Implantation of a totally implantable venous access port (TIVAP) through the subclavian vein under CT guidance is a highly safe and precise method that can effectively reduce the incidence of complications and facilitate early detection of potential complications.
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Method Article
Computed Tomography (CT) Guided Implantation of a Totally Implantable Venous Access Port (TIVAP) through Subclavian Vein
In This Article
Summary
Abstract
Totally implantable venous access ports (TIVAPs) have been proven to be safe and effective and are commonly used in cancer patients. Here, we introduce the entire procedure of CT-guided implantation of a TIVAP through the subclavian vein. A total of 283 nasopharyngeal carcinoma patients, including 215 males and 68 females, underwent TIVAP through the right subclavian vein, with an average age of 46.4 years (range 13-74). One patient experienced a failed right subclavian vein puncture but was able to successfully undergo a left subclavian vein puncture guided by ultrasound. The average operation time was 36.2 min (range 20-90 min), and the length of the catheter was 17.1 cm (range 14-21 cm). There were 3 cases of arterial puncture, 1 case of catheter displacement, 2 cases of hemothorax, 2 cases of pneumothorax, 2 cases of thrombosis, and 2 cases of wound infection. The overall complication rate was 5.3% (15/283). The computed tomography (CT)-guided implantation of a totally implantable venous access port (TIVAP) via the subclavian vein can, therefore, be considered a safe and reliable technique.
Introduction
Most patients with advanced cancer require long-term central venous access for the safe delivery of chemotherapeutic agents, total parenteral nutrition, antibiotics, transfusion of blood and blood products1,2,3. Totally implantable venous access port (TIVAPs) and peripherally inserted central catheters (PICCs) are widely used for these purposes. Compared to peripherally inserted central catheters (PICCs), totally implantable venous access ports (TIVAPs) are increasingly favored among cancer patients due to their demonstrated advantages, including higher catheterization success rates, prolonged indwelling duration, reduced risk of catheter-related complications (such as deep venous thrombosis), and simplified maintenance protocols1,4. TIVAPs had no detectable impact on the quality of life5,6.
The subclavian vein (SV) and the internal jugular vein (IJV) are most frequently used for this procedure. Vein puncture based on anatomical landmarks is a safe and effective procedure. Some clinical trials have shown that fluoroscopy and ultrasound are very useful and reproducible tools, leading to greater security by confirming the catheter position in real-time7,8,9. We present an IVAP performed through CT-guided subclavian vein puncture in the CT-interventional operating room. CT-guided implantation of TIVAPs enables dynamic monitoring of the catheter's position and precise determination of its tip location, while also offering immediate signs of potential complications such as pneumothorax or hemothorax. We report on the CT-guided TIVAP implantation via subclavian vein, addressing the limitations of traditional imaging modalities.
The presented protocol was performed in the outpatient department by a doctor who is trained and competent to perform TIVAP and one assistant who is familiar with the surgical procedure and can assist in the management of related complications. The equipment needed for this protocol is listed in Table 1. Appropriate modifications can be made based on local facilities, equipment, and materials.
Case Presentation:
A 56-year-old woman presented to the otolaryngology department with a 3-month history of progressive left-sided nasal obstruction and intermittent epistaxis. Nasopharyngoscopy and subsequent histopathological examination confirmed a diagnosis of undifferentiated non-keratinizing nasopharyngeal carcinoma (cT3N2M0, stage III). A totally implantable venous access port (TIVAP) was electively placed in the right infraclavicular region prior to therapy initiation. This approach ensured reliable vascular access for chemotherapy while avoiding interference with planned radiation fields targeting the neck and supraclavicular areas.
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Protocol
The Institutional Review Board of Sun Yat-sen University Cancer Center approved the protocol described. Informed consents were waived due to the retrospective nature of this study.
1. Preparations
- Prior to performing the procedure, assess the available information and clarify the surgical indications. Ensure there are no active infections and anatomical deformities of the cervical and thorax region that impede central venous access routes, such as clavicle fractures.
- Ensure the patient has completed hematology examination, blood test, and coagulation function. Exclusion criteria included coagulopathy (defined as a platelet count <50,000 mm3 and/or INR >1.5).
- Ensure that the patient has signed the informed consent. Inform patients of surgical risks and possible complications.
- Place the patient in a supine position on the operating table. Connect the ECG monitor and continuously monitor the ECG and blood oxygen saturation. Measure blood pressure every 3-5 min.
2. Procedure
- Completely expose the upper chest, with the head inclined toward the non-operative side. Disinfect the surgical site 2-3 times with iodophor, using maximal barrier precautions.
- Locate the puncture point and port location. Anesthetize the pouch area and puncture path locally with 1% lidocaine.
NOTE: The puncture point is located 2-3 cm below the midpoint of the right clavicle. Aim the direction of the puncture needle at the suprasternal notch.The Port is 1 cm below the puncture point. - Keeping the puncture needle beveled up, puncture the subclavian vein based on anatomical landmarks (Figure 1). Confirm the backflow of blood, fix the puncture needle, and rotate the needle so that the beveled side is toward the foot. Introduce the guide wire into the subclavian vein (Figure 2).
