BackTable / VI / Podcast / Transcript #396

Podcast Transcript: How I Perform a Port Removal

with Dr. Christopher Beck

In this episode of the BackTable Podcast, hosts Dr. Aaron Fritts and Dr. Chris Beck discuss their Mediport removal workflows and the common challenges of a port removal procedure. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Indications for Port Removal

(2) Conversations with Patients about Port Removal

(3) Approaches to Port Removal

(4) Anesthesia and Reopening the Site

(5) Tips and Techniques for Difficult Retrievals

(6) Closing the Wound

(7) Post-Procedure Management of an Infected Port

(8) Strategies for Managing Fractured and Stuck Mediports

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[Dr. Aaron Fritts]
Welcome to the BackTable Podcast. I got Chris Beck: here in my home in Paris, France. Really excited to have the Becks in Paris. Chris, how's it been so far?

[Dr. Christopher Beck]
So far, so good. We've been here a month and one week, I think total, and we're settled into the new apartment, very much like the new place, the new neighborhood. Comes with growing pains, but all in all hard to complain about Paris. Very good.

[Dr. Aaron Fritts]
Definitely some growing pains. Some of the audience probably know, we had some visa issues, so we just actually got back after being in the States for a couple of weeks dealing with that. Yes, it's definitely not easy. I think that's why a lot of people don't just get up and pack and go to Paris.

[Dr. Christopher Beck]
Sure. It's not easy, but it's fun. It's fulfilling and it's definitely an adventure, a challenge and we felt like we're up for it. We took the Fritts: playbook and we're trying to roll it out for 2023 and the first half of 2024.

[Dr. Aaron Fritts]
Yes. I've been telling a lot of people, the reason why I'm excited is because, other than my wife, I've never lived in the same town as somebody on BackTable. It's exciting because we can do stuff like this in person in my house. Today we're going to cover another basic topic like you and I usually typically like to cover. It was funny. I was texting with one of our former attendings at Vanderbilt, Jim McElmurray the other day, and he said that he listened to the Nephrostomy episode.

[Dr. Christopher Beck]
Did he have any strong thoughts about it?

[Dr. Aaron Fritts]
He was like, "Hey, man, I know I gave you guys a hard time. I didn't think I was that bad." I'll have to go back and listen to that one because I remember we probably said something about him getting on us about a technique or something like that, but that's how we learned, and I'm glad they got on us. Today we're going to talk about Mediport removal. We've talked about Mediport placement previously. Do you remember what episode that was?

[Dr. Christopher Beck]
No idea.

[Dr. Aaron Fritts]
Yes. We'll put in the show notes. We actually recently had Vishal Kumar on from UCSF. We were talking about anesthesia and what kinds of cases require which levels of anesthesia. It had me thinking about Mediports because I know people in my practice, some of them will just do it with local for Mediport retrieval. I don't know. I think that's odd. Don't you?

[Dr. Christopher Beck]
I think if the patient wanted it-- my standard practice is moderate sedation. Yes, that seems a little bit off to me.

[Dr. Aaron Fritts]
We'll get into it. We'll get into the reasons why. It had me thinking about, "Oh, here's actually a very straightforward procedure. We do a lot of them in terms of retrieval," but my thought was like, "Okay, why is this a worthy topic?" It's again, something we commonly do and there are actually some tips and tricks that go with it. Right?

[Dr. Christopher Beck]
I think so. I think there's an efficient-- like anything, it's not a hard procedure to do. You can argue it's not even an IR procedure. I don't mean to say it's not an IR procedure, it's not imaging based. Certainly, you don't really need to take a picture, but I still think there are some things to think about to make your procedure efficient and as pain free as possible. I don't know if pain free is the right way, but as less uncomfortable as possible.

[Dr. Aaron Fritts]
Yes. These are typically mostly cancer patients-- just to get into how these patients present. They're typically patients that are done with their treatment. I think you and I have maybe talked about this before, but the best thing about when they come in for this, what I love, I almost wish you had a bell to ring, because it's like they're done with treatment. It's a celebratory time. I always say, "Congratulations." I think you told me that too. That you do that.

[Dr. Christopher Beck]
I definitely tell my patients, congratulations. The tone of taking out a MediPort is very different from placing one. It's very much like, "Congratulations on having your port removed, having this behind you." There are other indications like an infected port or a malfunctioning or a broken port. If they're finished with treatment and they're 5, 10 years out and it's port removal time, yes, it's very much a congratulatory atmosphere and I try and keep it pretty upbeat.

