. In the study of Kim et al., the reported rate was 0.7% [28]. It is a relatively rare complication which also leads to port removal. Risk factors include BMI, extravasation, metastatic carcinoma, and local infection [56]. The malfunction was not encountered as a specific category in our study, as it is the result of thrombotic complications or migration. It is true that the definition of complications varies and the calculation of rates differs, and this provokes confusion in the literature and difficulty to compare complication rates.

The frequency of port handling and whether or not aseptic technique is applied in every use are important factors that cannot be calculated. Careful preoperative assessment, port implantation by interventional radiologists, and constant application of strict sterile conditions are important factors for the prevention of the most common complications. Moreover, interventional radiology methods comparing to surgical methods have the advantage to guide and restore in real time the route and position of the catheter. Also, some complications such as catheter migration and fibrin sheath formation cannot be corrected surgically. Interventional radiology methods achieve these corrections easily and bloodlessly.

Limitations

Our study was retrospective in a single institute, without control group. The low incidence of complications did not allow us to identify other potential prognostic factors. Nevertheless, it was a detailed analysis that confirmed the safety of the radiological placement of ports.

Conclusions

Placement of ports via the internal jugular vein under ultrasound and fluoroscopy guidance is a safe procedure, with low rates of early and late complications. Interventional radiologists eliminate the immediate complications and manage successfully the late complications such as fibrin sheath formation and catheter migration, salvaging the port. Cancer type is a risk factor for the development of a complication. Hematologic malignancy and sarcoma are correlated with high rates of complications. Additionally, hematologic malignancy may predispose to infection. A standardized classification of complications has to be established.


