Application of an ultrasound-guided low-approach insertion technique in three types of totally implantable access port

Abstract

Totally implantable access ports (TIAPs) are alternatives to central venous catheters for patients requiring chemotherapy. Since January 2003, we have used a central approach two-point incision technique to insert TIAPs. Following advances in ultrasound technique and clinical experience for tunneled dialysis catheter placement, we modified the central approach to a low-approach technique.
From January 2009 to June 2010, patients consulted for TIAP insertion in our department were enrolled in our study. Different brands and materials of central venous catheters of TIAPs were inserted by the low-approach two-point incision technique (Phase I) or the low-approach one-point incision technique (Phase II). The insertion time, failure rate, procedural and late complications, degree of satisfaction, and cosmetic scores were recorded.
Ninety-seven patients and 107 patients were implanted via the two-point and one-point low-approach techniques, respectively, with different kinds of TIAP. No matter which type of TIAP was used, the success rate in both phases was 100% without procedural complications using the low-approach technique. The average time for device insertion was 30 minutes for the two-point incision technique used during Phase I and 26-28 minutes for the one-point incision technique used during Phase II. Satisfaction and cosmetic scores were high.
Our study highlights a revised technique for placement of TIAP systems of differing types of material or size. Not only was the curvature of the device catheter smooth, but patients were satisfied with the cosmetic appearance.

Full text

Original Article
Application of an ultrasound-guided low-approach insertion technique
in three types of totally implantable access port
Hung-Wei Cheng, Chien-Kun Ting, Ya-Chun Chu, Wen-Kuei Chang, Kwok-Hon Chan,
Pin-Tarng Chen*
Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
Received April 3, 2013; accepted October 26, 2013
Abstract
Background: Totally implantable access ports (TIAPs) are alternatives to central venous catheters for patients requiring chemotherapy. Since
January 2003, we have used a central approach two-point incision technique to insert TIAPs. Following advances in ultrasound technique and
clinical experience for tunneled dialysis catheter placement, we modified the central approach to a low-approach technique.
Methods: From January 2009 to June 2010, patients consulted for TIAP insertion in our department were enrolled in our study. Different brands
and materials of central venous catheters of TIAPs were inserted by the low-approach two-point incision technique (Phase I) or the low-approach
one-point incision technique (Phase II). The insertion time, failure rate, procedural and late complications, degree of satisfaction, and cosmetic
scores were recorded.
Results: Ninety-seven patients and 107 patients were implanted via the two-point and one-point low-approach techniques, respectively, with
different kinds of TIAP. No matter which type of TIAP was used, the success rate in both phases was 100% without procedural complications
using the low-approach technique. The average time for device insertion was 30 minutes for the two-point incision technique used during Phase I
and 26e28 minutes for the one-point incision technique used during Phase II. Satisfaction and cosmetic scores were high.
Conclusion: Our study highlights a revised technique for placement of TIAP systems of differing types of material or size. Not only was the
curvature of the device catheter smooth, but patients were satisfied with the cosmetic appearance.
Copyright Ó2014 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.
Keywords: catheterization; central venous catheter; jugular vein; totally implantable access port; ultrasound
1. Introduction
Central venous catheters are frequently used for chemo-
therapy delivery in oncological patients. For patients requiring
frequent intravenous access, insertion of implanted central
venous catheters such as totally implantable access ports
(TIAPs) is usually performed.
Beginning January 2003, we used a modified two-point
incision percutaneous placement technique to insert TIAPs.
1
We found that the technique was as effective as the tradi-
tional venous cutdown technique. The anatomical landmark
technique was used for venipuncture of the right internal ju-
gular vein (RIJV) because of lack of assistance from an ul-
trasound device at that time.
1
The central approach
(paracricoid approach) was used to avoid major
complications.
2e5
To ensure a smooth curvature and prevent
kinking of the catheter over the neck, we invented the two-
point incision percutaneous placement technique.
1
Remarkable advancement of our technique came after the
introduction of ultrasound in our department. The real-time
Conflicts of interest: The authors declare that there are no conflicts of interest
related to the subject matter or materials discussed in this article.
* Corresponding author. Dr. Pin-Tarng Chen, Department of Anesthesiology,
Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112,
Taiwan, ROC.
