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Technique for placement of an implantable venous access system
HOW I DO IT
Technique for Placement of an Implantable Venous Access System Alan G. Wile, MO, FACS, Orange, California
The complexity of modern multiagent chemotherapy has necessitated the development of devices that will provide secure venous access. One of the currently available devices meeting this need is the Porta-Catha (Pharmacia Inc., Piscataway, NJ). This device is a totally implantable system composed of a silicone rubber diaphragm housed in a stainless steel port connected to a silicone rubber catheter. Access is gained by puncturing overlying skin and the rubber diaphragm with a Huber point needle. The tip of this needle is devised to avoid removing a core of the diaphragm during needle insertion. The advantages of this system are several. It requires no care by the patient when it is not being used; patients are less restricted in their activities because of the lack of an external component, which also appears to contribute to a substantial decrease in infection; the clinical utility of this device has been documented [I]; and the rate of acceptance by both the patient and treating physician is high. Although it is not the intent of this brief paper to discuss this issue in depth, it is imperative that each institution devise guidelines for placement of PortaCaths or similar devices. Clearly, only a fraction of patients undergoing systemic chemotherapy with cytotoxic agents require placement of a Porta-Cath. Technique We rely on an open cut-down approach to placement rather then attempting percutaneous access to the central venous system. Often we are called on to place a PortaCath in patients in the midst of chemotherapy with systemic compromise, including thrombocytopenia, with platelet counts of 10,000 cells/mm3 or less. The open approach is devoid of the mechanical risks of pneumothorax, puncture, or laceration of the subclavian vessels which can be compounded in these very ill patients The patient is given a parenteral antibiotic preoperaFrom the Departments of Surgery, University of California at Irvine Medical Center, Orange, California and Long Beach Veterans Administration Hospital, Long Beach, Callfornia. Requests for reprints should be addressed to Alan G. Wile, MD. Department of Surgery, University of Califomla at Irvine Medical Center, 101 City Drive Sooth, Orange, Californit 92666.
Volume 152, November 1966
tively for wound prophylaxis. The procedure can be performed under local anesthesia with sedation. The patient is positioned with the head turned slightly to one side to allow access to the external jugular vein. The neck and chest are prepped and draped. The external jugular vein is first isolated between two fine silk ligatures. A semicircular incision is made on the chest in a convenient location. This must be located over some bony prominence to provide support for the port when being punctured by the Huber needle. A pocket is developed in the avascular plane between the subcutaneous tissue and fascia. A tunnel is then created between the cervical and chest incisions. This can be accomplished conveniently by passing a no. 3 Bakes dilator cephalad through the chest incision (Figure 1, top). A O-O heavy silk suture is tied around the tip of the Bakes dilator and brought retrograde into the chest incision. The end of the heavy silk ligature brought through the chest incision is then tied to the end of the catheter. A secure tie can be facilitated by having an assistant stretch the catheter during the tying process. After tension is released, the catheter can be seen to bunch around the tie (Figure 1, bottom). At this point, the port and catheter are assembled by sliding the catheter and locking the hub over the sidearm of the port. Care must be taken to avoid incorporating any excess section of catheter between the locking hub and the port. This situation results in a spring effect that has the potential to cause separation of the port from the catheter. The catheter is positioned by pulling the heavy suture fixed to the end of it through the cervical incision. The tip of the catheter tied to the silk is removed by dividing the catheter as close to the silk as possible with heavy scissors. The port is secured to the chest wall fascia by placing 3-O nonabsorbable sutures through each of the four sewing rings, including generous portions of the pectoralis fascia. This will keep the port from turning in the pocket, thereby maintaining the rubber diaphragm in an upright position. The subcutaneous tissue is closed with 3-O absorbable sutures. The intent is to position the port and incision so that the incision will not immediately overlie the port. This plan facilitates immediate use of the device. Next, the catheter is tailored for insertion. Allowing for a gentle loop as it enters the external jugular vein, the catheter is transected as it crosses the sternal angle of 543
Wile
Figure 2. lnsertkm of a Huber needle Into the diaphragm Is necessary to flush air from the system and to demonstrate successfulblood withdrawaland saline infusionat the end of the procedure.
Ftgure 1. Top, a Bakes dilator Is passed cephalad throughthe chest incisionto create a tunnelbetween the cervical and chest openings Bottom,creatlon of a secure t/e facllftates passage of the Sllastlc catheter throughthe wbcutaneous timnet.
