Success Rate and Safety of Totally Implantable Access Ports Placed by the Cephalic Vein Cutdown Technique in Oncological Patients – a Single-Center Study

safety of totally implantable access


INTRODUCTION
The totally implantable access ports (TIAPs) are commonly used devices in oncologic patients undergoing ongoing chemotherapy. In comparison to frequent vein puncture and cannulation, the main advantages of these devices are the quick, simple, and easy placement of a vein access for medication administration with minimal discomfort experienced by patients. [1,2] The methods of choice for implantation are the subclavian vein puncture approach and the cephalic vein cutdown technique followed by internal jugular vein access and external jugular vein access. [3][4][5] The cephalic vein cutdown technique has been reported to have fewer complications but lower success rates. [6][7][8]

AIM
In the present study, we aimed to determine the success rate and safety of the cephalic cutdown technique for placement of totally implantable access ports.

MATERIALS AND METHODS
We analyzed all patients who underwent a surgery for placement of implantable central venous access performed by a single surgeon from October 2018 to January 2022 at our institution. The inclusion criteria were (1) patients >18 years old; (2) indications for totally implantable access port placement; and (3) histologically proven cancer. The exclusion criteria were (1) patients <18 years old and (2) indications for totally implantable access port placement other than cancer. The data, including patient demographics, operative time, success rate, oncological reason for insertion, complications, time and reason for removal, were collected and analyzed. All procedures were performed by a single surgeon and started as a cephalic cutdown technique.

Procedures
The patients were positioned supine on the operating table. The surgical site was prepared and draped in the standard manner. All procedures were performed under 1% lidocaine anesthesia. A 4-cm long incision was made at the deltopectoral groove on the right side. After sharp and blunt dissection in the subcutaneous tissue and facial structures, the cephalic vein was exposed between the deltoid and pectoral major muscle. Two 3/0 vicryl sutures were placed around the vein proximally and distally, as the distal suture was tied. A transverse venotomy was done with Potts-scissors between the ligatures. Back-bleeding was controlled by applying traction on the proximal suture. Then, the catheter was inserted in the cephalic vein with the help of a vein pick and advanced until the tip reached the cranial part of the superior vena cava. The proximal suture was tied to prevent bleeding and catheter migration attached to the port and the port was sutured in a prepectoral pocket. A test for functionality was performed by attempting to aspirate blood and then flushing the system with a 20 cc saline solution. Layer-by-layer closure of skin and subcutaneous tissue was done with resorbable sutures.

RESULTS
A total of 135 totally implantable access ports were inserted in the study period at our institution. Median age of patients was 69.2 years (range, 35-86 years). There were 71 (52.59%) women and 64 (47.41%) men. Oncological reason for insertion was colorectal carcinoma in 115 patients (85.19%), ovarian cancer in 4 patients (2.96%), breast cancer in 11 patients (8.15%), and endometrial or cervical cancer in 5 patients (3.70%) (Fig. 1). Median operative time was 42.6 min (range, 30-105 min). In 7 patients, the tip of the catheter was reported to go at the distal part of the subclavian vein and axillary vein on the ipsilateral side after initial placement and was repositioned under real-time fluoroscopic guidance. Successful placement of a totally implantable access port using the cephalic cutdown technique was reported in 127 patients (94.07%). The reasons for the inability to place the catheter were small cephalic vein or several small braches in 7 patients and missing cephalic vein in 1 patient. Of these 8 patients, the totally implantable access port was inserted in 1 patient by the cephalic cutdown technique on the contralateral side and in 7 patients using the subclavian vein puncture approach on the ipsilateral side.  No postoperative complications, such as pneumothorax, hemothorax, or a vessel injury were reported. One case of surgical site infection was seen on POD 7, treated locally for 5 days. Late postoperative complications occurred in 3 patients with catheter-related bacteremia all after POD 30 (81, 95, and 172 days after the procedure) and all 1-3 days after using the system for chemotherapy or routine flushing. One patient died at home after 48 hours of fever up to 40°C. The other two patients were septic, the port was removed and intravenous antibiotics were administered after antibiograms and were discharged on POD 5. Aseptic non-touch technique protocol for usage and flushing of ports was introduced after these cases. No other catheter-related bacteremia was seen 16 months after the introduction of the protocol.

DISCUSSION
Cancer patients benefit from totally implantable access ports because of the need for frequent and long-term i.v. drug administrations. Compared to the subclavian percutaneous approach, the cephalic cutdown technique has been reported to have fewer complications but lower success rates. [6,8] As a result, a subclavian percutaneous approach was preferred in the past. This study confirms that by using the cephalic cutdown technique, we can successfully insert totally implantable access ports with a success rate of up to 94.07%. Other studies report success rates of 70% to 100%. Comparison between studies accessing the safety and feasibility of totally implantable access ports is shown in Table 1. [1,[9][10][11][12][13][14][15][16] The higher success rates and lower complication rates of the cephalic cutdown technique reported in the last few years suggest that it should be preferred over puncture techniques. When the cephalic cutdown technique fails, access via the internal or external jugular veins is usually used as an alternative. Reasons for failure were too small vessel or missing vessel, as reported in most of the studies. The percutaneous subclavian puncture method is associated with significantly higher rates of pneumothorax, hemothorax, and great vessel injuries. [17,18] However, an external jugular cutdown technique is also described in cases where cephalic cutdown fails. [11] Nevertheless, a comparative pro- Seiler et al. [14] 2006 400 79.5 0 0.75 3.5 Di Carlo et al. [15] 2001 344 100 0 0.52 1.7 Torramade et al. [16] 1993 234 70 0 not reported not reported spective study by Iorio et al. suggests that external jugular cutdown could be superior to cephalic cutdown technique and could be considered a first choice in totally implantable access ports placement. [4] Cases of catheter-related bacteremia are probably due to improper non-aseptic technique in the use of the system. Management of infections related to totally implantable venous-access ports has been thoroughly described elsewhere. [19] In most of the cases, removal of the device and treatment with intravenous antibiotics are needed. As an alternative, combined systemic antibiotics and antibiotic lock therapy could be used. [20] CONCLUSIONS Totally implantable access ports placed by the cephalic vein cutdown technique can be used safely and with high success rates in oncological patients.