Today, implantable central venous ports (ICVP) are increasingly used in oncology patients and provide easy vascular access for delivery of chemotherapy, other intravenous treatments, as fluids, blood products and parenteral nutrition solutions. There is bias the best choice for ICVP insertion in oncology patients. No well conducted randomized studies have compared complications related to the subclavian vein and the jugular vein interventions. In many prospective studies, there is biased by a preference given to one intervention over the other as experience of the surgeon or other causes. However, in clinical studies who are not properly randomized, there is a risk of selection bias and this may be led to overestimation of the effect of study. Another problem nonrandomized studies is unequal group sizes. Thereby we choosed chose implantation to the first group via the subclavian vein and after to the next group via the jugular vein and presented our experience and comparison of efficacy and incidence of complications between subclavian versus jugular access.
Material and Method
Three hundred ten ICVP were implanted via the subclavian vein (SV) in 145 ports patients (66 men, 79 women) with average age of 56.55 (18-86) and were implanted via the external jugular vein (EJV) in 165 ports patients (75 men, 90 women) with average age of 56.81 (19-81) between November 1, 2006 and June 3, 2009. A single type port was used in all patients (Perouse Laboratoires Ivry Le Temple France, 8F silicone OD/ID of the catheter (mm) 2.4/1.2). All catheters were inserted by the same surgical team. ICVP was implanted to provide a long term intravenous access for chemotherapy and other intravenous treatments, as fluids, blood products and parenteral nutrition solutions in cancer patients. The catheter tip was inserted via SV or EJV into the superior vena cava (SVC) or into the proximal right atrium (PRA). All devices were implanted via a tunnel under the skin to the anterior chest wall under local anesthesia in the operating room using the Seldinger method. The catheter is manipulated under the fluoroscopy until the tip of the catheter is in correct position (same position as both ways). A catheter with its tip ranging from the middle third of the SVC to the PRA was evaluated acceptable. A catheter if any other position was considered repositioned. Right side was used initially in all patients except in SV group in 33 patients and EJV group in eight patients.. The insertion port for SV is the right middle infra subclavian area from the junction of the outer clavicle to the lowest landmark of the suprasternal notch and for EJV, the patient is placed in trendelenburg position with face turned to left side to well exposed right EJV. In patients who had undergone mastectomy, previous surgery of the head and neck, structural anomalies, etc, the contralateral side was preferred. Outpatients were sent home after four hours. All the ports had single lumen catheters and were controlled with easily flushed blood withdrawn from line before and after use. After the procedure, the catheter was filled with a solution containing of 0.2 ml heparin (100U/ml) and 5 ml of 0.009 NaCl and thus was protected from obstruction. Catheters were flushed once in 2 weeks or monthly if patients were given monthly chemotherapy or had catheter insitu. Information on port detail indications, complications, duration of stay, reasons of the catheter removal and statistically analysis of data were reported by retrospectively from patient records. The complications related to port implantation were recorded: early complication (before the first chemotherapy application) and late complication (after the first chemotherapy). The function of ICVP was controlled at each application by experienced staff. Chest X ray was done when the system could be obstruction obstructed. Obstruction was defined as the inability to draw blood on infused solution into the catheter. Displacement or cut-off was defined as the migration of the catheter or total breakage of it from the original place. All the catheters were inserted for chemotherapy and central venous access. Table 1 shows the baseline information for SV and EJV catheters. Infection was defined as a local inflammation at the catheter exit site. and subcutaneous infection was due to the catheter.
Descriptive statistics were used, including mean ± standard deviation, median and range, frequencies and proportions. Differences between proportions were tested with the chi-square test or Fisher’s exact test as appropriate. For statistical analysis, non-parametric tests, Student’s t-test and Logistic Regression were used (SPSS, version 17.0, SPSS Inc., Chicago, IL, USA). P values were two-tailed and results less than 0.05 were considered statistically significant.
There was no catheter related blood stream infection. Among the seven patients whom undergone port removal due to complications, second port was inserted (infection in 4 patients, malposition of catheter in one patient, jugular vein thrombosis in one patient, obstruction of catheter in one patient). In SV group 55 patients and in EJV group 133 patients died due to progression of their primary cancer during follow-up. There was no mortality caused by ICVP. Complications were summarized in table 2. There was no observe procedure related early infection. Late infection occurred in 11 patients. Microbiological examination identified methicillin-sensitive staphylococcus aureus(MSSA) as the source of the infection in three patients. Cultures were negative in the remaining eight patients. We successfully treated them with antibiotics. We didn’t consider a surgical intervention for the patient whose catheter was broken because of low life-expectancy and poor general status for anesthesia. In this patient, proximal piece of the catheter was removed and new catheter was inserted left into the subclavian vein.
