Keywords
Groshong valved catheter - retrograde tunneling - implantable port
Introduction
Retrograde port placement technique is required for port catheters that have distal
valve.[1] The advantages of retrograde tunneling include accurate tip placement and the distal
valve has the theoretical advantage of an antireflux mechanism.[2]
[3] Post-tunneling, the catheter is attached to the port chamber and the port chamber
is placed in a subcutaneous pocket, without any kinking or angulations. While trimming
the catheter length, a balance needs to be achieved between the operator comfort and
avoiding the kink due to excess length. Maintaining the optimum length of the catheter
to prevent angulations or kinks is essential to mitigate long-term port dysfunction.[4]
[5] This is technically challenging because of the restricted working space at the pocket
site. We describe a modified technique that gives more comfort to the operator during
attaching the port to the catheter.
Materials and Methods
This is a retrospective analysis of implantable ports that were placed using this
technique. All of the procedures were performed in an interventional radiology suite.
Informed consent was obtained before the procedure. The laboratory parameters like
an international normalized ratio of < 1.5 and a platelet count of more than 70,000
were desirable in all cases. Prophylactic antibiotics were administered 30 minutes
before the procedure as per the hospital protocol. Groshong valved implantable port
(X-port isp, BARD, single lumen venous catheter, 8F) was used in all cases. Undertaking
all aseptic precautions, the internal jugular vein (IJV) was accessed under ultrasound
(US) guidance. Right IJV was the preferred venous access. In cases where right chest
wall malignancy or thrombosis/stenosis precluded right internal jugular access, left
jugular access was selected. The patient is positioned supine with the head turned
toward the opposite side of the catheter insertion site. A standard surgical scrub
technique is performed in all cases. Skin is anesthetized with 1% lidocaine. IJV is
punctured in its inferior part under real-time US guidance. After blood is aspirated
to confirm the satisfactory position, a 0.035-inch guidewire was inserted into the
right atrium then to inferior vena cava under fluoroscopic guidance. Adequate blunt
dilation of the track was done before advancing the peel-apart sheath. Peel-away sheath
and dilator assembly were advanced over the guidewire as a single unit. Once the peel-away
sheath was adequately advanced, the dilator and J wire was removed. The port catheter
with stiffener wire was then advanced over the peel-away sheath. The peel-away sheath
is removed leaving the catheter in situ.
A subcutaneous pocket was created in the upper chest, preferably over the upper ribs.
Pocket creation was made in the upper lateral quadrant to facilitate a smooth curve
in the entire course of the port. Pocket size was made intentionally smaller so that
the port would snuggly fit into the pocket. Adequacy of the pocket size was checked
by introducing the port inside the subcutaneous pocket. The port was removed from
the subcutaneous pocket after checking the adequacy of the pocket size.
A subcutaneous tunnel was created from the port pocket to the venous access by advancing
the metallic tunneler. The catheter stiffener is removed and the end of the catheter
is attached to the tunneler barb with a twisting motion. Once the catheter end was
mounted on the tunneler, the tunneler was pulled out at the port pocket side. Using
fluoroscopy, the catheter was pulled back leaving the distal tip at the superior vena
cava-right atrial junction. Excess catheter length on the tunneler side was trimmed.
Suture thread (synthetic absorbable surgical suture, 3–0, 2 metrics, Vicryl, braided
coated polyglactin 910 violets, Ethicon, Johnson & Johnson Private Limited) was passed
into the catheter lock, and catheter lock was threaded over the catheter ([Figs. 1] and [2]). The catheter lock was pushed back to the subcutaneous tunnel leaving adequate
space for the attachment of the port. Port stem was advanced into the catheter after
proper alignment. Once the catheter tip is advanced up to midway of the port stem,
the catheter lock was pulled back close to the stem using the suture loop. The thread
loop was then removed after securing the lock. The catheter lock is advanced over
the catheter toward the port and moved to the locked position. The port is now placed
into a pocket created distal to incision. Stay sutures for the port base were not
used.
Fig. 1 (A) Clinical radiograph of the catheter lock anchoring technique. Implantable port placement
in progress. The tunneled port catheter is exiting from the chest wall incision. (B) The catheter lock is anchored with the suture and threaded over the catheter. (C) The port chamber is connected to the catheter after trimming. The catheter lock
is pushed deep in the subcutaneous tunnel for creating better working space. (D) Position of catheter lock after the catheter is connected to port chamber. (E) The catheter lock is pulled out from the subcutaneous tunnel. (F) The suture thread is removed and the catheter lock is advanced into the final position.
Fig. 2 (A) Pictoral illustration of the catheter lock anchoring technique. Implantable port
placement in progress. The catheter is tunneled and trimmed. (B) Enlarged view of the operating area. (C) Catheter lock is anchored over the suture thread and mounted over the catheter.
(D) The catheter lock is pushed back into the subcutaneous plane. (E) The catheter is connected to the port chamber stem. (F) The catheter lock is pulled back near the port chamber stem and the suture thread
is removed. (G) The catheter lock is advanced to the final locking position. (H) The port chamber is pushed into the port pocket.
Port functioning was assessed using a noncoring needle and a 10-mL syringe for free
flow or leak. The port pocket was flushed with normal saline to clear out blood. Heparin
lock solution was injected before removal of the noncoring needle. The incision site
of the port chamber was closed in two layers using Ethicon Vicryl 2–0 absorbable sutures.
