Patency and complications in the follow-up of totally implantable catheters for chemotherapy

ORIGINAL ARTICLE

Patency and complications in the follow-up of totally implantable catheters for chemotherapy

Robson Barbosa de Miranda^I; Jocefábia Reika Alves Lopes^II; Rafael Noronha Cavalcante^II; Ohannes Kafejian^III

^IVascular surgeon. Assistant physician, Angiology and Vascular Surgery, Faculdade de Medicina, Fundação do ABC (FMABC), Santo André, SP, Brazil.

^IIResidents in Vascular Surgery, Angiology and Vascular Surgery, FMABC, Santo André, SP, Brazil.

^IIIProfessor, Angiology and Vascular Surgery, FMABC, Santo André, SP, Brazil.

ABSTRACT

BACKGROUND: Availability of venous access for patients that receive long-term cytotoxic therapy is of great importance to the success of treatment. Totally implantable devices have been increasingly more used for this therapy, providing improvement in the quality of life of patients.

OBJECTIVE: To evaluate patency and complications of totally implantable catheters inserted in oncological patients.

METHODS: Retrospective longitudinal study of 74 patients that underwent placement of totally implantable catheter from January 2004 throughout February 2007.

RESULTS: Totally implantable catheters were placed in 74 patients with mean age of 48.9 years; the female gender was predominant. The most prevalent neoplasms were breast (40.5%), colon (20.8%) and lymphoma (18.9%). Cervical access (74.3%) was prevalent, using the internal jugular vein in 45.9% of cases. Only 13.5% of accesses were inserted via subclavian vein puncture. Mean duration of catheter use was 335.33 days. Thirty six (48.6%) patients remained with the catheter after the chemotherapy was discontinued. There were no complications in 67 (90.5%) patients. Among early complications, there was one (1.4%) pneumothorax and one (1.4%) hematoma. Among late complications, there were five (6.7%) infections. Ten (13.5%) catheters were removed, five due complications and five after ending the treatment. Eleven (14.9%) patients died from cancer, and the catheters were still functioning.

CONCLUSION: The outcomes obtained show low rate of complications, confirming that use of totally implantable catheters is safe and effective for patients undergoing chemotherapy.

Keywords: Chemotherapy, implantable catheters, infection, quality of life.

RESUMO

CONTEXTO: A disponibilidade de acesso venoso nos pacientes que recebem cursos prolongados de terapia citotóxica é de grande importância para o sucesso do tratamento. Os cateteres totalmente implantáveis vêm sendo cada vez mais utilizados para a referida terapia, proporcionando melhoria na qualidade de vida dos doentes.

OBJETIVO: Avaliar a perviedade e complicações dos cateteres venosos totalmente implantáveis instalados nos pacientes oncológicos.

MÉTODOS: Estudo longitudinal retrospectivo com 74 pacientes submetidos a colocação de cateter totalmente implantável de janeiro de 2004 a fevereiro de 2007.

RESULTADOS: Foram inseridos cateteres venosos totalmente implantáveis em 74 pacientes com idade média 48,9 anos, predominando o sexo feminino. As neoplasias mais prevalentes foram mama (40,5%), cólon (20,8%) e linfoma (18,9%). Houve predomínio do acesso venoso pela via cervical (74,3%), com utilização da veia jugular interna em 45,9% dos casos. Somente 13,5% dos acessos ocorreram por punção da veia subclávia. A duração média de uso dos cateteres foi de 335,33 dias. Trinta e seis doentes (48,6%) mantiveram-se com o cateter após o término da quimioterapia. Sessenta e sete doentes (90,5%) não apresentaram complicações. Entre as complicações precoces, houve um (1,4%) pneumotórax e um (1,4%) hematoma na loja de implantação. Entre as complicações tardias, ocorreram cinco (6,7%) infecções. Foram retirados 10 (13,5%) cateteres, cinco devido às complicações e cinco por término do tratamento. Houve 11 (14,9%) óbitos de pacientes em decorrência do câncer, com o cateter funcionante.

CONCLUSÃO: Os resultados obtidos demonstram baixa taxa de complicações, confirmando a segurança e conveniência do uso dos acessos totalmente implantáveis em paciente em regime de quimioterapia.

Palavras-chave: Quimioterapia, cateter implantável, infecção, qualidade de vida.