Many oncology patients require easy vascular access for delivery of chemotherapy, other intravenous treatments such as fluids, blood products and parenteral nutrition solutions [1,2]. They have great advantages over tunnelled catheters in terms of low infection rates, long patient life, patient comfort and ambulatory treatment [3-5]. In many authors and institution the anatomical site of central venous approach is chosen according to personal experience rather than on evidence based guidelines . However, no sufficient designed randomized studies have compared complications and usefulness related to EJV and SV approaches. However, there are several rare but still important complications associated with permanent central venous catheters . Early complications are accidental arterial punctures, pneumothorax, hematoma and air embolism . The latter late complications include infection, thrombosis, and mechanical causes. In a retrospective analysis on 225 port catheter system applications Yildizeli and et al. defined long term complications in 6.6% of the cases: infections (2.2%), thrombosis (1.3%), extravasation (1.3%) and catheter breakdown (1.8%) . We founded the rate of overall complication 19.3% in the SV group and in 16.9% in the EJV group. The rate of mechanic complications (arterial puncture, pneumothorax, hemothorax, mediastinal hematoma, nerve injury) had reported 0-12% in current studies [10,11]. We recorded that the rate of mechanic complication 13.1% in SV group, in 13.3% EJV group. The reason of high complication rate than literature, that we believe its We believe that the reason of high complication rate associated with initial learning curve and blind puncture catheterization.
One of the most frequently reported complications of ICVP insertion is arterial puncture . Rush et al.  reported that arterial punctures were significantly most more common with in the jugular approach than with in the subclavian approach (3% versus 0.5%). We found that arterial puncture was 14 (9.7%) in SV group, 20 (12.1%) in EJV group. However bleeding can usually be undercontrolled by compression and we also stopped bleeding in all patients with this way. Catheter malposition can have serious conditions. Displacement of a subclavian catheter into the other vein or neck veins may have more severe condition than displacement of a jugular catheter into the right atrium. In the meta-analysis, Ruesch and et al  reported that malposition was significantly less common with the jugular vein approach (5.3% vs 9.3%). Gladwin et al  also reported that this higher rate (14%) was observed with the internal jugular vein. We have seen malposition only one patient who underwent jugular approach. The port infection rate in the related literature ranges from 2.6% to 9% [3,14]. There was no procedure early related infection observed. In our study, port related infection developed during following up 7 (4.8%) in SV group, 4 (2.4%) in JV group. Port removal is usually not necessary unless systemic infection. We have also removal removed four ports because of due to systemic infection. The puncture of the subclavian vein is connected associated with pneumothorax in 0.6-4.3% of patients in all the published studies [3,5,15] and some publications were no evidence of any difference in the incidence of pneumothorax . We have founded found rate of pneumothorax 5 (3.4%) in SV group, 2 (1.2%) in JV group. We believe that the subclavian access is more possible to pneumothorax because of the anatomical trace. Recently, we prefer the jugular vein access because of the lower risk pneumothorax. There is an increased risk of pneumothorax in patients who have a severe emphysema, bullous lung and acute respiratory distress syndrome. A “pinch off syndrome” may occur in ports placed through the subclavian vein secondary to the pinching of the port catheter between the clavicle and first rib leading to catheter fracture [14,16]. The catheter was broken in one patient and migrated to the right ventricle (0.7%). Routine device removal cannot be recommended in every patient. Port systems must be removed in case of persistent sepsis, or recurrens of infection after antibiotic treatment, signs of port or catheter tunnel infection, unstable patients, systemic complications . Biffi et al.  were observed thrombosis in 15 cases with internal jugular access and eight cases in SV Access. The thrombosis was seen in one patient (0.7%) in our study. One of the reasons may be the when manoeuvered maneuvered around the bend at the innominate-caval junction the tip of the catheter or introducer may impair the endothelium, predisposing to mural thrombosis. Thus if tip of the catheter or introducer don’t touch to the vessel wall, may reduce risk of thrombosis. As a result, we have also removed seven ports for untreatable complications (infection in four patients, malposition of catheter in one patient, jugular vein thrombosis in one patient, obstruction of catheter in one patient). There is some evidence that there were more arterial punctures but less catheter malpositions with in the JV group compared with the SV group. Regarding this point, in literature studies were summarized in table 3 (table 3).
According to experience, our results show that central venous access insertion site does not influence early or late complication. There was no significant differences in complication rates between two groups despite a longer stay SV catheter (complication numbers 28 in SV group, 28 in JV group). A limitation of this study is that there was no randomization and however it should be noted that this study took place at a single centre experience with a limited number of cases included. So further studies are required to determine which one is to be better ways the best way for vascular access.
The authors declare that they have no competing interests.
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