References

  1. Niederhuber JE, Ensminger W, Gyves JW, Liepman M, Doan K, Cozzi E: Totally implanted venous and arterial access system to replace external catheters in cancer treatment. Surgery. 1982, 92:706-12.
  2. Bishop L, Dougherty L, Bodenham A, et al.: Guidelines on the insertion and management of central venous access devices in adults. Int J Lab Hematol. 2007, 29:261-78. 10.1111/j.1751-553X.2007.00931.x
  3. Vescia S, Baumgärtner AK, Jacobs VR, Kiechle-Bahat M, Rody A, Loibl S, Harbeck N: Management of venous port systems in oncology: a review of current evidence. Ann Oncol. 2008, 19:9-15. 10.1093/annonc/mdm272
  4. Chopra V, Flanders SA, Saint S, et al.: The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015, 163:S1-40. 10.7326/M15-0744
  5. Pinelli F, Cecero E, Degl'Innocenti D, et al.: Infection of totally implantable venous access devices: a review of the literature. J Vasc Access. 2018, 19:230-42. 10.1177/1129729818758999
  6. Ahn SJ, Kim HC, Chung JW, An SB, Yin YH, Jae HJ, Park JH: Ultrasound and fluoroscopy-guided placement of central venous ports via internal jugular vein: retrospective analysis of 1254 port implantations at a single center. Korean J Radiol. 2012, 13:314-23. 10.3348/kjr.2012.13.3.314
  7. Silberzweig JE, Sacks D, Khorsandi AS, Bakal CW: Reporting standards for central venous access. J Vasc Interv Radiol. 2003, 14:S443-52. 10.1097/01.rvi.0000094617.61428.bc
  8. Goossens GA, Stas M, Jérôme M, Moons P: Systematic review: malfunction of totally implantable venous access devices in cancer patients. Support Care Cancer. 2011, 19:883-98. 10.1007/s00520-011-1171-3
  9. Fisher RA: On the interpretation of χ2 from contingency tables, and the calculation of P. J R Stat Soc. 1992, 85:87-94. 10.2307/2340521
  10. Derrick B, Deirdre T, Paul W: How to compare the means of two samples that include paired observations and independent observations: a companion to Derrick, Russ, Toher and White (2017). The Quantitative Methods for Psychology. 2017, 13:120-6. 10.20982/TQMP.13.2.P120
  11. Stavrinos B, Panagiotakos D: Biostatistics. Gutenberg, Athens; 2007.
  12. Özkaçmaz S, Alpaslan M, Dadalý Y, Yavuz A: Assessement of the complications of ultrasound and fluoroscopy-guided placement of totally implantable venous access ports. East J Med. 2019, 24:15-22. 10.5505/ejm.2019.08108
  13. Perdikakis E, Kehagias E, Tsetis D: Common and uncommon complications of totally implantable central venous ports: a pictorial essay. J Vasc Access. 2012, 13:345-50. 10.5301/jva.5000055
  14. Dede D, Akmangit I, Yildirim ZN, Sanverdi E, Sayin B: Ultrasonography and fluoroscopy-guided insertion of chest ports. Eur J Surg Oncol. 2008, 34:1340-3. 10.1016/j.ejso.2007.12.001
  15. Randolph AG, Cook DJ, Gonzales CA, Pribble CG: Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med. 1996, 24:2053-8. 10.1097/00003246-199612000-00020
  16. Gebauer B, El-Sheik M, Vogt M, Wagner HJ: Combined ultrasound and fluoroscopy guided port catheter implantation: high success and low complication rate. Eur J Radiol. 2009, 69:517-22. 10.1016/j.ejrad.2007.10.018
  17. Biffi R, Orsi F, Pozzi S, et al.: Best choice of central venous insertion site for the prevention of catheter-related complications in adult patients who need cancer therapy: a randomized trial. Ann Oncol. 2009, 20:935-40. 10.1093/annonc/mdn701
  18. Cil BE, Canyiğit M, Peynircioğlu B, Hazirolan T, Carkaci S, Cekirge S, Balkanci F: Subcutaneous venous port implantation in adult patients: a single center experience. Diagn Interv Radiol. 2006, 12:93-8.
  19. Funaki B, Szymski GX, Hackworth CA, Rosenblum JD, Burke R, Chang T, Leef JA: Radiologic placement of subcutaneous infusion chest ports for long-term central venous access. AJR Am J Roentgenol. 1997, 169:1431-4. 10.2214/ajr.169.5.9353475
  20. Saber W, Moua T, Williams EC, et al.: Risk factors for catheter-related thrombosis (CRT) in cancer patients: a patient-level data (IPD) meta-analysis of clinical trials and prospective studies. J Thromb Haemost. 2011, 9:312-9. 10.1111/j.1538-7836.2010.04126.x
  21. Wu S, Huang J, Jiang Z, et al.: Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices: a meta-analysis of comparative studies. BMC Cancer. 2016, 16:747. 10.1186/s12885-016-2791-2
  22. Teichgräber UK, Kausche S, Nagel SN, Gebauer B: Outcome analysis in 3,160 implantations of radiologically guided placements of totally implantable central venous port systems. Eur Radiol. 2011, 21:1224-32. 10.1007/s00330-010-2045-7
  23. Moureau N, Poole S, Murdock M, Gray SM, Semba CP: Central venous catheters in home infusion care: outcomes analysis in 50,470 patients. J Vasc Interv Radiol. 2002, 13:1009-16. 10.1016/s1051-0443(07)61865-x
  24. Teichgräber U, Nagel SN, Kausche S: Evaluation of correlations between underlying disease and port complications. Rofo. 2014, 186:496-500. 10.1055/s-0033-1356040
  25. Schwarz RE, Groeger JS, Coit DG: Subcutaneously implanted central venous access devices in cancer patients: a prospective analysis. Cancer. 1997, 79:1635-40.
  26. Yu XY, Xu JL, Li D, Jiang ZF: Late complications of totally implantable venous access ports in patients with cancer: risk factors and related nursing strategies. Medicine (Baltimore). 2018, 97:e12427. 10.1097/MD.0000000000012427
  27. Voog E, Campion L, du Rusquec P, et al.: Totally implantable venous access ports: a prospective long-term study of early and late complications in adult patients with cancer. Support Care Cancer. 2018, 26:81-9. 10.1007/s00520-017-3816-3
  28. Kim DH, Ryu DY, Jung HJ, Lee SS: Evaluation of complications of totally implantable central venous port system insertion. Exp Ther Med. 2019, 17:2013-8. 10.3892/etm.2019.7185
