Massive hemothorax and Groshong catheters. Gonzales C,Westblom T U The West Virginia medical journal Central vascular access with cannulation of either the subclavian or internal jugular vein is a common procedure in the hospital. Complications are rare, but may be severe. We report a case with a near fatal complication in the form of massive hemothorax 19 days after placement of a Groshong catheter.
    ["Pinch-off sign" and spontaneous fracture of an implanted central venous catheter: report of a case]. Hou W Y,Sun W Z,Chen Y A,Wu S M,Lin S Y Journal of the Formosan Medical Association = Taiwan yi zhi Percutaneous subclavian implantation of an indwelling central venous catheter is an easy technique and provides convenient venous access for long-term intravenous therapy. Although rarely reported, spontaneous fracture of the catheter is an ominous complication which requires a prompt diagnosis and urgent treatment. We present a case of "pinch-off sign" resulting in a spontaneous fracture of an indwelling central venous catheter. A 49-year-old female breast cancer patient was admitted and Port-A-Cath was implanted for chemotherapy. Immediately after the implantation, fluid infusion and blood withdrawal was smooth until clinical "pinch-off sign" developed 3 weeks later. Chest X ray revealed no abnormal findings. Extravasation of antineoplastic drugs was noted 113 days after operation. Fracture of the indwelling catheter was found at the clavicle-rib junction. The fractured fragment was removed with a transvenous snare under fluoroscope. There was no hemodynamic derangement during the peri-operative period. Microscopy studies suggested that intermittent pressure on the catheter between the clavicle and the first rib may be responsible. The catheter wore on the medial side ue to a tearing and scissoring effect associated with free shoulder joint movement exerted additional forces on this wearing point which led to catheter fracture. The relationship between the spontaneous catheter fracture and "pinch-off sign" is reviewed. Our suggestions are: (1) By avoiding the traditional cannulation of the median subclavian vein, the lateral subclavian vein, infraclavicular axillary vein or internal jugular vein should be better routes for implantation. (2) Chest X ray (anterior-posterior and lateral view) should be examined routinely 3 weeks after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)
    Spontaneous migration of long-term indwelling venous catheters. DiGiacomo J C,Tarlian H S JPEN. Journal of parenteral and enteral nutrition Our institution recently encountered two patients with an unusual complication of indwelling catheters, spontaneous migration of the catheter tip. Both patients had indwelling subcutaneous ports placed via the left subclavian vein into the superior vena cava for the treatment of breast cancer. Both catheters functioned well but were noted on follow-up radiographs to have repositioned themselves, one into the azygous vein and the other into the internal jugular vein. One patient required surgical intervention to properly position the catheter for further chemotherapy. Chest roentgenograms are indicated to confirm the continued appropriate position of indwelling catheters when their position is in doubt to minimize the likelihood of complications associated with delivery of caustic chemotherapeutic agents in low flow vessels. 10.1177/0148607191015005574
    Surgical repair of superior vena cava syndrome. Calderon M C,Lozano V M,Jaquez A,Villaseñor C The Annals of thoracic surgery We present the case of a 53-year-old woman with a history of breast cancer, chemotherapy, and a long-term central venous access catheter, who presented with acute, severe superior vena cava syndrome. Angiography showed fibrous obstruction of the superior vena cava with thrombosis of the innominate, both axillary subclavian and internal jugular veins. Surgical repair consisted of thrombectomy of all the involved vessels and patch repair of superior vena cava and innominate vein. The patient had an uneventful recovery and remains asymptomatic 12 months after the procedure. 10.1016/s0003-4975(00)02429-2
    Spontaneous intrajugular migration of long-term central venous access catheters. Rasuli P,Hammond D I,Peterkin I R Radiology Two patients with long-term central venous access catheters introduced via the right subclavian vein demonstrated catheter migration into the right internal jugular vein several months after satisfactory catheter placement. One patient developed internal jugular vein thrombosis, which was treated with direct infusion of urokinase before catheter removal. In the other patient, the catheter was repositioned by using an intravascular snare loop, which was introduced via the femoral vein. In the first patient, an interim chest radiograph suggested the mechanism by which the catheter had migrated and provided a clue for early detection of catheter migration. 10.1148/radiology.182.3.822
    The CCSG prospective study of venous access devices: an analysis of insertions and causes for removal. Wiener E S,McGuire P,Stolar C J,Rich R H,Albo V C,Ablin A R,Betcher D L,Sitarz A L,Buckley J D,Krailo M D Journal of pediatric surgery This is an interval analysis of the 2-year prospective multicenter Childrens Cancer Study Group study of 1,141 chronic venous access devices in 1,019 children with cancer. Device type was external catheter (EC) 72%, totally implantable (TID) 28%, and did not differ for diagnosis or age except more double-lumen devices in bone marrow transplant protocols (77%) and more TIDs in children less than 1 year old (17.7%). Insertion characteristics evaluated in 1,078 (95%) were: operating room placement 99%; general anesthesia 98%; cutdown 67%; percutaneous 33%; atrial position 50%, caval position 50%; and perioperative antibiotics 48%. Vein entry was the external jugular 33%, internal jugular 22%, subclavian 35%, cephalic 7%, and saphenous 3%. Insertion was difficult or very difficult in only 10% and operative complications occurred in only 0.7%. Degree of difficulty bore no relationship to device type or patient age. The reasons for removal in 736 devices (67%) were due to complications in 39%, of which infections were the most frequent. There was some variance between centers ranging from 8.5% to 31% for infection; 2.8% to 24% for dislodgment; and 0% to 13% for occlusion. ECs had a higher risk of dislodgment; elective removals were more frequent in TIDs; there was no difference in infection as a cause for removal between ECs and TIDs. Dislodgment was associated with the shortest distance of the cuff to the skin exit (mean, 4 cm): less than or equal to 2 cm, 49%; greater than 2 cm, 28% (P = .009) and occurred most frequently in the younger patient (18.9%, 0 to 1 years; 0.5%, greater than 8 years. 10.1016/0022-3468(92)90304-p
