Port Placement

Port Placement

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Pre-Procedure

Indications:
• Most commonly long-term venous access for chemotherapy
• Blood withdrawal
• Contrast injection
• Antibiotic therapy
• Administration of blood products: Funnel shaped ports that accept an 18-gauge IV needle has been used for RBC exchange and plasma exchange
• Total Parenteral Nutrition (TPN)

Contraindications
• Infection and/or bacteremia
• Neutropenia
• Uncorrected bleeding diathesis

SIR periprocedural coagulation parameters:
• INR: correct to < 2.0
• Platelets: < 50,000/µl recommend transfusion
• aPTT: no consensus

Preprocedural evaluation:
• H&P
• Labs: INR (platelets and hematocrit not routinely recommended)
• Review prior imaging for anatomic variants and SVC patency
• Hold bevacizumab (Avastin) for 2 weeks before and 2 weeks after port insertion
Anatomic considerations
• History of venous occlusion
• Multiple prior vascular lines
• Prior/upcoming surgery such as mastectomy
• Chest wall post radiation treatment


Procedure

Antibiotic:
• No consensus on antibiotic but SIR guidelines recommends antibiotic prophylaxis
• Consider 1g cefazolin (Ancef) IV preprocedure
• PCN allergy: 1g Vancomycin IV preprocedure

Considerations:
• Indication for port
• Patient body habitus: possible low-profile port
• Location: chest port, arm port or lumbar port
• Type of port chosen based on patient's needs and body habitus

Procedure (chest wall port):
• Prepare the upper portion of the chest and neck in a sterile fashion
• Local anesthesia with 1% lidocaine with epinephrine; administer under US guidance
• Dermatotomy with 11 blade

Access
• Preferably internal jugular (IJ) vein with 21g micropuncture needle
• Needle will often tent vein; short thrust for venous entry
• On access, direct needle slightly caudal
• After venous entry, pull needle hub cephalad to direct needle caudal
• Advance 0.018" wire centrally with fluoroscopy
• Can typically skip aspiration with straightforward IJ access

Measure
• Place tip of 0.018" wire at desired location of port tip - distal SVC to high right atrium
• Measure length of 0.018" wire to determine intravascular length of port catheter
• Remove 0.018" wire with clamp to mark wire for length
• Alternatively, can bend the exposed 0.018" wire as it exits the transition dilator, pull wire to venous entry site, which can be visualized under fluoroscopy with hemostats marking skin site. Bend wire second time marking venous entry site.
Need to account for hub length of the micropuncture sheath
Keep in mind that port catheter may migrate proximally with patient in upright position, particularly in patient's with large body habitus

Advance 0.035" wire into IVC
• Deep inspiration and breath hold may help access IVC
• Angled catheter (Kumpe) may be needed to direct wire posteriorly into IVC
• Save image which confirms IVC position of wire
• Secure wire; flow switch can be used

Create port pocket
• Infraclavicular region a few centimeters below the clavicle; medial to the deltopectoral groove
• Some operators use 2 to 4 finger breadths below clavicle
• Ideal port pockets have reservoir positioned over 2nd anterior rib without interaction with mammary tissue
• Anesthetize pocket and planned tunnel with 1% lidocaine with epinephrine.
• Incision with #15 blade
• Make incision long enough to allow insertion of the port
• Typically incision is made cephalad to the pocket
• Dissect port pocket by blunt dissection with a Kelly hemostat and small retractors or simply with the operator’s finger
Ideal pocket:
• Large enough to allow the easy port insertion
• Incision can be closed without tension on the skin
• Incision does not overlie the diaphragm of the port reservoir

Assemble chest port
• Will vary with manufacturer
• Connect catheter to reservoir stem
• Connector/locking ring slides over catheter to secure catheter to port reservoir stem
• Test junction of the port reservoir and catheter by accessing the port with a Huber needle, flushing the catheter, and pinching off the distal end of the catheter to challenge the catheter/port junction (confirming absence of a leak)
• Attach tunneler to catheter tip

Insert chest port and tunnel
• Place port into pocket
• Tunnel catheter over clavicle to neck venous entry site
• Ensure no skin tag between tunneled catheter and venous entry site (good lighting is helpful)
• Note how many centimeters of catheter makes up chest wall tunnel
• Cut catheter to length using intravascular measurements from earlier

Insert catheter
• Remove micropuncture sheath
• Dilate tract if needed
• Place peel-away sheath
• Remove wire and inner dilator
• Advance catheter through sheath and remove peel-away

Close pocket
• Confirm final position with fluoroscopy
• Confirm function/patency with aspiration of blood followed by flushing with normal saline; use Huber needle
• Lock with 5 mL heparin 100 U/mL
• Some operators secure port to deep dermal tissues with 2-0 Prolene
• Close deep dermal layer with 2-0 Vicryl interrupted buried sutures (https://tinyurl.com/Deep-dermal-closure)
• May need to close subcuticular layer with 4-0 Vicryl or Monocryl (https://tinyurl.com/Subcuticular-Suture)
• Approximate skin edges with steri-strips or glue
• Close venous entry site with glue




Post-Procedure

Post Procedure Care
• 1 hour recovery
• The patient is given verbal and written instructions outlining care of the port and dressing. These instructions will give the patient information on how to manage the port based on whether it is left accessed or not

Outcomes
• Overall technical success rate is near 100%
• Puncture related complications are almost zero if ultrasound is used
• Position-related complications can be avoided with the use of high-quality real-time fluoroscopic equipment and strict attention to guidewire and catheter skills

Complications:
• Hematoma: most common
• Infection: 3-7%
• Port migration
• Catheter occlusion (fibrin sheath or thrombus)
• Wound dehiscence or skin necrosis: cachectic patient's higher risk
• Reservoir rotation
• Sepsis
• Catheter related venous thrombosis: 3-6%
• Pneumothorax
• SVC rupture: rare
• Cardiac tamponade: rare
• Catheter disconnection: rare
• Air embolism: rare but can happen after removal of inner portion of peel-away sheath

Related Procedures

No related procedures.

