External Jugular Venous Cutdown versus Percutaneous Technique for Chemoport Insertion in Children: A Comparative Study.

Aims: We aimed to compare the external jugular vein (EJV) cutdown technique with the percutaneous technique for difficulties in insertion, maintenance, and other complications of chemoport placement in children. Materials and
Methods: A retrospective study was carried out in children who underwent chemoport insertion between January 2007 and December 2019 either by EJV cutdown or percutaneous technique in the department of pediatric surgery at a tertiary center. All children aged <18 years undergoing chemoport insertion by EJV cutdown or percutaneous technique were included in the study. Data collected included the indication, procedure time, early and late complications, and the time to removal of chemoport.
Results: There was no significant difference between the EJV group and the percutaneous group in terms of the time taken for chemoport placement (40.9 ± 7.6 min vs. 37.6 ± 18.9 min; P = 0.14), failure to cannulate (one vs. six; P = 0.05), and the mean chemoport indwelling days (816.8 ± 729.2 days vs. 854.5 ± 705.1 days; P = 0.73). The chemoport placement by EJV cutdown method was found to have significantly fewer overall complications (4 vs. 14; P = 0.01) and a lesser rate of premature chemoport removal (4 vs. 12; P = 0.04) compared to the percutaneous group. Conclusions: Chemoport placement by the EJV cutdown was found to have fewer port-related complications and a lesser rate of premature chemoport removal compared to the percutaneous technique. The time taken for port placement and the mean chemoport-indwelling days were similar in both techniques. Copyright:

INTRODUCTION

The patients requiring chemotherapy and frequent transfusions need chronic venous access, and the chemoport is the best way to achieve this.[12] Ultrasound-guided percutaneous venous access and the use of fluoroscopy for chemoport placement is the preferred method.[2] However, the percutaneous technique is also associated with complications such as hematoma, failure to cannulate, and pneumothorax.[345] Venous cutdown is an alternate technique for chemoport placement, but it is a more invasive technique compared to the percutaneous technique. The superiority of one technique over the other is a never-ending debate. External jugular vein (EJV) cutdown for chemoport placement is less invasive than the other venous cutdowns because of direct visualization and easy accessibility.[456] Currently, data providing a head-to-head comparison of EJV cutdown with a standard percutaneous technique are scarce.[36] Hence, a study was conducted to compare the EJV cutdown technique with the percutaneous technique for the difficulties in insertion, maintenance, and other complications of chemoport placement in children in a tertiary center.

MATERIALS AND METHODS

A retrospective analysis was conducted in the department of pediatric surgery in a tertiary care center. The children who underwent chemoport insertion by either EJV or percutaneous technique were included. Data were retrieved from hospital records of children who underwent chemoport insertion between January 2007 and December 2019 with a minimum follow-up period of 6 months. Four different surgeons operated during the study period and all surgeons performed both techniques of insertion. The indication for chemoport placement, date of placement, age, gender, and the techniques of placement were recorded. The time taken for placement; and intraoperative and postoperative complications were noted. The date of chemoport removal and the indication for removal were documented. The study was concluded on June 30, 2020.

Techniques of chemoport placement

Informed written consent was obtained from the parents. Adequate blood and blood products were kept arranged as most of these children had anemia and thrombocytopenia secondary to hematological malignancies. The children with platelet count <50 × 109/L received platelet transfusion just before starting the procedure.[7] The procedures were performed under general anesthesia. At the time of anesthetic induction, a dose of prophylactic antibiotic was administered.

Cutdown technique

A 1.5-cm long transverse skin incision was placed in the neck keeping EJV as the center point. EJV was identified, dissected, hooked, and controlled with 3–0 polyglactin (Vicryl®) sutures placed proximally as well as distally [Figure 1]. The subcutaneous plane was dissected to accommodate the smooth curve of the chemoport catheter and to prevent its kink. A small nick was made in the EJV just to accommodate the chemoport catheter [Figure 2]. The EJV was ligated proximally once the chemoport catheter was successfully placed. In cases of failed EJV cannulations or small caliber EJV, internal jugular vein (IJV) was used by extending the incision medially by ½–1 cm.