    Costoclavicular pinching: a complication of long-term central venous catheters. A report of three cases. Nøstdahl T,Waagsbø N A Acta anaesthesiologica Scandinavica In the course of 1994-1995 we found three nearly identical cases involving fracture of polyurethane catheters from subcutaneous implantable vascular ports. This resulted in complications: leakage of drugs and infusions and thereby soft tissue damage. The leakage occurred in the costoclavicular space in all instances. We assume that the catheters have been subjected to repeated pinching, resulting in material fatigue. In order to eliminate the risk of this serious complication, the subclavian route should be avoided and preference given to the approach via the internal jugular vein.
    [A case of A-V fistula with severe hemolysis following internal jugular venipuncture]. Makuuchi H,Fuse K,Konishi T,Kukita M Nihon Geka Gakkai zasshi Severe hemoglobinuria was observed in a case with abdominal aortic aneurysm on the 23rd postoperative day. The typical continuous murmur was heard on the right upper chest, and IADSA revealed an A-V fistula connecting between the right subclavian artery and the internal jugular vein. This A-V fistula was thought to have been caused by an inadvertent arteriopuncture during the central venous cannulation at the time of the operation. Poloxamer 188 (a non-ionic surfactant) and haptoglobin were given intravenously, and they proved to be quite effective in improving intravascular mechanical hemolysis and hemoglobinuria. A division of the A-V fistula was done successfully, which was facilitated by the median sternotomy combined with the extension of the skin incision to the neck. It cannot be overemphasized that utmost care should be taken to prevent any complication at the time of the central venous cannulation.
    No impact of central venous insertion site on oncology patients' quality of life and psychological distress. A randomized three-arm trial. Biffi Roberto,Orsi Franco,Pozzi Simonetta,Maldifassi Andrea,Radice Davide,Rotmensz Nicole,Zampino Maria Giulia,Fazio Nicola,Peruzzotti Giulia,Didier Florence Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer PURPOSE:Though totally implantable access ports (TIAP) are extensively used, information from randomized trials about the impact of insertion site on patient's quality of life (QoL) and psychological distress is unavailable. PATIENTS AND METHODS:Four hundred and three patients eligible for receiving intravenous chemotherapy for solid tumours were randomly assigned to implantation of a single type of TIAP, either through a percutaneous landmark access to the internal jugular or an ultrasound-guided access to the subclavian or a surgical cut-down access through the cephalic vein at the deltoid-pectoralis groove. Patients' QoL and psychological distress were investigated at regular intervals by means of EORTC QLQ-C30 and HADS (Hospital Anxiety and Depression Scale) questionnaires, using univariate and multivariate repeated measure linear mixed models. A post hoc analysis investigated the impact of type of administered chemotherapy (adjuvant vs palliative). RESULTS:Three hundred and eighty-four patients (95.2%) were evaluable, 126 with the internal jugular, 132 with the subclavian and 126 with the cephalic vein access. The median follow-up was 361 days (range, 0-1,087). Mean score changes for the items of the EORTC QLQ-C30 scales were significantly associated with type of administered chemotherapy only (P < 0.001), and not with implantation site. Frequency distribution of patients with depression and anxiety score greater than 10 at HADS was not significantly different, with respect either to type of administered chemotherapy or TIAP implantation site. CONCLUSION:Central venous insertion sites had no impact on patients' QoL and psychological distress. Patients undergoing palliative therapies showed worse EORTC QLQ-C30 scales. 10.1007/s00520-010-0984-9
    Percutaneous innominate vein catheterisation: a new technique for venous access in the critically ill. Bender J S Clinical intensive care : international journal of critical & coronary care medicine Venous access in the critically ill can be a major problem despite the wide variety of methods now available. A new technique is described involving percutaneous catheterisation of the innominate vein via a right second intercostal space approach. It has been successful in five patients over a four-year period. While there have been no major complications, it is advocated for use only when access is necessary for life-saving administration of fluids or drugs. Venous access can be obtained in the majority of patients by a variety of safe and accepted measures such as peripheral venepuncture, central vein catheterisation by the subclavian or internal jugular vein, or by a cutdown. There remains, however, a small subgroup of patients with venous thrombosis from a previous catheter insertion or intravenous drug abuse for whom a number of ingenious methods have been devised. These include cutdowns on the intercostal vein; the middle thyroid vein in infants; and on the inferior epigastric vein, the azygos vein, the iliac vein, and even the inferior vena cava in adults. Access for patients suffering from haemorrhagic shock can be facilitated by multiple catheters in one or more subclavian veins. Even more rarely, these methods may be unsuccessful or contraindicated because of vein thrombosis, infection overlying the insertion site, or patient instability. A new method has been developed allowing percutaneous catheterisation of the innominate vein.