E-mail address: ptchen@vghtpe.gov.tw (P.-T. Chen).
Available online at www.sciencedirect.com
ScienceDirect
Journal of the Chinese Medical Association 77 (2014) 246e252
www.jcma-online.com
http://dx.doi.org/10.1016/j.jcma.2014.02.005
1726-4901/Copyright Ó2014 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.

ultrasound-guided technique was used to perform venipunc-
ture for vascular access.
6e12
With the assistance of real-time
ultrasound guidance, we were able to perform low-approach
venipuncture safely.
At first, we applied this ultrasound guidance technique for
tunneled dialysis catheter (TDC) insertion.
6
We also found
that by using low-approach venipuncture of the RIJV and a
1 cm transverse incision wound lateral to the venipuncture
site, we could create a more smooth curvature of the subcu-
taneous tunnel than that which resulted from the central
approach.
1,6
In recent years, we changed the venipuncture site
from the central approach to an ultrasound-guided low
approach for TIAP insertion. Initially, a two-point incision
technique was used to create a subcutaneous tunnel from the
port pocket to the venipuncture site. Subsequently, we modi-
fied the technique to a single small incision and tunneling
technique. Furthermore, there are TIAPs of different brands,
catheter materials, and diameters, and the material and size of
the catheter of the TIAP system may affect the curvature of the
device catheter and the success rate of insertion. Therefore, we
designed this study to evaluate whether the ultrasound-guided
one-incision low-approach technique could be applied for
TIAP insertion.
2. Methods
2.1. Patients
From January 2009 to June 2010, our department was
consulted regarding 214 patients requiring TIAP insertion. In
the preprocedure visit, we performed a bedside ultrasound
over the neck region to exclude those with thrombotic and
stenotic RIJVs. We excluded from this study patients with
thrombotic and stenotic RIJVs, local infection or pathology
over the intended venipuncture or incision site, a potential risk
of compromised airway, and abnormalities in image studies,
such as a huge mediastinal tumor seen on chest radiography or
compression of the superior vena cava by a tumor mass seen
on chest computed tomography.
Informed consent was obtained from every patient and/or
the patient’s family who agreed to TIAP placement via the
RIJV. Potential adverse events were explained in detail during
the preprocedure visit. For each patient, routine preprocedure
laboratory examinations included prothrombin time/activated
partial thromboplastin time and complete blood count. Blood
products were transfused to ensure that the prothrombin time
international normalized ratio was smaller than 1.2 and the
platelet count was greater than 70,000/mL.
2.2. General technique and catheter selection:
Preprocedure preparation
The same two anesthesiologists (P.T.C. and H.W.C.) were
responsible for all TIAP insertions. The study participants,
most of whom were inpatients at the time of their procedures,
underwent TIAP insertion in the anesthesia induction room.
Standard preparation, monitoring and anesthesia were
performed.
1
Induction of intravenous general anesthesia was
usually done with alfentanyl 200e400 mg and midazolam
1e2 mg after skin sterilization.
2.2.1. Phase I low-approach two-point incision technique
The Arrow Implantable Vascular Access System (Arrow
International Inc., Mount Holly, NJ, USA) was used for
placement from January 2009 to August 2009.
Briefly, the procedure was as follows: First, the finding
needle was slowly advanced from the intended skin puncture
site (point 1, usually 1e1.5 cm above the clavicle) to above
the RIJV under real-time ultrasound guidance, and 1e2mLof
1% lidocaine was injected over the skin puncture site and this
tract (Fig. 1). Ultrasound-guided venipuncture was then per-
formed using an 18-gauge hollow needle. Once the vein was
revealed, the hollow needle was removed after a guidewire
was inserted through it.
Second, 1% lidocaine was injected over the intended tunnel
tract and implantation site. A transverse incision 0.5 cm in
length (point 1) was made and dissected next to the skin
puncture site. Then, a skin incision 0.5 cm in length (point 2)
was made 3e4 cm lateral to the skin puncture site (Fig. 1).
