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Original Article |
1 Department of Surgical Sciences, Organ Transplantation and Advanced Technologies, University of Catania, Cannizzaro Hospital, Via Messina, 829, 95126 Catania, Italy
2 Department of Oncology, Garibaldi Hospital, 95100 Catania, Italy
Correspondence: Address correspondence and reprint requests to: Isidoro Di Carlo, MD, PhD; E-mail: idicarlo{at}unict.it
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Methods: Patients receiving a TIVAD from January 1995 to December 2003 were included in this study. Age, sex, surgical technique, disease, device used, length of the procedure, and morbidity were considered.
Results: A total of 427 TIVADs were placed in 425 patients: 253 men (59.5%) and 172 women (40.5%) aged 31 to 79 years. Of 425 patients, 5 were excluded; 420 underwent a CV cut down on the first attempt, and 391 (93.1%) procedures were successful. Among the final 29 patients, 20 (68.96%) underwent a TIVAD placement through the ipsilateral EJV cut-down approach. In the remaining nine patients (31.04%), TIVAD placement was performed through the ipsilateral internal jugular vein in four cases, via the ipsilateral axillary vein in three cases, and through the ipsilateral coracobrachial vein in the other cases. No immediate postoperative complications were detected in any of the patients.
Conclusions: TIVAD placement by the CV cut-down approach is safe and fast, and its success rate is very high. By avoiding the immediate complications associated with the percutaneous approach, the EJV cut down has to be considered a valid, safe, and suitable alternative when the CV is not feasible.
Key Words: Totally implantable venous access device • Chronic indwelling central venous access • Venous access • Cephalic vein • Internal jugular vein
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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However, the venous cut-down approach has been widely described in the literature as a safe, fast, and low-cost alternative.7,8 When the cephalic vein (CV) is not suitable for use because of previous chemotherapy or is absent because of an anatomical anomaly, the external jugular vein (EJV) can be approached, although there are not yet data in the literature to prove this. The aim of this work was to report a retrospective and monocentric study concerning the feasibility and complications of this surgical technique.
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PATIENTS AND METHODS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Three types of devices were used: one in silicone rubber (Port-a-Cath; SIMS Deltec Inc., St. Paul, MN) and two in polyurethane (Bard Port [Bard Access Systems, Salt Lake City, UT] and Celsite [B/ Braun Celsa, Chasseneuil, France]). The material of the injection port was titanium in all cases. The surgical technique is extensively described below.
All the devices were affixed in the operating room under fluoroscopic control. Perioperative antibiotic prophylaxis consisted of a single dose of cephalosporin given 10 minutes before the surgical procedure. TIVAD implantation necessitated only local anesthesia (usually 10 mL of 2%mepivacaine hydrochloride) in almost all patients, but short sedation was used in a few patients for psychological reasons. General anesthesia was used when TIVAD placement occurred during a major surgical procedure.
The choice of ipsilateral or contralateral EJV approach depended on its clinical appearance. Before surgery, the courses of both EJVs were marked on the skin via dermographic pen while the patient strained. When the veins were comparable, the CV contralateral to the dominant arm was selected; if an EJV appeared hypoplasic with respect to the other, then the CV contralateral to the hypoplasic EJV was approached. The selected neck and chest region was prepared and sterilely draped. After local anesthesia, the CV cut-down approach was attempted by a single skin incision at the Mohrenheim fossa. In cases in which the CV could not be visualized or was located but was hypoplasic or fibrotic because of previous chemotherapy, an ipsilateral EJV cut-down approach was attempted. In these cases, the patient’s head was turned to the contralateral side, and a transverse 1.5-cm skin incision was performed 2 cm above the clavicle, requiring a short tunnel later. The EJV was dissected out and surrounded by two separate 3-0 Vicryl (Ethicon, Inc., Somerville, NJ) sutures. The distal suture was tied down, and the EJV was partially transected transverse to the vessel’s midline while light traction was applied to the proximal suture.
A catheter was inserted into the EJV with the assistance of microsurgery forceps used to enlarge the vascular lumen. Under fluoroscopic control, the catheter was driven toward the subclavian vein, the innominate vein, and, finally, the superior vena cava, where the tip of the catheter was positioned.
Once correctly positioned, the EJV and the catheter inside were tied down via the proximal suture. The catheter was tunneled from the supraclavicular incision to the ipsilateral Mohrenheim fossa incision by using a tendon passer over the clavicle. The implanted port was positioned, fixed, tested, and heparinized (5000 IU of heparin sodium in 10 mL of isotonic saline) as previously described.7
If both the CV cut-down approach and the ipsilateral EJV cut-down approach failed because of a narrow EJV from previous chemotherapy, TIVAD placement was performed through ipsilateral internal jugular vein (IJV) cut down, ipsilateral axillary vein (AV) cut down, or ipsilateral coracobrachial vein cut down. The decision to approach the AV or the IJV for TIVAD placement depends on patient weight. The IJV approach is preferred for overweight patients. The technique for the AV cut-down approach for TIVAD placement has been described elsewhere.9 The technique for the IJV cut-down approach is that used by Le Veen et al.10 in ascitic patients.
