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BackTable / VI / Article
Port Removal Surgery: Strategies for Difficult Cases & Infected Sites
Thomas "T.J." Turner • Apr 1, 2024 • 40 hits
Port removals are often a time for celebration for patients as well as providers, signaling the end of a trial of chemotherapy, for example. This does not mean, however, that they occur without complications. Ports can become infected or become encapsulated in granulation tissue, causing difficulty for the interventional radiologist attempting to remove them.
Dr. Christopher Beck and Dr. Aaron Fritts share their strategies for managing problem port removals, what to do in the case of infection, and how to manage port removal patients post-procedure. This article features excerpts from the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Brief
• Pre- and post-procedural imaging is recommended to plan the approach and assess the success of the procedure.
• Make every attempt to open the incision over the previously made scar. Once the incision is made, methodically dissect fascial planes to reveal the reservoir tip and catheter.
• In the case of obscured visibility of the port, sharp dissection may be necessary.
• Wider incisions may be necessary in the case of infected ports to facilitate more thorough irrigation.
• Following the removal of an infected port, the wound is left open to allow for secondary intention and packed with iodoform gauze to promote healing. The gauze should be removed gradually over the course of several weeks to allow for proper healing.
• To avoid complications from stuck or fractured ports, it is recommended to always gain wire access through the port catheter. This reduces the risks of port fracture while also providing a safety net should the port get stuck or broken.
Table of Contents
(1) Tips & Techniques for Difficult Port Retrievals
(2) Post-Procedure Management of an Infected Port
(3) Strategies for Managing Fractured & Stuck Mediports
Tips & Techniques for Difficult Port Retrievals
In the case of difficult retrievals, operators should focus on the intentional dissection around the port reservoir, aiming to minimize unnecessary exploration by targeting the reservoir tip and the connective cuff, ultimately facilitating a controlled extraction. The importance of visual confirmation of the catheter and reservoir is key as a marker for appropriate dissection depth and the necessity of sharp dissection in cases of obscured visibility. Pre-procedural fluoroscopy is recommended to assess port position and integrity, and an emphasis is placed on limiting incision size to match or minimally exceed the original scar. In the case of a port with tightly secured sutures, meticulous dissection over forceful extraction is preferred to prevent patient discomfort and potential complications.
[Dr. Christopher Beck]
Then I also think it's important-- I feel like I see a lot of, especially trainees when I was seeing trainees, they flounder when it comes to taking out ports and that they don't exactly know where to start or where to go. They're just digging around. For me, I focus on the tip of that reservoir, I go down down and I try and scoop up underneath it. That gives me some intentionality to where I'm dissecting and what planes I'm trying to hit. I think once you do that, then you can then hack around a little bit or however you decide to get to the capsule around the reservoir is up to the operator. The most important thing is I like to go straight down, straight down, join those two and then birth the catheter.
[Dr. Aaron Fritts]
Yes, exactly. I always aim for the little piece that connects the tubing to the basic of the port, the little cuff. Yes, exactly. I get my curved hemostats around that cuff and then, like you said, birth it up and then get another one around the catheter and then just pull it out like spaghetti.
[Dr. Christopher Beck]
Another thing I'll say is, if you're not seeing glistening white catheter, you're probably not there yet. you can try and like tug away at it if you think you're real close, but sometimes it needs some sharp dissection. That goes for the catheter and the actual reservoir. If you're not seeing it crystal clear, there's usually a little sinew or a little thin layer of membrane or just some tissue that's covering it.
[Dr. Aaron Fritts]
Over top of it.
[Dr. Christopher Beck]
Yes. Those can be pretty tough, pretty resistant.
[Dr. Aaron Fritts]
Yes. In that case, I take my 11 blade, and I just very gently go along the plane of the catheter itself until you start to see that white. Then you can scoop it out of that fascial plane.
