Content available from World Journal of Surgical Oncology
This content is subject to copyright. Terms and conditions apply.
R E S E A R C H Open Access
Application and comparison of different
implanted ports in malignant tumor
, Yonghua Cai
, Xiaoqin Gan, Xinmei Ye, Jiayu Ling, Liang Kang, Junwen Ye, Xingwei Zhang,
Jianwei Zhang, Yue Cai, Huabin Hu, Meijin Huang
and Yanhong Deng
Background: The current study aims to compare the application and convenience of the upper arm port with the
other two methods of implanted ports in the jugular vein and the subclavian vein in patients with gastrointestinal
Methods: Currently, the standard of practice is placement of central venous access via an internal jugular vein
approach. Perioperative time, postoperative complications, and postoperative comfort level in patients receiving an
implanted venous port in the upper arm were retrospectively compared to those in the jugular vein and the
subclavian vein from April 2013 to November 2014.
Results: Three hundred thirty-four patients are recruited for this analysis, consisting of 107 in the upper arm vein
group, 70 in the jugular vein group, and 167 in the subclavian vein group. The occurrence of catheter
misplacement in the upper arm vein is higher than that in the other two groups (13.1 vs. 2.9 vs. 5.4 %, respectively,
P= 0.02), while the other complications in the perioperative period were not significantly different. The occurrence
of transfusion obstacle of the upper arm vein group is significantly lower than that of the jugular and subclavian
groups (0.9 vs. 7.1 vs. 7.2 %, P= 0.01). The occurrence of thrombus is also lower than that of other two groups
(0.9 vs. 4.3 vs. 3.6 %, P= 0.03). Regarding the postoperative comfort, the influences of appearance (0 vs. 7.1 vs. 2.9 %,
P= 0.006) and sleep (0.9 vs. 4.2 vs. 10.7 %, P= 0.003) are significantly better than those of the jugular and subclavian
Conclusions: Compared to the jugular and the subclavian vein groups, the implanted venous port in the upper
arm vein has fewer complications and more convenience and comfort, and might be a superior novel choice for
patients requiring long-term chemotherapy or parenteral nutrition.
Keywords: Vein port, Complication, Upper arm vein, Jugular vein, Subclavian vein
The incidences of gastrointestinal cancers are increasing.
Most of the patients require long-term chemotherapy or
have to receive 5-fluorouracil-based chemotherapy. There-
fore, more and more patients need a central venous
catheter in order to protect the peripheral vein. Totally
implantable central venous ports (CVP) comprise all the
devices embedded in the subcutaneous tissue, protected
by skin. CVP with the minimum limit to daily life applies
to patients requiring long-term repeated venipuncture,
chemotherapy, parenteral nutrition support, and transfu-
The jugular vein and the subclavian vein are com-
monly selected with the injection base embedded under
the clavicle and chest skin. However, these two methods
carry a risk of puncture resulting to pneumothorax,
hemothorax, and artery injury [2, 3]. Currently, the
standard of practice is placement of central venous
access via an internal jugular vein approach. The arm
port is a novel implanted port method, which only
* Correspondence: Maymay0129@139.com;email@example.com
Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-sen
University, Guangzhou, Guangdong 510655, China
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Li et al. World Journal of Surgical Oncology (2016) 14:251
requires selecting the basilica vein or brachial vein,
guided by vessel B ultrasonic set, for puncture by im-
proved Seldinger puncture technique in the peripher-
ally inserted central catheter (PICC) room. This
method solely requires a professional nurse for vein
therapy with PICC catheterizing qualification for op-
eration under the doctor’s supervision. The whole
procedure is simple and avoids occupancy of the op-
erating room. Any large cohort of patients undergoing
the new method has not been widely reported. The
current study aims to compare the operation time,
occurrence of postoperative complications, and pa-
tient comfort of the upper arm port with the other
two methods of implanted ports in the jugular vein
and the subclavian vein in patients with gastrointes-
A retrospective analysis was conducted for patients re-
ceiving implantation of three different access ports in
The Sixth Affiliated Hospital of Sun Yat-sen University,
Medical Oncology, from April 2013 to November 2014.
All of these patients were pathologically diagnosed with
gastrointestinal cancer. Follow-up starts from the day of
port implantation until the day of removal for any rea-
sons or patients’death. Admission criteria are as follows:
(1) all the patients should be more than 18 years, with
malignant tumor confirmed pathologically; (2) examin-
ation of the patients heart, liver, kidney, and blood
should be normal; (3) patients should have chemothera-
peutic indications without chemotherapeutic and venous
catheterization contraindications; and (4) the arm
circumference for implantation port on the arm should
be ≥25 cm. Exclusion criteria are as follows: (1) any
patient who has been confirmed or suspected of infec-
tion, bacteremia, or blood poisoning; (2) patients with
too small body size to accept implantation equipment;
(3) patients with chronic obstructive pulmonary disease;
and (4) patients with radiotherapy, trauma, and surgery
at the operative site. This study was approved by the in-
stitutional review board of The Sixth Affiliated Hospital,
Sun Yat-sen University (Guangzhou, Guangdong), and
written informed consent was obtained from every
Device for access port
The device for access port is 6F fine implanted port suite
manufactured by US Bard Co., Ltd. with a catheter
length of 75 cm, and the device for the jugular venous
and subclavian venous ports is 7.5F implanted access
port suite manufactured by Braun Medical Co., Ltd. with
a catheter length of 50 cm.
