Subcutaneous Infusion Ports Via the Internal Jugular Vein : Single Center Experience

Objective: Our purpose is to report and review the results and early complications of subcutaneous infusion port placement by our interventional radiology department. Materials and Methods: Three-hundred twenty-fi ve subcutaneous infusion ports were placed in 320 patients between January 2005 and May 2010. Ports were placed under both general and local anesthesia. Five patients were catheterized twice. The internal jugular veins were used for access. Both ultrasonographic and fl uoroscopic guidance were used in our interventions. Retrospectively, we evaluated the ports’ duration time. Results: Our technical success rate was 100% and only fi ve complications occurred during port placement. The common carotid arteries were punctured in three patients but bleeding stopped ten minutes following withdrawal of the needle and artery compression. An air embolism occurred in two patients and both were successfully treated with good positioning and suctioning. Early catheter removal was required in fi ve patients. One patient had a right internal jugular vein thrombosis, three patients had catheter occlusions and two patients had catheter fractures. The mean duration of catheter usage was 354 days (range: 2 to 1,478 days). Conclusion: Image guided placement of infusion ports has a greater success rate and lower early complication rate when compared with the unguided series. The right internal jugular vein is the fi rst choice for infusion port access.


Introduction
Subcutaneous infusion ports are a preferred form of long-term central venous access in patients treated by oncology departments due to long-term low infection rates and high levels of patient comfort [1].Ports have several advantages over other methods of venous access.One advantage is the ability for them to be implanted under local anesthesia as an outpatient procedure, thereby reducing costs.Before the first port implantation, performed in an angiography unit and first reported by Morris et al. in 1992, port implantation was performed by surgery departments under general anesthesia [2].Many reports suggest that port placement via the internal jugular vein is associated with lower complication rates than subclavian vein ports [3,4].The purpose of our study is to present and review subcutaneous infusion port placement under ultrasonographic and fluoroscopic guidance using the internal jugular vein as the access site of choice.

Materials and Methods
Between January 2005 and May 2010, 325 venous ports were placed in patients with malignancies.We followed patients for 656 days.Five patients had port placement performed twice.All ports were placed by two experienced radiologists.In three patients, the common carotid artery was punctured during the procedure, but bleeding was stopped after withdrawal of the needle and compression of the artery.The indications for infusion port placements were bone marrow transplantation, systemic chemotherapy and long-term antibiotic treatment.All ports had a single lumen.The ports were implanted in the following types: B.Braun Celsite ST 301, 301V (Melsungen Germany), Bard Titanium implanted port (Salt Lake City USA).

Port placement technique
All ports were placed via the internal jugular vein and all procedures were performed in the interventional radiology unit.Most of the patients were sedated with fentanyl and midazolam by an anesthesiologist.In some cases, only local anesthesia was required.One gram of prophylactic IV cefazolin sodium (sefazol Mustafa Nevzat ilaç Sanayi AŞ, İstanbul, Turkey) was administered one hour prior to the procedure if the white blood cell count was lower than 500/mm 3 .Patients with high INRs (international normalized ratio) received blood products prior the procedure to correct coagulation deficiencies.Ultrasound (US) examination was performed in the interventional radiology unit in a sterile fashion before the procedure began to evaluate the internal jugular vein diameter and potency.The right internal jugular vein was initially selected for introducing the port.If the right jugular vein was thrombosed, or if the patient had previously undergone a right mastectomy, the left internal jugular vein was selected as an alternative.All venous punctures were made with 18 gauge venous needles using real time US guidance.Insertion was performed in a standard sterile surgical technique.A 0.035 inch guide wire was advanced forward into the inferior vena cava from within the 18 gauge venous needle using fluoroscopic guidance.Next, the peel away sheath was placed, the guide wire was removed and the sheath was capped.Local anesthesia was used for dissection of the subcutaneous pocket.A large enough pocket for port reservation was dissected into the subcutaneous tissue of the chest wall.If necessary, surgical cautery was used to stop any bleeding.A tunnel was then made through the jugular vein at the access site using the trochar included with the port kit.The port was then connected to the catheter and checked by flushing through contrast and saline.
Next, the position of the tip and curve of the catheter was controlled with fluoroscopic assistance.The reservoir was flushed with 100 u/ml of heparin solution.Last, the incision and venous puncture sites were sutured.After a one-hour observation period all patients were discharged and called back for a one week follow-up.The region of port placement was observed for signs of swelling, redness, high local temperature and suture dehiscence.A well-positioned port is seen in Figure 1.The early complications and reasons for removal were obtained by retrospective review of patient records.
Both electronic and written records were retrospectively reviewed for all patients.