Introduction

Central venous access is recommended in the treatment of patients submitted to prolonged endovenous therapy, especially in patients receiving high doses of chemotherapy, transplantation of blood cells, parenteral feeding, among others.¹ After the development of the partially implantable catheter described by Broviac and modified by Hickman in 1970, the management of oncological patients became easier due to increased safety in this device compared with peripheral accesses.^2,3 Since the introduction of totally implantable venous catheters (TIVC) in 1980, it has been increasingly more used, revolutionizing treatment and quality of life of oncological patients.^4,5

This study aims at evaluating patency and complications of TIVC implanted in patients submitted to oncological cytotoxic therapy, at the chemotherapy unit, as part of the course on Angiology and Vascular Surgery at Faculdade de Medicina do ABC (FMABC).

Methods

Seventy-four patients submitted to TIVC were retrospectively evaluated from January 2004 to February 2007 at Hospital Estadual Mario Covas, Faculdade de Medicina do ABC, São Paulo, Brazil. All catheters were implanted in the operating room under local anesthesia and fluoroscopic control. By the end of the procedure catheter flow and reflow was tested, followed by system heparinization using a 50 IU/mL heparin solution. Patients were undergoing antibiotic prophylaxis with 2 g cefazolin before catheter implantation.

Complications were classified into two categories: early (intraoperative and postoperative period before use – first month) and late (complications that occurred after catheter use). Patients with local skin infection or clinical suspicion of systemic infection were not submitted to TIVC implantation. All infected catheters were removed.

Results

Mean age was 48.9 years, ranging between 18 and 74; 58 were female (78.4%) and 16 were male (21.6%). Of this group of patients, 13 had hypertension (17.6%), five had deep venous thrombosis (6.8%) and four were diabetic (5.4%).

Neoplasms were solid in 81.1% and hematologic in 18.9%. Breast neoplasm was the most frequent, followed by colon cancer and lymphoma (Table 1).

Table 1 - Click to enlarge

Venous access by puncture was performed in 63.5% of cases. Venous dissection was used to access external jugular and cephalic veins. Cervical approach (74.3% of cases) was predominant, and the internal jugular vein (45.9%) was the most frequently used. Only 13.5% of accesses occurred by subclavian puncture, as shown in Table 2.

Table 2 - Click to enlarge

Mean duration of catheter use was 335.33 days, and 36 patients (48.6%) remained with the catheter after chemotherapy was terminated.

There were no complications in 67 patients (90.5%). There were two early complications, one (1.4%) pneumothorax and one (1.4%) hematoma at the implantation site. Among late complications, there were five infections (6.7%), as described in Table 3.

Table 3 - Click to enlarge

Ten catheters were removed (13.5%), five due to complications (6.7%) and five due to end of treatment (6.7%).

Over the study period, 11 patients (14.9%) died from neoplastic disease. Of these, all had patent and functioning catheters.

Discussion

Since their introduction in 1980, TIVC have been widely used for application in chemotherapy,⁴ especially in patients with poor peripheral venous circulation. They have also been used in patients under parenteral feeding^6-8 and hemodialysis.⁹

TIVC are comprised of a silicon catheter, whose distal extremity is placed on the junction between the superior vena cava and the right atrium, and the proximal is connected to a reservoir implanted on the subcutaneous cell tissue. This provides a safe and repeated use of this vascular access in endovenous treatment. TIVC have advantages over partially implantable systems: low infection rates and more freedom for patients' physical activities.^10-13

TIVC are associated with complications such as infection, hematoma, pneumothorax, catheter obstruction, deep venous thrombosis,^4,14-16 and fracture with possible catheter migration.⁵

Despite the advantages TIVC offer, such devices require handling by experienced professionals and may occasionally be associated with complications, such as bleeding, pneumothorax and infection, among others.⁴ Local pain or subcutaneous extravasation during use of this device warn to the possibility of catheter occlusion or fracture. A fragmented catheter in the heart can remain asymptomatic for years.¹⁷

Solid neoplasms were predominant, and there was no case of leukemia, as it is a common disease in youngsters. In our institution, pediatrician surgery is in charge of TIVC implantation in patients under 18 years, according to an agreement between surgical teams and oncology.

Cervical access (74.3% of cases) was the most frequently used, and the internal jugular vein by puncture was predominant (45.9%); of seven complications found in this study, four occurred in accesses performed by dissection.

Complications seen in this study were similar to those described in published scientific articles, as shown in Table 4.

Table 4 - Click to enlarge

There was one case of pneumothorax that was followed by physical and radiological examination and treated conservatively with spontaneous remission on the first postoperative day. Low incidence of this complication is probably because the subclavian vein by puncture was little used. The only case of hematoma at the puncture site was treated conservatively.

