CardioVascular and Interventional Radiology

Springer-Verlag New York, Inc. 2001 Published Online: 27 April 2001

Cardiovasc Intervent Radiol (2001) 24:180 184 DOI: 10.1007/s002700001721

Central Venous Access Ports Placed by Interventional Radiologists: Experience with 125 Consecutive Patients
Heike Lorch,1 Martin Zwaan,2 Christiane Kagel,1 Hans-Dieter Weiss1
1 2

Department of Radiology, Medical University of Lubeck, Ratzeburger Allee 160, D-23538 Lubeck, Germany Department of Radiology, Ammerlandklinik Westerstede, Lange Strasse 38, D-26655 Westerstede, Germany

Abstract
Purpose: To assess safety and function of central venous port systems implanted percutaneously in the interventional radiology suite. Methods: One hundred and twenty-ve consecutive ports in 123 patients were evaluated retrospectively. One hundred and twenty ports were implanted via the subclavian vein. Results: Technical success was 100%. Fourteen patients (11.2%) experienced immediate procedural complications, all minor (pneumothorax 1.6%). During follow-up (4 343 days, mean service period 97.8 days), nine complications occurred, six of which were major. These were three port infections which led to hospitalization and port removal, one chamber penetration through the skin, and two port occlusions. Port removal as a result of complications was performed in six patients. Altogether, 20 complications occurred within a total of 11,056 days of service, which means 1.8 events per 1000 days of service. Conclusion: Percutaneous implantation of central venous port systems is safe and easy to perform. Complication rates of this study compare favorably with those of other radiological and surgical series. Key words: Catheters and catheterizationCentral venous accessComplications, venous ports Infusion therapy via a subcutaneously implanted venous port system is an attractive alternative to infusion via peripheral veins, peripherally inserted central catheters or tunneled catheters [1], especially in patients who receive chemotherapy for malignancy, undergo an infusion therapy over several weeks, or who cannot care for an external device. Percutaneous placement of central venous ports has become an alternative to surgical port implantation under general
Correspondence to: H. Lorch, M.D.; e-mail: lorch@medinf.mu-luebeck.de

anesthesia via venous cutdown [2]. This procedure can be performed by interventional radiologists in the angiography suite with good success and complication rates comparable to surgery [3 6]. We report our experience with percutaneously inserted central venous ports in the interventional radiology suite placed under local anesthesia, predominantly via the subclavian vein. At our hospital, these ports had formerly been implanted by the surgeons by venous cutdown under general anesthesia. Starting in November 1997, the number of ports implanted by interventional radiologists has been increasing at our hospital, whereas surgical port implantation has become uncommon.

Materials and Methods

Patients
We started radiological percutaneous placement of implanted venous access devices on November 17, 1997. One hundred and twenty-ve venous ports were implanted in 123 patients [68 men (55.3%), 55 women (44.7%); age range 30 81 years, mean SD 56.6 11.5 years] by three interventional radiologists (C.K., H.L., M.Z.) up to November 19, 1998. Common diagnoses were bronchial carcinoma (n 18), gastrointestinal cancer (n 34), malignant hematologic disease (n 19), gynecologic malignancies (n 30), and others (n 22). Indications for port implantation were chemotherapy in 107 cases (85.6%) and antibiotic therapy, parenteral nutrition, or analgesia in the others. Devices placed included: Vital Port, n 123 (large n 7; petite n 78; mini n 37; double port n 1; Cook Vascular, Leechburg, PA, USA); Vortex-Port, n 2 (Vortex, Norfolk Medical, Skokie, IL, USA).