Louis. The system is flushed with heparin and saline solution. A full syringe is connected to an 18 inch extension tube and Huber needle. The needle is then passed through the skin and diaphragm until the needle tip touches the metal back of the port (Figure 2). Saline solution is then injected until excess solution is observed running from the end of the catheter. The distal ligature about the external jugular vein is tied. A venotomy is performed with a no. 11 blade and the catheter is inserted. Proper positioning is determined by aspiration with the syringe. The goal of the procedure is to gain venous access
for the purpose of infusing chemotherapeutic agents and for the withdrawal of blood for sampling. Successful infusion of saline solution and aspiration of blood at this point satisfy these requirements and ensure that the proper position has been achieved. In the vast majority of cases, the catheter tip will lie in the superior vena cava, but in a small number of cases, the catheter will reside in the subclavian or internal jugular veins. The catheter is small and flexible. In those patients in whom it is misplaced, it will usually float with blood flow into a central position within 24 hours. This phenomenon has been reported by other investigators [2] and has been confirmed by our experience. The proximal ligature is tied around the catheter and vein with the assistant injecting heparin and saline solution to avoid crimping the catheter with the tie.The loop of catheter is placed under the skin and platysma in the neck. Both incisions are closed with 4-Oabsorbable suture in subcuticular fashion. Benzoin and Steristripse are then applied. The syringe is removed, continuous infusion of saline solution is begun, and light dressings are applied. At this point, the patient is taken to the recovery room, and a portable chest radiograph is obtained to document
544
the position of the catheter tip. Inpatients are then taken to the main hospital, where the Porta-Cath may be used immediately. For outpatients, a nurse oncologist is called to fill the Porta-Cath with a more concentrated solution of heparin and saline (100 units/ml) and to remove the Huber needle. This last step permits the nurse oncologist to identify the position of the port with respect to the incision. Subsequent access is easier in patients with a thick layer of subcutaneous fat in whom palpation of the port may be difficult. Comments We have found this approach to placement of the Porta-Cath to be safe and simple. Operative time is generally between 30 and 45 minutes, and kept to a minimum by not performjng intraoperative radiographic procedures. In rare instances, the external jugular vein will not be suitable for catheter placement. Alternative procedures are to extend the cervical incision medially and isolate the internal jugular vein between the two heads of the sternocleidomastoid muscle or to utilize a separate incision and insert the catheter through the cephalic vein. Summary Increasingly complex programs of cancer chemotherapy have necessitated a system of reliable venous access that is relatively free of infectious complications. These criteria are met by the Porta-Cath, a totally implantable system consisting of an injection port and Silastic catheter. A technique for implantation of this device has been presented. It focuses on patient safety and comfort, ease of placement, and minimization of time and expense in the operating room. References 1. Sothe A, Piccione W, Ambrosino JJ, Senotti PN, Lokich JJ. Implantable central venous access system. Am J Surg 1984;147:565-9. 2. Starker PM, LaSala PA, Askanazi J. Placement of Broviac catheters for total parenteral nutrition. Surg Gynecol Obstet 1983; 156:229-30.
The American Journal of Surgery
Technique for Placement of an Implantable Venous Access System Alan G. Wile, MO, FACS, Orange, California
The complexity of modern multiagent chemotherapy has necessitated the development of devices that will provide secure venous access. One of the currently available devices meeting this need is the Porta-Catha (Pharmacia Inc., Piscataway, NJ). This device is a totally implantable system composed of a silicone rubber diaphragm housed in a stainless steel port connected to a silicone rubber catheter. Access is gained by puncturing overlying skin and the rubber diaphragm with a Huber point needle. The tip of this needle is devised to avoid removing a core of the diaphragm during needle insertion. The advantages of this system are several. It requires no care by the patient when it is not being used; patients are less restricted in their activities because of the lack of an external component, which also appears to contribute to a substantial decrease in infection; the clinical utility of this device has been documented [I]; and the rate of acceptance by both the patient and treating physician is high. Although it is not the intent of this brief paper to discuss this issue in depth, it is imperative that each institution devise guidelines for placement of PortaCaths or similar devices. Clearly, only a fraction of patients undergoing systemic chemotherapy with cytotoxic agents require placement of a Porta-Cath. Technique We rely on an open cut-down approach to placement rather then attempting percutaneous access to the central venous system. Often we are called on to place a PortaCath in patients in the midst of chemotherapy with systemic compromise, including thrombocytopenia, with platelet counts of 10,000 cells/mm3 or less. The open approach is devoid of the mechanical risks of pneumothorax, puncture, or laceration of the subclavian vessels which can be compounded in these very ill patients The patient is given a parenteral antibiotic preoperaFrom the Departments of Surgery, University of California at Irvine Medical Center, Orange, California and Long Beach Veterans Administration Hospital, Long Beach, Callfornia. Requests for reprints should be addressed to Alan G. Wile, MD. Department of Surgery, University of Califomla at Irvine Medical Center, 101 City Drive Sooth, Orange, Californit 92666.