Bacteremia or septicemia related to TIVC may occur by puncture site infection, contamination of infused solution or even by hematogenic seeding based on an infectious focus at a distance. Femoral access can have higher rate of infection. Wolosker et al.¹⁸ observed infectious complications with frequency of 0.69/1,000 days of use when implanting TIVC by femoral access. More conservative approaches in the treatment of this infectious complication have been proposed.¹⁹ In this series, the five patients with clinical suspicion of catheter infection (local hyperemia, bacteremia, arterial hypotension or positive blood culture) were submitted to catheter removal and administration of antibiotic therapy.

In conclusion, low complication rates obtained in this study, equivalent to the literature, confirm safety and convenience of totally implantable accesses in patients undergoing prolonged chemotherapy.

References

• 1. Biffi R, Pozzi S, Agazzi A. Use of totally implantable central venous access ports for high-dose chemotherapy and peripheral blood stem cell transplantation: results of a monocentre series of 376 patients. Ann Oncol. 2004;15:296-300.
• 2. Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet. 1973;136:602-6.
• 3. Hickman RO, Buckner CD, Clift RA, Sanders JE, Stewart P, Thomas ED. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet. 1979;148:871-5.
• 4. Wolosker N, Yazbek G, Nishinari K. Totally implantable venous catheters for chemotherapy: experience in 500 patients. São Paulo Med J. 2004;122:147-51.
• 5. Kapadia S, Parakh R, Grover T, Yadav A. Catheter fracture and cardiac migration of a totally implantable venous device. Indian J Cancer. 2005;42:155-7.
• 6. Di Carlo I, Cordio S, La Greca G. Totally implantable venous access devices implanted surgically: a retrospective study on early and late complications. Arch Surg. 2001;136:1050-3.
• 7. Kurul S, Saip P, Aydin T. Totally implantable venous-access ports: local problems and extravasation injury. Lancet Oncol. 2002;3:684-92.
• 8. Freytes CO. Indications and complications of intravenous devices for chemotherapy. Curr Opin Oncol. 2000;12:303-7.
• 9. Sandhu J. Dialysis ports: A new totally implantable option for hemodialysis access. Tech Vasc Interv Radiol. 2002;5:108-13.
• 10. Freytes CO, Reid P, Smith KL. Long-term experience with a totally implanted catheter system in cancer patients. J Surg Oncol. 1990;45:99-102.
• 11. Gyves JW, Ensminger WD, Niederhuber JE, et al. A totally implanted injection port system for blood sampling and chemotherapy administration. JAMA. 1984;251:2538-41.
• 12. Carde P, Cosset-Delaigue MF, Laplanche A, Chareau I. Classical external indwelling central venous catheter versus totally implanted venous access systems for chemotherapy administration: a randomized trial in 100 patients with solid tumors. Eur J Cancer Clin Oncol. 1989;25:939-44.
• 13. Vanek VW. The ins and outs of venous access: Part I. Nutr Clin Pract. 2002;17:85-98.
• 14. Hackert T, Tjaden C, Kraft A, Sido B, Dienemann H, Buchler MW. Inatrapulmonal dislocation of a totally implantable venous access device. World J Surg Oncol. 2005;11:3-19.
• 15. Chang HM, Hsieh CB, Hsieh HF, et al. An alternative technique for totally implantable central venous access devices. A retrospective study of 1311 cases. Eur J Surg Oncol. 2006;32:90-3.
• 16. Charvát J, Linke Z, Horáèková M, Prausová J. Implantation of central venous ports with catheter insertion via the right internal jugular vein in oncology patients: single center experience. Support Care Cancer. 2006;14:1162-5.
• 17. Van Den Akker-Berman LM, Pinzur S, Aydinalp A, et al. Uneventful 25-year course of an intracardiac intravenous catheter fragment in the right heart. J Interv Cardiol. 2002;15:421-3.
• 18. Wolosker N, Yazbek G, Munia MA, Zerati AE, Langer M, Nishinari K. Totally implantable femoral vein catheters in cancer patients. Eur J Surg Oncol. 2004;30:771-5.
• 19. Koldehoff M, Zakrzewski JL. Taurolidine is effective in the treatment of central venous catheter-related bloodstream infections in cancer patients. Int J Antimicrob Agents. 2004;24:491-5.

Correspondence

Publication Dates

• Publication in this collection
  20 Feb 2009
• Date of issue
  Dec 2008

History

• Received
  03 July 2008
• Accepted
  31 Oct 2008