Third, a subcutaneous pocket was created using the right
deltopectoral groove approach with a 3e4 cm transverse skin
incision, which was then dissected above the fascia of the
pectoralis muscle to fix the TIAP in situ. Fourth, a subcu-
taneous tunnel was created from the port pocket using a
tunneler over the clavicle, with the catheter mounted to its rear
end, directed toward point 2 and later pulled out from point 2
along with the tunneler. Fifth, another tunnel between point 1
and point 2 was created using a mosquito from point 1 toward
Fig. 1. Low-approach two-point incision technique. Ultrasound-guided veni-
puncture was performed on point 1 (0.5 cm in length, usually 1e1.5 cm above
the clavicle). Then, a skin incision 0.5 cm in length (point 2) was made
3e4 cm lateral to point 1. A subcutaneous pocket was then created using the
right deltopectoral groove approach with a 3e4 cm transverse skin incision. A
subcutaneous tunnel was created from the port pocket using a tunneler over the
clavicle, directed toward point 2 and later pulled out from point 2 along with
the tunneler. Another tunnel between point 1 and point 2 was created using a
mosquito from point 1 towards point 2, and the catheter was then pulled from
point 2 to point 1.
247H.-W. Cheng et al. / Journal of the Chinese Medical Association 77 (2014) 246e252

point 2, then the catheter was pulled from point 2 to point 1
(Fig. 1).
Next, the catheter was trimmed to an appropriate length
using the fourth right intercostal space as the estimated pro-
jection of the cavoatrial junction and inserted through the
RIJV using a peel-away sheath and dilator that were fed over
the guidewire. Good blood aspiration was performed via the
TIAP to confirm correct placement, and the device was then
flushed with heparinized saline (1000 U/mL). The incision
wounds were sutured and covered with a sterile adhesion strip.
Patients were then sent to the radiology suite for postoperative
chest x-ray (CXR) to confirm the final catheter position and
the subcutaneous tunnel curve.
2.2.2. Phase II low-approach one-point incision technique
We modified our two-point incision technique to a one-
point incision technique with ultrasound guidance from
September 2009, using the Arrow Implantable Vascular Ac-
cess System (Arrow International Inc.) at first. Then we used
Port-A-Cath II Low Profile (5.8 French; Smiths Medical Inc.,
St. Paul, MN, USA) and the X-Port isp Implantable Port (8
French; Bard Access Systems, Salt Lake City, UT, USA) for
placement of TIAPs from January 2010. Patients were
randomly implanted with one of the two polyurethane TIAPs.
After completion of the ultrasound-guided venipuncture,
insertion of the guidewire, and injection of local anesthetic, a
transverse incision 0.5 cm in length was made and dissected
next to the skin puncture site (point A; Fig. 2). Then, we bent
the front 4 cm of the steel tunneler about 60(Fig. 3), and
created a subcutaneous tunnel from the port pocket using the
tunneler over the clavicle. The tunneler was pointed toward a
point 3e4 cm lateral to the skin puncture site (imaginary point
B) with the catheter mounted to its rear end, along the lateral
side of the sternocleidomastoid muscle. The tunneler was then
redirected from imaginary point B to point A, and the catheter
was pulled out from point A with the tunneler (Figs. 2 and 3).
The remaining procedures were as described for Phase I
(Fig. 4).
2.3. Follow-up
For the remainder of their hospitalization, patients were
followed up by the anesthesiology staff. After discharge, pa-
tients received twice weekly telephone calls from the anes-
thesiology staff regarding their access device. In addition, the
oncology staff who evaluated and used the access devices as
part of outpatient treatment served, as needed, as liaisons
between patients and anesthesiology staff.
2.4. Outcome measures
Clinical outcome measures included the duration of the
procedure, periprocedural complications such as arterial
puncture, pneumothorax, or continued oozing or frank
continued bleeding, kinking of the catheter over the subcu-
taneous tunnel, curvature of the device catheter, and late
device-associated complications including infection, venous
thrombosis, and device malfunction.
Periprocedural perceptions and long-term satisfaction with
the access device itself were followed for patient outcomes.
Periprocedure satisfaction and comfort scores were defined as
follows: (1) comfortable and in no pain; (2) comfortable but
with a slight sensation of pain; (3) tolerable pain; and (4)
intolerable pain.