    [Thrombosis and thrombophlebitis after catheterization of the subclavian vein]. Shishkin S A,Matveev A V,Sadovnikov V A Khirurgiia The authors analysed 685 catheterizations of the subclavian vein. Thrombophlebitic complications were diagnosed in 13 patients--phlebothrombosis in 9 of them and thrombophlebitis in 4. The complications developed mostly in cases with a severe general disease, in ++pyo-septic conditions. In 19 patients the catheter was displaced into the internal jugular vein during phlebography. Catheterization had to be repeated in 73 patients, thrombophlebitic complications occurred in 4 of them. A conclusion is drawn on the expediency of the principle of unilateral manipulations in catheterization repeated many times.
    Ultrasonographic diagnosis of catheter-induced combined subclavian and internal jugular vein thrombosis. Abulafia O,Sherer D M,DeEulis T G American journal of critical care : an official publication, American Association of Critical-Care Nurses Catheter-induced subclavian and internal jugular vein thrombosis in a patient with unresectable ovarian carcinoma was diagnosed by sonography following subtle clinical symptomatology. Ultrasonographic diagnosis of central vein thrombosis offers applicable, noninvasive bedside diagnosis. The case we describe suggests that a low threshold should be maintained for application of this technique in the diagnosis of this potentially life-threatening complication, especially with the current widespread application of invasive monitoring.
    Experience of anesthesiologists with percutaneous nonangiographic venous access. Chen Pin-Tarng,Sung Chun-Sung,Wang Chao-Chun,Chan Kwok-Hon,Chang Wen-Kuei,Hsu Wen-Hu Journal of clinical anesthesia STUDY OBJECTIVE:To compare percutaneous nonangiographic insertion of a venous access device with a standard surgical cutdown insertion technique. DESIGN:Prospective, controlled, randomized study. SETTING:Operating room and anesthesia induction room of a university hospital. PATIENTS:100 consecutive oncology patients scheduled for intravenous chemotherapy. INTERVENTIONS:Patients were randomized to two groups: (1) The percutaneous group received implantation through the internal jugular vein by experienced anesthesiologists, whereas (2) the surgical group received venous cutdown insertion through the cephalic or subclavian vein by surgeons (n = 50 for each group). MEASUREMENTS:Duration of procedure, long-term device function, complications such as hematoma formation, infection, hemothorax, pneumothorax, and patients' satisfaction with the placement procedure at two months of follow-up were all measured and recorded. MAIN RESULTS:The percutaneous technique was found to have several advantages, including reduced time for insertion and greater patient satisfaction with procedure. The percutaneously implanted devices also had fewer insertion-associated complications. CONCLUSION:The simplified, percutaneous, nonangiographic technique is as effective as the traditional venous cutdown technique and can be safely done by surgeons as well as by experienced physicians who are not surgeons. 10.1016/j.jclinane.2007.06.016
    Best choice of central venous insertion site for the prevention of catheter-related complications in adult patients who need cancer therapy: a randomized trial. Biffi R,Orsi F,Pozzi S,Pace U,Bonomo G,Monfardini L,Della Vigna P,Rotmensz N,Radice D,Zampino M G,Fazio N,de Braud F,Andreoni B,Goldhirsch A Annals of oncology : official journal of the European Society for Medical Oncology BACKGROUND:Central venous access is extensively used in oncology, though practical information from randomized trials on the most convenient insertion modality and site is unavailable. METHODS:Four hundred and three patients eligible for receiving i.v. chemotherapy for solid tumors were randomly assigned to implantation of a single type of port (Bard Port, Bard Inc., Salt Lake City, UT), through a percutaneous landmark access to the internal jugular, a ultrasound (US)-guided access to the subclavian or a surgical cut-down access through the cephalic vein at the deltoid-pectoralis groove. Early and late complications were prospectively recorded until removal of the device, patient's death or ending of the study. RESULTS:Four hundred and one patients (99.9%) were assessable: 132 with the internal jugular, 136 with the subclavian and 133 with the cephalic vein access. The median follow-up was 356.5 days (range 0-1087). No differences were found for early complication rate in the three groups {internal jugular: 0% [95% confidence interval (CI) 0.0% to 2.7%], subclavian: 0% (95% CI 0.0% to 2.7%), cephalic: 1.5% (95% CI 0.1% to 5.3%)}. US-guided subclavian insertion site had significantly lower failures (e.g. failed attempts to place the catheter in agreement with the original arm of randomization, P = 0.001). Infections occurred in one, three and one patients (internal jugular, subclavian and cephalic access, respectively, P = 0.464), whereas venous thrombosis was observed in 15, 8 and 11 patients (P = 0.272). CONCLUSIONS:Central venous insertion modality and sites had no impact on either early or late complication rates, but US-guided subclavian insertion showed the lowest proportion of failures. 10.1093/annonc/mdn701