[Dr. Christopher Beck]
The same thing when you go for the reservoir. If you're dissecting down and that thin fibrous capsule over the top of it, I continue to attack that until I'm actually seeing truly bright-- for me, it's bright purple reservoir. Then once I see that, then I attack that plane and try and dig that out.
[Dr. Aaron Fritts]
Totally. Yes, exactly the same. Just to back up real quick, I always have the tech take a picture, just a single fluoroscopic image of the chest, showing where the port is. You want to look at the picture, make sure the catheter doesn't look kinked or anything like that. Everything looks like it's in place. You're not chasing after a foreign body. Then I'm not wearing lead during the procedure at all. That's one of the few procedures where I don't wear lead in the IR suite, I would say.
[Dr. Christopher Beck]
Same. I take a pre-picture before I walk in or have the technologist doing it, and then take a post-picture when everything's out. I don't watch it coming out under fluoro and-
[Dr. Aaron Fritts]
Yes.
[Dr. Christopher Beck]
Yes. Ideally you'd also check that op note and see how much catheter length they had, so whenever you take it out. I rarely do that. I just go with the pictures and if it looks like you took it out–
[Dr. Aaron Fritts]
Yes, you know what you got. If it looks super short, something's off.
[Dr. Christopher Beck]
Yes.
[Dr. Aaron Fritts]
Exactly. That being said, I still come out of there sweating sometimes because sometimes there's a lot of scar around that reservoir. It takes me a little while to get the scar around, especially when somebody has tied it down and you're really searching for those sutures. Part of the reason why I don't like to tie mine down, I like to just make a tight pocket, but people can go back and review our Mediport placement discussion to hear more around that. I just hate having to search for sutures.
[Dr. Christopher Beck]
I feel the same way. I don't know if that's why I do it, but certainly one of the reasons. I'll also say if you think it's tied down or you have any suspicion that it's tied down and you think you're just going to pull it hard enough to break those sutures, good luck. I'm sure you can generate the amount of force, but it's not an amount of force-- because I've been there. I've tried.
[Dr. Aaron Fritts]
Yes, and it's going to hurt.
[Dr. Christopher Beck]
You have to find them. You have to cut them. That's what you have to do.
[Dr. Aaron Fritts]
Right, and pull them out.
[Dr. Christopher Beck]
Yes, and also tell people, don't be afraid-- I try and do the incision on the old incision. Last thing I want to do is leave them with an incision that's double the length. If you have to widen the incision just a couple millimeters on each side, that's just the cost of removing a port and I think that's just something that has to be done. Ideally I try and keep that incision just as tight as like the old scar tissue.
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Post-Procedure Management of an Infected Port
Infected ports can pose distinct challenges. The need for extensive irrigation sometimes necessitates wider incisions for infected ports. Unlike standard procedures, infected sites are not closed immediately but are left open to heal by secondary intention, employing iodoform packing. The use of broad-spectrum antibiotics is standard, with adjustments based on culture results. For wound management in infected cases, a gradual reduction in iodoform gauze is advised to promote healing.
When a new port is necessary, placement is typically contralateral, considering patient-specific factors such as previous radiation treatment or personal preferences. The specimens sent for culture will also vary depending on an indication of bacteremia versus a purulent pocket: the catheter tip will be sent in the case of bacteremia and the reservoir in the case of a purulent pocket. Post-procedure, the approach varies with infected cases requiring follow-up for wound management, while standard port removals involve minimal post-op care, highlighting the procedural nuances and patient care strategies in mediport management.
[Dr. Aaron Fritts]
Yes, perfect. Then what do you do if it's infected?
[Dr. Christopher Beck]
If you're dealing with an infected port or a fractured port, if that's going in, it's a different game and I'm geared up for it differently. An infected port, I'm probably still not going to wear lead. A fractured port I would. The difference would be a much more extensive irrigation of that pocket. I'm really going to clean that pocket out. I might even have a slightly wider incision just to make sure I'm capturing all the areas that I think could be infected and I'm going to irrigate it much longer and a little bit more aggressively and then I don't close the wound but just leave it open. Iodoform packing and then I'll let that close by secondary intention.
