- Email: [email protected]
Use of a Totally Implantable Access Port Through the External Jugular Vein When the Cephalic Vein Approach is Not Feasible
Use of a Totally Implantable Access Port Through the External Jugular Vein When the Cephalic Vein Approach is Not Feasible Yi-Chang Lin, Chi-Hong Chu, Kuang-Wen Ou, De-Chuan Chan, Chung-Bao Hsieh, Teng-Wei Chen, Huan-Ming Hsu, and Jyh-Cherng Yu, Taiwan, Republic of China
Background: We report our experience of using a totally implantable access port (TIAP) through the external jugular vein (EJV) when the cephalic vein (CV) approach is not feasible. Methods: We reviewed 197 cases involving TIAP implantation through the EJV in a single medical center between January 1995 and January 2009. All the ports were implanted after the CV approach was found unfeasible. Patient characteristics, operating time, and early and late complications were recorded. Results: The mean patient age was 50 years (range: 33-75). The mean operating time was 54.5 ± 7.5 minutes. Early complications within the first 30 postoperative days included port hematoma (2%) and catheter migration (2%). The late postoperative complications included catheter occlusion (2.5%), venous thrombosis (2%), and port infection (1.5%). There were no complications associated with TIAP disconnection. Conclusions: The EJV approach is an easy and safe alternative method for TIAP implantation when the CV approach is not feasible. This method can avoid conversion to percutaneous puncture of the subclavian vein, which could result in life-threatening complications such as pneumothorax and hemothorax. In patients with breast cancer or those who are contraindicated for TIAP implantation on the opposite side, the EJV cutdown approach provides an alternative route with comfortable and satisfactory results as complications with this approach are rare.
INTRODUCTION Totally implantable access ports (TIAPs) are commonly used for the administration of chemotherapy, blood transfusion, parenteral nutrition, and blood sampling.1 The most common purpose of TIAP in clinical practice is to provide a secure and comfortable route for cytotoxic oncological therapy for patients with malignancies. The catheter of the TIAP can be inserted using various venous
Department of Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan, Republic of China. Correspondence to: Jyh-Cherng Yu, MD, Department of Surgery, National Defense Medical Center, Tri-Service General Hospital, No.325, Cheng-Kung Road 2nd section, Taipei 114, Taiwan, Republic of China, E-mail: [email protected] Ann Vasc Surg 2011; 25: 217-221 DOI: 10.1016/j.avsg.2010.07.017 Ó Annals of Vascular Surgery Inc. Published online: October 6, 2010
routes, including cutdown or percutaneous puncture approaches.2 The cutdown approach to the cephalic vein (CV) is a common method with fewer complications as compared with the approach through the percutaneous subclavian vein.2 Although the CV cutdown approach has been reported to be feasible in 82% of cancer patients, the TIAP using the CV cutdown approach might be impossible when the CV is too small or absent.3 After the CV cutdown approach has failed, conversion to puncture of the subclavian vein or an approach through the contralateral CV can be used as alternative routes. However, approach to the ipsilateral external jugular vein (EJV) can also be used as an alternative route to avoid making a contralateral operation wound. In this article, we summarize our experience of applying TIAP with catheter insertion through the EJV when a CV cutdown approach was not feasible. 217