Cosmetic outcome was assessed postoperatively on Day 10
via evaluation of change in dressing habits after TIAP im-
plantation: (1) comfortable and no need to change dressing
habit; (2) comfortable but needed to wear a polo shirt; (3)
comfortable but needed to button the top button of the polo
shirt; and (4) difficulty in dressing.
All patients received long-term empirical antibiotic treat-
ment and device care according to standard practice. Patients
were regularly followed up and interventions were considered
in cases of suspected local wound or systemic infection, he-
matoma formation, or device malfunction.
3. Results
Between January 2009 and June 2010, our department was
consulted regarding 214 patients who required TIAP place-
ment, and a total of 204 patients were enrolled in our study.
During Phase I (from January 2009 to August 2009), 99 pa-
tients were assessed, with two patients excluded because of
local infection over the skin puncture site and suspected ma-
lignancy over the supraclavicular region, respectively. Ninety-
seven patients were therefore implanted with the Arrow
Implantable Vascular Access System (Arrow International
Inc.) by the low-approach two-point incision technique
(Table 1).
During Phase II, 115 patients were assessed, and 8 patients
were excluded (5 stenotic RIJVs, 2 RIJVs with large thrombus,
and 1 local infection over the skin puncture site). Thirty-nine
patients were implanted with the Arrow Implantable Vascular
Fig. 2. Low-approach one-point incision technique. The subcutaneous tunnel
was created antegrade from the subcutaneous pocket to imaginary point B and
then incision point A.
248 H.-W. Cheng et al. / Journal of the Chinese Medical Association 77 (2014) 246e252

Access System (Arrow International Inc.), and 36 patients and
32 patients were implanted with the Port-A-Cath II Low
Profile (Smiths Medical Inc.) and the X-Port isp Implantable
Port (Bard Access Systems), respectively, using the low-
approach one-point incision technique (Table 1).
No matter what type of TIAP system was used, the success
rate for each subgroup was 100% for device placement without
immediate occlusion. Meanwhile, there was no kinking of the
subcutaneous tunnel and a good curvature in all four groups, as
observed by postoperative CXR (Fig. 4). Patients felt comfort-
able after the procedure while under intravenous general anes-
thesia, and also were satisfied with the improved appearance and
the ease of covering the subcutaneous catheter over the lower
neck region with a polo shirt (Table 2).
In addition, there were no episodes of desaturation, nor
were there any immediate procedural complications such as
pneumothorax, arterial puncture, active bleeding or oozing, or
great vessel perforation in any group. The average time for
device insertion was 30 minutes for the two-point incision
technique used during Phase I and 26e28 minutes for the one-
point incision technique used during Phase II.
Premature removal of the device was required for six pa-
tients (6/204): three TIAPs were removed because the patients
died, two TIAPs were shifted to a Hickman catheter for bone
marrow harvest, and one TIAP was removed because of sus-
pected infection. The surviving patients were then treated
successfully with oxacillin.
4. Discussion
Dudrick et al
13
suggested the use of central venous cathe-
ters in clinical practice; thus, externalized tunneled central
Fig. 3. Low-approach one-point incision technique. The Bard X-Port isp Implantable Port was implanted in a 40-year-old male patient. (A) The steel tunneler was
bent at the front 4 cm to about 60. (B) The ultrasound-guided venipuncture and insertion of the guidewire were performed at point A (skin puncture site, 1 cm
above the clavicle). The pre-shaped tunneler was pointed from the port pocket toward a point (imaginary point B) 3 cm lateral to point A over the clavicle (red line,
the upper edge of the clavicle). (C) The tunneler was then redirected from imaginary point B to point A. (D) The catheter was pulled out from point A with the
tunneler mounted to its rear end. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
Fig. 4. TIAP implantation and postoperative chest X-ray (CXR). (A) The
smooth subcutaneous tunnel was created antegrade from the subcutaneous
pocket to imaginary point B and then incision point A. (B) Postoperative CXR
revealed no kinking of the subcutaneous tunnel, with a good curvature (red
circle, implanted port). (For interpretation of the references to color in this
figure legend, the reader is referred to the web version of this article.)
249H.-W. Cheng et al. / Journal of the Chinese Medical Association 77 (2014) 246e252

venous catheters equipped with Dacron cuffs and subcutane-
ously implanted ports became an important part of the man-
agement of chronic diseases.