 

References

[1] Nezami N, Xing M, Groenwald M, Silin D, Kokabi N, Latich I. Risk Factors of Infection and Role of Antibiotic Prophylaxis in Totally Implantable Venous Access Port Placement: Propensity Score Matching. Cardiovasc Intervent Radiol. 2019;42(9):1302-1310. doi:10.1007/s00270-019-02255-
[2] Sun D, Kobayashi K, Samuel M, Stewart G, Skummer P. Right- versus Left-Sided Chest Ports in Oncologic Patients with a History of Right-Sided Port Removal: Are There Any Differences in the Complication Rates?. J Vasc Interv Radiol. 2019;30(5):726-733. doi:10.1016/j.jvir.2019.01.008
[3] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007
[4] Zhang S, Kobayashi K, Faridnia M, Skummer P, Zhang D, Karmel MI. Clinical Predictors of Port Infections in Adult Patients with Hematologic Malignancies. J Vasc Interv Radiol. 2018;29(8):1148-1155. doi:10.1016/j.jvir.2018.04.014
[5] Duncan C, Trerotola SO. Outcomes of a Percutaneous Technique for Shortening of Totally Implanted Indwelling Central Venous Chest Port Catheters. J Vasc Interv Radiol. 2016;27(7):1034-1037. doi:10.1016/j.jvir.2016.02.025
[6] Gurkan S, Seber S, Gur O, Yetisyigit T, Okan Donbaloglu M, Ozkaramanli Gur D. Retrospective evaluation of totally implantable venous access port devices: early and late complications. J BUON. 2015;20(1):338-345.
[7] LaRoy JR, White SB, Jayakrishnan T, et al. Cost and Morbidity Analysis of Chest Port Insertion: Interventional Radiology Suite Versus Operating Room. J Am Coll Radiol. 2015;12(6):563-571. doi:10.1016/j.jacr.2015.01.012
[8] Kulkarni S, Wu O, Kasthuri R, Moss JG. Centrally inserted external catheters and totally implantable ports for the delivery of chemotherapy: a systematic review and meta-analysis of device-related complications. Cardiovasc Intervent Radiol. 2014;37(4):990-1008. doi:10.1007/s00270-013-0771-3
[9] Pandey N, Chittams JL, Trerotola SO. Outpatient placement of subcutaneous venous access ports reduces the rate of infection and dehiscence compared with inpatient placement. J Vasc Interv Radiol. 2013;24(6):849-854. doi:10.1016/j.jvir.2013.02.012
[10] Patel IJ, Davidson JC, Nikolic B, et al. Addendum of newer anticoagulants to the SIR consensus guideline. J Vasc Interv Radiol. 2013;24(5):641-645. doi:10.1016/j.jvir.2012.12.007
[11] Walser EM. Venous access ports: indications, implantation technique, follow-up, and complications. Cardiovasc Intervent Radiol. 2012;35(4):751-764. doi:10.1007/s00270-011-0271-2
[12] Gonda SJ, Li R. Principles of subcutaneous port placement. Tech Vasc Interv Radiol. 2011;14(4):198-203. doi:10.1053/j.tvir.2011.05.007
[13] Vo JN, Hoffer FA, Shaw DW. Techniques in vascular and interventional radiology: pediatric central venous access. Tech Vasc Interv Radiol. 2010;13(4):250-257. doi:10.1053/j.tvir.2010.04.003
[14] Charles HW, Miguel T, Kovacs S, Gohari A, Arampulikan J, McCann JW. Chest port placement with use of the single-incision insertion technique. J Vasc Interv Radiol. 2009;20(11):1464-1469. doi:10.1016/j.jvir.2009.07.035
[15] Schutz JC, Patel AA, Clark TW, et al. Relationship between chest port catheter tip position and port malfunction after interventional radiologic placement. J Vasc Interv Radiol. 2004;15(6):581-587. doi:10.1097/01.rvi.0000127890.47187.91
[16] Nosher JL, Bodner LJ, Ettinger LJ, et al. Radiologic placement of a low profile implantable venous access port in a pediatric population. Cardiovasc Intervent Radiol. 2001;24(6):395-399. doi:10.1007/s00270-001-0071-1
[17] McBride KD, Fisher R, Warnock N, Winfield DA, Reed MW, Gaines PA. A comparative analysis of radiological and surgical placement of central venous catheters. Cardiovasc Intervent Radiol. 1997;20(1):17-22. doi:10.1007/s002709900103
[18] Funaki B, Szymski GX, Hackworth CA, et al. Radiologic placement of subcutaneous infusion chest ports for long-term central venous access. AJR Am J Roentgenol. 1997;169(5):1431-1434. doi:10.2214/ajr.169.5.9353475
[19] Simpson KR, Hovsepian DM, Picus D. Interventional radiologic placement of chest wall ports: results and complications in 161 consecutive placements. J Vasc Interv Radiol. 1997;8(2):189-195. doi:10.1016/s1051-0443(97)70537-2



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