Totally Implantable Venous Access Devices

Retrospective Analysis of Different Insertion Techniques and Predictors of Complications in 796 Devices Implanted in a Single Institution

Elisa Granziera; Marco Scarpa; Angelo Ciccarese; Bogdan Filip; Matteo Cagol; Valentina Manfredi; Rita Alfieri; Connie Celentano; Sandra Cappellato; Carlo Castoro; Muzio Meroni

Disclosures

BMC Surg. 2014;14(27) 

In This Article

Discussion

Different and long term chemotherapy treatments or nutritional support require a long term venous access in a cancer patient. Since 1982, the increasingly frequent use of TIVADs has reduced the burden of peripheral vein complications and the restriction on physical activities of patients and, thus, improving quality of life. On the other hand, there is a strict association between the incidence of TIVAD-related complications and the occurrence of psychosocial complaints (eg, depression, fatigue, social impairment, and decreased quality of life).[15] Ideally, TIVAD positioning should have a low rate of morbidity after insertion and in the long term follow up, and should be easily tolerable for the patient during his daily routine. In our retrospective series, three different implantation techniques were used and compared in order to identify the technique that may guarantee the best outcome.

In our series, the overall complication rate is consistent with data reported by several studies,[4,16–18] that range between 2 to 14.4%. Furthermore, similarly to recent series, we observed a decreasing trend for early complications. Rare major complication as described in previous studies or case series reports, such as hemothorax,[19] air embolism,[20] pericardial tamponade[21] and brachial plexus injury[22] did not occur in our series. At the beginning of our experience, the surgical cutdown technique in cephalic vein was used and it had the advantage of no early complications but at the price of a higher technical failure rate. Nevertheless, the complications rate did not seem to be correlated with the experience of the operator.[6,7,23] In our series, 4 cases of pneumothoraxes occurred after the blind percutaneous technique and, three of them needed to be treated with a chest drain tube. Pneumothorax seems to be the most frequent and important complication after insertion, with an immediate clinical impact. Its incidence varies between 0.5–6%,[24] highly correlated with the blind subclavicular approach and with the multiple attempts of needle passage. In our series, US-guided insertion completely eliminated this complication probably because it provides a direct visualization of the needle and all the underlying anatomical structures during the whole procedure. Although accidental arterial puncture seems to occur mainly during subclavicular approach with a frequency between 6–8%,[8] in our series we observed 8 accidental artery puncture of the ultrasound guided approach group occurred during the "learning curve" period of the technique (first 3 months). However, they did not require any treatment except for a longer monitoring before discharge.

According to the results of this study, the occurrence of these complications was reduced by limiting the number of needle passages with ultrasonic identification of the vein. Indeed, this technique permitted to obtain a significantly lower rate of technical failure without changing the access site for TIVAD implantation. A further benefit from two dimensional US guidance for central venous access compared with the other methods was a faster access. In fact, the operating time was significantly shorter in the ultrasound group compared to the others. As demonstrated in a meta analysis investigating ultrasound guidance,[25] data reflected on cost effectiveness. The resource saving is obtained by shortening the time spent by clinicians and nurses to achieve successful cannulation and to deal with complications. This time saving procedure reduced the use of expensive operative room time.

In our series, surgical cutdown technique in cephalic vein and low levels of white blood cells resulted to be a significant predictor of TIVAD removal for complication. In the series described by Mansfield et al., the factor associated to early complications after TIVAD placement are prior attempts or catheterisation of the vein, local modification due to previous radiotherapy, a high body mass index and multiple needle passages on the puncture site.[26] The difference of the predictors of TIVAD complication may be ascribed to the different techniques adopted in the two series: in our series the prevalent access was the US guided through internal jugular vein compared to the subclavicular access used in the Mansfield series.

The infection of the pocket was the most frequent late complications and the main cause of TIVAD removal in our series. Similarly, in the series described by Koch et al., this complication occurred in around 5% of all cases.[5] In fact, the infection of the pocket occurred more often after 20 weeks and after 60 weeks and this observation suggests that the postoperative infection is extremely rare and the causes are mainly related to its use (20 weeks peak) or lack of monthly maintenance (60 weeks peak). Curiously enough, in our series, hematologic malignancies were not more prone to infection and TIVAD extraction. The second most important complication, thrombosis, can occur in around 4.7 to 8.46%[27,28] but in our series it was much less frequent probably because of the regular rinsing of the catheter with heparin. Catheter malfunction can be caused mainly by the formation of a fibrin sheath that functions as a one-way valve in over 50% of all cases and by intraluminal thrombotic occlusion in 2–3%. Finally in our series, we did not observe any late complications such as: catheter rupture or migration, pinch-off syndrome, erosion with perforation of superior vein cava.

The main limit of this study is its retrospective design. Nevertheless, this limit was in part ridden over by the use of a prospectively collected database. The second limit of this study was the different sample size of the three groups. In fact, the first two groups are smaller than the last one. However, the overall sample size of the three groups was sufficient to make adequate comparison. Although our study provides a good definition of pro and cons of the different techniques a proper randomized controlled trial should be warranted to definitely determine the best TIVAD insertion technique.

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