13,14
Although most venous
access devices are inserted by the traditional surgical venous
cutdown technique, percutaneous techniques have been pro-
posed for routine use.
15
In our institute, we have performed percutaneous placement
of TIAPs for more than 20 years, but because of the lack of
ultrasound assistance, we were only able to perform percuta-
neous placement of TIAPs via the RIJV by the central
approach to avoid major complications.
2e5
For a better cur-
vature of the device catheter, we have used a modified tech-
nique since January 2003, and have demonstrated that the two-
point incision percutaneous placement technique is as effec-
tive as the traditional venous cutdown technique.
1
The importance of a preprocedure ultrasound cannot be
overemphasized, according to our clinical experience of
tunneled dialysis catheter placement. In this study, from January
2009 to June 2010, seven patients had abnormal findings during
the preprocedure bedside ultrasound: stenotic RIJVs in five
patients and RIJVs with large thrombi in two patients. Six
TIAPs were placed via the left internal jugular vein and one
TIAP was placed via the right subclavian vein. We advocate that
preprocedure ultrasound examination is crucial for complete
preoperative evaluation to exclude inappropriate patients. All of
these seven patients had received central venous catheterization
via the RIJV prior to consultation. Careful preprocedural ul-
trasound examination of the selected IJV is useful for detecting
severe venous stenosis or thrombus, especially related to tem-
porary or long-term central venous catheterization (catheter-
induced venous thrombosis).
16e18
This examination can help us
to improve periprocedure safety and avoid unnecessary trials,
time wasting, thrombus dislodgement, or change of the access
vein prior to actual venipuncture.
With real-time ultrasound assistance, venipuncture can be
performed safely, decreasing procedure-related complications
such as accidental arterial puncture, pneumothorax, or great
vessel injury.
6,7,19,20
Initially, ultrasound-guided central
approach venipuncture and the two-point incision technique
were used for TIAP insertion.
1
But some patients who un-
derwent TIAP placement by the central approach complained
of an unesthetic appearance, with an obvious subcutaneous
catheter over the neck region. We subsequently changed the
venipuncture site to a low approach to increase the cosmetic
outcome.
With our wide experience in the placement of tunneled
dialysis catheters (TDCs), we presumed that, using the low
approach, one small incision (1 cm) technique could result in a
larger plane for subcutaneous tunneling during placement, a
smoother curvature of the device catheter, a good appearance,
and no kinking when turning the head to extremes.
6
We
therefore decided to apply this technique for TIAP placement
starting November 2009.
However, because of low stocks of the Arrow Implantable
Vascular Access System (Arrow International Inc.) in January
2010, we had to change to two other polyurethane catheter
TIAP systems: the Smith Port-A-Cath II Low Profile (Smiths
Medical Inc.) and the Bard X-Port isp Implantable Port (Bard
Access Systems), with catheters of different sizes: a Smith
PolyFlow polyurethane catheter 5.8 Fr (1.0 mm inner diam-
eter) and a Bard ChronoFlex polyurethane catheter 8 Fr
(1.6 mm inner diameter), respectively. These two TIAP sys-
tems were both made of polyurethane, which was less likely to
kink compared with silicone. From January 2010 to June 2010,
we randomly assigned patients for insertion of one of the two
TIAP systems. Most importantly, the TDC that we use is a
14.5 French polyurethane catheter, much larger than any TIAP
catheter. Therefore, we designed this study to survey whether
the one-incision ultrasound-guided low approach technique
could be applied to insert TIAP catheters of different sizes and
materials. In this study, we did not perform the two-incision
technique using different brands of TIAP system, because
our goal was to invent an effective new technique.
In the current study, a smooth curvature of the device
catheter and a decreased incidence of catheter kinking resulted
from using the low-approach two-point or one-point incision
technique. The success rate, complication rate, patient
Table 1
Demographics of the enrolled patients and their underlying diseases.