Figure 1

Chemoport placement by external jugular vein cutdown: An incision placed in the neck and the external jugular vein was being controlled with vicryl sutures. An infraclavicular incision was placed to accommodate chemoport

Figure 2

The chemoport catheter was placed into the vein and the catheter was brought out through the incision for the chemoport via a subcutaneous tunnel between the incisions. The subcutaneous plane was dissected to accommodate the smooth curve of the chemoport catheter and to prevent its kink

Percutaneous technique

The right subclavian vein was preferentially selected. Left subclavian vein or IJV was used in cases of difficult cannulation, previous cannulation, or the failed cannulation. A Seldinger technique was used to cannulate the vein.[1] The vein was accessed using a needle and syringe. As soon as the access was confirmed by aspiration of blood, the syringe was disconnected from the needle and a guidewire was advanced through the needle. Number 11 surgical blade was used to nick the skin at the site of entry. The track was dilated with the dilator provided. Now, the introducer was placed over the guidewire, and then, the guidewire was removed. The chemoport catheter was inserted through the introducer and advanced to a predetermined length. The introducer was then peeled away and removed in toto.

The fluoroscopy was used to place the tip of the chemoport catheter (6F attachable polyurethane) at the junction of the right atrium and superior vena cava [Figure 3]. An infraclavicular subcutaneous pouch was created; the chemoport (6F MRI® ULTRA SLIMPORT® IMPLANTABLE PORT by Bard Access Systems) was placed. The chemoport was connected to the chemoport catheter; free backflow from the chemoport was confirmed and then flushed with heparin solution (Hep-Lock®10 IU/mL). A Huber needle was inserted into the chemoport once the procedure is done and was used from the immediate postoperative period. The chemoport was flushed with Hep-Lock solution after each usage and once monthly if the port was not in use. The follow-up was ended once the chemoport was removed or on the day child expired or at the end of the study on June 30, 2020.

Figure 3

Intraoperative fluoroscopy was used to place the tip of the chemoport catheter at the right atrium/superior vena cava junction

Complications

The complications studied include port-related bloodstream infection, blocked chemoport, decubitus-over-port, injury to surrounding structures, avulsion of the vein, overlying skin necrosis, catheter fracture or dislocation, catheter migration, and port pocket infection. The complications which occurred within 30 days of port placement were considered early and those that occurred after 30 days were considered delayed. Port-related bloodstream infection was defined as a suspected systemic infection characterized by fever, neutrophilia/neutropenia, leukopenia/leukocytosis, and elevated C-reactive protein caused by chemoport with or without positive blood or catheter tip culture.[1] If the chemoports were removed before the completion of chemotherapy, it was considered premature removal.

The data retrieved from the hospital records were divided into two groups. Group “A” included children who underwent chemoport placement by EJV cutdown, while Group “B” included children with chemoport insertion by percutaneous technique. The complications during placement and maintenance of chemoport were analyzed.

Sample size calculation

To calculate the sample size, the baseline incidence of complication was considered as 12.66% (based on study by Teichgraber et al)[2], precision was assumed to be 0.05, and power of the study was 80% with an odds ratio of 3 between the group A and group B. A sample size of 168 with 84 in each group was calculated using Fleiss method.

Statistical analysis

Continuous variables such as the time taken for port placement, age, and the total chemoport days were expressed as mean ± standard deviation and analyzed using the independent sample t-test. Categorical variables (gender, veins used, indication, and techniques used for port placement) were expressed as numbers and percentages and were analyzed using Chi-square or Fisher's exact test. The complications were recorded and expressed per 1000 chemoport days as well as number and percentage and were analyzed using the independent sample t-test. The difference between the groups was considered significant when the “P” value was <0.05 with a 95% confidence interval. Odds ratio or mean difference with 95% confidence interval was also used to evaluate the significance between the groups.

RESULTS

A total of 168 children were recruited for the study, with 84 in each group. Acute lymphoblastic leukemia was the most common indication for chemoport insertion [90 (54%); Table 1]. IJV was used in 23 (14%) children and the subclavian vein in 61 (36%) children. The mean chemoport indwelling days was 836 ± 715 days with a median of 593 days (interquartile range: 212–1528). There were no anesthetic complications.

