|Year : 2014 | Volume
| Issue : 1 | Page : 15-18
Totally implanted vascular access devices: A retrospective study of indications and complications in a single pediatric institute
Akram J Jawad1, Yassen F Alalayet1, Fawaz Alkasim2, Saad Alhamidi1, Mohammad J Shoura1, Eatedal Fathy Ghareeb2, Bashar S Najjar2
1 Department of Pediatric Surgery, King Saud Medical City, Riyadh, Saudi Arabia
2 Department of Pediatric Oncology and Hematology, King Saud Medical City, Riyadh, Saudi Arabia
|Date of Web Publication||2-May-2014|
Akram J Jawad
Department of Pediatric Surgery, King Saud Medical City, Pediatric Surgery, Riyadh
Source of Support: None, Conflict of Interest: None
Background and Objective: Recently totally implanted vascular access devices (TIVADs) have played an essential role in the management of pediatric patients. The purpose of this study was to describe the indications, techniques and complications of the procedures. Design and Setting: A retrospective study of all patients' files underwent TIVADs procedures between 2009-2012, in a single service providing institute in Saudi Arabia (King Saud Medical city-Riyadh). Patients and Methods: Fifty four TIVADs were inserted in fifty one patients (thirty males and twenty one females). Age ranged six months and twelve years (average 5.6 years). All TIVADs were implanted by pediatric consultant surgeons under general anesthesia. Seldinger technique used in fifty procedures and open approach in four patients. Results: The main indications for TIVADs use were acute lymphocytic leukemia forty six (90%), congenital nephrotic syndrum two (4%), hemophilia two (4%) and solid tumor one (2%). TIVADs were in situe for a total of 35222 days (average 652 days/catheter). Over all complications rate was (30%). Conclusion: TIVADs provided a simple almost pain free venous system access, allow children to conduct a normal life style and sport activities. We believe this study is one of very few reviews originating from developing countries with results comparable to those of world literature.
Keywords: Children, complications, implanted vascular device, portacath
|How to cite this article:|
Jawad AJ, Alalayet YF, Alkasim F, Alhamidi S, Shoura MJ, Ghareeb EF, Najjar BS. Totally implanted vascular access devices: A retrospective study of indications and complications in a single pediatric institute. J Appl Hematol 2014;5:15-8
|How to cite this URL:|
Jawad AJ, Alalayet YF, Alkasim F, Alhamidi S, Shoura MJ, Ghareeb EF, Najjar BS. Totally implanted vascular access devices: A retrospective study of indications and complications in a single pediatric institute. J Appl Hematol [serial online] 2014 [cited 2019 Jun 18];5:15-8. Available from: http://www.jahjournal.org/text.asp?2014/5/1/15/131820
| Introduction|| |
Since their introduction (over 20 years ago), totally implanted vascular access devices (TIVADs) have played an important role in the management of pediatric patients in need of frequent blood products infusion, blood sampling, albumin, and chemotherapy medications. ,,
Among the oldest tunneled catheters used are Hickman and Broviac. These catheters have an external exit site and usually require frequent site care.
On the other hand, TIVADs are becoming more popular to use recently as they require less frequent professional care, provide more freedom, and grant the patients the advantage of the ability to participate in leisure and sport activities such as swimming. ,
With the expanding use of TIVADs, however, new and more frequent complications are encountered. 
The majority of the reported complications with the use of (TIVADs) in the literature are based on adult studies. 
The aim of this study is to analyze the complications and the results encountered with prolonged use of TIVADs in developing countries, and to discuss possible recommended methods to prevent its associated complications.
| Materials and methods|| |
Fifty-one children with ages ranging between 6 months and 12 years (average 5.6 years) required TIVADs insertion during this study period (2009-2012). Of them, 30 were males (59%) and 21 were female (41%) [Table 1]. A second TIVAD insertion was required in three (6%) children. Each procedure was recorded as a separate event; therefore, the total number of TIVADs analysis was 54. In an attempt to reduce the possible care-related complications, a special preimplantation educational course was given to all our patients and their parents [Summary 1].
Bard Port (Bard Access System, Inc) with hard plastic base was used in all our patients. All TIVADs were assembled at the time of insertion by connecting to a single-lumen polyurethane catheter with an external diameter of 1.6 mm. A slim system was used in only one patient due to the patient's thin skin and low body weight.