Phase I
(n¼97)
Phase II
(n¼107)
Two-point One-point
Device Arrow Arrow Bard Smiths
Total number 97 39 36 32
Male/female (n) 50/47 17/22 20/16 15/17
Age (mean SD) 57.5 18.1 55.2 20.1 54.9 21.6 58.1 19.1
Origin of malignancy
Esophagus 11 3 1 3
Lung 35 14 12 13
Nasopharynx 10 2 3 4
Lymphoma 9 5 3 4
Musculoskeletal 4 6 2 2
Colon 28 9 15 6
Insertion time
[min (range)]
30 (26e35) 28 (26e32) 26 (22e28) 27 (20e30)
Table 2
Outcomes and complications.
Phase I
(n¼97)
Phase II
(n¼107)
Two-point One-point
Port device Arrow Arrow Bard Smiths
Procedure failure rate 0 0 0 0
Comfort and satisfaction score
a
1e21e21e21e2
Cosmetic outcome
b
1e21e21e21e2
Procedural complication
Arterial puncture 0 0 0 0
Kinking of catheter 0 0 0 0
Pneumothorax 0 0 0 0
Active bleeding or oozing 0 0 0 0
Late complication (follow-up)
Infection 1 (1/97) 0 0 0
Venous thrombosis 0 0 0 0
Malfunction or occlusion 0 0 0 0
Data are presented as %, unless otherwise indicated.
a
1¼best score (least pain); 4 ¼worst pain (intolerable pain).
b
1¼no need to change; 4 ¼difficulty in dressing.
250 H.-W. Cheng et al. / Journal of the Chinese Medical Association 77 (2014) 246e252

comfort, and cosmetic rating did not differ significantly be-
tween the four groups during Phases I and II. In the low-
approach technique, the distance from the skin puncture site
to the clavicle was 1e1.5 cm. In other words, the lowest skin
puncture for RIJV insertion made was 1 cm above the clavicle,
because of the width of the sterile prepared ultrasound probe.
If we focus on the results of Phase II, our new low-
approach one-point incision technique could be applied with
different kinds of TIAP, no matter what size or material of
device catheter was used. In addition to the low-approach
venipuncture with ultrasound assistance technique, the way
we created the subcutaneous tunnel was also an important
factor for better curvature of the device catheter. To decrease
the incision wound, we used an imaginary turning point (point
B) and a bent steel tunneler. The theory was similar to that of
the two-point incision technique, but we replaced the incised
point 2 by an imaginary point B. In other words, a subcu-
taneous tunnel was made from the port pocket to 3e4cm
lateral to the incision site as point B (near the lateral margin of
the sternocleidomastoid muscle), and the tunneler was turned
to point A. However, the attached straight steel tunneler in the
manufactured set was not suitable for passing through point B
to point A. Therefore, we bent the steel tunneler to about 60
to achieve our goal.
If the tunnel were to be made directly from the port pocket
to the skin puncture site without using this technique, we
hypothesized that the curvature of the device catheter would
be easily transformed into a sharp angle, which would increase
the incidence of catheter malfunction or kinking. We also
considered that tunneling with a lateral imaginary turning
point would not be suitable in the central approach technique,
because the smaller subcutaneous plane over the higher neck
region could be difficult for turning with the bent tunneler.
In our experience, patients who underwent TIAP placement
via the RIJV by the central approach complained of an
unesthetic appearance, with an obvious subcutaneous catheter
over the neck region. By using the low-approach technique,
we were able to achieve a smoother curvature of the device
catheter over the lower neck region to avoid catheter kinking
and also to provide a more satisfactory cosmetic appearance.
The lower neck wounds and subcutaneous catheter could be
easily covered with a polo shirt, and the patients were all
satisfied with the cosmetic outcome. Compared with the two-
point incision technique, only one wound would be seen over
the neck region when using the one-incision technique. In this
study, we did not compare the cosmetic outcome between the
central approach and the low approach, because we routinely
used the ultrasound-guided low-approach technique for TIAP
insertion after the introduction of ultrasound, and it was
difficult to collect the data from patients in whom a TIAP had
been previously inserted.
In conclusion, our study demonstrated a revised novel
clinical technique for percutaneous placement of TIAPs of
differing materials or sizes, which resulted in a high success
rate, a shorter procedural time, smooth curvature of the device
catheter, and an acceptable cosmetic appearance.
Acknowledgments
We would like to thank the anesthesia faculty for their ef-
forts regarding data collection and the Anesthesiology
Research and Development Foundation, Taipei, Taiwan, for
their financial support.
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