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RESULTS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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A total of 253 patients were male (59.5%), and 172 were female (40.5%); the mean patient age was 55 years (range, 31–79 years). The device was most commonly used for solid-tumor chemotherapy (98.6%) but was also implanted in several cases of hematological disease (1.4%). The most frequent indications for TIVAD placement are listed in Table 1
. One hundred forty-eight patients (34.8%) of a total of 425 were previously treated with chemotherapy.
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The procedure was performed with local anesthesia and cardiac monitoring in 420 patients (98.8%); only 2 patients (.04%) required intravenous sedation (for psychological reasons). In three patients, the procedure was performed under general anesthesia (two cases of gonadal vein approach and one case of vena cava approach) because TIVAD placement occurred during a major abdominal operation.
Of 425 consecutive patients who required TIVAD placement, 420 were suitable for a CV cut-down approach. Of the remaining five patients, two (.04%) underwent TIVAD placement via the saphenous vein because of previous neck/thorax radiotherapy (one of the two patients also had a previous operation on the neck region). The final three patients (.07%) underwent two gonadal TIVAD placements and one vena cava placement.
Seven patients (1.6%) had previous TIVAD: two in the CV, two in the subclavian vein (one of them ruptured and migrated in the cardiac cavity), and three in the IJV. Except for the patients with TIVAD in the CV, the patients underwent operation elsewhere. In all these patients, after the removal of the previous TIVAD, the opposite CV was used to insert a new catheter.
Among the 420 patients eligible for CV placement, 391 (93.1%) underwent a successful TIVAD placement via the CV cut-down approach, whereas the other 29 patients (6.9%) received an alternative approach. The mean operative time for the successful 391 CV cut-down approaches was 35 minutes (range, 12–40 minutes).
Concerning the 29 patients in whom successful TIVAD placement via the CV cut-down approach was not technically feasible, 27 patients had an CV too small to pass the catheter (25 because of a narrow vein due to previous chemotherapy and 2 because the vein was hypoplasic). There was no detectable CV in 2 patients.
Of the 29 patients in whom successful TIVAD placement via the CV cut-down approach was not feasible, 20 (68.96%) underwent a successful TIVAD placement through the ipsilateral EJV cut-down approach. The mean total operative time for those 20 procedures was 45 minutes (range, 35–70 minutes). In the remaining nine patients (31.04%), both the CV cut-down approach and the ipsilateral EJV cut-down approach failed because of narrow CV and EJV from previous chemotherapy. Of these cases, TIVAD placement was performed through ipsilateral IJV cut down in four cases, through ipsilateral AV cut down in three cases, and through ipsilateral coracobrachial vein cut down in the last two cases. The mean total operating time for those nine patients was 90 minutes (range, 70–120 minutes). For all patients and procedures, only 1 day of hospitalization was needed.
The combined success of the CV and ipsilateral EJV cut-down approach was 97.85% (391 plus 20 of 420 patients). However, if the remaining nine patients in whom the ipsilateral veins were approached are considered, then the success rate of the cut-down approach reaches 100%. No instances of immediate postoperative complications, including pneumothorax, hemothorax, or injury to the great vessels, were detected among the patients undergoing a successful TIVAD placement via CV cut-down approach and EJV cut-down approach. Additionally, no complications were detected among patients who underwent the IJV, AV, or coracobrachial vein cut-down approaches after the CV and the EJV approaches failed.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Subclavian and IJV percutaneous approaches have a well-documented risk of causing serious complications. Of these, pneumothorax is the most important and frequent ailment, with an incidence ranging from 1%to 4%.4,5,12,13 This complication causes intense psychological stress for the oncological patient7 and greatly increases the cost of the procedure.1 Contrary to the venous percutaneous approach, many studies analyzing the CV cut-down approach have shown an absence of immediate perioperative complications,7,8,11,14,15 and for this reason, it should be considered a more valid approach for TIVAD placement.14,15
This study considered the potential role of the EJV cut-down approach for TIVAD placement when the CV cut-down approach is not technically feasible. In this study, the success rate of the CV cut-down approach alone was 93.09% (391 of 420 patients). This percentage reaches 97.85%if patients who underwent an ipsilateral EJV approach after the CV approach (411 of 420 patients) are considered. If the last 9 patients who underwent a different approach are included, an ipsilateral neck/thorax region cut-down approach was feasible in 100% of cases (420 of 420 patients).
This impressive rate of success eliminates the need to use the percutaneous approach for TIVAD placement in selected cancer patients; also, this report represents additional confirmation of the absence of immediate complications—including pneumothorax, hemothorax, and injury of the great vessels or nerves—with use of the CV or the EJV cut-down approaches. Moreover, in the few cases in which neither the CV nor the EJV was suitable for catheter placement, the IJV or AV was considered and successfully used without any further surgical incisions.7
In conclusion, venous cut-down approaches for TIVAD placement are safe and fast, and the success rate for these procedures is very high. The EJV cut-down approach should be considered a valid, safe, and suitable adjunct to the CV approach. Unless it is contraindicated, anatomical knowledge of the ipsilateral veins of the neck and axillary region and a thorough understanding of the surgical protocol allow for TIVAD placement in all circumstances. Additionally, these procedures avoid many of the possible complications reported for the subclavian vein and IJV percutaneous approaches.
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ACKNOWLEDGMENTS |
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Received for publication April 19, 2004. Accepted for publication January 19, 2005.
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REFERENCES |
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