    Evaluation of three different techniques for insertion of totally implantable venous access device: A randomized clinical trial. Tagliari Ana Paula,Staub Fernanda Luiza,Guimarães José Ricardo,Migliavacca Alceu,Mossmann Diego da Fonseca Journal of surgical oncology BACKGROUND:Although totally implantable venous access devices (TIVAD) are increasingly being used in oncology patients, more robust evidence about the best technique is lacking, especially regarding to ultrasound (US) guided puncture. METHODS:One hundred ten patients with indication of intravenous chemotherapy were randomly assigned to TIVAD implant through US-guided internal jugular vein (USG) puncture (39) or internal jugular vein blindly (IJB) (36) or subclavian vein blindly (SCB) (35). Procedure data and complications were prospectively recorded within 30 days of the procedure. RESULTS:All patients completed the follow up. Immediate complication rate was 5.1%, 13.9%, and 0% in the USG, IJB, and SCB groups, respectively (P = 0.05). First attempt success rate was 79.5% in the USG, 52.8% in the IJB and 47.2% in the SCB group (P = 0.012). Technique failure was observed in 2.6%, 22.2%, and 8.6% of the population in the USG, IJB, and SCB, respectively (P = 0.021). Early complication rate was 5.1% in USG group, 2.8% in the IJB, and 0% in the SCB (P = 0.401). CONCLUSION:The findings of our study suggest superiority of the USG approach in terms of first puncture success rate and technique failure, without increasing the procedure duration. Long-term follow-up results should help to further clarify the current debates. 10.1002/jso.23962
    Cost effectiveness of different central venous approaches for port placement and use in adult oncology patients: evidence from a randomized three-arm trial. Biffi Roberto,Pozzi Simonetta,Bonomo Guido,Della Vigna Paolo,Monfardini Lorenzo,Radice Davide,Rotmensz Nicole,Zampino Maria Giulia,Fazio Nicola,Orsi Franco Annals of surgical oncology BACKGROUND:No randomized trials have so far investigated the cost effectiveness of different methods for implantation and use of central venous ports in oncology patients. PATIENTS AND METHODS:Overall, 403 patients eligible for receiving intravenous chemotherapy for solid tumours were randomly assigned to implantation of a single type of port, either through a percutaneous landmark access to the internal jugular vein, an ultrasound (US)-guided access to the subclavian vein, or a surgical cut-down access through the cephalic vein at the deltoid-pectoralis groove. Insertion and maintenance costs were estimated by obtaining the charges for an average implant and use, while the costs of the management of complications were analytically assessed. The total cost was defined as the purchase cost plus the insertion cost plus the maintenance cost plus the cost of treatment of the complications, if any. RESULTS:A total of 401 patients were evaluable-132 with the internal jugular vein, 136 with the subclavian vein and 133 with the cephalic vein access. No differences were found for the rate of early complications. The US-guided subclavian insertion site had significantly lower failures. Infections occurred in 1, 3, and 3 patients (internal jugular, subclavian, and cephalic access, respectively; p = 0.464), whereas venous thrombosis was observed in 15, 8, and 11 patients, respectively (p = 0.272). Mean cost for purchase, implantation, diagnosis and treatment of complications in each patient was <euro>2,167.85 for subclavian US-guided, <euro>2,335.87 for cephalic, and <euro>2,384.10 for internal jugular access, respectively (p = 0.0001). CONCLUSION:US real-time guidance to the subclavian vein resulted in the most cost-effective method of central venous port placement and use. 10.1245/s10434-014-3784-5
    Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Ge Xiaoli,Cavallazzi Rodrigo,Li Chunbo,Pan Shu Ming,Wang Ying Wei,Wang Fei-Long The Cochrane database of systematic reviews BACKGROUND:Central venous access (CVA) is widely used. However, its thrombotic, stenotic and infectious complications can be life-threatening and involve high-cost therapy. Research revealed that the risk of catheter-related complications varied according to the site of CVA. It would be helpful to find the preferred site of insertion to minimize the risk of catheter-related complications. This review was originally published in 2007 and was updated in 2011. OBJECTIVES:1. Our primary objective was to establish whether the jugular, subclavian or femoral CVA routes resulted in a lower incidence of venous thrombosis, venous stenosis or infections related to CVA devices in adult patients.2. Our secondary objective was to assess whether the jugular, subclavian