The neck incision was closed with sutures.
A chest radiograph was taken to assess the catheter-nut angle. Catheter-nut angle
is defined as the angle between the port stem to the catheter. Patients were followed
up till the completion of treatment or till death with fully functional port (clinical
success). Early port removal secondary to infection or port dysfunction were also
noted, and if any, was also made note of (clinical failure)
Post-port care: The first dressing is changed after 48 hours and the second dressing is changed
1 week after the procedure. All patients were reviewed after 7 days of suture removal
if not absorbed spontaneously. Nursing staff were advised to use a 10-mL syringe for
flushing the port. The push and pause technique is recommended during flushing. After
medication, flushing with 10 mL of normal saline and after every blood withdrawal
flush with 20 mL of normal saline flush was suggested. When the port was not in use,
a flush with 10 mL of normal saline every 4 weeks was suggested.
Results
Total 29 patients underwent port placement with catheter lock anchor technique. Clinical
success was achieved in 27/29 (93.1%) patients (i.e., port maintained till completion
of treatment or death) ([Table 1]). In one patient, the port was removed early after 30 days due to port site infection.
In another patient, the port was removed due to the nonhealing of the wound. One patient
reported withdrawal malfunction but was able to complete the treatment with no further
intervention required. There were no periprocedural complications, and there have
been no other late complications.
Table 1
Summary of cases
|
No of patients
|
29
|
|
M: F
|
4:25
|
|
Median
|
52 (21-75 yr)
|
|
Diagnosis
Ca breast
Ca ovary
Ca lung
Ca colon
Ca pancreas
Sarcoma
|
17
2
1
5
1
3
|
|
Site
Right IJV
Left IJV
Catheter-nut angle
>170
<170
|
27
2
29
0
|
|
Total catheter days
Average catheter days
Patients died during follow up
The patient completed treatment or maintained port till death
|
12016
414 (11–1718)
4
27
|
|
|
|
Malfunction
Inability to draw blood samples
Inability to inject
Complete Obstruction of the line
|
1
0
0
|
|
Pinch-off syndrome
|
0
|
|
Late catheter break-embolization
|
0
|
|
Dislocation
|
0
|
|
Venous thrombosis
|
0
|
|
Port infection
Cutaneous site infection
Port-related bacteraemia plus pocket infection
|
1
0
|
|
Non-healing
|
1
|
|
Leak
|
0
|
|
Toddlers syndrome
|
0
|
Discussion
Many port-related complications can be avoided with good placement techniques.[1] The construction of gentle curves along the entire length of the implantable port
and optimal tip positioning helps to prevent long-term problems. The port pocket should
be made as small and as tight as possible to prevent movement of the port inside the
patient.[6]
[7]
[8]
Trimming the length of the catheter is very important; otherwise, the excessive length
may lead to kinks and abnormal catheter-nut angle.
When port pockets are made smaller, the working space during port placement is constrained
especially for retrograde port placement, since the port chamber needs to be attached
to the catheter toward the end of the procedure. The problem of limited space is more
exaggerated after the lock is mounted over the stump of the catheter. The lock needs
to be pushed into a subcutaneous tunnel to get an adequate working length to connect
to the port chamber. There is always the risk of migration and losing the catheter
lock in the subcutaneous tunnel while working on attaching the port chamber to the
catheter.
Our catheter lock anchor technique addresses this issue faced by operators during
the placement of retrograde implantable ports. The lock which is anchored with suture
thread can be pushed into the subcutaneous tunnel deeply to create working space for
the port chamber attachment. This technique eliminates the fear of migration of lock
deep inside the subcutaneous tunnel, during attachment of port chamber to the catheter
in constrained space. Operators need not cut extra length to become comfortable during
chamber attachment which may cause the abnormal catheter-nut angle.[9]
The catheter-nut angle in our series is below 170 degrees suggesting a smooth curve
at the port chamber end.[10] In our series, it was possible to achieve this angle due to our suture anchor technique.
The suture anchor technique provides extra working space for port attachment, which
otherwise requires extra catheter length. The extra length may cause the abnormal
catheter-nut angle when the final port chamber is planted in a subcutaneous pocket.
Because of the catheter lock technique, we never had to trim the extra length and
did not encounter any kinks in our series. This modified technique is simple, cheap,
and elegant.
Accurate placement of the catheter tip was achieved in all cases. No cases of leak,
detachment, catheter damage, and toddle syndrome were noted in our series. One case
of withdrawal dysfunction was noted, with maintained forward flow. This case was managed
conservatively. One case of nonhealing of the wound was noted in an old patient. This
was most likely due to patient-related comorbid factors and chemotherapy, rather than
modified technique. She was treated with port removal and secondary suturing of the
wound after refreshing wound edges.[11]
One case of infection was noted 1 month after the placement which resulted in port
removal. We give prophylaxis intravenous antibiotics that are usually administered
before the port placement.[12] Whenever possible chemotherapy is delayed for a week until the wound heals (7 days).[13] These might have contributed to good infection control in our series.
Open-ended catheters are generally preattached before antegrade tunneling. Hence,
working space constraint is not a major issue with preattached open-ended catheters.
To the best of my knowledge, this technique has never been described in the literature.
Conclusion
The catheter lock anchor technique is a safe and handy technique for the placement
of the port requiring retrograde tunnelling. Excellent catheter-nut angle can be achieved
with this technique.