Volume 152, November 1966
tively for wound prophylaxis. The procedure can be performed under local anesthesia with sedation. The patient is positioned with the head turned slightly to one side to allow access to the external jugular vein. The neck and chest are prepped and draped. The external jugular vein is first isolated between two fine silk ligatures. A semicircular incision is made on the chest in a convenient location. This must be located over some bony prominence to provide support for the port when being punctured by the Huber needle. A pocket is developed in the avascular plane between the subcutaneous tissue and fascia. A tunnel is then created between the cervical and chest incisions. This can be accomplished conveniently by passing a no. 3 Bakes dilator cephalad through the chest incision (Figure 1, top). A O-O heavy silk suture is tied around the tip of the Bakes dilator and brought retrograde into the chest incision. The end of the heavy silk ligature brought through the chest incision is then tied to the end of the catheter. A secure tie can be facilitated by having an assistant stretch the catheter during the tying process. After tension is released, the catheter can be seen to bunch around the tie (Figure 1, bottom). At this point, the port and catheter are assembled by sliding the catheter and locking the hub over the sidearm of the port. Care must be taken to avoid incorporating any excess section of catheter between the locking hub and the port. This situation results in a spring effect that has the potential to cause separation of the port from the catheter. The catheter is positioned by pulling the heavy suture fixed to the end of it through the cervical incision. The tip of the catheter tied to the silk is removed by dividing the catheter as close to the silk as possible with heavy scissors. The port is secured to the chest wall fascia by placing 3-O nonabsorbable sutures through each of the four sewing rings, including generous portions of the pectoralis fascia. This will keep the port from turning in the pocket, thereby maintaining the rubber diaphragm in an upright position. The subcutaneous tissue is closed with 3-O absorbable sutures. The intent is to position the port and incision so that the incision will not immediately overlie the port. This plan facilitates immediate use of the device. Next, the catheter is tailored for insertion. Allowing for a gentle loop as it enters the external jugular vein, the catheter is transected as it crosses the sternal angle of 543
Wile
Figure 2. lnsertkm of a Huber needle Into the diaphragm Is necessary to flush air from the system and to demonstrate successfulblood withdrawaland saline infusionat the end of the procedure.
Ftgure 1. Top, a Bakes dilator Is passed cephalad throughthe chest incisionto create a tunnelbetween the cervical and chest openings Bottom,creatlon of a secure t/e facllftates passage of the Sllastlc catheter throughthe wbcutaneous timnet.
Louis. The system is flushed with heparin and saline solution. A full syringe is connected to an 18 inch extension tube and Huber needle. The needle is then passed through the skin and diaphragm until the needle tip touches the metal back of the port (Figure 2). Saline solution is then injected until excess solution is observed running from the end of the catheter. The distal ligature about the external jugular vein is tied. A venotomy is performed with a no. 11 blade and the catheter is inserted. Proper positioning is determined by aspiration with the syringe. The goal of the procedure is to gain venous access
for the purpose of infusing chemotherapeutic agents and for the withdrawal of blood for sampling. Successful infusion of saline solution and aspiration of blood at this point satisfy these requirements and ensure that the proper position has been achieved. In the vast majority of cases, the catheter tip will lie in the superior vena cava, but in a small number of cases, the catheter will reside in the subclavian or internal jugular veins. The catheter is small and flexible. In those patients in whom it is misplaced, it will usually float with blood flow into a central position within 24 hours. This phenomenon has been reported by other investigators [2] and has been confirmed by our experience. The proximal ligature is tied around the catheter and vein with the assistant injecting heparin and saline solution to avoid crimping the catheter with the tie.The loop of catheter is placed under the skin and platysma in the neck. Both incisions are closed with 4-Oabsorbable suture in subcuticular fashion. Benzoin and Steristripse are then applied. The syringe is removed, continuous infusion of saline solution is begun, and light dressings are applied. At this point, the patient is taken to the recovery room, and a portable chest radiograph is obtained to document
544
the position of the catheter tip. Inpatients are then taken to the main hospital, where the Porta-Cath may be used immediately. For outpatients, a nurse oncologist is called to fill the Porta-Cath with a more concentrated solution of heparin and saline (100 units/ml) and to remove the Huber needle. This last step permits the nurse oncologist to identify the position of the port with respect to the incision. Subsequent access is easier in patients with a thick layer of subcutaneous fat in whom palpation of the port may be difficult. Comments We have found this approach to placement of the Porta-Cath to be safe and simple. Operative time is generally between 30 and 45 minutes, and kept to a minimum by not performjng intraoperative radiographic procedures. In rare instances, the external jugular vein will not be suitable for catheter placement. Alternative procedures are to extend the cervical incision medially and isolate the internal jugular vein between the two heads of the sternocleidomastoid muscle or to utilize a separate incision and insert the catheter through the cephalic vein. Summary Increasingly complex programs of cancer chemotherapy have necessitated a system of reliable venous access that is relatively free of infectious complications. These criteria are met by the Porta-Cath, a totally implantable system consisting of an injection port and Silastic catheter. A technique for implantation of this device has been presented. It focuses on patient safety and comfort, ease of placement, and minimization of time and expense in the operating room. References 1. Sothe A, Piccione W, Ambrosino JJ, Senotti PN, Lokich JJ. Implantable central venous access system. Am J Surg 1984;147:565-9. 2. Starker PM, LaSala PA, Askanazi J. Placement of Broviac catheters for total parenteral nutrition. Surg Gynecol Obstet 1983; 156:229-30.
The American Journal of Surgery