[Dr. Aaron Fritts]
Got it. Then antibiotics, are you just consulting with the referring doc or are you sitting them home-- Let's say they're outpatient or you send them home with something. Obviously, if they're inpatient, they probably got ID team working on them. If they're outpatient and t's infected, do you have like a protocol for that?
[Dr. Christopher Beck]
I don't have a protocol. It's in my epic order set where I will put them on a broad-spectrum antibiotic, and for the life of me I can't remember it. Then I'll culture everything and then depending on the cultures and sensitivities, I may change that when they go home. When the cultures come back after two or three days.
[Dr. Aaron Fritts]
Yes, I do usually Clinda, but very similar. You say you pack with iodoform. What are you doing for wound closure if it's infected?
[Dr. Christopher Beck]
Wound closure, totally different scenario in which case it's not going to get sutured shut. I'll pack it with iodoform gauze and then after that depending on how capable the patients or caregiver is-- so you pack it and then after two days, three days, you have the patient pull out just a little bit iodoform gauze, cut that, that gets discarded and they do that over the course of a week or 10 days until there's just no iodoform gauze left and then all that starts to heal up and as the iodoform is taking up less space, it's closing and closing, then hopefully just seal seals up on secondary intention. They'll follow up with a wound check either with me or one of my partners in maybe 7 to 14 days depending on how long we think it's going to take to heal.
[Dr. Aaron Fritts]
Yes. Sometimes they need a new one placed, right? You just typically go on the other side.
[Dr. Christopher Beck]
If they need a new one placed, I guess the scenario can differ between inpatients and outpatients. Usually, we have to give them another line and so we'll do a tunnel-- I don't know what you call them. Our brand names PowerLines.
[Dr. Aaron Fritts]
Yes.
[Dr. Christopher Beck]
Yes. Five or six inch tunnel dual lumen catheter and that's usually on the contralateral side and I could convert that over to a port, but I'll usually just do a new stick. Yes, contralateral side. Not to say that I couldn't use the same side. Some patients there's probably plenty of room and there may be a reason to avoid the left or the right. Like if that's going to be in the radiation field or if they've had a vasectomy with a lot of radiation treatment. I'm not saying you couldn't use the ipsilateral infected side, but I usually go contralateral all things being equal.
[Dr. Aaron Fritts]
Yes. When they're infected, you're just-
[Dr. Christopher Beck]
Oh, hold on. I also want to say this. In Louisiana, there's usually a reason a lot of people want you to use the left side for the right side. Do you have this in Texas? Hunters. They're like, "I'm going to get in the way of how I map my gun." I'm like, "I don't know, dude, but I think you'll be fine."
[Dr. Aaron Fritts]
That's interesting.
[Dr. Christopher Beck]
A lot of hunters have a preference whether it went in the right side or left side, but I assure them it will all be fine.
[Dr. Aaron Fritts]
Yes. Also when they're infected, when it's bacteremia, I'm usually sending the tip of the catheter that's inside the bloodstream. When it's the port pocket itself, I'm usually sending the reservoir. Actually the whole thing. I'm just sending the specimen cup.
[Dr. Christopher Beck]
Yes. Same. Like you said, if it's bacteremia, catheter tip. If it's a purulent pocket, then I just send the whole thing.
[Dr. Aaron Fritts]
Yes.
[Dr. Christopher Beck]
Yes. I don't know if they necessarily need the whole thing because if you have like a sample of pus, but I send it.
[Dr. Aaron Fritts]
Yes, maybe the–
[Dr. Christopher Beck]
We're having a pathologist on we can ask. Maybe they're like, "Why do you guys keep sending us this whole port"
[Dr. Aaron Fritts]
Whole port, yes.
[Dr. Christopher Beck]
Have you had any patients ask if they could keep it?
[Dr. Aaron Fritts]
No, but usually the IVC filter is what. Because I show it to them and they're like, "Whoa, that's cool. Can I keep that?"