218 Lin et al.
Annals of Vascular Surgery
MATERIALS AND METHODS
RESULTS
A series of 197 cancer patients underwent TIAP implantation through the EJV at the Tri-Service General Hospital, Taipei, Taiwan, between January 1995 and January 2009. The medical charts of all the patients were reviewed. The infusion for chemotherapy was used as an indication for implantation. Each patient’s disease, age, and any underlying disease were recorded and analyzed. All the patients in this study had complete preoperative laboratory examinations such as complete blood cell counts, prothrombin time, and activated prothrombin time. A single dose of prophylactic antibiotics was prescribed before surgery for all the patients. All of the procedures were performed by wellexperienced surgeons, and the patients received intravenous sedation and local anesthesia in the operating room. In each TIAP procedure, the patient was put in a supine position and the head was turned slightly to the contralateral side. The EJV was inspected and marked before each TIAP procedure. Sometimes, the patients were put in the Trendelenburg position to engorge the EJV. The whole chest and neck of the patient were prepared and draped. All the patients underwent the CV cutdown approach initially at the deltopectoral groove. If the CV was too small or absent, the procedure was modified to insert the catheter through the ipsilateral EJV. We made a small horizontal skin incision about 5 mm long over the ipsilateral EJV, just above the clavicle. With careful dissection, the EJV was isolated, and two separate 30 silk sutures were placed around it proximally and distally. One purse-string suture with 6-0 prolene was applied to the EJV and a venotomy was performed. With the assistance of a vein pick, the catheter was passed into the lumen and directed centrally. Using real-time fluoroscopic guidance, the tip of the catheter was positioned in the superior vena cava. When the catheter had been positioned correctly, the purse-string suture was tightened around the catheter. One subcutaneous tunnel from the lower neck incision to the deltopectoral incision of the CV cutdown approach was created using a mosquito hemostatic clamp. The catheter was put through the tunnel and the ports were implanted in the subcutaneous space developed from the dissection of the CV cutdown approach (Fig. 1). Finally, a test puncture was performed to check the blood flow and patency. Retention with a solution of heparin sodium (5,000 U in 3 mL normal saline) was prescribed. The wound was closed in layers.
There were 43 men and 154 women in this series, with mean age of 50 years (range: 33-75 years). Of these patients, 139 (70.6%) had unilateral breast cancer, 54 (27.4%) had gastrointestinal malignancies, 3 (1.5%) had lymphoma, and 1 (0.5%) had lung cancer. The characteristics of the patients and the complication rates are shown in Table I. The mean operating time was 54.5 ± 7.5 minutes. There were no immediate postoperative complications. Early complications within the first 30 postoperative days included a port hematoma because of inadequate hemostasis for four patients and catheter migration in another four. Patients with port hematomas were simply observed and no revision was necessary for patients with catheter migration. Late postoperative complications occurred in 12 patients including port infection in three, venous thrombosis in four, and catheter occlusion in five. These patients eventually required revision of the TIAP. There were no cases of TIAP disconnection.
DISCUSSION TIAPs have been used widely in treating oncology patients for the administration of intravenous medications. These devices also provide a safe and comfortable vascular access to facilitate laboratory blood examinations, parenteral nutrition, and prolong cytotoxic chemotherapy regimens. The TIAP is most frequently implanted by surgical cutdown of the CV, with satisfactory results and few complications. Another choice is the percutaneous approach to the subclavian vein.2,3 Use of the CV cutdown approach can avoid the risks of pneumothorax, hemothorax, and catheter fragmentation,2,4 but this procedure is technically demanding and anatomical variations can result in failure rates of 6-30%.5 However, if the surgeon uses a direct puncture after failure of the cutdown method, it may increase the rate of complications such as pneumothorax. In such cases, the EJV cutdown approach is a useful alternative method to avoid percutaneous puncture of the subclavian vein when the CV cutdown method is not feasible. Although the EJV cutdown approach has been described in the published data6-8 there are few data available on the potential use of this approach in TIAP placement when the CV cutdown method is not feasible. In Povoski’s study, 17 of 18 patients who failed to undergo successful TIAP placement through the CV cutdown approach underwent an ipsilateral EJV cutdown approach successfully with no instances of postoperative complications.6 In
Vol. 25, No. 2, February 2011
Use of TIAP through the EJV 219
Fig. 1. A One incision was made on the deltopectoral groove for the cephalic vein (CV) cutdown approach (IJ, internal jugular vein; EJ, external jugular vein; SV, subclavian vein; SVC, superior vena cava). B If the CV was too small or absent, one horizontal incision approximately 5 mm long was made on the external jugular vein (EJV). The catheter was placed into the EJV through
this venotomy. The tip of the catheter was placed in the superior vena cava and its position was checked by realtime fluoroscopy. C The tunnel from the incision on the EJV to the incision on the deltopectoral groove was established. D The Port was placed in the subcutaneous layer.
