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1DepartmeAdvanced TechCatania, Italy.
2DepartmeItaly.
CorrespondSurgical SciencCannizzaro HoCatania, Italy;
Ann Vasc SurgDOI: 10.1016/� Annals of VPublished onli
Totally Implanted Venous Access DevicesImplanted in the Saphenous Vein. RelationBetween the Reservoir Site and Comfort/Discomfort of the Patients
Adriana Toro,1 Maurizio Mannino,1 Giovanni Cappello,1 Sofia Celeste,1 Stefano Cordio,2
and Isidoro Di Carlo,1 Catania, Italy
Background: When a totally implantable venous access device (TIVAD) is implanted in thefemoral or saphenous vein, the port can be placed in the abdominal wall, thigh, or anteroinferiorthoracic wall. This study analyzed the relationship between the position of the port and patientcomfort.Methods: All patients who underwent TIVAD implantation from 1995 to 2011 were included inthe study. Sex, age, indication for TIVAD implantation, contraindication for implantation in a veindraining into the superior vena cava, surgical technique, length of procedure, complications, diffi-culties recorded by nurses, and patient comfort or discomfort were recorded.Results: The TIVAD was implanted in the saphenous vein in 6 of 581 patients (1.3%) whoreceived a TIVAD, consisting of four male subjects and two female subjects aged 35 to 56years (mean age: 47.3 years), who all underwent TIVAD implantation for the treatment ofa solid tumor. The port was positioned in the anteroinferior thoracic wall in one patient, theabdominal wall in one patient, the anterior thigh in three patients, and the lateral thigh inone patient. The mean procedure duration was 52 minutes (range: 20e135 minutes). Noimmediate or early complications were recorded. The nurses had difficulty in puncturing theport in the abdominal wall. Patient comfort levels were high when the port was placed in theanterior thigh.Conclusion: The anterior thigh may be the most useful and comfortable position for the port ofa TIVAD implanted in the inferior vena cava. Larger studies should be undertaken to confirmthis.
The totally implantable venous access device
(TIVAD) is currently an indispensable tool for
patients undergoing continuous venous infusion
therapy. This device is now routinely used to avoid
nt of Surgical Sciences, Organ Transplantation, andnologies, Cannizzaro Hospital, University of Catania,
nt of Oncology, Garibaldi-Nesima Hospital, Catania,
ence to: Isidoro Di Carlo, MD, PhD, FACS, Department ofes, Organ Transplantation, and Advanced Technologies,spital, University of Catania, Via Messina 829, 95126E-mail: idicarlo@unict.it
2012; 26: 1127.e9e1127.e13j.avsg.2012.02.025ascular Surgery Inc.ne: August 29, 2012
a number of common and serious problems related
to peripheral vascular access, especially in patients
with cancer.1
TIVADs are most commonly implanted in the
veins draining into the superior vena cava (cephalic,
subclavian, external, and internal jugular veins),
with the port placed in the anterior thoracic wall.
However, TIVAD implantation in these veins is not
always feasible, and there may be no suitable loca-
tion for a port in the thorax or neck. Contraindica-
tions to TIVAD implantation or port placement in
this area include massive local recurrence of breast
cancer, planned radiation therapy to the neck or
mediastinum, severe radiodermatitis of the chest
or mediastinum, tumor of the neck or mediastinum,
venous thrombosis, burns to the head or neck,
1127.e9
1127.e10 Case reports Annals of Vascular Surgery
extensive cervical or thoracic trauma, oropharyn-
geal fistula, or tracheostomy.2,3 In these cases, an
alternative route has to be used, especially in
patients being treated for cancer. The femoral vein
can be accessed percutaneously, or the saphenous
vein can be accessed by surgical cut-down. In these
cases, the port is usually placed in the anterior
abdominal wall, but placement in the thigh or in
the anteroinferior thoracic wall has also been repor-
ted.4e6 To the best of our knowledge, this is the first
report evaluating patient satisfaction with various
positions of the port in cases of TIVAD implantation
in a vein draining into the inferior vena cava. The
aim of this study was to analyze the relationship
between patient comfort and port placement in
these cases.
PATIENTS AND METHODS
We analyzed all patients who underwent TIVAD
implantation at the Department of Surgical
Sciences, Organ Transplantation, and Advanced
Technologies from 1995 to 2011. Sex, age, indica-
tion for TIVAD implantation, contraindication to
TIVAD implantation in a vein draining into the
superior vena cava, type of TIVAD, procedure used
for TIVAD implantation with special reference to
the position of the port, duration of the procedure,
and duration of hospitalization were recorded.
Surgical Technique
All procedures were performed in the operating
room under sterile conditions, and local anesthesia
was administered to the patients. Only one patient
required sedation. Cephalosporin (1 g) was adminis-
tered intravenously 1 hour before skin incision.