[Dr. Christopher Beck]
I don't blame them for wanting to keep the IVC filters. They do look cool.
[Dr. Aaron Fritts]
Yes. Okay, that's pretty much it for the procedure. Any post procedure? We talked about follow-up for cases when they're infected. Definitely need to follow up with them. What about just your standard port retrieval? I imagine just giving them some instructions on keeping it clean and dry, but they don't really need to follow up.
[Dr. Christopher Beck]
I don't follow up with them after I pull it. They always have our number where they can contact us and our post-op nurses will give them a call day after ask if there's any problems, but usually it's like follow-up PRN for us.
[Dr. Aaron Fritts]
Yes, because you're doing Dermabond over top and then are you doing Steri-Strips as well?
[Dr. Christopher Beck]
No. No Steri-Strips.
[Dr. Aaron Fritts]
Just Dermabond.
[Dr. Christopher Beck]
Yes. Great.
[Dr. Christopher Beck]
Do people mix Steri-Strips and Dermabond?
[Dr. Aaron Fritts]
Some do. Some do. Yes, some reinforce it. I think with big people-- any time where it looks like it's going to pull. Yes, I usually will have them reinforced a little bit.
[Dr. Christopher Beck]
You want that tension-free closure.
[Dr. Aaron Fritts]
Exactly. Then did you say you're doing 4.0 and 3.0?
[Dr. Christopher Beck]
3.0, 2.0.
[Dr. Aaron Fritts]
3.0, 2.0. Okay.
[Dr. Christopher Beck]
That's too bulky?
[Dr. Aaron Fritts]
No, I think that also helps with that tension. We do 4.0, 3.0.
[Dr. Christopher Beck]
I will do with some 4.0 Monocryl for like a running Sim-Q layer. That's where I go 4.0 if needed.
[Dr. Aaron Fritts]
Yes. Sorry, 3.0 is my deep, 4.0 is my running. I think that's it.
Strategies for Managing Fractured & Stuck Mediports
Fractured and stuck ports are a common complication during removal. A good rule of thumb is to routinely insert a wire through the catheter as to maintain retrieval options should something go awry. This has the benefit of decreasing the risk of complications as the wire reinforces the catheter during traction while also providing a safety net. Techniques for dealing with stuck ports include gentle traction, strategic pushing and pulling, and, if necessary, direct cut down at the venotomy site or snaring from an alternative access point for complete control.
[Dr. Christopher Beck]
Do you want to talk a little bit about fractured ports or stuck ports?
[Dr. Aaron Fritts]
Yes. I don't know if I've ever had a stuck. Well, I have had-- you're right. Sometimes the catheter doesn't come out because it's stuck on something. What do you do in that case?
[Dr. Christopher Beck]
If it's a stuck catheter, first thing I do is get a wire and get it through it. You may not end up needing it, but for me, more often the reason I'm dealing with a stuck catheter is because I'm dealing with a referring doc, a lot of the surgeons put in their own and take out their own, and I guess just with that many referring docs, they just run into this issue. It's not infrequent that I get a call from a referring doc, like, the catheter's stuck and they've already pulled real hard on it.
[Dr. Aaron Fritts]
Yes.
[Dr. Christopher Beck]
If my catheter is stuck, the reason I don't pull on it, like a lot of traction initially, I just go ahead and get the wire and get it down, is because like the more you pull on it, that catheter will stretch, and the less likely you will be to actually get a decent wire through it. I'll try and get a glide wire through it, and then I'll give it starting out gentle traction, a little bit more traction, and then I just try and choke up on it as much as possible. Then I pull, hoping that the catheter stretches over the wire.
When that catheter stretches, it just grabs on to the glide wire. Then once it's done that, I try and remove it in its entirety. I do try and get that wire down a fair amount. To me, I guess it's just IR, it's built into your brain. As long as you have a wire through something, you have options. I just feel like there are things you can do, but as soon as the catheter's stuck, get the wire in.