All TIVADs were placed by a consultant pediatric surgeon using general anesthesia. Surgical implantation of the device was achieved using the percutaneous Seldinger catheter insertion technique (right internal jugular (41, 76%) and subclavian vein (nine, 17%)). Open insertion technique of catheter via right internal jugular vein dissection with 6/0 nylon purse string suture was used in four patients (7%). In all patients, catheter length was estimated perioperatively from the site of venous entry to the junction of manubrium and the sternal body. Catheter tip position was verified using fluoroscopy. The port's chamber was implanted on the anterior pectoral muscle fascial surface and anchored with 3/0 vicryl sutures. Chambers were flushed with 3-6 mL of heparinized normal saline (100 IU/mL) at the time of insertion with the use of a Huber non-coring needle.
Details regarding the underlying diagnosis, nature of port use, complications, and management were obtained by retrospective case notes review.
| Results|| |
A total of 54 TIVADs insertions were done in 51 patients. The main TIVADs insertion indications were acute lymphocytic leukemia (ALL) (46, 90%) with absolute white blood cell (WBC) of more than 500; congenital nephrotic syndrome, two (4%); hemophilia, two (4%); and solid neoplasm, one (2%). TIVADs were in situ for a total of 35,222 days with an average of 652 days/catheter (range 28-1,320 days).
The overall complication rate was 30%. Seven patients (13%) showed signs of port-related systemic infections and were treated with systemic antibiotics and antifungal medications (five non-coagulase Staphylococcus aureus, one Pseudomonas, and one candidiasis). Five patients (9%) developed signs of blockage, of which two ports responded to thrombolytic treatments and three ports were replaced for complete blockage and unsuccessful thrombolytic treatment. Two patients (4%) developed partial skin-covering erosion; successful relocation of the chamber under general anesthesia was achieved [Figure 1]. Two patients (4%) in ALL remission had catheters that were severely adherent to the vascular system. Successful removal of the proximal part of the catheters was achieved in a tertiary cardiac center [Table 2].
| Discussion|| |
One of the main problems that patients with pediatric neoplasms, hematologic disorders, and patients that require long-term total parenteral nutrition (TPN) encounter is venous access exhaustion.
Among the main causes is vein irritation due to chemotherapy agents, hyperosmolar solutions, and the type of catheters used.
In addition, peripheral veins are not easily accessible in younger patients and thus are not useful for repeated long-term infusion.
Tunneled, cuffed silastic catheters, first described by Broviac et al.,  and subsequently modified by Hickman et al.,  were developed for long-term use in patients requiring frequent vascular access and have proven to be more flexible, inert, and are associated with fewer complications.
Recently, TIVADs offered a viable alternative in some patients who require less skin care, wanted to preserve their body image, or wanted fewer limitations to their lifestyle. , Many studies reported fewer complications with TIVADs compared to the tunneled central catheter. ,, Device-related infection remains a significant cause of morbidity in all central venous catheters' insertion. 
Reported infection rates vary in different series (15-48%) depending on the criteria used to define infection. , Our infection rate was 13% (0.2/1,000 days). On reviewing patient's demographic criteria, no specific predisposing factors were identified; however, all cases were successfully managed conservatively.
Babu and Spicer reported that two ports (3.6%) were removed due to infection,  in comparison to our series where no catheter removal was documented. Broad spectrum antibiotics were used in all our insertion procedures. However, as reported in the literature,  we could not document that the use of prophylactic antibiotics during catheter insertion is of benefit in reducing sepsis or prolonging catheter survival. Freytes and Cesar claimed that the use of TIVADs impregnated with antibiotic reduces the rate of catheter colonization and catheter-related bloodstream infections as compared with the use of unimpregnated catheters for short use. 
Ports blockage rate as reported in the literature is 7-8%.  Our study showed partial blockage in two (4%) patients who later responded well to thrombolytic treatment. Complete TIVADs blockage required ports replacements in three (5%) patients. Catheter blockage is suspected when the catheter fails to allow blood to withdraw (ball valve effect) or there is a failure in infusing the device. Intraluminal thrombosis can be lysed in most situations (80-95%) with fibrinolytic agents (urokinase, streptokinase, and tissue plasminogen activators). 
TIVADs require a high concentration of heparinized saline (100 IU/mL) and a large volume to flush the device (3-6 mL). Failure to do this every 3-4 weeks and each time after access may result in blockage. 
Leakage and extravasations can occur when the port is dislodged or the catheter connection device is loosened.  Inappropriate device access technique like the use of excessive force or the use of a very long needle can result in a hole in the plastic base of the device.  Securing the catheter connection (lock) to the device is very important.
Catheter dislodgement, breakage, and embolization have been reported in the literature. Cardiac catheterization is required for retrieval of an embolized catheter. Pre-assembled devices may avoid catheter disconnection, though catheter breakage could still result in an embolization risk. 