or femoral CVA routes influenced the incidence of catheter-related mechanical complications in adult patients; and the reasons why patients left the studies early. SEARCH METHODS:We searched CENTRAL (The Cochrane Library 2011, Issue 9), MEDLINE, CINAHL, EMBASE (from inception to September 2011), four Chinese databases (CBM, WANFANG DATA, CAJD, VIP Database) (from inception to November 2011), Google Scholar and bibliographies of published reviews. The original search was performed in December 2006. We also contacted researchers in the field. There were no language restrictions. SELECTION CRITERIA:We included randomized controlled trials comparing central venous catheter insertion routes. DATA COLLECTION AND ANALYSIS:Three authors assessed potentially relevant studies independently. We resolved disagreements by discussion. Dichotomous data on catheter-related complications were analysed. We calculated relative risks (RR) and their 95% confidence intervals (CI) based on a random-effects model. MAIN RESULTS:We identified 5854 citations from the initial search strategy; 28 references were then identified as potentially relevant. Of these, we Included four studies with data from 1513 participants. We undertook a priori subgroup analysis according to the duration of catheterization, short-term (< one month) and long-term (> one month) defined according to the Food and Drug Administration (FDA).No randomized controlled trial (RCT) was found comparing all three CVA routes and reporting the complications of venous stenosis.Regarding internal jugular versus subclavian CVA routes, the evidence was moderate and applicable for long-term catheterization in cancer patients. Subclavian and internal jugular CVA routes had similar risks for catheter-related complications. Regarding femoral versus subclavian CVA routes, the evidence was high and applicable for short-term catheterization in critically ill patients. Subclavian CVA routes were preferable to femoral CVA routes in short-term catheterization because femoral CVA routes were associated with higher risks of catheter colonization (14.18% or 19/134 versus 2.21% or 3/136) (n = 270, one RCT, RR 6.43, 95% CI 1.95 to 21.21) and thrombotic complications (21.55% or 25/116 versus 1.87% or 2/107) (n = 223, one RCT, RR 11.53, 95% CI 2.80 to 47.52) than with subclavian CVA routes. Regarding femoral versus internal jugular routes, the evidence was moderate and applicable for short-term haemodialysis catheterization in critically ill patients. No significant differences were found between femoral and internal jugular CVA routes in catheter colonization, catheter-related bloodstream infection (CRBSI) and thrombotic complications, but fewer mechanical complications occurred in femoral CVA routes (4.86% or 18/370 versus 9.56% or 35/366) (n = 736, one RCT, RR 0.51, 95% CI 0.29 to 0.88). AUTHORS' CONCLUSIONS:Subclavian and internal jugular CVA routes have similar risks for catheter-related complications in long-term catheterization in cancer patients. Subclavian CVA is preferable to femoral CVA in short-term catheterization because of lower risks of catheter colonization and thrombotic complications. In short-term haemodialysis catheterization, femoral and internal jugular CVA routes have similar risks for catheter-related complications except internal jugular CVA routes are associated with higher risks of mechanical complications. 10.1002/14651858.CD004084.pub3
    Venous cutdown versus the Seldinger technique for placement of totally implantable venous access ports. Hsu Charlie C-T,Kwan Gigi N C,Evans-Barns Hannah,Rophael John A,van Driel Mieke L The Cochrane database of systematic reviews BACKGROUND:Totally implantable venous access ports (TIVAPs) provide patients with a safe and permanent venous access, for instance in the administration of chemotherapy for oncology patients. There are several methods for TIVAP placement, and the optimal evidence-based method is unclear. OBJECTIVES:To compare the efficacy and safety of three commonly used techniques for implanting TIVAPs: the venous cutdown technique, the Seldinger technique, and the modified Seldinger technique. This review includes studies that use Doppler or real-time two-dimensional ultrasonography for locating the vein in the Seldinger technique. SEARCH METHODS:The Cochrane Vascular Trials Search Co-ordinator searched the Cochrane Vascular Specialised Register (last searched August 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 7), as well as clinical trials registers. SELECTION CRITERIA:We included randomised or quasi-randomised controlled clinical trials that randomly allocated people requiring TIVAP to the venous cutdown, Seldinger, or modified Seldinger technique. Two review authors independently assessed studies for inclusion eligibility, with a third review author checking excluded studies. DATA COLLECTION AND ANALYSIS:Two review authors independently extracted data. We assessed all studies for risk of bias. We assessed heterogeneity