this study, early and late complications were rare, but port hematomas, catheter migration, catheter occlusion, venous thromboses, and port infections were noted. The EJV cutdown approach seemed to be a highly successful and safe route (94-100%) in previous studies.6,7 However, this procedure might fail when the EJV is too thin or small to be cannulated or if it is difficult to advance the catheter through the angle between the EJV and the subclavian vein. In this series, we did not encounter any difficulties while inserting the catheter through the EJV. If the EJV cutdown approach fails, cutdown of the contralateral CV or a percutaneous approach
to the ipsilateral internal jugular vein can be another option.6 In previous studies, formation of a port hematoma was a rare early complication (0.4-1.1%) in either the CV cutdown approach or percutaneous subclavian vein approach.2,4,7 In this study, four patients (4%) developed a port hematoma 1 day after the surgery because of inadequate hemostasis. This rate was a slightly higher as compared with previous results. All of the patients in this study underwent the EJV cutdown approach after we first attempted the CV cutdown approach. When it was verified that the CV was
220 Lin et al.
Annals of Vascular Surgery
Table I. Patient characteristics and complication rates Number of patients Mean age (years) Mean operating time (minutes) Early complications (<30 days postoperatively) Hematoma Catheter migration Late complications (>30 days postoperatively) Catheter occlusion Venous thrombosis Port infection
197 50 (range: 33-75) 54.5 ± 7.5
4 (2%) 4 (2%)
5 (2.5%) 4 (2%) 3 (1.5%)
too small or absent, the EJV cutdown was used. This procedure needs more extensive dissection and vascular exploration. If the hemostasis is performed inadequately, it may easily lead to a port hematoma. Catheter migration has not been reported previously for the EJV cutdown approach.6,7 Four patients in this study had backward catheter migration in the subclavian vein by 1 week after the procedure. The technique of EJV cutdown approach used in this study is slightly different from those used in previous studies.6,7 We created a venotomy and one purse-string suture with 6-0 prolene on the EJV, instead of tie-down fixation with 2-0 silk suture around the proximal end of the EJV and the catheter. The major advantage of this method is that it preserves the normal venous drainage of the EJV; however, it may provide insufficient fixation of the catheter before the fibrotic tissue around the catheter tract grows to fix it. Central venous thrombosis (CVT) is a notable complication associated with long-term use of indwelling catheters. The majority of patients with catheter-related CVT are asymptomatic or have nonspecific symptoms.9 The reported incidence of symptomatic catheter-related CVT in adult patients varies from 0.3 to 28.3%,10 but the TIAP-related CVT for EJV cutdown approach had not been reported. In this study, the follow-up may not be long enough to fully reflect this complication. In the case of clinical suspicion of catheter-related CVT, compressive ultrasound and venography could be used to confirm the diagnoses. In this study, four patients presented with arm swelling, neck swelling, erythema, pain, and congestion of subcutaneous collateral veins. The diagnoses were made after screening with the venography of upper extremities. All these patients were treated with lowmolecular-weight heparin and recovered without hemorrhagic complications.
Fig. 2. A 55-year-old male patient with gastric cancer had one permanent pacemaker implanted through the left subclavian vein. The totally implantable access port was implanted successfully through the right EJV because the right CV was too small.
Most of the women in this study had breast cancer. For such patients and for those requiring a permanent pacemaker to be implanted through the subclavian vein (Fig. 2), the selection of a central vein for TIAP implantation is restricted because only the contralateral side can be used. The results of this study can provide the surgeons with an alternative and safe route when either the CV cutdown approach or percutaneous subclavian vein approach has failed. Moreover, this method is valuable for patients with unilateral breast cancer or patients who are contraindicated for TIAP implantation on the opposite side. In conclusion, the EJV cutdown approach is an easy and safe alternative route for TIAP implantation when the CV cutdown approach is not feasible. This method can avoid the alternate percutaneous puncture of the subclavian vein, which can result in life-threatening complications such as pneumothorax and hemothorax. In patients with breast cancer or patients who are contraindicated for TIAP implantation on the opposite side, the EJV cutdown is an alternative approach. It gives a safe, comfortable, and satisfactory result with fewer complications.