Implanted Venous Access Device Technique

Our preferred port is the titanium Cook Petite Vital Port (height 9.7 mm, diameter 24.1 mm, septum thickness 10.2 mm, weight 9 g). The port chamber contains a uid volume of 0.35 ml. The silicone

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Table 1. Summary of the complications among the whole population during the whole follow-up period n Immediate (among 125 patients) 8 1 2 1 1 1 14 1 2 1 1 2 1 8 1 % 6.4 0.8 1.6 0.8 0.8 0.8 11.2 0.9 0.18 0.9 0.9 0.18 0.9 7.1 5.9 Nature and gradea Hematoma (m) Dehiscence of the skin suture (m) Pneumothorax (m) Catheter malposition (m) Brachial paresis (m) Torsion of the port chamber (m) All minor Delayed wound healing (m) Port occlusion (M) Pinch-off (m) Catheter-tip malposition (m) Infection (M) Chamber penetration (M) 3 minor, 5 Major Recurrent infections, HIV (M) Outcome Surgical drainage in one patient Surgical revision Drainage in one patient Catheter exchange Transient Radiological revision Ports not usable Port removal Catheter exchange Port removal Port removal Port removal

Overall immediate complications Early (among 110 patients)

Overall early complications Late (among 17 patients)

a

major; m

minor

catheter (inner diameter 1 mm, outer diameter 2.16 mm) ts through a 7 Fr peel-away sheath. If necessary, a 0.035-inch guidewire can be passed through the catheter. Where possible, devices were inserted via the subclavian vein and placed below the clavicle at the nondominant arm. The dominant arm was chosen in the case of vein occlusion or planned or performed radiation therapy at the contralateral side. Four ports were inserted via the jugular vein because the subclavian vein was not puncturable with the standard length needle. One port was inserted via the brachial vein in a patient who underwent radiation therapy of the whole upper thorax. No routine antibiotic prophylaxis was administered. Port implantation was performed under sterile conditions. The subclavian vein was punctured at its lateral third under road-map guidance, after injection of contrast medium (10 ml Visipaque 270, Nycomed Arzneimittel, Ismaning, Germany) via a peripheral brachial vein. A guidewire was passed through the puncture needle and the peelaway sheath was inserted. After removing the dilator of the sheath, the saline-ushed port catheter was inserted. The peel-away sheath was then removed. Under local anesthesia, a subcutaneous pocket was dissected beneath the puncture site. Whenever possible, skin thickness over the port was 1 cm or more to prevent skin erosion. Under uoroscopic guidance, the tip of the port catheter was positioned at the entrance of the right atrium, the catheter was cut to length and connected with the port chamber. If blood could be aspirated without problems, the port was ushed with heparinized saline (5000 IU in 2 ml saline) and placed into the subcutaneous pocket. Fixation sutures were not routinely used. The incision was closed with interrupted 4.0 polyamide sutures (Seralon, Serag Wiessner, Naila, Germany) and covered with a sterile dressing. A digital image was obtained to document port and catheter position and to exclude pneumothorax. The ports can be used immediately. The sutures were removed 10 days later. Ports were ushed with heparinized saline routinely once a month if not used for infusions. In the case of jugular and brachial insertion, venous puncture was performed under sonographic guidance (jugular route) or under road-map conditions (brachial route). The insertion technique was principally the same as in subclavian ports with the exception that port catheters were tunneled subcutaneously in the case of jugular insertion.

Follow-Up
The follow-up period ended on November 23, 1998; the length of follow-up ranged from 4 to 343 days. The service interval was dened as the period beginning with device placement and ending with the last clinical evaluation before the end of the follow-up period, device removal, or patient death. Complications were divided into immediate ( 24 hr), early (24 hr to 180 days), and late ( 180 days) and into minor and major complications according to the SCVIR guidelines [7]. At the end of the study period, in patients who were still alive ports were dened as functional, explanted because of complications, explanted electively, lost to follow-up/not used, or nonfunctional and not explanted. In patients who died during the study period ports were categorized as functional or not functional at the time of death. Data were evaluated retrospectively by reviewing clinic charts or, in the case of patients treated elsewhere, by contacting the responsible physician.

