Comparison of Central Venous Port Procedures Between Puncture vs. Cut-down and Residents vs. Senior Surgeons

Patients and Methods

The ethics committee of our institution approved this study and the use of the details in the patients’ medical records for the study (20061519). The study met the guidelines of the Declaration of Helsinki. We retrospectively reviewed the records of 296 oncologic patients undergoing TICVAD implantation from April 2014 to December 2019 in the Department of Surgical Oncology at Nagasaki University Hospital. Because we excluded 28 patients in whom TICVAD implantations were performed by the P method via the subclavian vein, 268 oncologic patients were eligible for this study. All puncture sites for the P method were jugular veins, and all procedures for the P method were performed under real-time intraoperative US. The study group comprised 98 men and 170 women, with a median age of 64 years. The main primary diagnosis was digestive system cancer (n=92), followed by haematological malignancy (n=63), breast cancer (n=57), gynaecological cancers (n=20), lung cancer (n=19), and other tumours (n=17). A single preoperative dose of a first-generation cephalosporin was administrated in patients not receiving antibiotics. Four types of TICVADs were used: 169 (63.1%) were Safe Guide™ MicroNeedle ports with a closed-end 8.0-Fr single lumen (Cardinal Health, Dublin, OH, USA), 78 (29.1%) were PowerPort devices with a closed-end 8.0-Fr single lumen (Bard Access Systems, Salt Lake City, UT, USA), 13 (4.9%) were P-U Celsite ports with an open-end 6.0-Fr single lumen (Toray Medical Co., Ltd. Tokyo, Japan), and 8 (3.0%) were PowerPort Slims with an open-end 6.0-Fr single lumen (Bard Access Systems). The position of the distal tip of the catheter in the superior vena cava was confirmed in all patients using intraoperative fluoroscopic guidance to identify the tracheal bifurcation.

We divided patients into two groups based on the operating procedures: P method (172 procedures performed by 51 surgeons) and CD method (96 procedures performed by 21 surgeons). We also divided the patients into two additional subgroups on the basis of the surgeons’ experience for both the P and CD methods, as follows: P method performed by resident surgeons (P-R, 131 procedures performed by 32 resident surgeons), P method performed by senior surgeons (P-S, 41 procedures performed by 19 senior surgeons), CD method performed by resident surgeons (CD-R, 59 procedures performed by 15 resident surgeons), and CD method performed by senior surgeons (CD-S, 37 procedures performed by 6 senior surgeons) (Figure 1). None of the resident surgeons were board-certified surgeons, at 3 years after graduation from medical school, whereas all senior surgeons were board-certified. We compared operation time, including changing the P site and changing the procedure from CD to P, completion rate, complications, and preoperative US findings (vein diameter, depth, and convergence between the cephalic vein and axillary vein). Complications were divided into intraoperative and postoperative complications.

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Figure 1.

Flow chart of all cases. TICVADs: Totally implantable central venous access devices; P-R: Puncture method performed by resident surgeons; P-S: puncture method performed by senior surgeons; CD-R: cut-down method performed by resident surgeons; CD-S: cut-down method performed by senior surgeons.

Percutaneous puncture procedure (P-R and P-S). All puncture sites were the internal jugular veins, and real-time intraoperative US visualized the needle as it was guided through the skin and into the vein. Successful P was confirmed by venous return in the syringe. The Seldinger technique was used with a guide wire, a dilator, and a peel-away sheath for catheter insertion, and fluoroscopy was used to confirm the position of the tip of the catheter in the superior vena cava. Two incisions were necessary: a small neck incision at the catheter exit site from the skin and a second larger incision to implant the reservoir on the chest wall. A subcutaneous tunnel was made from the larger incision to the small incision in front of the clavicle, and the catheter was passed from the small incision in the neck to the larger incision in the chest wall. Next, the catheter was connected to the reservoir and placed on the major pectoral fascia. Fixation between the reservoir and the major pectoral fascia was not usually performed with the P method. Postoperative X-ray examination was performed to rule out pneumothorax and catheter kinks.

Cephalic vein cut-down procedure (CD-R and CD-S). Primary approach. Generally, when resident surgeons performed the CD procedure, a senior surgeon helped as the first assistant surgeon. After sterilizing the patient’s skin, the skin and subcutaneous layer were incised for approximately 4 cm in the upper anterior chest wall along the deltopectoral groove. The fascia between the deltoid and major pectoral muscle was cut along the muscles, and the cephalic vein was exposed then ligated distally and encircled cranially with 3-0 absorbable suture. The cephalic vein was transected, and the catheter was then inserted directly into the cephalic vein through a transverse venotomy with a vein pick. We used fluoroscopy to confirm the position of the tip of the catheter in the superior vena cava. Using the same incision, we created a subcutaneous pocket on the major pectoral fascia, and connected the catheter to the reservoir. Patency for blood retrieval and no leakage at infusion were verified by direct puncture with a Huber needle, and the reservoir was sutured to the major pectoral fascia with two absorbable sutures (Figure 2). Postoperative X-ray examination was performed to confirm the location of the catheter and reservoir.

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Figure 2.

Intraoperative images showing the cut-down approach in the right cephalic vein. A) The deltopectoral groove was exfoliated. B) The cephalic vein was encircled and cut. C) Small venotomy of the cephalic vein (arrow). D) The vein pick was inserted into the cephalic vein. E) The catheter was inserted using the vein pick. F) The connected reservoir was implanted on the major pectoral muscle.

Secondary approach. If the cephalic vein was not identified, was too small to perform CD, the catheter could not be advanced into the superior vena cava, or other reasons prevented the primary approach, the Seldinger technique was performed in the ipsilateral internal jugular vein using real-time intraoperative US. Venous access was performed using the same procedure as for P-R and P-S, and the reservoir was placed using the incision for the cephalic vein CD approach and sutured to the major pectoral fascia as for the primary approach.

Preoperative ultrasonography. When the CD approach was attempted, preoperative US was performed with an 8.0-MHz-frequency linear probe (Viamo, Toshiba Medical System, Tochigi, Japan). The cephalic vein is located in the fat below the fascia between the deltoid and the major pectoral muscle. We evaluated the cephalic vein transverse diameter and depth near the coracoid process of the scapula, and venous convergence between the cephalic and axillary vein by searching upward, to improve the completion rate (9).

Statistical analysis. We first compared data between the P and CD methods and then compared data between residents and senior surgeons for each method. Continuous data and categorical data are expressed as medians with ranges and as cases with percentages, respectively. The statistical program JMP 14 (SAS Institute, Inc., Cary, NC, USA) was used to analyze the data. Continuous data were compared using the Wilcoxon signed-rank test, and categorical data were compared using the χ² test or Fisher’s exact test, when appropriate. Probability values <0.05 were considered statistically significant for all tests.