using Chi(2) statistic and variance (I(2)statistic) methods. Dichotomous outcomes, summarised as odds ratio (OR) with 95% confidence interval (CI), were: primary implantation success, complications (in particular infection), pneumothorax, and catheter complications. We conducted separate analyses to assess the two access veins, subclavian and internal jugular (IJ) vein, in the Seldinger technique versus the venous cutdown technique. We used both intention-to-treat (ITT) and on-treatment analyses and pooled data using a fixed-effect model. MAIN RESULTS:We included nine studies with a total of 1253 participants in the review. Five studies compared Seldinger technique (subclavian vein access) with venous cutdown technique (cephalic vein access). Two studies compared Seldinger (IJ vein) versus venous cutdown (cephalic vein). One study compared the modified Seldinger technique (cephalic vein) with the venous cutdown (cephalic vein), and one study compared the Seldinger (subclavian vein) versus the Seldinger (IJ vein) technique.Seldinger technique (subclavian or IJ vein access) versus venous cutdown (cephalic vein): We included seven trials with 1006 participants for analysis. Both ITT (OR 0.40; 95% CI 0.25 to 0.65) and on-treatment analysis (OR 0.59; 95% CI 0.36 to 0.98) showed that the Seldinger technique for implantation of TIVAP had a higher success rate compared with the venous cutdown technique. We found no difference between overall peri- and postoperative complication rates: ITT (OR 1.16; 95% CI 0.76 to 1.75) and on-treatment analysis (OR 0.93; 95% CI 0.62 to 1.40). In the Seldinger group, the majority of the trials reported use of the subclavian vein for venous access, with only a limited number of trials utilising the IJ vein for access. When individual complication rates of infection, pneumothorax, and catheter complications were analysed, the Seldinger technique (subclavian vein access) was associated with a higher rate of catheter complications compared to the venous cutdown technique: ITT (OR 6.77; 95% CI 2.31 to 19.79) and on-treatment analysis (OR 6.62; 95% CI 2.24 to 19.58). There was no difference in incidence of infections, pneumothorax, and other complications between the groups.Modified Seldinger technique (cephalic vein) versus venous cutdown (cephalic vein): We identified one trial with 164 participants. ITT analysis showed no difference in primary implantation success rate between the modified Seldinger technique (69/82, 84%) and the venous cutdown technique (66/82, 80%), P = 0.686. We observed no differences in the peri- or postoperative complication rates.Seldinger (subclavian vein access) versus Seldinger (IJ vein access): We identified one trial with 83 participants. The primary success rate was 84% (37/44) for Seldinger (subclavian vein) versus 74% (29/39) for the Seldinger (IJ vein). There was a higher overall complication rate in the subclavian group (48%) compared to the jugular group (23%), P = 0.02. However, when specific complications were compared individually, we found no differences between the groups.The overall quality of the trials included in this review was moderate. The methods used for randomisation were inadequate in four of the nine included studies, but sensitivity analysis excluding these trials did not alter the outcome. The nature of the interventions, either venous cutdown or Seldinger techniques, meant that it was not feasible to blind the participant or personnel, therefore we judged this to be at low risk of bias. The majority of participants in the included trials were oncology patients at tertiary centres, and the outcomes were applicable to the typical clinical scenario. For all outcomes, when comparing venous cutdown and Seldinger technique, serious imprecision was evident by wide confidence intervals in the included trials. The quality of the overall evidence was therefore downgraded from high to moderate. Due to the limited number of included studies we were unable to assess publication bias. AUTHORS' CONCLUSIONS:Moderate-quality evidence showed that the Seldinger technique has a higher primary implantation success rate compared with the venous cutdown technique. The majority of trials using the Seldinger technique used the subclavian vein for venous access, and only a few trials reported the use of the internal jugular vein for venous access. Moderate-quality evidence showed no difference in the overall complication rate between the Seldinger and venous cutdown techniques. However, when the Seldinger technique with subclavian vein access was compared with the venous cutdown group, there was a higher reported incidence of catheter complications. The rates of pneumothorax and infection did not differ between the Seldinger and venous cutdown group. We identified only one trial for each of the comparisons modified Seldinger technique (cephalic vein) versus venous cutdown (cephalic vein) and Seldinger (subclavian vein access) versus Seldinger (IJ vein access), thus a definitive conclusion cannot be drawn for these comparisons and further research is recommended. 10.1002/14651858.CD008942.pub2