Results
Ports were implanted on the left side in 103 cases (82.4%) and on the right side in 22 cases (17.6%). Primary technical success was 100%. Mean duration of implantation (table time) was 58.1 34.4 min (median 55.0 min, range 20 155 min). Average duration of uoroscopy was 4.8 3.9 min (median 3.6 min, range 1.324 min). Immediate procedural complications ( 24 hr) occurred in 14 patients (11.2%); all were minor (Table 1). The dehiscence of the skin suture which had to be revised surgically happened early in our practice. Two patients (1.6%) developed pneumothorax. In one patient, the port could not be used because of unrecognized caval stenosis. In this case the port catheter was changed for a longer one. One patient complained about paresis of the left arm which was fully reversible and probably due to local anesthesia. In one patient torsion of the port chamber occurred. The reason for this complication was too large a subcutaneous pocket. The port was then xed with subcutaneous sutures.

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Fig. 1. Pinch-off sign in a female patient (31 years) with Hodgkins disease after an implantation period of 9 months (arrow indicates the site of catheter leakage between the clavicle and rst rib).

Fig. 2. Status of venous ports at the end of the study period.

Thirteen patients were lost to follow-up, so 112 ports in 110 patients were available for further follow-up. Among these 110 patients, eight complications occurred between 24 hr and 180 days (7.1%, Table 1); three were minor and ve were major. These led to premature port explantation in ve cases. Delayed wound healing was observed in one patient. One port was removed after catheter leakage due to pinch-off (Fig. 1). One port had to be removed because of malpositioning of the catheter tip too peripherally due to tissue traction in the upright position in an obese female patient. After that, we started to place the catheter tip deep in the right atrium in these patients. Five major complications occurred: two ports became infected with Staphylococcus aureus (local infection and sepsis) which led to port explantation and hospitalization for intravenous antibiotics; one port had to be explanted and revised surgically because of chamber penetration through the skin; and two port occlusions occurred (one of these ports was not used and not regularly ushed). After 180 days, only one complication was reported. This occurred in an HIV-positive patient who experienced recurrent port infections, which led to port explantation after 218 days of service. Removal as a result of complications was performed in six patients; in three patients the port was functional, in three patients it was not. At the end of the study period, ports were functional in 77 patients. Elective port explantation was performed in two patients. In one patient, a nonfunctional port remained in place. Twenty-six patients died during the study period, all of them with a functional port (Fig. 2).

Altogether, the total number of complications was 23. Three of the patients who experienced early complications were lost to follow-up, so that 20 complications occurred within 11,056 days of service (mean service period 97.8 days, median 70.5 days; 50% of the data ranging between 34 and 147 days, representing the 2nd and 3rd quartiles), which means 1.8 events per 1000 days of service.

Discussion
Venous port systems are of benet in patients undergoing long-term infusion therapy, especially chemotherapy, in whom peripheral venous access often becomes increasingly difcult during the course of therapy. They allow good comfort as the patients can perform their usual daily activities. In contrast to tunneled catheters, subcutaneous ports can be left in place long term with no catheter protruding through the skin, which leads to a lower infection rate, especially in immunocompromised patients [8, 9]. For several years, venous ports have been implanted under local anesthesia by radiologists in the interventional radiology suite. This study and literature data show that venous port implantation can be performed by interventional radiologists quickly and safely and that complication rates compare favorably with surgical data [3, 6] as well as with published radiologic studies (Table 2). The greater availability and short duration of port placement in the angiography suite is highly appreciated by cli-

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Table 2. Complications of percutaneously implanted venous port devices Author No. Days of Pneumothorax Infection Infections Catheter/chamber Thrombosis Thrombosis Skin Explantation Complications of service (%) (%) per 1000 complications (%) per 1000 erosion for per 1000 days ports (overall) days (%) days (%) complication (%) 4.3 5.0 3.0 2.8 6.7 3.2 5.0 4.1 2.4 2.2 3.8 0 0 2.8 2.0 6.0 0.9 0 2.0 2.5 4.0 4.5 2.4 0 0.9 0 0 0.6 1.0 5.4 12.6 7.0 2.8 6.9 11.9 13.0 4.0 0.8 4.8

