Outcomes of Port A Catheter Implantations in Cancer Patients: Experience in 102 Cases

Central venous port catheters (CVPCs) are critical in the treatment of cancer patients since they enable secure vascular access. According to the types of catheters, they are categorised as basic IV catheter, peripherally inserted central catheter (PICC), central line, tunnelled venous catheter, Hickman catheter and implantable port or port-a-cath.

The Hickman catheter, a long-term venous access catheter, was first used in 1979 for chemotherapy in cancer patients^[1]. Patients with cancer frequently require venous vessel punctures for treatment, chemotherapy administration or blood transfusions. As a result, central venous catheters and implanted port devices have made vascular access significantly easier. To date, safe and simple-to-use port systems have become an important element of oncology’s everyday clinical practice^[2].

Chemotherapy administration is an advantage of central catheters and venous port catheters, and over a thousand catheters are implanted worldwide each year. Despite the many advantages of port catheters for cancer patients, during insertion, they can trigger various problems. Pneumothorax, haemothorax, malfunction, ventricular perforation, bleeding in the port compartment, arteriovenous fistula and brachial plexus injury are some early complications of CVPCs^[3].

There are currently no precise guidelines or reliable recommendations available for CVPCs and associated risk factors. In this research, we review the literature and discuss the port catheter insertion, problems, advice and outcomes in 102 cancer patients.

This study comprised 102 adult cancer patients who received CVPC implantation at the cardiovascular department of Düzce State Hospital (Düzce, Turkey) for more than a 24-month period (from July 2018 to June 2020). A total of 102 oncology patients (54 males, 48 females; mean age: 54.1 ± 20.3 years; range) were included in the study. Only those patients who had a port for the first time in our clinic and were followed up for 24 months were included in the study. Patients who were implanted outside of our clinic and whose implantation period was unknown, and those with coagulopathy, thrombocytopenia (below 50,000) or infection were excluded from the study. When applicable, after obtaining ethical approval, a retrospective data review was performed to acquire information on demographics, surgical and port-related factors and complications. Patients were screened until the port was removed, death occurred, or follow-up was lost, or until 30 July 2020. The ages of the patients, the place of insertion, the entrance vessel and complications were all considered.

2.1

Insertion of port catheter

A port catheter was inserted under local anaesthesia under sterile conditions, and X-ray control was provided except for four patients. Local anaesthesia was applied to the venous access site, the port pocket and the entire subcutaneous tissue where the catheter line passed. After the venous vessel was punctured, the port was implanted (Figure 1A–D). Anaesthesia was achieved in all patients by infiltration of the puncture site and port pocket with 2% prilocaine hydrochloride (priloc vial 400 mg/vial; Vem, İstanbul, Turkey). Ports systems from two different manufacturers were implanted in patients in numbers: 54 Braun (B. Braun, Melsungen, Germany) and 38 Arrow (B. Braun; Arrow International, Reading, PA, USA). Only eight patients underwent intervention with a Toshiba Xario (Tokyo, Japan) 7.5–11 MHz linear-array transducer device.

Figure 1

In 58 patients (57%), CVPCs were implanted via the left subclavian vein, in 28 patients (27%) via the right subclavian vein, in 10 patients (10%) via the left femoral vein and in 6 patients (3%) via the right femoral vein. The average length of stay for an implanted CVPC was 16.7 months (range: 1–24 months).

The highest number of patients with port catheter implantation consisted of those with cancers of the gastrointestinal system (42 patients; Table 1).

Technically, 99.8% of the cases were successful. There were no severe problems, and the minor complication rate of the surgical technique was 2% (total: two occurrences during local anaesthesia/haematomas). Complications of port catheter occurred early (≤30 days) and delayed (>30 days) at rates of up to 8% and 15%, respectively. The most common early and late complications were pneumothorax and non-functional port (thrombosis, occlusion, kinking), respectively (Table 2).

Treatment of a cancer patient necessitates the establishment of stable vascular access for a variety of underlying conditions such as chemotherapy, blood supply and antibacterial medication, and fluid resuscitation. Patient stress due to frequent vessel punctures can be reduced by using long-term venous access devices or CVCs^[4]. Because most clinical practitioners see intravascular ports as vascular access rather than as part of a malignancy treatment regimen, there has been little consensus on advice. As cancer treatment has progressed, the risk of subsequent malignancy has increased, as has the requirement for port reimplantation^[5].

Currently, more than 50% of new cancer patients need chemotherapy worldwide. A total of 1,898,160 additional cancer cases are expected in 2021^[6]. Chemotherapy treatments are frequently administered intravenously. A drug is injected directly into the port catheter when it has to enter the bloodstream promptly. If one out of every two patients is expected to receive chemotherapy, many individuals will require a port catheter.

Generally, a complication rate of 7.2%–12.5% has been recorded, with CVCs system infection being the most prevalent^[7]. Arterial rupture, haematoma, air embolism, pneumothorax and vessel perforation are the common intraoperative complications, while catheter-related thrombosis, infections, pinch-off syndrome, catheter kinking, drug extravasation and leakage are the common long-term complications. Port complication rates in literature reviews are: pneumothorax 0.1%–3.2%, infection 0.8%–7.5%, lymphoedema 3.6%, port revision 2.6% and skin infection 0.88%^[8,9]. A rare consequence is the transection and embolisation of a port catheter, which is known as ‘pinch-off’ syndrome^[10]. The reported incidence rate is around 1.6%. Catheter-related thrombosis is also rather common, with an incidence of 5%–18%, and does not always necessitate catheter removal. According to the requirement for central vascular access, the state of the catheter system, the examination of anticoagulation contraindications, and the status of the patient^[11].

In this study, internal jugular vein malposition was confirmed by X-ray in one patient following an uncomplicated subclavian port placement. However, it was seen in the images of the patient taken after the intervention during the procedure that the catheter tip was in the superior vena cava. After all intravascular intervention techniques, X-ray or fluoroscopy should be used for confirmation, according to our experience. As a result, difficulties like moving in different directions, extravasation or kinking, and collapsing during port catheter insertion can be avoided and rectified. The tip of the catheter was optimally terminated at the SVC above the right atrium. In our study, exactly two people were malpositioned. The catheter was removed and relocated via described of an X-ray.

We recommend early replacement of the port chamber, which is superficial in the subcutaneous cut, partially moved and visible from the outside, because all interventional procedures for subsequent chemotherapy will increase the risk of infection. Early removal not only provides a more effective port, but also prevents infection. Despite all its potential complications, the intravenous port catheter is a comfortable and safe system in cancer patients. At the choice of the practitioner, cases with clinically suspected catheter-related were evaluated by Doppler ultrasound. The removal of the port catheter and complete anticoagulant medication were used to treat confirmed thrombosis.

Although Nakazawa and Savvari discuss effective techniques for the prevention and management of infections and thrombotic problems, Timsit et al.’s update, ‘Expert consensus-based clinical practice recommendations on the management of intravascular catheters in the ICU’, also discusses the infections in detail^[12,13,14].

It is worth noting that there is a significant association between catheter-related thrombosis and catheter-related infection; the occurrence of one is connected to the occurrence of the other. Regardless of when thrombosis or infection develops, this link increases the patient morbidity.

In our research, we evaluated adverse outcomes such as thrombosis that might occur when port catheters are inserted into the central venous system of cancer patients. In difficult circumstances, early removal of the dysfunctional port catheter and radiological imaging will be advantageous.