  29. Luciani A, Clement O, Halimi P, et al.: Catheter-related upper extremity deep venous thrombosis in cancer patients: a prospective study based on Doppler US. Radiology. 2001, 220:655-60. 10.1148/radiol.2203001181
  30. Tabatabaie O, Kasumova GG, Kent TS, et al.: Upper extremity deep venous thrombosis after port insertion: what are the risk factors?. Surgery. 2017, 162:437-44. 10.1016/j.surg.2017.02.020
  31. Verso M, Agnelli G: Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. J Clin Oncol. 2003, 21:3665-75. 10.1200/JCO.2003.08.008
  32. Cunningham MS, White B, Hollywood D, O'Donnell J: Primary thromboprophylaxis for cancer patients with central venous catheters: a reappraisal of the evidence. Br J Cancer. 2006, 94:189-94. 10.1038/sj.bjc.6602917
  33. Chaukiyal P, Nautiyal A, Radhakrishnan S, Singh S, Navaneethan SD: Thromboprophylaxis in cancer patients with central venous catheters: a systematic review and meta-analysis. Thromb Haemost. 2008, 99:38-43.
  34. Yildizeli B, Laçin T, Batirel HF, Yüksel M: Complications and management of long-term central venous access catheters and ports. J Vasc Access. 2004, 5:174-8. 10.1177/112972980400500407
  35. Walser EM: Venous access ports: indications, implantation technique, follow-up, and complications. Cardiovasc Intervent Radiol. 2012, 35:751-64. 10.1007/s00270-011-0271-2
  36. Hsieh CC, Weng HH, Huang WS, Wang WK, Kao CL, Lu MS, Wang CS: Analysis of risk factors for central venous port failure in cancer patients. World J Gastroenterol. 2009, 15:4709-14. 10.3748/wjg.15.4709
  37. Samaras P, Dold S, Braun J, et al.: Infectious port complications are more frequent in younger patients with hematologic malignancies than in solid tumor patients. Oncology. 2008, 74:237-44. 10.1159/000151393
  38. Wang TY, Lee KD, Chen PT, et al.: Incidence and risk factors for central venous access port-related infection in Chinese cancer patients. J Formos Med Assoc. 2015, 114:1055-60. 10.1016/j.jfma.2015.06.013
  39. Yoshida J, Ishimaru T, Kikuchi T, Matsubara N, Asano I: Association between risk of bloodstream infection and duration of use of totally implantable access ports and central lines: a 24-month study. Am J Infect Control. 2011, 39:e39-43. 10.1016/j.ajic.2010.11.013
  40. Touré A, Vanhems P, Lombard-Bohas C, Souquet JC, Lauverjat M, Chambrier C: Is diabetes a risk factor for central venous access port-related bloodstream infection in oncological patients?. Eur J Clin Microbiol Infect Dis. 2013, 32:133-8. 10.1007/s10096-012-1728-1
  41. Chang L, Tsai JS, Huang SJ, Shih CC: Evaluation of infectious complications of the implantable venous access system in a general oncologic population. Am J Infect Control. 2003, 31:34-9. 10.1067/mic.2003.29
  42. Tsuruta S, Goto Y, Miyake H, Nagai H, Yoshioka Y, Yuasa N, Takamizawa J: Late complications associated with totally implantable venous access port implantation via the internal jugular vein. Support Care Cancer. 2020, 28:2761-8. 10.1007/s00520-019-05122-3
  43. Shim J, Seo TS, Song MG, et al.: Incidence and risk factors of infectious complications related to implantable venous-access ports. Korean J Radiol. 2014, 15:494-500. 10.3348/kjr.2014.15.4.494
  44. Vidal M, Genillon JP, Forestier E, et al.: Outcome of totally implantable venous-access port-related infections. Med Mal Infect. 2016, 46:32-8. 10.1016/j.medmal.2015.12.006
  45. Gallieni M, Pittiruti M, Biffi R: Vascular access in oncology patients. CA Cancer J Clin. 2008, 58:323-46. 10.3322/CA.2008.0015
  46. Wildgruber M, Lueg C, Borgmeyer S, et al.: Polyurethane versus silicone catheters for central venous port devices implanted at the forearm. Eur J Cancer. 2016, 59:113-24. 10.1016/j.ejca.2016.02.011
  47. Busch JD, Vens M, Mahler C, Herrmann J, Adam G, Ittrich H: Complication rates observed in silicone and polyurethane catheters of totally implanted central venous access devices implanted in the upper arm. J Vasc Interv Radiol. 2017, 28:1177-83. 10.1016/j.jvir.2017.04.024
  48. Biffi R, Toro A, Pozzi S, Di Carlo I: Totally implantable vascular access devices 30 years after the first procedure. What has changed and what is still unsolved?. Support Care Cancer. 2014, 22:1705-14. 10.1007/s00520-014-2208-1
  49. Collin GR, Ahmadinejad AS, Misse E: Spontaneous migration of subcutaneous central venous catheters. Am Surg. 1997, 63:322-6.
  50. Fan WC, Wu CH, Tsai MJ, et al.: Risk factors for venous port migration in a single institute in Taiwan. World J Surg Oncol. 2014, 12:15. 10.1186/1477-7819-12-15
  51. Craft PS, May J, Dorigo A, Hoy C, Plant A: Hickman catheters: left-sided insertion, male gender, and obesity are associated with an increased risk of complications. Aust N Z J Med. 1996, 26:33-9. 10.1111/j.1445-5994.1996.tb02904.x
  52. Wyschkon S, Löschmann JP, Scheurig-Münkler C, Nagel S, Hamm B, Elgeti T: Apparent migration of implantable port devices: normal variations in consideration of BMI. J Vasc Access. 2016, 17:155-61. 10.5301/jva.5000502
  53. Smith T, Kaufman C, Quencer K: Internal jugular central venous catheter tip migration: patient and procedural factors. Tomography. 2022, 8:1033-40. 10.3390/tomography8020083
  54. Toro A, Di Carlo I: Pocket hematoma. Totally Implantable Venous Access Devices. Di Carlo I, Biffi R (ed): Springer, Milano; 2012. 153-6. 10.1007/978-88-470-2373-4_19
  55. Michaud GF, Pelosi F Jr, Noble MD, Knight BP, Morady F, Strickberger AS: A randomised trial comparing heparin initiation 6 h or 24 h after pacemaker or defibrillator implantation. J Am Coll Cardiol. 2000, 35:1915-8. 10.1016/s0735-1097(00)00633-1
  56. Toro A, Di Carlo I: Skin necrosis. Totally Implantable Venous Access Devices. Di Carlo I, Biffi R (ed): Springer, Milano; 2012. 213-20. 10.1007/978-88-470-2373-4_30