Implantation of access port
Implantation of access port should be conducted with
local anesthesia. Access port on the arm should be im-
planted by two professional nurses with PICC implant-
ation qualification. Basilica or cephalic vein of the upper
right arm is selected for puncture guided by the color
vessel Doppler ultrasound with improved Seldinger
puncture technique. Subsequent to catheter implant-
ation, routine chest X-ray should be examined for the
feeding of the catheter and the position of the tip. If the
catheter reverses or the tip position is abnormal, it
should be readjusted with the aid of X-rays. Under a
physician’s guidance, the nurses transect the skin about
3 cm with the center of the puncture point to split the
subcutaneous tissue for the capsular bag and embed the
port foundation under the skin of the upper arm without
establishing the subcutaneous tunnel.
Jugular venous access and subclavian venous access
ports should be implanted by qualified physicians into
the right jugular vein or subclavian vein with puncture
point 2 cm below the middle point between the right
cleidomastoid sternal branch and top or right clavicle at
the clavicle angle. After implanting the catheter, a sub-
cutaneous tunnel is established on the right chest wall.
Subsequently, a routine chest X-ray film is examined for
the feeding and the catheter position.
Maintenance and follow-up of catheter
Fluid can be injected after implanting the access port.
Intact butterfly needle is used to puncture into the port
foundation after skin disinfection. Normal saline is used
to wash the catheter to detect an obstacle and subcuta-
neous seepage in the catheter. When consecutive infu-
sion is required, intact butterfly needle should be
replaced every week. Upon completion of the infusion
therapy, 10 ml heparin saline (100 IU/ml) is used to
wash the catheter. If the catheter cannot be used for
more than 4 weeks, it should be washed in the hospital
every 4 weeks. Follow-up starts from the port implant-
ation until the removal surgery, and the withdrawal date
should be treated as the final usage date of the infusion
Collection of complications
Major observation indices refer to the perioperative time
of three different access ports (the date of port implant-
ation) and incidence rates of postoperative complications
by recording the types and the time of complication in-
cidence. The complications in the perioperative period
include catheter misplacement, pneumothorax, hemo-
thorax, artery injury, and failed puncture, which requires
a change of the puncture path. The postoperative com-
plications include infection, thrombogenesis, poor trans-
fusion, catheter breakage, pinch-off syndrome, seepage
Li et al. World Journal of Surgical Oncology (2016) 14:251 Page 2 of 6
on foundation, and foundation exposure. The investiga-
tion of postoperative comfort is carried out in a subse-
quent visit (after 15 days); nurses who do not attend this
study inquire and record the patient’s appearance effects,
concerns about catheter breakage, and effect on sleep
and daily life.
Perioperative time, postoperative complications, and
postoperative comfort level in patients receiving an im-
planted venous port in the upper arm were retrospect-
ively compared to those in the jugular vein and the
subclavian vein. The statistical software is SPSS19.0.
Statistical data is represented as a mean ± standard
deviation. ANOVA is used for mean comparison, and
LSD of post hoc inspection is used for the comparison
of two averages. Chi-squared test is used to compare the
complication incidence. P< 0.05 is considered statisti-
General condition of the patients
The analysis recruited 344 patients, including 107 pa-
tients in the upper arm vein group, 70 in the jugular
vein group, and 167 in the subclavian vein group. Table 1
shows the clinical characteristics of patients in the three
groups, with similar basic information. In the three
groups, the average follow-up durations were 257.6 ±
134.1, 307.9 ± 134.3, and 253.4 ± 152.8 days (p= 0.03),
and seven, two, and nine patients failed the follow-up,
Complications in ports in the perioperative period
The patients in all the groups have successfully received
port implantation. Patients in the three groups prefer
right implantation. Complications in the operation include
catheter misplacement, pneumothorax, hemothorax, ar-
tery injury, and failed puncture or catheterizing, which
requires changing puncture access. The upper vein group
should take the left upper vein access, while the jugular
and subclavian vein groups should take the subclavian ac-
cess and jugular access, respectively, because of failed
puncture or catheterizing. The incidence of catheter mis-
placement in the upper arm vein group is higher than that
of the other two groups (13.1 vs. 2.9 vs. 5.4 %, P=0.02),
while the other complications in the perioperative period
do not alter significantly, as shown in Table 2.
Table 3 shows complications after port implantation.
Any differences in the complications of foundation ex-
posure, seepage in the foundation, infection, and
thrombus among the three groups were not observed.
However, the incidence of poor transfusion in the upper
vein group is significantly lower than that in the jugular
and subclavian vein groups (0.9 vs. 7.1 vs. 7.2 %, P=
0.01), and its incidence of thrombus was also lower (0.9
vs. 4.3 vs. 3.6 %, P= 0.03); 3, 5, and 13 patients required
the removal of the port because of complications, without
any statistical significance (P=0.23).