(1) Indications for Port Removal

[Dr. Aaron Fritts]
Yes. I didn't use to do that until I think you told me about it and now every port retrieval that comes in as an outpatient post cancer treatment, I do that and they just smile and they're like, "Thank you." It does brighten my day and it makes it a more fun procedure, instead of just like a road, like, "Oh, I don't know. Here's another basic procedure," because we do celebrate around it. That is probably the most common indication is that they're just done with treatment, but some other indications you mentioned infection.

[Dr. Christopher Beck]
Yes, port infection, malfunction or broken fractured port.

[Dr. Aaron Fritts]
Yes. Thankfully, I haven't seen too many fractured ones. The ones that are out there that are placed subclavian seem less and less nowadays. I guess it depends on where you practice.

[Dr. Christopher Beck]
I was about to say there's one hospital that-- you don't want to call anyone out, but one of the hospitals that I work at, there's a couple docs that still do subclavians and one of them never has a problem with their ports as long as I've been there, and the other one, I do more port retrievals or fractured port where you'd form body retrievals from this one provider. They're out there. It's not quite done. It just makes me think there's something about the subclavian approach because two different docs and the one who I never see problems with actually puts in probably more ports than the other one. There's something about-- it's not just like subclavian is bad, they're doing it differently.

[Dr. Aaron Fritts]
Yes. I wonder if it's just the angle at which you go under the clavicle.

[Dr. Christopher Beck]
Right. It's got to be something like that.

[Dr. Aaron Fritts]
Because I think that proximity of the clavicle is what causes it because it's a junction point, right?

[Dr. Christopher Beck]
Pinch point for sure.

[Dr. Aaron Fritts]
Pinch point and that's what's causing it. There's something that's tight in there. Over time as they move their arm up and down their shoulder, it's wearing on that little, silicone. Again, I don't see many of those. If it's not somebody who's done all the treatment, then it's somebody who has an infected port, whether it be bacteremia or their incision opened up. Usually when it's a purulent port pocket, like their incision opened up, it's a case where it was placed probably within the last month and it got infected. When it's bacteremia, it might be somebody who had one placed five years ago and they have a port in place and they're in the hospital sick and maybe it's something entirely different. Because that patient's blood cultures are positive, the ID team or the hospitalist team, they're like, "We want that port out."

[Dr. Christopher Beck]
Yes. Want that port out, want that pacemaker out, whatever central line is giving them access to the antibiotics should come out. VP shunts come out. Everything. That's standard operating procedure. I don't mean to make fun of ID docs, but I think that's page 1 of the playbook, like, "Take out all things that do not belong to the patient."

[Dr. Aaron Fritts]
Yes. Whatever it could be. An -itis or the source.

[Dr. Christopher Beck]
Yes, exactly. An -itis.

(2) Conversations with Patients about Port Removal

[Dr. Aaron Fritts]
We'll talk about infection a little bit, what you do for those, but I want to talk about the conversation that we have with the patient. Mostly it's congratulatory. When it is infected, what kind of conversation do you have with a patient about the infection and why we have to take it out? Do you ever talk to them about that sort of thing?

[Dr. Christopher Beck]
Only I talk to them and it's just a little bit firm in that, "It's too bad that this got infected." I try not to dwell on the past. I don't know why it got infected. I don't try and cover a lot of the past ground. I just say, "This is where we are and this is what we have to do to move forward." Because a lot of times it feels like a step in the wrong direction for them. I just tell them that, "This is just a part of the process. We got to get this old one out. The old one's bad. The new one will be good as soon as we can clear the infection." In the informed consent, that's where I stand.

Because I think a lot of them wonder how they got there, what happened. I just try and focus on where we're at and not really how the port got infected or why it did. Because sometimes they even internalize it. They're like, "Oh, is it anything I did? Is it because I took an extra bath or I take long hot showers?" I'm like, "No, no, no. It's none of those things." Even if it were, which it probably is not, I'm just like, "It's infected. We think it's infected. Let's get it out, get the infection treated, and then get you some new access until we can get you another port in."

[Dr. Aaron Fritts]
Yes. The other thing that I talk to them about, especially if you can see the incision opened up, it's pus coming out, purulent stuff coming out. I let them know, "Hey, I'm not going to be able to suture this back up the way it was. You're probably going to have a bigger scar than you would have," because sometimes they're not prepared for that, for the sort of secondary closure and everything like that. That's the only other thing other than what you said already.