Original article
peer-reviewed

Complications of Totally Implantable Central Venous Catheters (Ports) Inserted via the Internal Jugular Vein Under Ultrasound and Fluoroscopy Guidance in Adult Oncology Patients: A Single-Center Experience


Author Information

Viktoria Kartsouni Corresponding Author

Interventional Unit of Radiology, Saint Savvas Hospital, Athens, GRC

Hippocrates Moschouris

Interventional Unit of Radiology, General Hospital of Piraeus “Tzaneio”, Athens, GRC

Fragiskos Bersimis

Department of Midwifery, University of West Attica, Athens, GRC

George Gkeneralis

Interventional Unit of Radiology, Saint Savvas Hospital, Athens, GRC

Myrsini Gkeli

Interventional Unit of Radiology, Saint Savvas Hospital, Athens, GRC

Stamatia Dodoura

Interventional Unit of Radiology, Saint Savvas Hospital, Athens, GRC

Aikaterini Chouchourelou

Department of Radiology, University of Thessaly, Larissa, GRC

Ioannis Fezoulidis

Department of Radiology, University of Thessaly, Larissa, GRC

Athanasios Kotsakis

Department of Oncology, University of Thessaly, Larissa, GRC

Christos Rountas

Department of Radiology, University of Thessaly, Larissa, GRC


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained or waived by all participants in this study. Ethics Committee of the University of Thessaly issued approval 14/12.02.2019. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the University of Thessaly (14/12.02.2019) and by the Institutional Review Board of Saint Savva’s Hospital (ΕΣ16287/12.12.2018, ΔΣ530/14.12.2018). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.



Original article
peer-reviewed

Complications of Totally Implantable Central Venous Catheters (Ports) Inserted via the Internal Jugular Vein Under Ultrasound and Fluoroscopy Guidance in Adult Oncology Patients: A Single-Center Experience


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