Table 1

Clinical profile of the study population

Variables	Total (n=168), n (%)	EJV group (n=84), n (%)	Percutaneous group (n=84), n (%)	P
Male:female ratio	102:66	53:31	49:35	0.53^
Mean age of the study group (years)	5.7±3.9	6.1±4.1	5.3±3.7	0.18*
Indications for chemoport insertion (n=168)
Hematological disorders	17 (10)	10 (12)	7 (8)	0.44^
Thalassemia major	13 (8)	9 (11)	4 (5)	0.15^
Aplastic anemia	3 (2)	0	3 (3)	0.25#
Pure red cell aplasia	1 (1)	1 (1)	0	1#
Malignancy	150 (89)	74 (88)	76 (91)	0.61^
Acute lymphoblastic leukemia	90 (54)	47 (56)	43 (51)	0.54^
Acute myeloid leukemia	16 (10)	5 (6)	11 (13)	0.11^
Lymphoma	15 (9)	7 (8)	8 (10)	0.79^
Wilms’ tumor	9 (5)	5 (6)	4 (5)	0.73^
Neuroblastoma	2 (1)	1 (1)	1 (1)	1^
Hepatoblastoma	2 (1)	1 (1)	1 (1)	1^
Intracranial germ cell tumor	1 (1)	0	1 (1)	1#
Medulloblastoma	3 (2)	1 (1)	2 (2)	0.57^
Retinoblastoma	2 (1)	1 (1)	1 (1)	1^
Dysgerminoma	1 (1)	1 (1)	0	1#
Primitive neuroectodermal tumor	1 (1)	0	1 (1)	1#
Retroperitoneal germ cell tumor	2 (1)	1 (1)	2 (2)	0.57^
Langerhans histiocytosis X	3 (2)	2 (2)	1 (1)	0.57^
Nasopharyngeal carcinoma	1 (1)	1 (1)	0	1#
Osteosarcoma	1 (1)	1 (1)	0	1#
Severe combined immunodeficiency	1 (1)	0	1 (1)	1#

*Independent sample t-test, ^Chi-square test, #Fisher’s exact test. Data are presented as, n (%) or mean±SD unless stated otherwise. EJV: External jugular vein, SD: Standard deviation

There was no significant demographic difference between the EJV group and the percutaneous group [Table 1]. There was no significant difference between the EJV group and the percutaneous group in terms of the time taken for chemoport placement (40.9 ± 7.6 min vs. 37.6 ± 18.9 min; P = 0.14), failure to cannulate (one vs. six; P = 0.05), and the mean chemoport indwelling days (816.8 ± 729.2 days vs. 854.5 ± 705.1 days; P = 0.73). The chemoport placement by EJV cutdown method was found to have a significantly lesser rate of premature chemoport removal (4 vs. 12; P = 0.04; OR [95% CI] =3.3 [1.1–10.7]) compared to the percutaneous group [Table 2].

Table 2

Operative and postoperative parameters

Variables	Total (n=168), n (%)	EJV cuthown (n=84), n (%)	Percutaneous (n=84), n (%)	P	OR or mean difference$ (95% CI)
Time taken of chemoport placement	39.2±14.5§	40.9±7.6§	37.6±18.9§	0.14*	3.3 (-1·1 to +7·7)$
Failure to cannulate	7 (4)	1 (1)	6 (6)	0.05^	0.16 (0.02-1.3)
Total chemoport days (days)	140,388	68,613	71,775	-	-
Mean chemoport days (days)	835.6±715.3	816.8±729.2	854.5±705.1	0.73*	−37.6 (-256 to +180)$
Median chemoport days‡	593 (212-1528)	565 (224-1442)	629 (212-1562)	0.47†	-
Chemoports removed after the completion of treatment	102 (61)	40 (48)	62 (74)	-	-
Premature removal	16 (10)	4 (5)	12 (14)	0.04^	3.3 (1.1-10.7)
Port-related blood stream infection	13 (8)	4 (5)	9 (11)	0.15^	2.4 (0.7-8.1)
Blocked chemoport	2 (1)	0	2 (2)	0.50#	1 (1-1.1)
Overlying skin necrosis	1 (1)	0	1 (1)	1#	0.3 (0.01-8.2)
Chemoports still in situ	39 (23)	38 (45)	1 (1)	-	-
Deceased patients (chemoports not removed)	11 (7)	2 (2)	9 (11)	-	-

‡Median (IQR), §Min, *Independent sample t-test, $Mean difference, ^Chi-square test, #Fisher’s exact test, †Mann-Whitney “U” test. Data are presented as n (%) or mean±SD unless stated otherwise. EJV: External jugular vein, OR: Odds ratio, CI: Confidence interval, SD: Standard deviation, IQR: Interquartile range

There were a total of 18 (11%; 0.13 per 1000 chemoport days) complications noted during the study period. The chemoport placement by EJV cutdown method was found to have significantly fewer overall complications compared to the percutaneous group [4 vs. 14; P = 0.01; OR (95% CI) = 0.25 (0.1–0.8); Table 3]. Among the early complications, one child in the percutaneous group had an avulsion of the subclavian vein which was repaired by open technique and had the chemoport inserted a week later [Table 3].