    Cephalic vein approach for the implantable central venous access: A retrospective review of the single institution's experiences; Cohort Study. Rhu Jiyoung,Jun Kang Woong,Song Byung Joo,Sung Kiyoung,Cho Jinbeom Medicine Long-term venous access is usually required in patients receiving chemotherapy. We hypothesized that, out of the various central line approach techniques, the cephalic vein cut-down technique can be a safe and simple alternative in terms of surgical safety, feasibility, cost-effectiveness, and functional outcomes.We retrospectively reviewed the medical records of 569 patients who underwent implantable central venous access between January 2012 and December 2014 at our hospital.We classified our cohort according to access routes, as follows: 230 patients underwent subclavian vein access, 134 patients underwent internal jugular vein access, 25 patients underwent external jugular vein access, and 119 patients underwent cephalic vein access. The cephalic vein group had a significantly longer operation time than the subclavian group (P < .01); however, there was no difference in operation time between the internal jugular vein and cephalic vein groups (P = .59). The procedure-related complications and functional outcomes of the implanted venous port during chemotherapy were comparable between the cephalic group and other groups. Additionally, body mass index, operation time, and age did not correlate with catheter dysfunction in the multivariate logistic regression analysis (P = .53; P = .66; P = .19, respectively).We suggest that a cut-down central venous catheter insertion through the cephalic vein can be performed easily and safely with no differences in surgical and clinical outcomes compared to those of conventional percutaneous approaches. Moreover, the cephalic vein approach requires no specialized equipment, including percutaneous vascular kits, tunneling instruments, and intraoperative ultrasonography. Therefore, this technique might incur less medical expenses than conventional approaches and would be helpful for both patients and surgeons. 10.1097/MD.0000000000018007
    External jugular vein cross-over as a new technique for percutaneous central venous port access in case of left central venous occlusion. Marcy Pierre Yves,El Hajjam Mostafa,Lacout Alexis,Nöel Caroline,Simon Jean Jacques,Figl Andrea The journal of vascular access PURPOSE:To report the cross-over venous catheter technique in case of left-sided central venous (internal jugular, subclavian and innominate veins) occlusion and right-sided central vein patency. METHODS:A 60-year-old right breast cancer patient presented with a local recurrence requiring chemotherapy. He presented with a left-sided catheter-related central venous occlusion and radiodermatitis of the right chest and neck. The nonsymptomatic side of insertion was defined as the patient's left side. Successful percutaneous left-to-right external jugular vein (EJV) cross-over access tips and tricks are reported. They include performing (a) the EJV access at the lower neck, (b) the 0.032 hydrophilic guidewire (GW) catheterization of the venous curves, (c) the GW anchor technique into the inferior vena cava, (d) the GW + Glidecath catheter stiffening technique and (e) the over-the-stiff wire implantable catheter push. RESULTS:The cross-over technique was successful by using real-time ultrasonography/X-ray monitoring and interventional radiology tools (hydrophilic 0.032 in. and stiff 0.0035 in. GW and "J-shaped" Glidecath catheter) and the five-step technique. CONCLUSIONS:In case of left innominate vein occlusion and necessity of left neck venous access, percutaneous EJV access should be attempted under real-time ultrasound/X-ray monitoring when other standard (subclavian venous port and internal jugular vein) routes are no longer available. 10.5301/jva.5000162
    Long-term complications in totally implantable venous access devices: randomized study comparing subclavian and internal jugular vein puncture. Ribeiro Rodrigo C,Abib Simone C V,Aguiar Alexandre S,Schettini Sérgio T Pediatric blood & cancer BACKGROUND:This prospective randomized study evaluated complications related to long-term totally implantable catheters in oncologic children and adolescents by comparing venopunction performed either in the jugular or subclavian vein. METHODS:A total of 83 catheters were implanted from January 2004 to April 2006 and followed-up until March 2008. Patients were randomly allocated to the subclavian or jugular vein group. The endpoint was complications that led to catheter revision or catheter removal. RESULTS:Six patients were excluded, 43 had the catheter implanted in the subclavian and 34 in the jugular vein. Subclavian catheters were used for up to 12.6 months, while jugular catheters were kept in place for up to 14.8 months (P = 0.38). No statistical differences