This new CV-port system, which uses an inner guide tube and over-the-wire technique to advance the catheter into the SVC, was successfully used in all implantations with a success rate similar to that of conventional systems using a peel-away sheath. Except for one procedure involving the pneumothorax and tube placement, no major intraprocedural complications and symptoms of bleeding from the puncture site or complications associated with the use of peel-away sheaths (air embolism, SVC rupture/perforation, and hemothorax) were encountered. This CV-port differs from the conventional port only in the implantation method. The catheter and port are the same as the conventional one, allowing for medication administration, blood sampling, and high-pressure contrast injections for cross-sectional imaging.
Several complications, including air embolism, SVC rupture, and hemothorax, have been reportedly associated with the use of peel-away sheaths [4, 5]. Air embolism refers to air migration in the venous system through the catheter or sheath, which occurs in 0.3–1.4% of cases when a peel-away sheath is used [4, 9]. According to the Society of Interventional Radiology (SIR) guidelines, the incidence of perforation and hemothorax is 0.5–1% and 1–3%, respectively [6]. Although the guidelines fail to specify the exact number of perforations and hemothorax caused by the use of peel-away sheaths, it is likely that some instances could be attributed to the use of peel-away sheaths. In contrast, our results showed that these complications occurred in 0% of cases.
The reported success rate of image-guided (usually under real-time ultrasound guidance) implantation of a CV-port through the IJV is approximately 100% [1, 10,11,12,13], which is consistent with our new implantation method. The difficulty of this procedure was not high, and trainees performed 66.7% of the implantations. The SIR guidelines state that ultrasound-guided access confers a higher initial venous cannulation success [6]. In this study, all venous punctures were successfully performed under ultrasound guidance.
CV-port implantation is a safe procedure, and the use of real-time ultrasound guidance is recommended because it may reduce the risk of complications [14, 15]. Intraprocedural complications include bleeding, hematoma, catheter malposition, arrhythmias, pneumothorax, air embolism, perforation, hemothorax, and others [10, 11, 16, 17]. The SIR guidelines state that the suggested thresholds for major complications of image-guided central venous access in the internal jugular and subclavian vein approach are pneumothorax (4%), hematoma (4%), procedure-induced sepsis (4%), air embolism (2%), perforation (2%), and hemothorax (2%) [6]. The 11 intraprocedural complications observed were not specific to this implantation method but were common and minor, except for pneumothorax (n = 1). The incidence rate of pneumothorax was 0.2–0.5% in cases of IJV puncture [18], similar to the results of our study. We followed the SIR guidelines, which recommend that anticoagulants and antiplatelet medications should not be interrupted because this procedure targets the vein as a low-bleeding risk procedure [19]. However, intraoperative bleeding is usually not a clinical problem and does not require special treatment. The method of catheter advancement into the vein has changed in this device; however, the catheter, technique of puncturing the IJV, and guiding image used are the same as those used in the conventional method. Therefore, our CV-port patients appear to be comparable with the conventional ones regarding the frequency of late postprocedural complications (≥ 30 days).
Although central vein puncture-related deaths have also been reported, they are rare. The cause of such deaths included asphyxia due to neck hematoma associated with IJV puncture, superior mediastinal and right thoracic hemorrhage due to vertebral artery injury, circulatory changes due to pneumothorax, and fatal arrhythmia secondary to cardiac tamponade due to catheter perforation into the right ventricle [20, 21]. Thus, reducing the risk of hematoma formation at the IJV puncture site makes CV-port implantation safer. Patients with bleeding or coagulation abnormalities, as well as those on anticoagulant and/or antiplatelet medications, may particularly benefit from reduced bleeding at the venous puncture site.
Air migration in small amounts may be asymptomatic; however, migration of a large amount of air leads to cyanosis, increased respiratory rate, hypotension, and cardiac murmurs [2], culminating in neurological or fatal complications [22, 23]. Furthermore, hyperbaric oxygen therapy is indicated when the signs are severe [24]. However, there is a risk of neurological and cardiac complications in some patients (those with pulmonary arteriovenous malformations and septal defects of the heart) [22]. To reduce air embolization during CV-port implantation, operators must strive to minimize intravenous and atmospheric traffic by shortening the time between the removal of the inner peel-away sheath and the insertion of the catheter. In a study that investigated air embolism in 15 central venous catheter insertions, a peel-away sheath was used in all the procedures [4]. An in vitro study showed that aerostasis (air inflow) can occur under stressed conditions (with a wire in the sheath), even when using a valved peel-away sheath [25]. In the present implantation method (disuse of a peel-away sheath), the risk of air migration is relatively low.
This study has some limitations. First, the study was conducted retrospectively at a single center. Second, we did not compare our results with the results of CV-port implantation using a peel-away sheath. However, because all implantations were successfully performed with no major complications except for one case of pneumothorax, there seems to be no difference. Finally, this CV-port device could theoretically reduce the risk of some complications (air embolization, SVC rupture/perforation, hemothorax, and bleeding from the puncture site). However, as these complications are clinically rare, it may be difficult to statistically prove this benefit.
In conclusion, this new CV-port device demonstrated success and complication rates comparable to those of conventional devices. Therefore, it may be a desirable and safer alternative for patients requiring central venous access, offering additional potential benefits, such as the elimination of complications associated with the use of a peel-away sheath.
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