Incidents and complications of permanent venous central access systems: a series of 1,460 cases.

BACKGROUND: Implanted venous access devices or permanent central venous access systems (PCVASs) are routinely used in oncologic patients. Complications can occur during the implantation or use of such devices. We describe such complications of the PCVAS and their management.
METHODS: Our retrospective study included 1,460 cases in which PCVAS was implanted in the 11 years between January 2002 and January 2013, including 810 women and 650 men with an average age of 45.2 years. We used polyurethane or silicone catheters. The site of insertion and the surgical or percutaneous procedure were selected on the basis of clinical data and disease information. The subclavian and cephalic veins were our most common sites of insertion.
RESULTS: About 1,100 cases (75%) underwent surgery by training surgeons and 360 patients by expert surgeons. Perioperative incidents occurred in 33% and 12% of these patients, respectively. Incidents (28%) included technical difficulties (n=64), a subcutaneous hematoma (n=37), pneumothoraces (n=15), and an intrapleural catheter (n=1). Complications in the short and medium term were present in 14.2% of the cases. Distortion and rupture of the catheter (n=5) were noted in the costoclavicular area (pinch-off syndrome). There were 5 cases of catheter migration into the jugular vein (n=1), superior vena cava (n=1), and heart cavities (n=3). No patient died of PCVAS insertion or complication.
CONCLUSION: PCVAS complications should be diagnosed early and treated with probable removal of this material for preventing any life-threatening outcome associated with complicated PVCAS.

INTRODUCTION

Implanted venous access devices or permanent central venous access systems (PCVASs) have been routinely used in oncologic patients since the 1980s [1]. They are made of a central venous catheter connected to a chamber or reservoir surgically implanted in a subcutaneous pocket [2]. The most common insertion sites are the internal jugular, subclavian veins, and, more rarely, the cephalic veins, external jugular, and brachial and femoral veins [3]. These implantable chambers ensure the possibility of direct, repetitive central venous access with a lower risk of infection [4] by sparing the patients' venous integrity, which can be compromised by drug toxicity [2].

Additionally, parenteral nutrition, blood transfusion, and blood sampling can be performed via PCVAS [5]. A few authors have reported the benefit of PCVAS use in refractory ascites and pleural effusions for avoiding morbidity and patients' anxiety related to repeated puncture and aspiration [6].

Nevertheless, the presence of an intravascular catheter could lead to 4 major complications: infection, thrombosis, catheter rupture, and extravasations of fluid around the reservoir [5]. Although rare, these complications could be severe and life threatening. We aim to report retrospectively the prevalence and management of perioperative incidents and complications associated with PCVAS.

METHODS

Our retrospective study comprised 1,460 cases with PCVAS implanted between January 2002 and February 2013, including 810 women and 650 men with an average age of 45.2 years. Radiopaque polyurethane catheters were the most commonly used, whereas silicone catheters were used less frequently. These catheters had an internal diameter of 1 mm and a reservoir capacity of 0.3 or 0.5 mL. The chambers were made of metallic (titanium) or plastic material. The insertion site was selected on the basis of clinical data. In patients with lung cancer, we used the same side to perform a vessel puncture, while the opposite side was preferred in cases of breast cancer. The cephalic and subclavian veins were our most common insertion sites.

We used a direct approach toward the cephalic vein if the patient presented with subclavian lymph nodes or hematological diseases, or had undergone a pneumonectomy previously. This approach could prevent arterial puncture in the case of hematological disease with a probable coagulation disorder, was easier than performing percutaneous puncture in the case of subclavian lymph nodes, and protected the pneumonectomy cavity from septic puncture. In this report, we call any perioperative problem an 'incident' and any medium- or long-term problem a 'complication.'

RESULTS

The procedures were direct surgery of the cephalic or the jugular vein in 452 cases and percutaneous subclavian or jugular vein puncture in 1,008 cases. All patients underwent radioscopic control on the operating table or a chest X-ray after surgery.