Table 3

Complications of chemoport

Complications	Total (n=168), n (%)	EJV cuthown (n=84), n (%)	Percutaneous (n=84), n (%)	P	OR (95% CI)
Port related blood stream infection	13 (7)	4 (4)	9 (10)	0.15*	2.4 (0.7-8.1)
Blocked chemoport	2 (1)	0	2 (2)	0.50^	1 (1-1.1)
Avulsion of vein	1 (1)	0	1 (1)	1^	0.3 (0.01-8.2)
Overlying skin necrosis	1 (1)	0	1 (1)	1^	0.3 (0.01-8.2)
Port pocket infection	0	0	0	-	-
Fractured catheter noted at removal	1 (1)	0	1 (1)	1^	0.3 (0.01-8.2)
Operative site bleeding	0	0	0	-	-
Catheter dislocation	0	0	0	-	-
Distal migration causing arrhythmias	0	0	0	-	-
Decubitus-over-port	0	0	0	-	-
Total	18 (11)	4 (4)	14 (16)	0.01	0.25 (0.1-0.8)

*Chi-square test, ^Fisher’s exact test. Data are presented as n (%). EJV: External jugular vein, OR: Odds ratio, CI: Confidence interval

The most common delayed complication noted was port-related bloodstream infection (13 patients; 0.09 per 1000 chemoport days). There were two cases of blocked chemoport (0.01 per 1000 chemoport days) and one (0.007 per 1000 chemoport days) each of overlying skin necrosis and fractured chemoport catheter (all noted in the percutaneous group). There was no significant difference between the two study groups in terms of these complications [Table 3].

There were no cases of significant bleeding, migration of catheter, decubitus-over-port, or port pocket infection in the study population.

DISCUSSION

Implantable devices for venous access are required in patients requiring long-term intravenous therapy such as parenteral nutrition, chemotherapy, or immunosuppressant therapy.[8] Chemoport or totally implantable venous access device serves as the best option for safe and chronic venous access in children.[1] The most preferred method of chemoport placement has been percutaneous venous access under ultrasound guidance and placing the tip of the chemoport catheter with the help of fluoroscopy.[12] However, the success of the percutaneous technique using ultrasound guidance is highly operator dependent.[9] Open cutdown is a more invasive method but considered safer than the percutaneous technique in patients with bleeding tendencies.[9] Hence, the debate on the superiority of one technique over the other is never ending.

The chances of late recurrence of malignancy and second malignancy are high in our patients as they belong to the pediatric age group. To save the IJV and SCV for future use in these children, we started using the EJV for chemoport placement. There are studies on chemoport placement in children by percutaneous technique as well as cutdown technique. However, there are hardly any studies that compare the EJV cutdown with percutaneous techniques. Hence, this study was undertaken.

Malignancy was the most common indication for chemoport placement with acute leukemia contributing the most of it, similar to other pediatric studies.[1241011] The time taken for chemoport placement by EJV cutdown in our study was comparable to other studies such as Di Carlo et al., Tsai et al., and Cavallaro et al.[3412] and was superior to other studies such as Povoski, Lin et al., Wolosker et al., and Lin et al.[5131415] The operative time was similar between EJV cutdown and percutaneous techniques.

The success rate of placing a chemoport by EJV cutdown varies from 70% to 100%. The success rate was 74% in Wolosker et al., while it was 98%, 100%, 99%, 100%, and 100%, respectively, in Di Carlo et al., Tsai et al., Povoski, Cavallaro et al., and Lin et al.[3451215] We had a success rate of 99% by EJV cutdown and 94% by percutaneous technique. The reasons for the higher success rate of EJV cutdown include the superficial location of the vein, the straight course of the vein, and the course of the vein that does not cross the costoclavicular space.[6]