- Perform a CT scan to confirm the placement of the guide wire in the superior vena cava (Figure 3).
- Remove the puncture needle. Make a 2-mm incision, insert an 8 French peel-away sheath through the guidewire.
- Remove the guidewire and dilator. Place the catheter into the peel-away sheath.
- Perform an additional CT scan to confirm the catheter tip is positioned at the cavoatrial junction (Figure 4).
- Incise the skin and subcutaneous tissue approximately 1 cm below the puncture site. Use blunt dissection to create a subcutaneous capsule (Figure 5).
- Use the tunnel needle guide to guide the catheter to the subcutaneous capsule. Keep the catheter subcutaneously.
- Pass the lock catch through the catheter.
- Cut the catheter at the appropriate location. Make sure the catheter tip is at the cavoatrial junction.
- Connect the catheter to the port and secure it with the latch (Figure 6).
- Place the port in the pocket. Put the exposed catheter into the sheath.
- Inject normal saline into the port to ensure the patency of the catheter and proper function of the Port. Remove peel-away sheath.
- Suture the incision subsequently, using absorbable sutures (Figure 7).
- Insert the butterfly needle and test the port (Figure 8).
- Finally, cover the wound.
- If necessary, perform a final CT scan to confirm the accurate placement of the catheter tip at the cavoatrial junction and assess for potential complications such as pneumothorax or hemorrhage.
3. Postoperative management
- Change the wound dressing every 3-5 days after surgery.
- Evaluate by observation, touch and active inquiry of the patient to determine whether there was redness, swelling, pain, etc., whether the port body was separated from the catheter, whether the port body was turned over, and whether there was swelling of the chest and neck on the same side, thickening of the arm circumference on the same side and other suspected symptoms of thrombosis.
NOTE: TIVAP maintenance is recommended every 4 weeks during intermittent treatment.
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Results
A total of 283 nasopharyngeal carcinoma patients underwent TIVAP through the right subclavian vein, with an average age of 46.4 years (range 13-74), including 215 males and 68 females (Table 1). One patient experienced a failed right subclavian vein puncture but was able to successfully undergo a left subclavian vein puncture guided by ultrasound. The average operation time was 36.2 min (range 20-90 min), and the length of the catheter was 17.1 cm (range 14-21 cm). There were 3 cases of arterial puncture...
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Discussion
First implantation of a TIVAP was performed in 1982 by John Niederhuber using the cephalic vein with the surgical technique10. Now it is generally used in oncology. There are two approaches to perform TIVAPs, the surgical approach and the percutaneous approach. Due to the specialized surgical skills required for the open technique and the widespread perception of percutaneous methods as a more straightforward and safer alternative, the surgical approach has experienced a decline in utilization, wi...
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Disclosures
The authors declare no conflict of interest.
Acknowledgements
This study was supported by Natural Science Foundation of Guangdong Province, China (Grant No. 2021A1515010479), Guangdong Province Key Field R&D Program Project (2019B110233001), and Guangdong Province Science and Technology Planning Project (2017A010105028).
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Materials
| Name | Company | Catalog Number | Comments |
|---|---|---|---|
| Basic Surgical Instrument Set | 120-5000 | Fine Science Tools Inc. | ISO 13485 certified |
| Computed Tomography System (SOMATOM Definition AS) | 20173301123 | Siemens Healthcare GmbH | NMPA valid until 2027-08-21 |
| Heparin Sodium Injection (5000 IU/mL) | H51021209 | Chengdu Haitong Pharmaceutical Co., Ltd. | NMPA Approval H51021209 |
| Implantable Vascular Access Port (Celsite) | 20173661677 | B. Braun Medical SAS (France) | CE Mark No. 0123 |
| Lidocaine HCl Injection (2%, 10mL) | H3102107 | Shanghai Zhaohui Pharmaceutical Co., Ltd. | NMPA Approval H31021073 |
| Patient Monitor (CARESCAPE B650) | 20213170093 | GE Medical Systems Finland Oy | NMPA National Medical Device Registration No. 20213170093 |
| Povidone-iodine Skin Disinfectant Solution | 3211-0003 | Likang Pharmaceutical Technology Jiangsu Co., Ltd | Jiangsu Provincial Health License |
| Sodium Chloride Injection (0.9%, 500mL) | H43020455 | Hunan Kelun Pharmaceutical Co., Ltd. | NMPA Approval H43020455 |
| Sterile Surgical Gloves (Latex, Size 7.5) | MG-100 | Winner Medical (Guilin) Co., Ltd. | Guiyang Medical Equipment Registration No. 20152140022 |
| Surgical Scalpel Blade (#11) | SL-011 | Suzhou Shilai Medical Equipment Co., Ltd. | Suxie registration 20162021476 |
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