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 3

DISCUSSION

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.

REFERENCES

1. Nagel SN, Teichgr€aber UK, Kausche S, Lehmann A. Satisfac-

tion and quality of life: a survey-based assessment in

patients with a totally implantable venous port system.

Eur J Cancer Care (Engl) 2012;21:197e204.

2. Chen SY, Lin CH, Chang HM, et al. A safe and effective

method to implant a totally implantable access port in

patients with synchronous bilateral mastectomies: modified

femoral vein approach. J Surg Oncol 2008;98:197e9.

3. Di Carlo I, Toro A. Choice of venous sites. Surgical implant/

technique. In: Di Carlo I, Biffi R eds. Totally implantable

venous access devices.Milan, Italy: Springer, 2011. pp 43e54.

4. Bertoglio S, DiSomma C, Meszaros P, et al. Long-term

femoral vein central venous access in cancer patients. Eur

J Surg Oncol 1996;22:162e5.5. Toro A, Sofia M, Sparatore F, et al. Assessment of patient’s

comfort and functioning of a totally implantable venous

Vol. 26, No. 8, November 2012 Case reports 1127.e13

system placed in the safenous vein [in Italian]. G Chir

2005;26:282e5.6. Appelqvist P, Pantzar P. A new site for totally implanted

central venous access system in patients with malignancy:

long-term results of 10 cases. J Surg Oncol 1988;38:1e3.7. Di Carlo I, Pulvirenti E, ManninoM, Toro A. Increased use of

percutaneous technique for totally implantable venous access

devices. Is it real progress? A 27-year comprehensive review

on early complications. Ann Surg Oncol 2010;17:1649e56.8. Di Carlo I, Barbagallo F, Toro A, et al. External jugular vein

cutdown approach, as a useful alternative, supports the

choice of the cephalic vein for totally implantable access

device placement. Ann Surg Oncol 2005;12:570e3.9. Knebel P, Fischer L, Huesing J, et al. Randomized clinical

trial of a modified Seldinger technique for open central

venous cannulation for implantable access devices. Br

J Surg 2009;96:159e65.10. Di Carlo I, Toro A, Pulvirenti E, et al. Could antibiotic

prophylaxis be not necessary to implant totally implantable

venous access devices? Randomized prospective study. Surg

Oncol 2011;20:20e5.

11. Karanlik H, Kurul S, Saip P, et al. The role of antibiotic

prophylaxis in totally implantable venous access device

placement: results of a single-center prospective randomized

trial. Am J Surg 2011;202:10e5.

12. Wolosker N, Yazbek G, Munia MA, et al. Totally implantable

femoral vein catheters in cancer patients. Eur J Surg Oncol

2004;30:771e5.13. Jones PF. Suspected acute appendicitis: trends in manage-

ment over 30 years. Br J Surg 2001;88:1570e7.