The early complications (within 30 days of placement) of chemoport include avulsion of the vein, arterial or nerve injury, pneumothorax, hemothorax, bloodstream infection, port pocket infection, bleeding, hematoma, blocked chemoport, and arrhythmias. Late complications can be catheter dislocation, migration of chemoport catheter, port-related bloodstream infection, port pocket infection, blocked chemoport, overlying skin necrosis, deep vein thrombosis, and decubitus-over-port.[16]

The rate of complication in our study was 0.13/1000 chemoports, which was superior to other studies such as Teichgraber et al. (0.41/1000 chemoport days), Tsai et al. (0.26/1000 chemoport days), and Aparna et al. (0.67/1000 chemoport days).[2411] In our study, the overall complication by EJV cutdown was significantly lesser than that in the percutaneous technique. The avulsion of the vein, neurovascular injury, pneumothorax, and hemothorax are exclusively seen in the percutaneous technique.[26] The EJV cutdown is not known to be associated with these complications. Arrhythmias can occur irrespective of the technique of insertion. The incidence of arrhythmias varies from 0·1% to 0·9%, and it occurs when the chemoport catheter is placed into the right atrium.[13] It is treated by electric or pharmacological intervention and repositioning or removal of the chemoport catheter.[13]

The port-related bloodstream infection is the most common complication of chemoport, and it can occur irrespective of the technique of chemoport placement.[12411] This can occur as an early or a delayed complication. As most of our children had hematological malignancies, the associated immunocompromised state could have led to increased risk for port-related bloodstream infection as well as a port pocket infection. A strict aseptic protocol of chemoport placement, as well as chemoport use, can help us reduce this dangerous complication.[1] While placing a chemoport, we always use an instrument to hold the chemoport and the chemoport catheter (aseptic nontouch technique). We also make sure the chemoport and its catheter always stay on a sterile mop during the procedure and do not come in direct contact with the skin of the patient. The rate of port-related bloodstream infection was 0.15/1000 chemoport days in Teichgraber et al., 0.34/1000 chemoport days in Tsai et al., 0.46/1000 chemoport days in Aparna et al., and 0.23/1000 chemoport days in Wolosker et al.[241013] To the best of our knowledge, our study had one of the least rates of port-related bloodstream infection (0.09/1000 chemoport days). The most common organism causing port-related bloodstream infections reported in the literature was Staphylococcus.[1411] In all the suspected cases of port-related bloodstream infection, we removed chemoport and treated it with an appropriate antimicrobial agent. However, a standard procedure of handling the chemoport reduces the risk of infection.[1]

Blocked chemoport secondary to thrombosis of chemoport catheter was reported in 1.8%–14% of cases.[4] It was 1% in our study. The risk factors for blocked chemoport are catheter tip malposition, hypercoagulable state, and improper handling of chemoport.[14] Cutdown techniques were found to have lesser risk compared to percutaneous techniques as the guidewire and/or fascial dilator used in the percutaneous technique can cause endothelial damage leading to thrombosis.[4]

The most common complication for premature chemoport removal in our study was port-related bloodstream infection which is similar to other studies such as Tsai et al., Chandrasekaran and Somasundaram, and Aparna et al.[41011] Other indications for premature removal include blocked chemoport, overlying skin necrosis, kinking of chemoport catheter, arrhythmias, port-pocket infection, and spontaneous disunion of the port and the catheter.[1211]

The overall mean chemoport indwelling days in our study was 835·6 ± 715·3 days with a median of 593 days which is superior to other studies such as Teichgraber et al. (292 days), Chandrasekaran et al. (216 days), and Aparna et al. (270 days).[2911] We could achieve longer chemoport indwelling days because of our standard protocol of chemoport care.

In resource-challenged settings, fluoroscopy may not be available for usage. In that case, the length of the chemoport catheter can be calculated by measuring the distance between the point of skin puncture to the point of insertion of right second costal cartilage to the manubrium sternal joint via ipsilateral clavicular notch.[16] This measurement holds good for bilateral superior vena cava and IJV access ports. Hand hygiene is the most important factor to prevent bloodstream infection so that the catheter can be used for a longer duration. Prevention of complications will also help to reduce the cost.

CONCLUSIONS

Chemoport placement by the EJV cutdown was found to have fewer port-related complications and a lesser rate of premature chemoport removal compared to the percutaneous technique. The time taken for port placement and the mean chemoport-indwelling days were similar in both techniques. The EJV cutdown technique, by logical conclusions, will also provide an opportunity to use deeper veins in the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.