Device malposition is not a frequently reported complication; we encountered two (4%) patients with partial skin erosion [Figure 1]. Relocation with wound debridement was successful in both patients. Proper device pocket creation at the time of insertion and accurate port size selection in relation to the age of the patient is essential to avoid this complication.
|Figure 1: The arrow shows the eroded skin with part of the port chamber exposed|
Click here to view
Other potential complications reported in the literature during the initial insertion of central venous catheters are pneumothorax (3.6%),  subclavian and carotid arteries injury, thoracic duct injury, brachial plexus injury, and air embolism. 
| Conclusion|| |
We believe this is the first study of TIVADs in Saudi Arabia for pediatric age group. The results of our experience with TIVADs are comparable with other series. Apart from the two cases that required cardiac catheterization to remove the proximal adherent part of the catheter, TIVADs provided a simple almost pain-free access to the venous system, allowing children to maintain a normal lifestyle along with leisure and sport activities. Also, TIVADs requires minimal maintenance by monthly catheter flush performed by well-trained and experienced personnel.
| References|| |
|1.||Ball AB, Duncan FR, Foster FJ, Davidson TI, Watkins RM, Hodson ME. Long term venous access using a totally implantable drug delivery system in patients with cystic fibrosis and brochiectasis. Respir Med 1989;83:429-31. |
|2.||Biffi R, Corrado F, de Braud Fcases, de Lucia F, Scarpa D, Testori A, et al. Long-term, totally implantable central venous access ports connected to a Groshong catheter for chemotherapy or solid tumor: Experience from 178 cases using single type of device. Eur J Cancer 1997;33:1190-4. |
|3.||Biffi R, de Braud F, Orsi F, Pozzi S, Mauri S, Goldhirsch A, et al. Totally implantable central venous access ports for long term chemotherapy. A prospective study analyzing complications and cost of 333 devices with a minimum follow-up of 180 days. Ann Oncol 1998;9:767-73. |
|4.||Krul EJ, van Leewen EF, Vos A, Voûte PA. Continuous venous access in children for long-term chemotherapy by means of implantable system. J Pediatr Surg 1986;21:689-90. |
|5.||Lambert ME, Chadwick GA, Mc Mahon A, Scarffe JH. Experience with portacath. Hematol Oncol 1988;6:57-63. |
|6.||Babu R, Spicer RD. Implanted vascular access devices (ports) in children: Complications and their prevention. Pediatr Surg Int 2002;18:50-3. |
|7.||Kock HJ, Pietsch M, Krause U, Wilke H, Eigler FW. Implantable vascular access systems: Experience in 1500 patients with totally implanted central venous port systems. World J Surg 1998;22:12-6. |
|8.||Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet 1973;136:602-6. |
|9.||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. |
|10.||Harvey WH, Pick TE, Reed K, Solenberger RI. A prospective evaluation of the Port-A-Cath implantable venous access system in chronically ill adults and children. Surg Gynecol Obstet 1989;169:495-500. |
|11.||Mirro J Jr, Rao BN, Kumar M, Refferty M, Hancock M, Austin BA, et al. A comparison of placement techniques and complications of externalized catheters and impalpable port use in children with cancer. J Pediatr Surg 1990;25:120-4. |
|12.||Groeger JS, Lucas AB, Thaler HT, Friedlander-Klar H, Brown AE, Kiehn TE, et al. Infections morbidity associated with long-term use of venous access devices in patients with cancer. Ann Intern Med 1993;119:1168-74. |
|13.||Bollard CM, Teague LR, Berry EW, Ockelford PA. The use of central venous catheters (portacaths) in children with haemophilia. Haemophilia 2000;6:66-70. |
|14.||Panthagkool W, Singhapakdi S, Teeraratkul S, Molagool S, Pakakasama S, Hathirat P, et al. Subcutaneous portacath utilization in pediatric oncology patients: Ramathibodi Hospital experience. J Med Assoc Thai 1999;82:S77-81. |
|15.||Freytes CO. Indications and complications of intravenous devices for chemotherapy. Curr Opin Oncol 2000;12:303-7. |
|16.||Lawson M, Bottino JC, Hurtubise MR. The use of urokinase to restore patency of occluded central venous catheters. Am J Intraven Ther Clin Nutr 1982;9:29-32. |
|17.||Poorter RL, Lauw FN, Bemelman WA, Bakker PJ, Taat CW, Veenhof CH. Complications of an implantable venous access device (Port-a-Cath) during intermittent continuous infusion of chemotherapy. Eur J Cancer 1996;32A: 2262-6. |
|18.||Venous Access and Prots: leeds MDT April 2008- Totally indwelling venous access device. [online] Department of respiratory medicine St-Jame's university hospital, UK. Available from: www.cysticfibrosismedicine.com. [Last accessed on 2008 April]. |
[Table 1], [Table 2]