I also talk to them about the anesthesia. I say, "Look, it's very similar to when you had it placed." I use moderate sedation for virtually everybody unless there are some hospitals where they book them, but just local. Then I talk to them, I say, "Look, I'm going to put a lot of lidocaine in there to try and make you as comfortable as possible. If you want to be sedated, then I'm happy to reschedule you and have you come back another time."

Because sometimes people aren't prepared for that either. Again, it's just because sometimes, I'm covering for the doctor. That other doc might do all theirs under local and they convince the patients to do it under local. I just feel like it's not that different from when you put it in. There's a lot of scar tissue that you have to dissect through and that can be painful. That's why all mine are moderate.

(3) Approaches to Port Removal

[Dr. Christopher Beck]
Aaron and I are in the same room. I'm rolling my eyes, but I don't mean to roll my eyes about it. I think that taking them out, to me, there's way more dissecting on the port removal than there is the port placement. Whenever I'm placing a port, it's almost easy to find a nice clean pocket to tuck it in. Don't get me wrong. I dissect with my finger and I do have to make sure I have adequate local anesthesia on board.

Whenever it's a port removal, it's a little bit more of like, you're dissecting around those boundaries and sometimes cutting into scar tissue. To me, it's not dissimilar from putting it in. I use moderate sedation for placement, but if it's working for other docs then kudos to them. There's certain patients who the risk of anesthesia certainly is outweighed by the benefits. If the patients are up for it, I don't disagree necessarily. For me, it feels like moderate sedation right on board.

[Dr. Aaron Fritts]
Some patients are totally fine because they're like, "Look, I couldn't get a ride home." It's just a pain in the butt to have to do sedation because they've already been through it. Or it's an elderly patient who the family is like, "Look, she doesn't do well with sedation. Can you just give her a lot of lido?" Those are the kinds of things, exceptions to the rule. Not to say that I'd never do it local only, but I just prefer moderate because I want them to be comfortable. Every time you're dissecting through that scar, they're flinching. I just want them to be comfortable.

[Dr. Christopher Beck]
I totally agree. Totally agree.

[Dr. Aaron Fritts]
We covered anesthesia.

[Dr. Christopher Beck]
Hold on. Can I back it up almost like the very first part. I know when you were introducing the topic, you called it a Mediport. Is that what you call? You call them always Mediports?

[Dr. Aaron Fritts]
Mediports. Yes. What do you call them?

[Dr. Christopher Beck]
I just call them ports.

[Dr. Aaron Fritts]
Yes. That's what we call them on our website too. Mediport.

[Dr. Christopher Beck]
I noticed that. I just call them ports.

[Dr. Aaron Fritts]
Let's see. This is a good thing to cover. What else are they known as? Because they're known by multiple names. There's some places where they call them port-a-caths.

[Dr. Christopher Beck]
Port-a-caths. Mediports-

[Dr. Aaron Fritts]
Mediport, PowerPorts.

[Dr. Christopher Beck]
-and ports is what I see all the time. I didn't know what the actual official-- if you look at the CPT code, I wish I had it in front of me, but we'll have to look it up and include in the show notes. There's a CPT code. It's subcutaneous tunneled central catheter or something with port.

[Dr. Aaron Fritts]
With port. Yes, you're right. It really says Mediport.

[Dr. Christopher Beck]
It doesn't roll off the tongue, certainly.

[Dr. Aaron Fritts]
Yes. I don't know. I'm sure I got it from training somewhere.

[Dr. Christopher Beck]
No doubt.

[Dr. Aaron Fritts]
What else? There's something else that it's called. It's escaping me, but yes, it's known by multiple things. Actually, that's what I was thinking of. When I'm looking for a dictation, like I'm at a new hospital or something, it's like, yes, not everybody calls it Mediport. Sometimes people just call it the PowerPort. Because they're like, "Mediport is what my grandma put it."

[Dr. Christopher Beck]
That's right. Yes. I see PowerPorts, which is probably more accurate. Everything I put in is a PowerPort.

[Dr. Aaron Fritts]
Yes, exactly. All right, we've got that out.

(4) Anesthesia and Reopening the Site

[Dr. Christopher Beck]
We have. We have that out of the way. Let's jump into the typical procedure. You'll just walk us through how once the patient's on the table, got your local in-- tell us how you put your local in.

[Dr. Christopher Beck]
First I like to know a little bit about the patient ahead of time. How long has it been in and are they having any problems with it? I want to know if it's subclavian or IJ. I want to know if I put it in. Ideally, if there's a note, because I don't suture mine in, but there are plenty of docs that do. I want to know those things ahead of time. If I don't, it's all things that I can figure out, but I just wanted to say that.