Results
Our technical success rate was 100%.The left internal jugular vein (IJV) was used in 296 patients, and the right one was used in 29 patients.All of the ports were single lumen catheters, and all ports were placed on the anterior chest wall.The tips of the catheters were placed in the right cavoatrial junction or just proximal to the right atrium.The common carotid artery was punctured in three patients while introducing the port through the jugular veins.After withdrawing the needle and holding pressure on the artery, the bleeding stopped and no hematomas were seen at the site of puncture.Air embolisms occurred in two patients and were treated successfully with good positioning and suctioning.
The mean duration of catheter usage was 354 days (range: 2 to 1478 days) recorded by written and electronic data.
Early catheter removal was performed in five patients.One patient had a right IJV thrombosis and three patients had catheter occlusions at 3, 5 and 8 days post-operatively.Two patients had catheter fractures in the second and third day post-catheterization. Nonfunctioning ports were identified in two patients by forceful saline infusion.In those cases, we noted that the skin over the patients' port was swelling while injecting saline associated with a simultaneous feeling of pain in their neck.Following the saline injection, 10 cc of contrast material was administered via the port allowing for visualization of the port fracture site on the side of venous entry (Figure 2).In both of these patients, fractured ports were exchanged with new ones.For the patient with a right IJV thrombosis, the catheter was removed and a new catheter was placed on the left side.We did not search for late complications affecting the venous ports.There were no procedure related infections (measured at 10 days after port placement) in our patient group.

Discussion
Long-term central venous access is required for administration of IV medications to oncology patients.It is also important for delivery of nutritional therapy, transfusion of blood products and withdrawal of blood.Central venous catheters were first described by Dudrick et al. [5].Subcutaneous chest ports have fewer infection complications compared to external catheters [1, 6, and 7].They allow patients unrestricted mobility and the freedom to choose their activities [1].
During the last decade, ports have been inserted by interventional radiologist rather than surgeons.The major difference is that a radiologist uses real time ultrasonographic and fluoroscopic guidance.Thus, complications such as pneumothorax, hemothorax, arterial injury and catheter malposition can be eliminated [8].Many studies have shown that the outcomes of ports placed by interventional radiologists compare favorably to reports of surgical series when examining the rates of infections and technical complications [3,9].Image-guided port placement enables precise venous puncture and catheter positioning.Additionally, US-guided venous puncture minimizes the risk of arterial hematoma and pneumothorax which are reported in the surgical series [10].In our cases, no hematoma or pneumothorax were noted.Fluoroscopic guidance prevents superior vena cava lacerations and ensures that catheter tips are positioned correctly.Our technical success rate was 100%, comparable to that of the current literature [3].Most of our patients received chemotherapy within 3-6 hours after the procedures.The other advantage of using an interventional radiology department is that they are not typically as busy as surgical operating rooms, and, in our department, most of the procedures were performed the day after a request is made.
We had an air embolism occur in two patients, both treated successfully, and an arterial puncture occurred in three patients.With the exception of these patients, no major complications were noted based on the Society of Interventional Radiology (SIR) guidelines [11].In our study group, there were no cases of early infection during the first 10 days.Similarly Çil et al. reported no early infections in their study [12].
The right IJV was preferred for venous access in our interventions.Internal jugular vein access was first described by Hermasura et al. in 1996 [13].It is superior to the subclavian vein for many reasons.First, the right IJV follows a straight course towards the superior vena cava, and its catheterization does not cause a significant or sustained increased intracranial pressure [14].We had two patients with right IJV thromboses, but no pulmonary or systemic complications occurred.Complications unique to subclavian vein catheters, such as catheter pinch-off, chylothorax and brachial plexus injuries, are not seen with internal jugular vein catheters [3], nor did they occur in our series.The left IJV was preferred if the right one had occluded or a right mastectomy had been performed.
The creation of a superficial port pocket with large profile chambers can cause skin erosions; this has been reported in the literature in 0-1% of cases [9].To avoid this complication, operator experience is critical.We did not notice any skin erosion in our cases.
We reported a catheter fracture in two cases.In these cases, careful contrast injections should be made under fluoroscopic guidance because extravasations of the chemotherapeutic agent into the subcutaneous tissue can cause soft tissue necrosis and non-healing wounds [15].
In patients that develop pain and skin swelling over the port area, a fluoroscopic evaluation before using the port is recommended [12].
We did not evaluate late complications of the venous ports.The technical success and early complication rates correlated closely with the results of Yip, Çil and Lorch et al. [3,12,9].This study suggests that image guided placement of infusion ports are associated with a great success rate and low early complication rates compared to the unguided series.The right internal jugular vein is the preferred choice for port access.

Figure 1 .
Figure 1.A well-placed standard port catheter on the chest wall is seen on the X-ray above.

Figure 2 .
Figure 2.After the injection of 10 cc contrast, an extravasation from the fractured site of the catheter to the neck is seen on the flouroscopic images above.