were found between the groups concerning age, sex, leukocyte count, platelet count, type of admission (in or outpatient), or previous chemotherapy regimens. When analyzed individually, long-term complications did not present statistically significant differences either. Infection occurred in 20 and 11% (P = 0.44), while catheter embolism took place in 23 and 8% (P = 0.11) of patients with subclavian and jugular catheters, respectively. A statistical difference was seen in the total number of complications, which occurred in 48 and 23% (P = 0.02) of patients in the subclavian and in the jugular groups, respectively. CONCLUSIONS:Catheters implanted by puncture in the subclavian vein were more prone to late complications than those implanted in the jugular vein. 10.1002/pbc.23220
    Complications in internal jugular vs subclavian ultrasound-guided central venous catheterization: a comparative randomized trial. Shin Hyun-Jung,Na Hyo-Seok,Koh Won-Uk,Ro Young-Jin,Lee Jung-Man,Choi Yoon-Ji,Park Seongjoo,Kim Jin-Hee Intensive care medicine PURPOSE:The use of real-time ultrasound (US) has been shown to reduce complications of central venous (CV) catheterization. However, complication rates have not been compared according to insertion points for CV catheterization using US. Accordingly, this study aimed to compare the complication rates of internal jugular vein (IJV) with those of subclavian vein (SCV) catheterization. METHODS:Three tertiary academic hospitals in South Korea participated in this multicenter, randomized study. A total of 1484 patients were preoperatively randomized into two groups. The IJV group (n = 742) was cannulated via the right IJV, and the SCV group (n = 742) was cannulated via the right SCV under US guidance. The primary outcome measure was total complication rate. Secondary outcomes included access time for the first attempt, number of attempts, and catheter position. RESULTS:The total complication rate did not demonstrate a significant difference between the IJV (0.1%) and SCV (0.7%) groups (P = 0.248). In the IJV group, arterial puncture occurred in 0.1% of patients; in the SCV group, arterial puncture occurred in 0.6% and pneumothorax in 0.1%. The success rate on the first attempt was significantly higher in the IJV group (98.4%) than in the SCV group (95.9%) (P = 0.004). The access time for the first attempt (P < 0.001) and the median number of attempts (P = 0.006) were significantly lower in the IJV group than in the SCV group. More catheter misplacements were observed in the SCV group (5.9%) than in the IJV group (0.4%) (P < 0.001). CONCLUSION:Results demonstrated that the complication rates of IJV and SCV catheterizations using US are very low, showing no superiority of the SCV approach compared to the IJV. 10.1007/s00134-019-05651-9
    Comparison of comfort and complications in breast cancer patients of implantable venous access port (IVAP) with ultrasound guided internal jugular vein (IJV) and axillary vein/subclavian vein (AxV/SCV) puncture: a randomized controlled study protocol. Chen Yan-Bo,Bao Hao-Shi,Deng He-Ran,Hu Ting-Ting,Wen Biao-Lin,Yi Chun-Yan,Chen Xiu-Wan,Yan Li,Wu Jian-Nan Annals of palliative medicine BACKGROUND:Internal jugular vein (IJV) and axillary vein/subclavian vein (AxV/SCV) are commonly used for implantable venous access port (IVAP) implantation in breast cancer (BC) patients with chemotherapy. Previous studies focused on complications between these different approaches and ignored patient comfort. In this study, we aim to compare patient comfort between IJV and AxV/SCV approaches, as well as surgery duration and complications. METHODS:This is a single-center prospective randomized controlled clinical trial. A total of 200 patients diagnosed with invasive BC will be enrolled in this study. After signing written informed consent, patients schedule to undergo IVAP implantation will be randomized at a 1:1 ratio to receive central venous catheters (CVC) with either IJV or AxV/SCV approaches. Baseline as well as demographic data and procedure time of port implantation will be recorded. All patients will receive assessment of comfort with a comfort scale table at days 1, 2 and 7 after implantation surgery. Patients will be followed up and complications will be recorded until devices are removed at the end of the treatment period, or in case of complications. Patient comfort, procedure time of implantation and complications will be compared and analyzed between these two arms. DISCUSSION:To the best of our knowledge, this is the first study to compare patient comfort as primary outcome measure between IJV and AxV/SCV puncture. This study will further confirm the benefits of ultrasound guidance and may provide a better choice of IVAP implantation for BC patients. TRIAL REGISTRATION:This study has been registered at Chinese Clinical Trial Registry (ChiCTR, www. chictr.org.cn) and Chinese Ethics Committee of Registering Clinical Trials (No. ChiCTR2000034986). 10.21037/apm-20-1752