At the patient on the table, anesthetize, I use a lot of anesthetic. I know that we talked about on the podcast about anesthesia, about the dose limits for lidocaine. I use a lot of lidocaine. I've never had a patient who had side effects from lidocaine. I use a large amount of lidocaine a lot of times with Epi, but if for some reason it's not with Epi or there's a contraindication, then I don't sweat that.

I usually will try and use the same incision that they used to place it. People place their ports differently, but I'll try and make the incision that the original provider who placed the port used. Don't have to, but that's what I try and do. 90% of the time and a hundred percent of the time when it's me, that's at the top end of the Mediport. It's where the reservoir meets the port of catheter.

I do the anesthetic, I cut down deep and break through the sub-Q layer, careful to not cut the actual port catheter. That's the one thing. I feel like the golden rule of removing ports is, you don't want to cut that catheter. I'm not saying it's going to get sucked into the patient's body, but it can.

[Dr. Aaron Fritts]
It could.

[Dr. Christopher Beck]
Yes, for sure. There's no doubt. There's a surgeon at one of the hospitals that I work at. He's a good buddy. He just sometimes is a little bit lackadaisical with hooking up his reservoir with his catheter. He'll just take his eyes off at a second, then they get sucked into the body and we'll go retrieve it in the OR in the cath lab the next day.

[Dr. Aaron Fritts]
Oh my God.

[Dr. Christopher Beck]
It happens enough to where we started giving him a really hard time about it. It's really funny. I think now that we've started giving him a hard time, he's making more effort. Anyway, I cut down and I try and cut down deep, but care to air towards the side of the reservoir because I do not want to cut that catheter. Then once I've made that first incision, I dig straight down on both sides of the reservoir and near the tip of the reservoir where it connects to the catheter. I go deep on the right side, deep on the left side. Then I try and loop or try and scoop a pair of curved hemostats underneath that.

Then once I can connect those two things, I can inch it cranially. Then I'm always trying to birth the catheter first. Once I have the catheter out, then it's game over and you just have to go to the workmanship of-- it's the blocking and tackling of just getting the reservoir out. That to me is-- priority one is to not cut the catheter, get the catheter out. Then once the catheter is out, then you know the game is won, is just getting the reservoir.

[Dr. Aaron Fritts]
Yes, I completely agree. That's the big thing that you're scared of is cutting that catheter. One thing when I was a fellow that Robbie Morrison, my co-fellow taught me actually, and I guess one of the fellows before him taught him was to hold the incision scar over-- you'll grab the skin and pull it over top of the actual port reservoir. Then when you're making your incision, you're making it over the port reservoir and not over where the catheter is.

Then you can basically cut down to it. Even if we cut the silicone at the top, it's not a big deal, but at least you know you're safe and you're not going to cut that catheter. That's what I do to prevent that. Because yes, that's my worst-- It's not a worst nightmare, but just to watch that catheter get sucked up into the body.

[Dr. Christopher Beck]
Have you ever seen that? Have that ever happened to you?

[Dr. Aaron Fritts]
No.

[Dr. Christopher Beck]
Oh, yes. Never happened to me either.

[Dr. Aaron Fritts]
No, absolutely not.

(5) Tips and Techniques for Difficult Retrievals

[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 curve 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 node 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.

(6) Closing the Wound

[Dr. Aaron Fritts]
Yes. You got the catheter out. You got the reservoir out, ports out. Sometimes a joke I say, "It's a boy," and if the patient's awake, they get a little laugh.

[Dr. Christopher Beck]
Sure.

[Dr. Aaron Fritts]
Then what do you do?

[Dr. Christopher Beck]
I'll usually irrigate the pocket a little bit just out of habit. I'll come dunk some water in it and then clean that out. I don't know why but I just inspect the pocket very briefly. Like digital palpation. Then once that's done, I'll usually close with 2-0 Vicryl, for the deep layer 3-0. I'll try and bring it as close to approximated as possible. Then if I can, if I feel like it's coming together nicely the rub on the top.

(7) Post-Procedure Management of an Infected Port

[Dr. Aaron Fritts]
Yes, perfect. Then what do you do if it's infected?
[Dr. Christopher Beck]
If you're dealing with infected port or a fractured port, if that 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.

(8) Strategies for Managing Fractured and Stuck Mediports

[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.

[Dr. Aaron Fritts]
Yes, it's efficient. All right, well, sounds good, Chris. Thanks for your insights and we'll get this one out. Another basic topic.

[Dr. Christopher Beck]
All right, good deal.

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.