[Dr. Aaron Fritts]
Yes. The wire in serves actually two purposes. I think it was Baron that told me this at Vanderbilt is, A, it's a safety piece in case it does break. The other thing is the silicone, whether you're dealing with a Mediport or a PICC line or a Permcast, is it's less likely to snap with that wire inside.
[Dr. Christopher Beck]
That's right.
[Dr. Aaron Fritts]
Because it's like reinforcing it.
[Dr. Christopher Beck]
Yes, that's exactly right.
[Dr. Aaron Fritts]
You said it like hugs it so that you can use that excessive force to pull the whole thing. You're right, that's the first step, just getting a wire through it anytime it's stuck. Same thing you could have with Permcasts where they're just super buried. That cuff has got a lot of scar around it. You can only dissect so much until you're about to the point where you're going to have to cut down at the neck. It's like, "All right, well, let me just try getting a wire through and just pulling really hard."
[Dr. Christopher Beck]
Yes, exactly. That's the stuck port. Then sometimes, for whatever reason-- you always think to pull, sometimes pushing is the right. As long as you have control over it, sometimes I'm pushing and then I pull and sometimes that'll jar something loose and I don't know why. I try a couple of different-- there's only two ways you can pull and push it. That's before I decide to cut down on it and get control over the venotomy site.
I haven't done this. This actually hasn't come up in my practice, but my algorithm is, "Push pull. If you can't get it out there, cut down the venotomy site." If that doesn't work, then I'm probably going to get groin access and then snare the other end to have control on both sides. I would just imagine if I can't tell where it's stuck, it could be intravascularly adhered to something or it could be at the venotomy site. If you just don't know, I wouldn't hesitate to go ahead and get groin access. All this is like venous access. To me, it's not a barrier. I don't sweat it. I'm just like, "Prep the groin and let's get a hold of both ends."
[Dr. Aaron Fritts]
Yes. This made me think that we should do a whole episode on foreign body retrieval, but not just IVC filter retrieval, but cases like coils, catheter tips, all this sort of thing.
[Dr. Christopher Beck]
Stents.
[Dr. Aaron Fritts]
Stents, yes. Those are the, "Oh shit," moments, right?
[Dr. Christopher Beck]
Yes, we should.
[Dr. Aaron Fritts]
We should just do it. We'll think of who would be a good guest.
[Dr. Christopher Beck]
I know some perfect guests for that.
[Dr. Aaron Fritts]
Okay, perfect.
[Dr. Christopher Beck]
Yes. Because all of us have done it, but you really want to go to a super high volume sitter where they're pulling stuff out of people like all the time. I know a couple of good IR docs and one who does neuro interventional. He has to pull stuff out of the brain occasionally. Yes, I think he's got some next level tips that-- I've seen him present an angio club that I didn't necessarily think of straight away. Sometimes things come to you in the moment. You just have to wait for that, ":Oh shit," moment before your brain kicks in and kicks that neuron into gear.
[Dr. Aaron Fritts]
When do you stop? Because I remember there has been cases at Vanderbilt where there's like catheter tip stuff, where it's like you're trying, you're trying, you're trying. Then finally it was like, "Maybe this isn't going to have any effect on the patient at all. Maybe we should just stop. We're doing more harm than good."
[Dr. Christopher Beck]
I've had cases like that. I think it's totally case dependent, certainly radiation. If for some reason I'm starting to create that patient out then I'm definitely going to stop and then regroup. Sometimes it's just like, you get a foreign body fever. You just have this feeling that you have to get it out. Sometimes it just takes a second to take a step back and be like, "What's the chance of this actually going anywhere significant?" I think that's different for every patient depending on the indication, why you're taking out, depending on how long that patient's going to be around.
[Dr. Aaron Fritts]
Yes.
[Dr. Christopher Beck]
Certainly the conversation is different for someone who's having their port removed and they're cancer free versus someone who's stage four salvage therapy, but an infected port. If they have a retained fragment. I don't know if it's as significant.