DAngelo 92 [11] Eastridge [13] 113 1.7 Ballarini [12] 102 1.0 Bif [6] 68 18,213 1.4 Kluge [5] 124 17,634 3.2 Kock [3] 1,500 426,000 0.3 Morris [2] 102 15,880 0.9 Struk [18] 38 6,863 DeGregorio 288 90,720 [19] Own data 125 11,056 1.6

0.1 0.34 0.17 0.31 1.3 0.1 0.2

0 0.1 0.25 0 0.1 0.25

0.63 0.4 0.88 1.7 0.7 1.8

nicians and patients. Ports can be implanted on an outpatient basis. Port systems can be used immediately. Port infection occurred in three patients (2.4%). One of these patients had AIDS, which is a predisposing condition for infectious port complications [10]. Compared with catheters, the rate of infection is signicantly lower in ports in an AIDS population (52.2% vs 27.6% [8]) and in an oncologic population (43% vs 8% [9]). In a general oncologic population, port infections are reported in 0.4% 6.7% of cases [25, 1113]. The SCVIR guidelines threshold for sepsis due to ports is 2% [7]. We prefer access through the subclavian vein because the distance to the vena cava and the right atrium is short and no tunneling is necessary, which shortens the procedure time; it also requires no second incision at the neck, which might be an advantage especially in cachectic patients. The port catheter does not cross large joints and patients can move their arms freely even when the port needle is in place. Pneumothorax, which is the main risk compared with the jugular approach, occurred in 1.6% of cases. The literature reports pneumothorax as a complication of attempted subclavian puncture in 0.1%3.2% of cases [3 6, 12, 13]; the SCVIR guideline threshold is 3% [7]. We chose the jugular vein only in obese patients and the brachial route in cases of thoracic irradiation. In our experience, xing the port chamber with sutures in the subcutaneous tissue is not necessary if the port pocket size is adequate. The two cases of port chamber inversion occurred early in our practice and were corrected without problems. Thrombosis of the upper extremity veins seems to be a minor problem as far as the risk of pulmonary embolism and long-term clinical symptoms is concerned. The lowest rate of thrombotic complications is seen in silicone catheters with their tips in the lower half of the superior vena cava or in the right atrium [14], with a rate of up to 6% reported [2, 3, 5, 12, 13] (SCVIR guidelines threshold 8% [7]). None of our patients experienced this complication clinically during the study period. This might be due to our relatively short

observation period. The position and function of the catheter tip can be evaluated uoroscopically during the implantation, so that primary catheter malposition should not occur. No catheter malposition into the azygos vein, the jugular veins, or the contralateral subclavian vein occurred. The rate of catheter dislocation in the literature is 0 4% [2, 3, 5, 6, 11]. Special attention to the position of the catheter tip is necessary in obese female patients. If the catheter tip is positioned at the correct place at the entrance of the right atrium in the supine intraprocedure position, the catheter tip often migrates back into the innominate or subclavian vein in the upright postprocedure position, probably caused by a soft tissue shift due to gravity. Therefore, especially in these patients, we place the catheter tip in the right atrium. It is generally recommended to place the catheter tip initially 3 4 cm more centrally than the desired nal position [15]. Catheter leakage due to pinch-off as a consequence of catheter narrowing between the clavicle and rst rib occurred in one patient and was recognized clinically before any serious harm happened to the patient. If symptoms such as pain or swelling during infusion are present, we strongly recommend a uoroscopic evaluation of the port and replacement of the catheter, if necessary, to avoid complications such as extravasation of chemotherapeutic agents or catheter fragmentation [16]. When possible, a lateral puncture of the subclavian vein should be performed to avoid pinch-off [17] if subclavian access is chosen. The overall number of ports placed at our department between November 17, 1997 and October 10, 2000, was 567a number which reects good acceptance of the procedure. Percutaneous port implantation via the subclavian vein is easy to perform and feasible. Although subclavian puncture was not common in our department previously, complication rates compare favorably with published surgical and radiologic data. We think that implantation of central venous access ports by interventional radiologists should be strongly encouraged.

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