Perioperative incidents (Table 1) included a technical difficulty in 64 cases, subcutaneous hematoma in 37 cases, pneumothoraces in 15 cases, and accidental intrapleural catheter placement in 1 case (Fig. 1). We considered the case of intrapleural catheter as an accidental displacement because the catheter was not located inside a vessel but was free in the pleural space. Short- and medium-term complications developed in 14.2% of the cases (Table 2). Subclavian vein thrombosis was not observed in our patients, either uniquely or in association with another complication. Catheter distortion and rupture was noted in the costoclavicular area (pinch-off syndrome) (n=5) (Fig. 2). The 5 noted cases of catheter migration were into the jugular vein (n=1), superior vena cava (n=1), and heart chambers (n=3) (Fig. 3). The treatment of these complications consisted of PCVAS removal in the cases of catheter infection, sepsis, occlusion, disconnection, or associated vein thrombosis. Skin necrosis (Fig. 4) was repaired surgically if possible or if not infected. Migrated catheter extraction was performed by venous catheterization or via catheterization of the femoral artery in the case of migration into the cardiac chambers. In 13 cases, device occlusion was successfully treated without PCVAS removal by tunneling the catheter and injecting heparin into the reservoir. None of the patients included in our study died of a complication arising from PCVAS insertion. We observed no complications related to inadvertent arterial puncture during percutaneous PCVAS insertion. The mean operation time was 34.7 minutes (median, 30; range, 19 to 92 minutes). The cephalic vein (Fig. 5) was not detected in 10 cases, and the cephalic vein was too narrow to insert the catheter in 5 cases. About 1,100 cases (75%) underwent surgery by in-training surgeons, and 360 patients were operated on by expert surgeons. Perioperative incidents occurred in 33% and 12%, respectively, of the patients in these groups. The use of ultrasound for locating and puncturing a vein involves delicate operator coordination between the hand holding the needle and syringe, the hand holding the probe over the vein, and the eyes watching the image on the screen of a portable ultrasound machine. These skills are naturally developed over time. We used ultrasound in just 52 cases (3.5%). We consider direct venous aboard to be indicated after three missed punctures.

Table 1

Perioperative incidents of implantation of permanent central venous access system

Values are presented as number (%).

a)Patients with platelet inhibitors.

Fig. 1

Chest computed tomography showing a left intrapleural catheter.

Table 2

Complications of the PCVAS and related-disease data

PCVAS, permanent central vein access system.

a)Eighty-seven percent of complicated PCVAS were removed.

Fig. 2

Perioperative view showing the rupture distortion of the catheter (pinch-off syndrome).

Fig. 3

Chest radiograph with a catheter ruptured and migrated into the right ventricle with complete disconnection between the distal and the proximal catheters.

Fig. 4

Perioperative view of a skin necrosis related to permanent central vein access system.

Fig. 5

Perioperative view with an exposure of the left cephalic vein before insertion of the permanent central vein access system.

DISCUSSION

PCVASs are now routinely used for facilitating the care of chronically ill patients. A PCVAS contains a chamber covered by a silicone membrane and with a lateral opening to which a catheter tube is connected. The catheter tube is tunneled subcutaneously or by using the open venous cut-down technique, usually under local anesthesia. Vein dissection and pouch creation for the portal can be performed through the same 4-cm-long incision, and the catheter is introduced by way of the subclavian or jugular vein to a position just above the right atrium.

The port can be used directly after implantation. Port punctures must be performed with a strictly aseptic technique [7]. Depending on the particular model, ports can be punctured 1,000 to 8,000 times [8].

When palpated, the port membrane can be punctured easily. The port membrane and the skin should be punctured at a site different from that of the last puncture [9]. Redness, swelling, or discharge at the implantation site should be noted before any puncture.

Technical difficulties include difficult venous puncture. A few risk factors are known to be associated, such as obesity, female gender, previous local surgery or radiotherapy, and lack of operator training.

A few intraoperative complications are slightly related to the chosen procedure. Pneumothorax is more frequently associated with subclavian rather than jugular vein puncture [10]. The direct vein cut-down ensures a safe procedure because it preserves the pleural space. The intrapleural catheter placement was accidental. Therefore, we insist that PCVAS surgery should be performed by experienced personnel or under supervision at training hospitals.

Subcutaneous hematoma or bleeding complications must be anticipated. Management of antiplatelet agents and anticoagulants should be subject to the same rules as any other surgery, particularly in patients with hematological diseases or in the case of probable arterial puncture. Intraoperative heart rhythm disorder principally induced by the presence of the catheter in the cardiac cavities is a classical sign for confirming that the catheter is in the right direction before radiological control. The catheter length should be reduced just above the right atrium.