[Dr. Aaron Fritts]
I just had a couple docs on recently talk about closure devices. One of the vascular surgeons was talking about retrieving Angio-Seal plugs. Yes, the little plug that's on the inside.
[Dr. Christopher Beck]
Foot plate.
[Dr. Aaron Fritts]
The foot plate. Yes. That's another one where you could cover. Whatever, all over the body retrievals.
[Dr. Christopher Beck]
Yes. Primarily we have to treat foreign body retrievals because it just looks so bad to leave it in. It's hard to take that picture and there this fractured fragment still hanging out. I think of one patient where I left it in. We don't have to go too far into it, but you couldn't get access from below it because it was placed too short. It hadn't been used in years. I forgot why we were taking it out, but maybe the patient just wanted it out. I can't blame him. There was no intravascular access from below.
I'm not saying I couldn't have recannulated something and got into a channel, but from just below, a femoral approach, I wasn't able to snare it. Then it was stuck from a subclavian standpoint. I stuck down on it, I stuck a needle into the fractured segment and got a wire as far as it would go, which is just a terminal end of the catheter, which is in a left subclavian, tried to balloon it, just break it open and retrieve it, but would not give for anything.
[Dr. Aaron Fritts]
Yes. Then you just got to go leave those.
[Dr. Christopher Beck]
That patient, by the way, did just fine.
[Dr. Aaron Fritts]
Just fine, right.
[Dr. Christopher Beck]
Never aware.
[Dr. Aaron Fritts]
Could have caused more harm than good, for sure. All right, well, on that note, that's all I got, Chris. Do you think we left anything out?
[Dr. Christopher Beck]
I'm trying to think.
[Dr. Aaron Fritts]
The Mediport tool? The one thing that, I don't know if we talked about in depth was, if the pocket is infected, even if with bacteremia, I just do copious irrigation of that poor pocket.
[Dr. Christopher Beck]
Oh, yes. Bacteremic, yes, I'll close the pocket in those cases, especially if it's a soft indication from ID and that they're just trying to rule out everything that could be a potential nidus. I'll definitely close the pocket, culture the pocket, culture the tip, but I will close that. I'm trying to think of what else I was going to say. One more thing about fractured ports. Oh, one of the things I've been surprised about, we have a fair amount that are fractured that we take out. A lot in their pinch off at the subclavian. Have you ever seen what they look like when they're only partially fractured, when you just have extrav.
[Dr. Aaron Fritts]
Yes.
[Dr. Christopher Beck]
I have a lot of longitudinal tears.
[Dr. Aaron Fritts]
Ah, interesting.
[Dr. Christopher Beck]
Yes, so we've taken out plenty for that and I'll take pictures of it and I'll send them to the referring doc and I'm like, "This is what's happened to your subclavian catheters." They're always surprised, like, "Oh, this never happens." I'm like, "No, no, it happens all the time. Look at our text chain."
[Dr. Aaron Fritts]
Yes. Well, when that, you're putting a wire through before you pull it?
[Dr. Christopher Beck]
Yes. If it's fractured, I'll usually put a wire in and I think that's a little bit overkill because a lot of times they come out nice and easy, but in the event that they don't, I like that wire access. The reason I do it is because there was one that was fractured and it looked like just a little amount of extrav. I'm like, "Oh, but if I tug on it, it'll all come out," and it completely separated as soon as I had any traction. Then the wire just wanted to go every way, but through both of them.
[Dr. Aaron Fritts]
Yes, so you had to snare it from below.
[Dr. Christopher Beck]
Yes, I had to snare it from below. I'm trying to think if I could have cut down on it, maybe. No, I don't think so. Yes, I had to snare it from below. Which, to me, it's not a big deal. That's the easiest place to snare.
Podcast Contributors
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Dr. Aaron Fritts
Dr. Aaron Fritts is a Co-Founder of BackTable and a practicing interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2023, December 25). Ep. 396 – How I Perform a Port Removal [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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