An inguinal incision was made, and the saphe-
nous vein was isolated. Two nonabsorbable sutures
were placed on the saphenous vein. The distal
suture was tied; venotomy was performed; and the
catheter was introduced into the inferior vena
cava via the saphenous vein. The tip of the catheter
was advanced to the level of the renal veins under
fluoroscopic guidance, and the catheter was secured
to the saphenous vein with absorbable sutures.
Because there is an elevated risk of infection in the
inguinal region when a TIVAD is placed in the
saphenous vein, the port was placed at least 5 to
10 cm from the inguinal incision.
Port placement was in one of three sites: 1) the
catheter was tunneled subcutaneously to the ante-
roinferior thoracic wall; 2) the catheter was
tunneled to the lower abdominal wall at the level
of the transverse line between the anterior superior
lilac spines, to the lateral half on the right side or the
lateral third on the left side; or 3) the catheter was
tunneled subcutaneously to the anterior or lateral
aspect of the proximal third of the thigh. Once
placed, the TIVAD was checked for blood return,
and the system was flushed with 20 mL of heparin-
ized saline solution (5,000 IU of heparin in 10 mL of
isotonic saline). The port was anchored to the
underlying fascia with at least two 3-0 Prolene
sutures. The skin was sutured with 4-0 Prolene
sutures. Portal access for drug deliverywas routinely
performed using Huber point needles.
Complications
The patientswere followed up by the teamof doctors
and nurses until the skin sutures were removed.
Dressing changes were performed by the nursing
team. Signs of infection in the TIVAD, subcutaneous
tunnel, or incision were recorded. The nursing team
advised the patients and their relatives to remain
vigilant for signs of infection during the treatment
period. The patients were followed up until the
time of catheter removal or death of the patient.
Immediate, early, and late complications, dura-
tion of use, and difficulties recorded by nurses
were analyzed. Immediate complications were
defined as occurring within the first 24 hours after
implantation; early complications were defined as
occurring between 24 hours and 4 weeks; and late
complications were defined as occurring after 4
weeks. Patient comfort or discomfort with respect
to the port position was recorded.
RESULTS
A total of 581 patients underwent TIVAD implanta-
tion during the study period using a surgical cut-
down technique. Six of these patients (1.3%)
underwent TIVAD implantation in the saphenous
vein. Among these patients, four were male subjects
and two were female subjects, aged 35 to 56 years
(mean age: 47.3 years), and all had TIVAD implan-
tation for the treatment of solid tumors: bilateral
breast cancer in one case, mediastinal tumor in
three cases, laryngeal cancer in one case, and testic-
ular cancer with mediastinal metastases in one case.
Contraindications to placement of the TIVAD cath-
eter in a vein draining into the superior vena cava
or to positioning of the port in the chest wall were
bilateral radiodermatitis in three cases and superior
vena cava thrombosis in three cases. All implanted
TIVADs were Port-a-Cath devices (SIMS Deltec
Inc., St. Paul, MN) with a titanium port coated in
polysulfone and an 8-F polyurethane catheter. The
Table I. Method used for evaluating patient
comfort or discomfort
Questions Yes No
1. Do you sense the presence of the device?
2. Do you have pain in the orthostatic
position?
3. Do you have pain in the sitting position?
4. Do you have pain in the supine position?
5. Do you have discomfort in the
orthostatic position?
6. Do you have discomfort in sitting position?
7. Do you have discomfort in the
supine position?
8. Do you have any device-related
difficulty while sleeping?
9. Do you have difficulty during
chemotherapy?
10. Do you have difficulty walking?
11. Do you have difficulty getting dressed?
12. Do you have a limitation caused by the
device in performing your daily activities?
13. Do you want the device removed?
Table II. Patient comfort or discomfort according
to the position of the port
Patient number Port location Answers: yes Answers: no
1 Thorax 13 e2 Abdomen 9 4
3 Thigh anterior 13 e4 Thigh anterior 13 e
Vol. 26, No. 8, November 2012 Case reports 1127.e11
catheter was inserted into the inferior vena cava via
the saphenous vein in all patients. The port was
positioned in the anteroinferior thoracic wall in
one patient, the abdominal wall close to the antero-
superior iliac crest in one patient, the anterior thigh
in three patients, and the lateral thigh in one
patient. The mean procedure duration was 52
minutes (range: 20e135 minutes). The patients
were able to walk after approximately 2 hours.
One patient was hospitalized for only 6 hours, and
the other five patients stayed in the hospital for up
to 24 hours. The thoracic, abdominal, and inguinal
incisions did not affect patient movements.
No immediate or early complications were
recorded during follow-up.One patientwith amedi-
astinal tumor developed a distal femoral vein
thrombosis 2 months after the procedure, and
vascular patency was re-established after systemic
anticoagulation treatment with low-molecular-
weight heparin and warfarin. There were no cases
of extremity obstruction, port rotation, extravasa-
tion of medication, migration or rupture of the cath-
eter. The nurses commented on the difficulty of
puncturing the port placed in the abdominal wall
because of the absence of a rigid underlying plane
and the abundant subcutaneous tissue, as the
patient was overweight.
Patient complaints and comfort levels in relation
to their port position are presented in Tables I and II.
