Totally Implantable Venous Access Port Systems: Implant Depth-based Complications in Breast Cancer Therapy - A Comparative Study

Background: Totally implantable venous access port system (TIVAPS) is widely used in breast cancer therapy; TIVAPS has several associated complications depending on the depth of implantation in breast cancer (BC) patients during continuous infusional chemotherapy regimens. The purpose of this study is to find out the optimal depth of TIVAPS implantation to reduce the incidence of complications during infusional chemotherapy. Methods: This study reviewed the depth TIVAPS implantation in the internal jugular vein in 1282 breast cancer patients over a ten-year period (2009-2019), and associated complications. We segregated the patients as 5 groups: ‘Group A (depth < 4 mm), Group B (depth of 4-8 mm), Group C (depth of 8-12 mm), and Group D (depth of 12-16 mm), and Group E (depth of > 16 mm)’. Consequently, the ‘internal complications’ such as infection, venous thrombotic syndrome, catheter folding & migration, extravasation, whereas the ‘external complications’ viz., inflammation, local hematoma, local cutaneous reactions, and port exteriorization were significantly analyzed during TIVAPS implantation at different depths in BC patients. Results: Overall incidence of ‘internal complications’ such as infections, venous thrombotic syndrome, catheter folding & migration, and extravasation was comparatively lesser in Group C (8-12 mm) than Group A, Group B, Group D, and Group E, respectively. Mainly, the external complications such as inflammation Group C (8-12 mm) (p<0.01) were lesser (6.8%, 3/44 cases) than Group A, Group B, Group D, Group E. On a similar note, the local hematoma, and local cutaneous reaction, and port exteriorization were observed as ‘5% (1/20 cases), 4.2% (2/47 cases), and (3.2%, 1/31 cases)’ in Group C patients (p<0.01), which were comparatively lesser than the other groups. Conclusion: Subcutaneous implantation of TIVAPS at a depth of 8-12 mm could be preferred due to the lowest incidence of internal and external complications compared to the incidence of these complications in other groups; this depth could be referred to as the safe and convenient implantation depth for the effective delivery of chemotherapy regimen in BC patients without difficulty in transcutaneous access to the port.

Effectiveness of mechanical recanalization for intraluminal occlusion of totally implantable venous access ports

Purpose: To evaluate if the mechanical injection of saline is effective in restoring patency of a totally implantable venous access port (TIVAP) with an intraluminal occlusion. Materials and methods: From January 2017 to June 2019, 64 cases of dysfunction of a TIVAP were referred to interventional radiology. Among these, 16 cases showed normal function of the TIVAP, 19 cases the showed the appearance of a fibroblastic sheath, and 29 cases showed intraluminal occlusion. Mechanical recanalization was performed for intraluminal occlusion of the TIVAP with an indeflator and a 20G non-coring needle. Linograms were performed in all recanalized cases. The success or failure of recanalization and the pressure of the indeflator were recorded. Linograms were evaluated for breakage or migration of catheters. Medical records were retrospectively reviewed. Results: Among the 29 intraluminal occlusion cases, 24 cases (82.7%) were recanalized by mechanical recanalization via an indeflator. The pressure of the indeflator ranged from 29 to 220 psi (median: 118 psi). Linograms revealed breakage of the catheter of the TIVAP in two failed cases. The median interval from implantation to dysfunction was 405 days (range: 43–1723 days). The median interval from last use to dysfunction was 8 days (mean: 15.4 days; range: 1–119 days). The median re-occlusion free period after successful mechanical recanalization was 100.5 days (range: 6–859 days). Conclusion: In the absence of an available thrombolytic agent, mechanical injection of saline was a tolerable alternative method for restoring occluded catheters and sustaining the function of catheters. Because breakage of the catheter can occur during mechanical recanalization of a TIVAP, a linogram should follow the procedure.

Totally implantable venous access port insertion via open Seldinger approach of the internal jugular vein—a retrospective risk stratification of 500 consecutive patients

Purpose Modern oncological treatment algorithms require a central venous device in form of a totally implantable venous access port (TIVAP). While most commonly used techniques are surgical cutdown of the cephalic vein or percutaneous puncture of the subclavian vein, there are a relevant number of patients in which an additional strategy is needed. The aim of the current study is to present a surgical technique for TIVAP implantation via an open Seldinger approach of the internal jugular vein and to characterize risk factors, associated with primary failure as well as short- (< 30 days) and long-term (> 30 days) complications. Methods A total of 500 patients were included and followed up for 12 months. Demographic and intraoperative data and short- as well as long-term complications were extracted. Primary endpoint was TIVAP removal due to complication. Logistic regression analysis was used to analyze associated risk factors. Results Surgery was primarily successful in all cases, while success was defined as functional (positive aspiration and infusion test) TIVAP which was implanted via open Seldinger approach of the jugular vein at the intended site. TIVAP removal due to complications during the 1st year occurred in 28 cases (5.6%) while a total of 4 (0.8%) intraoperative complications were noted. Rates for short- and long-term complications were 0.8% and 6.6%, respectively. Conclusion While the presented technique requires relatively long procedure times, it is a safe and reliable method for TIVAP implantation. Our results might help to further introduce the presented technique as a secondary approach in modern TIVAP surgery.