Vol. 25, No. 2, February 2011
Use of TIAP through the EJV 221
REFERENCES 1. Kock HJ, Pietsch M, Krause U, Wilke H, Eigler FW. Implantable vascular access systems: experience in 1500 patients with totally implanted central venous port systems. World J Surg 1998;22:12-16. 2. Jablon LK, Ugolini KR, Nahmias NC. Cephalic vein cutdown versus percutaneous access: a retrospective study of complications of implantable venous access devices. Am J Surg 2006;192:63-67. 3. Povoski SP. A prospective analysis of the cephalic vein cutdown approach for chronic indwelling central venous access in 100 consecutive cancer patients. Ann Surg Oncol 2000;7: 496-502. 4. Chang HM, Hsieh CB, Hsieh HF, et al. An alternative technique for totally implantable central venous access devices. A retrospective study of 1311 cases. Eur J Surg Oncol 2006;32:90-93. 5. Seiler CM, Frohlich BE, Dorsam UJ, et al. Surgical technique for totally implantable access ports (TIAP) needs
6.
7.
8.
9.
10.
improvement: a multivariate analysis of 400 patients. J Surg Oncol 2006;93:24-29. Povoski SP. External jugular vein cutdown approach for chronic indwelling central venous access in cancer patients: a potentially useful alternative. World J Surg Oncol 2004; 2:7. Karanlik H, Kurul S. Modification of approach for totally implantable venous access device decreases rate of complication. J Surg Oncol 2009;100:279-283. 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;12:570-573. De Cicco M, Matovic M, Balestrieri L, et al. Central venous thrombosis: an early and frequent complication in cancer patients bearing long term silastic cathter. A prospective study. Thromb Res 1997;86:101-113. Verso M, Agnelli G. Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. J Clin Oncol 2003;21:3665-3675.
Background: We report our experience of using a totally implantable access port (TIAP) through the external jugular vein (EJV) when the cephalic vein (CV) approach is not feasible. Methods: We reviewed 197 cases involving TIAP implantation through the EJV in a single medical center between January 1995 and January 2009. All the ports were implanted after the CV approach was found unfeasible. Patient characteristics, operating time, and early and late complications were recorded. Results: The mean patient age was 50 years (range: 33-75). The mean operating time was 54.5 ± 7.5 minutes. Early complications within the first 30 postoperative days included port hematoma (2%) and catheter migration (2%). The late postoperative complications included catheter occlusion (2.5%), venous thrombosis (2%), and port infection (1.5%). There were no complications associated with TIAP disconnection. Conclusions: The EJV approach is an easy and safe alternative method for TIAP implantation when the CV approach is not feasible. This method can avoid conversion to percutaneous puncture of the subclavian vein, which could result in life-threatening complications such as pneumothorax and hemothorax. In patients with breast cancer or those who are contraindicated for TIAP implantation on the opposite side, the EJV cutdown approach provides an alternative route with comfortable and satisfactory results as complications with this approach are rare.
