|Year : 2021 | Volume
| Issue : 3 | Page : 536-537
Totally implantable venous access devices: Necessity or luxury?
Swapnil Patel, Preeti Vijayakumaran
Department of Surgical Oncology, MPMMCC, Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
|Date of Submission||10-Sep-2021|
|Date of Decision||11-Sep-2021|
|Date of Acceptance||13-Sep-2021|
|Date of Web Publication||08-Oct-2021|
Department of Surgical Oncology, MPMMCC, Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi - 221 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Patel S, Vijayakumaran P. Totally implantable venous access devices: Necessity or luxury?. Cancer Res Stat Treat 2021;4:536-7
Long-term venous access devices (LTVADs) refer to access channels into the central venous system to facilitate the delivery of various medical products. These are of three main types – centrally inserted tunneled catheters or Hickman-type devices (Hickman), peripherally inserted central catheters (PICCs), and centrally inserted totally implantable venous access devices (TIVADs), As one of the most common indications is insertion for the delivery of chemotherapeutic agents, these devices are popularly termed as chemoports. While being easy and comfortable to use, these devices safeguard against the thrombophlebitic side effects of the drugs. However, placement of these TIVADs demands technical expertise and is associated with its own set of complications, chiefly infections.
The study by Chandveetil et al. published in this issue of the journal is a descriptive study of a single-center experience with the use of the chemoports for oncological indications. It is a retrospective analysis, in which the authors have analyzed the data from 34 patients who underwent placement of TIVADs for the purpose of delivery of chemotherapy. Total catheter days analyzed in the study period were 8421 with an average of 227.6 days per patient. Complications were noted in 18.9% cases, most common being infections (8.11%).
The strengths of the study lie in the fact that it is a single-center experience which ensures a standard practice with regard to uniformity in surgical technique. The study provides real-world data about the identification and management of complications in the Indian setup. The weakness of the study stems from the low number of patients included. The events (infections, thrombosis, and kinking of the catheter) were too few to draw meaningful conclusions. A larger number of patients would facilitate comparison between image-guided port placement and anatomical landmark-guided port placement. Detailed insights on the need of general anesthesia for the placement of ports would be valuable to formulate real world guidelines.
The merits of the TIVADs are that they provide a safe route to the central venous system with minimal long-term maintenance and continuous comfort for the patient. A port in place provides an easy access for repeated blood sampling alongside facilitating the administration of medicinal products. Port placement is done either by a surgeon or an interventional radiologist. Ports, made of silicon or polyurethane central venous catheters, are usually inserted in the internal jugular vein or subclavian vein and then connected to a reservoir implanted subcutaneously in the upper thoracic region, usually over the pectoralis muscle. The placement of ports needs technical expertise along with the availability of ultrasound guidance for placement and a C-arm system for confirmation of the position. TIVADs have been shown to be superior in terms of complications, when compared other forms of LTVADs. The Cancer And Venous Access (CAVA) trial compared TIVADs (Port) with peripherally inserted catheters (PICC) and Hickman type catheters and found that TIVADs halved the risk of complications compared with the other two. The patients' quality of life was similar with all three devices, although a quality-of-life measure specific to these devices showed some emotional and psychological benefits in favor of TIVADs. However, the higher cost associated with the use of TIVADs prevents their widespread use, especially in economically weaker setups. TIVADs are the most costly devices to use, followed by the Hickman-type devices, with the peripherally inserted central devices being the cheapest. Studies comparing different sites of TIVADs insertion have shown that the upper arm is a safe and feasible option for insertion besides chest ports, especially in patients with head-and-neck cancer or breast cancer.
Physicians using TIVADs as venous access channels should be aware of the complications and the method of salvaging the ports in case of complications. Three out of seven ports could be salvaged in the current study, emphasizing the need for a team trained in identifying and managing the complications related to ports including infections, thrombosis, or flipping of the port chamber to increase the salvage rates.
Ninety percent of ports at the authors' center were placed under ultrasound guidance, emphasizing the need for image guidance for such procedures to enhance the ease and accuracy of the technique. Only 6 ports (~16%) required general anesthesia; the others were placed under local anesthesia. This highlights the feasibility of port placement as a day care procedure while ensuring a safe standardized conduct of the procedure. Patients with cancer needing port placement often have comorbidities which preclude the administration of general anesthesia. Hence, conduct of the procedure under local anesthesia should be the standard of care while taking adequate procedural precautions. At times, despite ensuring all possible safety measures, the placement of central venous access devices may be associated with vascular injuries which can rarely lead to the need of an emergency sternotomy. The timely identification and management of such injuries with preparedness can prevent disastrous complications from a seemingly easy procedure.
The placement of TIVADs in oncology settings should become a routine in the near future, especially when financial constraints do not exist. The procedure needs to be standardized and personalized to individual healthcare delivery setups. A dedicated trained team for the management of TIVADs during the course of treatment is imperative to facilitate timely detection and management of catheter-related complications.
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