PCVAS infection is a relatively common complication (frequency of up to 6.5%) [11]. In our series, infection or PCVAS-related sepsis was almost 7.8%. Gram-negative bacilli and gram-positive cocci were the most commonly isolated microorganisms (60% and 31%, respectively). A meta-analysis of 14 prospective studies reported a 3.6% prevalence of infection in hemato-oncological patients and an incidence density of 0.1/1,000 catheter-days [12]. The main risk factors are neutropenia, parenteral nutrition, young age, difficulties during insertion, and poor general status. Recent guidelines have defined intravascular catheter-related infections [13]. A strict clinical and microbiological work-up, including simultaneous culture of blood drawn from the catheter and a peripheral vein, should be performed.

More recently, an observational study showed an association between the frequency of complications and the time of first use: 10.6%, 6.7%, and 2%, respectively, when the PCVAS was used within 3 days, between 4 and 7 days, and 7 days after the placement [14]. We allowed device use 24 hours after its implantation. Device removal was mandatory when an infection was documented.

The use of prophylactic antibiotics is controversial. A few investigators use them, but many do not. We chose to not use them initially and have stuck to our original choice. We insist on prevention by the strict aseptic handling of the PCVAS. Only special needles with a 'Huber tip' should be used for puncturing the device: conventional needles punch holes in the membrane, and once the needle is removed, the port is unusable because the membrane is no longer reliably sealed.

Venous thrombosis has been described as an early complication of PCVAS [15]. The literature contains only a few reports of the complete thrombosis of the superior vena cava and the development of a superior vena cava syndrome [16]. In our study, the occurrence of venous thrombosis is 1.5%, and the majority of the occurrences were recorded in the second month after implantation. In the literature, it is higher and ranges from 6% to 61% due to different clinical and radiologic diagnostic criteria. We performed Doppler ultrasonography only in the presence of clinical phlebitis symptoms and differentiated central venous catheter thrombosis (1.9% in our series) from venous thrombosis. Doppler ultrasonography has low sensitivity in the diagnosis of PCVAS, particularly in the detection of subclavian vein thrombosis [17]. However, in our study, no case of subclavian thrombosis was detected.

A recent study recommended the combination of venography and echography for the diagnosis of asymptomatic thrombosis [18]. In the literature, several risk factors have been studied, such as large bulky cervical or mediastinal tumors. Silicone and polyurethane catheters are less thrombogenic than polyvinylchloride and polyethylene catheters [19]. Catheter heparinization was not proven to prevent thrombosis [20]. There is no consensus concerning therapy for the vein thrombosis of PCVAS. The catheter tip must be placed at the level or under T4 using radioscopic guidance. Luciani et al. [16] have demonstrated an association between the positioning of the distal catheter tip and thrombotic complications. There is no study on the role of the insertion method (percutaneously versus direct surgery) and the choice of vein (jugular or subclavian). The patient's age, primary tumor type, and chemotherapy were not considered specific risk factors [21]. Systematic prophylactic treatment with low-molecular-weight heparin did not show any benefit in the treated patients [22]. We typically heparinize the catheter after any perfusion to prevent fibrin adhesion to the catheter wall and distal end occlusion.

The pinch-off syndrome (POS) has been reported as a PCVAS complication. This syndrome is caused by the compression of the catheter by the clavicle and the first rib [23], which leads to catheter obstruction and fracture. The cut-down technique seems to have a lower association with the pinch-off syndrome in a number of studies [24,25]. In our study, 2 of the 5 cases with POS were asymptomatic and incidentally discovered. The other cases were diagnosed with luminal narrowing or complete catheter fracture on a chest radiograph. In our opinion, the use of the subclavian route and polyurethane catheters seems to have a greater association with this complication. POS treatment involves careful catheter removal. If the catheter tip is embolized, it can usually be retrieved percutaneously with a transvenous snare. POS can be prevented by using the internal jugular vein for access rather than the subclavian vein. This complication can be ascribed to forceful injections or to intrathoracic pressure changes generated by coughing or intrathoracic disorders [26].

Catheter migration was secondary to the total rupture of the catheter, which warrants percutaneous retrieval. Transvenous retrieval was successful in 4 cases. In the fifth case of catheter migration, there was a high risk of surgery, therefore the catheter was retained in place and the patient died six months later by an advanced lymphoma.

In summary, PCVAS provides a safe and inexpensive means of venous access and patient comfort. The exclusion criteria for PCVAS installation are infected areas, major coagulation disorders, skin metastasis, previously irradiated areas, and thrombosis of the superior vena cava or the subclavian vein. Appropriate handling is of crucial importance so that complications such as port thrombosis and infections can be avoided. Clinicians should carefully watch for the evidence of central venous line dysfunction that usually accompanies these complications.