INTRODUCTION Totally implantable access ports (TIAPs) are commonly used for the administration of chemotherapy, blood transfusion, parenteral nutrition, and blood sampling.1 The most common purpose of TIAP in clinical practice is to provide a secure and comfortable route for cytotoxic oncological therapy for patients with malignancies. The catheter of the TIAP can be inserted using various venous
Department of Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan, Republic of China. Correspondence to: Jyh-Cherng Yu, MD, Department of Surgery, National Defense Medical Center, Tri-Service General Hospital, No.325, Cheng-Kung Road 2nd section, Taipei 114, Taiwan, Republic of China, E-mail: [email protected] Ann Vasc Surg 2011; 25: 217-221 DOI: 10.1016/j.avsg.2010.07.017 Ó Annals of Vascular Surgery Inc. Published online: October 6, 2010
routes, including cutdown or percutaneous puncture approaches.2 The cutdown approach to the cephalic vein (CV) is a common method with fewer complications as compared with the approach through the percutaneous subclavian vein.2 Although the CV cutdown approach has been reported to be feasible in 82% of cancer patients, the TIAP using the CV cutdown approach might be impossible when the CV is too small or absent.3 After the CV cutdown approach has failed, conversion to puncture of the subclavian vein or an approach through the contralateral CV can be used as alternative routes. However, approach to the ipsilateral external jugular vein (EJV) can also be used as an alternative route to avoid making a contralateral operation wound. In this article, we summarize our experience of applying TIAP with catheter insertion through the EJV when a CV cutdown approach was not feasible. 217
218 Lin et al.
Annals of Vascular Surgery
MATERIALS AND METHODS
RESULTS
A series of 197 cancer patients underwent TIAP implantation through the EJV at the Tri-Service General Hospital, Taipei, Taiwan, between January 1995 and January 2009. The medical charts of all the patients were reviewed. The infusion for chemotherapy was used as an indication for implantation. Each patient’s disease, age, and any underlying disease were recorded and analyzed. All the patients in this study had complete preoperative laboratory examinations such as complete blood cell counts, prothrombin time, and activated prothrombin time. A single dose of prophylactic antibiotics was prescribed before surgery for all the patients. All of the procedures were performed by wellexperienced surgeons, and the patients received intravenous sedation and local anesthesia in the operating room. In each TIAP procedure, the patient was put in a supine position and the head was turned slightly to the contralateral side. The EJV was inspected and marked before each TIAP procedure. Sometimes, the patients were put in the Trendelenburg position to engorge the EJV. The whole chest and neck of the patient were prepared and draped. All the patients underwent the CV cutdown approach initially at the deltopectoral groove. If the CV was too small or absent, the procedure was modified to insert the catheter through the ipsilateral EJV. We made a small horizontal skin incision about 5 mm long over the ipsilateral EJV, just above the clavicle. With careful dissection, the EJV was isolated, and two separate 30 silk sutures were placed around it proximally and distally. One purse-string suture with 6-0 prolene was applied to the EJV and a venotomy was performed. With the assistance of a vein pick, the catheter was passed into the lumen and directed centrally. Using real-time fluoroscopic guidance, the tip of the catheter was positioned in the superior vena cava. When the catheter had been positioned correctly, the purse-string suture was tightened around the catheter. One subcutaneous tunnel from the lower neck incision to the deltopectoral incision of the CV cutdown approach was created using a mosquito hemostatic clamp. The catheter was put through the tunnel and the ports were implanted in the subcutaneous space developed from the dissection of the CV cutdown approach (Fig. 1). Finally, a test puncture was performed to check the blood flow and patency. Retention with a solution of heparin sodium (5,000 U in 3 mL normal saline) was prescribed. The wound was closed in layers.
There were 43 men and 154 women in this series, with mean age of 50 years (range: 33-75 years). Of these patients, 139 (70.6%) had unilateral breast cancer, 54 (27.4%) had gastrointestinal malignancies, 3 (1.5%) had lymphoma, and 1 (0.5%) had lung cancer. The characteristics of the patients and the complication rates are shown in Table I. The mean operating time was 54.5 ± 7.5 minutes. There were no immediate postoperative complications. Early complications within the first 30 postoperative days included a port hematoma because of inadequate hemostasis for four patients and catheter migration in another four. Patients with port hematomas were simply observed and no revision was necessary for patients with catheter migration. Late postoperative complications occurred in 12 patients including port infection in three, venous thrombosis in four, and catheter occlusion in five. These patients eventually required revision of the TIAP. There were no cases of TIAP disconnection.