All the patients were asked these questions at least
every 3 months during TIVAD use. The follow-up
period ranged from 3 to 18 months.
5 Thigh anterior 13 e6 Thigh lateral 10 3DISCUSSION
TIVADs are used in patients requiring continuous
administration of intravenous drugs because of the
universally accepted evidence that these devices
improve quality of life owing to the increased ability
in patients to continue normal activities. The
majority of these patients have cancer and would
otherwise receive chemotherapy or cytotoxic agents
by repeated peripheral venous puncture. A TIVAD is
usually implanted in a vein draining into the supe-
rior vena cava, with the port in the anterosuperior
thoracic wall. Percutaneous access via the subcla-
vian or internal jugular veins is the most common
method,7 but surgical cut-down via the cephalic
vein is the only method that completely avoids
immediate life-threatening complications, and, in
experienced hands, results in a 100% success rate
for vein cannulation.8,9
When the veins draining into the superior vena
cava are unsuitable for use or the anterior thoracic
wall is unsuitable for port placement, a vein drain-
ing into the inferior vena cava has to be used. The
femoral vein is the most commonly used, accessed
by the Seldinger technique. The saphenous vein is
accessed by surgical cut-down, and can be used pref-
erentially or when the femoral vein cannot be used
such as in cases with coagulopathy.
The catheter was inserted into the saphenous
vein by surgical cut-down in all patients in the
current study. This technique avoids the risk of
hematoma, which occurs more frequently when
the Seldinger technique is used to access the femoral
vein. Hematoma is associated with an increased risk
of early infection and can affect the patency of the
TIVAD. Hematoma formation is more frequent in
obese patients, and in these patients, surgical isola-
tion of the saphenous vein permits accurate hemo-
stasis and prevents bleeding. TIVAD implantation
via a cephalic vein without antibiotic administration
Fig. 1. Different positions for port location in cases of
saphenous or femoral vein access for TIVAD implanta-
tion: (1) Anteroinferior thoracic wall at the junction of
the midclavicular line and the 10th rib. (2) One-third
the distance from the umbilicus to the anterior superior
iliac spine.2 (3) Left lateral third of the line passing
through both anterior superior iliac spines. (4) Proximal
third of the thigh. (5) Proximal third of the thigh, 5 to
6 cm lateral to the previous position.
1127.e12 Case reports Annals of Vascular Surgery
has been studied.10,11 However, there is a higher risk
of infection with access via the inguinal region than
via the infraclavicular fossa, and infection rates
without antibiotic use have not been studied for
the inguinal region. Therefore, antibiotic prophy-
laxis was administered to our patients.
When a TIVAD is implanted in the inferior vena
cava, the port can be positioned in the anteroinferior
thoracic wall, the anterior abdominal wall, or the
thigh (Fig. 1). The anteroinferior thoracic wall is the
most commonly used port location because of the
solid underlying structures and the ease of use for
nurses and comfort for the patient, but the excessive
length of the catheter increases the risk of thrombotic
occlusion.5 In the abdominal wall, the port can be
positioned at the level of the transverse line between
the anterior superior lilac spines, in the lateral half on
the right side or in the lateral third on the left side,5,12
or lower than this at one-third of the distance from
the umbilicus to the anterior superior iliac spine.2
In the thigh, the port is usually placed anteriorly at
the junction of the upper one-third and lower two-
thirds of the thigh,6 and can also be positioned 5 to
7 cm laterally to this point. When the port is placed
in the thigh, the lengthof the catheter is short relative
to placement in the other positions, and the risks of
occlusion and catheter kinking are lower.
The abdominal wall is the preferred site for port
placement except in obese patients, for whom the
thigh is preferred.4 The first reason to avoid the
abdominal wall is the large amount of subcutaneous
tissue,which increases the distance between the port
and the skin, andmay dislodge theHuber needle and
risk extravasation of drugs with related complica-
tions. The pain associated with introducing the nee-
dle through the skin also causes muscle contraction,
which increases the difficulty of placing the needle in
the port. Some authors have reported their prefer-
ences regarding which side of the abdominal wall is
used.2 These authors recommend avoiding the right
side because the symptoms of local port infection
may mimic acute appendicitis, which is one of the
most common causes of an acute abdomen in
patients who need surgical intervention.13 However,
symptoms on the left side may mimic sigmoid diver-
ticulitis, in which case a surgical procedure could be
more catastrophic for a patient with a TIVAD.
The thighmay be the ideal position for port place-
ment, especially the anterior aspect. The thigh has
less subcutaneous fat than the abdomen in obese
people, and the fascia is closer to the skin. The lateral
aspect of the thigh should be avoided if the patient
sleeps on their side. If the patient does not sleep
on their side, the port can be positioned on the
lateral aspect of the thigh if preferred.
The present study is limited by the low number of
patients, but until larger studies have been under-
taken, it seems that the anterior thigh may be the
safest and most useful position for the port when
the inferior vena cava is used for TIVAD
implantation.
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