DISCUSSION TIAPs have been used widely in treating oncology patients for the administration of intravenous medications. These devices also provide a safe and comfortable vascular access to facilitate laboratory blood examinations, parenteral nutrition, and prolong cytotoxic chemotherapy regimens. The TIAP is most frequently implanted by surgical cutdown of the CV, with satisfactory results and few complications. Another choice is the percutaneous approach to the subclavian vein.2,3 Use of the CV cutdown approach can avoid the risks of pneumothorax, hemothorax, and catheter fragmentation,2,4 but this procedure is technically demanding and anatomical variations can result in failure rates of 6-30%.5 However, if the surgeon uses a direct puncture after failure of the cutdown method, it may increase the rate of complications such as pneumothorax. In such cases, the EJV cutdown approach is a useful alternative method to avoid percutaneous puncture of the subclavian vein when the CV cutdown method is not feasible. Although the EJV cutdown approach has been described in the published data6-8 there are few data available on the potential use of this approach in TIAP placement when the CV cutdown method is not feasible. In Povoski’s study, 17 of 18 patients who failed to undergo successful TIAP placement through the CV cutdown approach underwent an ipsilateral EJV cutdown approach successfully with no instances of postoperative complications.6 In
Vol. 25, No. 2, February 2011
Use of TIAP through the EJV 219
Fig. 1. A One incision was made on the deltopectoral groove for the cephalic vein (CV) cutdown approach (IJ, internal jugular vein; EJ, external jugular vein; SV, subclavian vein; SVC, superior vena cava). B If the CV was too small or absent, one horizontal incision approximately 5 mm long was made on the external jugular vein (EJV). The catheter was placed into the EJV through
this venotomy. The tip of the catheter was placed in the superior vena cava and its position was checked by realtime fluoroscopy. C The tunnel from the incision on the EJV to the incision on the deltopectoral groove was established. D The Port was placed in the subcutaneous layer.
this study, early and late complications were rare, but port hematomas, catheter migration, catheter occlusion, venous thromboses, and port infections were noted. The EJV cutdown approach seemed to be a highly successful and safe route (94-100%) in previous studies.6,7 However, this procedure might fail when the EJV is too thin or small to be cannulated or if it is difficult to advance the catheter through the angle between the EJV and the subclavian vein. In this series, we did not encounter any difficulties while inserting the catheter through the EJV. If the EJV cutdown approach fails, cutdown of the contralateral CV or a percutaneous approach
to the ipsilateral internal jugular vein can be another option.6 In previous studies, formation of a port hematoma was a rare early complication (0.4-1.1%) in either the CV cutdown approach or percutaneous subclavian vein approach.2,4,7 In this study, four patients (4%) developed a port hematoma 1 day after the surgery because of inadequate hemostasis. This rate was a slightly higher as compared with previous results. All of the patients in this study underwent the EJV cutdown approach after we first attempted the CV cutdown approach. When it was verified that the CV was
220 Lin et al.
Annals of Vascular Surgery
Table I. Patient characteristics and complication rates Number of patients Mean age (years) Mean operating time (minutes) Early complications (<30 days postoperatively) Hematoma Catheter migration Late complications (>30 days postoperatively) Catheter occlusion Venous thrombosis Port infection
197 50 (range: 33-75) 54.5 ± 7.5
4 (2%) 4 (2%)
5 (2.5%) 4 (2%) 3 (1.5%)
too small or absent, the EJV cutdown was used. This procedure needs more extensive dissection and vascular exploration. If the hemostasis is performed inadequately, it may easily lead to a port hematoma. Catheter migration has not been reported previously for the EJV cutdown approach.6,7 Four patients in this study had backward catheter migration in the subclavian vein by 1 week after the procedure. The technique of EJV cutdown approach used in this study is slightly different from those used in previous studies.6,7 We created a venotomy and one purse-string suture with 6-0 prolene on the EJV, instead of tie-down fixation with 2-0 silk suture around the proximal end of the EJV and the catheter. The major advantage of this method is that it preserves the normal venous drainage of the EJV; however, it may provide insufficient fixation of the catheter before the fibrotic tissue around the catheter tract grows to fix it. Central venous thrombosis (CVT) is a notable complication associated with long-term use of indwelling catheters. The majority of patients with catheter-related CVT are asymptomatic or have nonspecific symptoms.9 The reported incidence of symptomatic catheter-related CVT in adult patients varies from 0.3 to 28.3%,10 but the TIAP-related CVT for EJV cutdown approach had not been reported. In this study, the follow-up may not be long enough to fully reflect this complication. In the case of clinical suspicion of catheter-related CVT, compressive ultrasound and venography could be used to confirm the diagnoses. In this study, four patients presented with arm swelling, neck swelling, erythema, pain, and congestion of subcutaneous collateral veins. The diagnoses were made after screening with the venography of upper extremities. All these patients were treated with lowmolecular-weight heparin and recovered without hemorrhagic complications.
Fig. 2. A 55-year-old male patient with gastric cancer had one permanent pacemaker implanted through the left subclavian vein. The totally implantable access port was implanted successfully through the right EJV because the right CV was too small.
Most of the women in this study had breast cancer. For such patients and for those requiring a permanent pacemaker to be implanted through the subclavian vein (Fig. 2), the selection of a central vein for TIAP implantation is restricted because only the contralateral side can be used. The results of this study can provide the surgeons with an alternative and safe route when either the CV cutdown approach or percutaneous subclavian vein approach has failed. Moreover, this method is valuable for patients with unilateral breast cancer or patients who are contraindicated for TIAP implantation on the opposite side. In conclusion, the EJV cutdown approach is an easy and safe alternative route for TIAP implantation when the CV cutdown approach is not feasible. This method can avoid the alternate percutaneous puncture of the subclavian vein, which can result in life-threatening complications such as pneumothorax and hemothorax. In patients with breast cancer or patients who are contraindicated for TIAP implantation on the opposite side, the EJV cutdown is an alternative approach. It gives a safe, comfortable, and satisfactory result with fewer complications.
Vol. 25, No. 2, February 2011
Use of TIAP through the EJV 221
REFERENCES 1. Kock HJ, Pietsch M, Krause U, Wilke H, Eigler FW. Implantable vascular access systems: experience in 1500 patients with totally implanted central venous port systems. World J Surg 1998;22:12-16. 2. Jablon LK, Ugolini KR, Nahmias NC. Cephalic vein cutdown versus percutaneous access: a retrospective study of complications of implantable venous access devices. Am J Surg 2006;192:63-67. 3. Povoski SP. A prospective analysis of the cephalic vein cutdown approach for chronic indwelling central venous access in 100 consecutive cancer patients. Ann Surg Oncol 2000;7: 496-502. 4. Chang HM, Hsieh CB, Hsieh HF, et al. An alternative technique for totally implantable central venous access devices. A retrospective study of 1311 cases. Eur J Surg Oncol 2006;32:90-93. 5. Seiler CM, Frohlich BE, Dorsam UJ, et al. Surgical technique for totally implantable access ports (TIAP) needs
6.
7.
8.
9.
10.
improvement: a multivariate analysis of 400 patients. J Surg Oncol 2006;93:24-29. Povoski SP. External jugular vein cutdown approach for chronic indwelling central venous access in cancer patients: a potentially useful alternative. World J Surg Oncol 2004; 2:7. Karanlik H, Kurul S. Modification of approach for totally implantable venous access device decreases rate of complication. J Surg Oncol 2009;100:279-283. 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;12:570-573. De Cicco M, Matovic M, Balestrieri L, et al. Central venous thrombosis: an early and frequent complication in cancer patients bearing long term silastic cathter. A prospective study. Thromb Res 1997;86:101-113. Verso M, Agnelli G. Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. J Clin Oncol 2003;21:3665-3675.