Postoperative comfort after port implantation
The comparison of postoperative comfort shows that
the appearance concern (0 vs. 7.1 vs. 2.9 %, P= 0.006)
and the sleep influence (0.9 vs. 4.2 vs. 10.7 %, P= 0.003)
in the upper arm vein group were not significant as
compared to those in the jugular and subclavian vein
groups (Table 4).
The current study compared the application of the
upper arm venous port, the jugular venous port, and the
Table 1 Baseline characteristics
Variable Upper vein
Patients 107 70 167
Age (years) 54.4 ± 12.3 53.8 ± 13.0 53.0 ± 13.3
Male 64 (59.8) 41 (58.6) 104 (62.3)
Female 43 (40.2) 29 (41.4) 63 (37.7)
Colon cancer 33 (30.8) 31 (44.3) 66 (39.5)
Rectal cancer 52 (48.6) 31 (44.3) 84 (50.3)
Gastric cancer 12 (11.2) 7 (10.0) 13 (7.8)
Pancreatic cancer 2 (1.9) 1 (1.4) 0 (0)
Small intestinal carcinoma 1 (0.9) 0 (0) 0 (0)
Esophageal cancer 1 (0.9) 0 (0) 3 (1.8)
Bile duct carcinoma 1 (0.9) 0 (0) 0 (0)
Hepatic carcinoma 1 (0.9) 0 (0) 0 (0)
Others 4 (3.7) 0 (0) 1 (0.6)
Follow-up duration (days) 257.6 ± 134.1 307.9 ± 134.3 253.4 ± 152.8
Data in parenthesis is a percentage
Table 2 Complications in the perioperative period
Complications Upper arm
Catheter misplacement 14 (13.1) 2 (2.9) 9 (5.4) 0.02
Pneumothorax 0 (0) 1 (1.4) 2 (1.2) 0.50
Hemothorax 0 0 0
Artery injury 1 (0.9) 4 (5.9) 6 (3.6) 0.18
Change of puncture
10 (9.3) 3 (4.3) 9 (5.4) 0.31
Data in parenthesis is a percentage
Li et al. World Journal of Surgical Oncology (2016) 14:251 Page 3 of 6
subclavian venous port in patients with malignant
tumor. The result shows that there is no significant dif-
ference in the perioperative period among the three
groups. While the incidence of the postoperative compli-
cations in the upper arm venous group is lower, the
comfort level is higher.
Implantation of the upper arm port is conducted in
the PICC catheterizing room; hence, the catheter feeding
and tip position cannot be determined during the oper-
ation. Moreover, because the catheterizing route is elon-
gated, it is easy to mislead the feeding to the jugular
vein, thus reversing the catheter, or catheterizing deeply
into the heart to cause discomfort in the neck or precor-
dial area. Therefore, we measure the distance between
the planned puncture point and the sternum midpoint
in a preoperative routine as the reference depth of
catheterization during operation. Meanwhile, routine
inspection with a chest X-ray film is conducted to distin-
guish the catheter feeding and tip position after cathe-
terizing, rather than cutting the skin to implant the
foundation. If the catheter position is abnormal, the ad-
justment should be conducted under the X-ray machine.
Although the incidence of catheter misplacement is high
(13.1 %) in the upper arm vein group, the position can
be adjusted to normal under perspective. Also, without a
subcutaneous tunnel, the complication of poor transfu-
sion is also lower than that in the jugular and subclavian
groups (P= 0.06). The lumen of the upper arm vein is
remarkably small, such that the puncture failure rate
was reported to be 5–11 % [4, 5], and the ratio of chan-
ging puncture access in this group was 9.3 %. Kawamura
et al.  assessed the implantation of the upper arm port
in 113 patients with metastatic colorectal cancer receiv-
ing chemotherapy. All the patients received puncture
under the guidance of real-time ultrasound or radiation,
and none of them demonstrated complications in the
perioperative period; only nine patients showed postop-
erative complications (8.0 %). It was concluded that the
upper arm port exhibited favorable short- and long-term
The upper arm port access can completely avoid
severe puncture complications, such as pneumothorax
and hemothorax, and only one patient had artery injury
(0.9 %). The blind puncture was conducted in the jugu-
lar and subclavian vein groups, which is greatly influ-
enced by the experience of operators and individual
anatomic differences. Thus, the probability of pneumo-
thorax (0.3–3.2 %) [7, 8] and artery injury is high. The
incidence of catheter misplacement is low when choos-
ing the jugular vein as the puncture access, but is simple
to distort and narrow for the catheter to cause poor
transfusion. Since the injection foundation is embedded
on the upper wall, the catheter should be downward
feeding after turning 180° and the subcutaneous tunnel
elongated. Moreover, the tractive feeling in the neck
after the operation is obvious, lowering the comfort
level. The subcutaneous tunnel in the subclavian venous
access is short. Thus, the patients have no tractive feel-
ing in the neck. However, severe complications, such as
pneumothorax, hemothorax, mediastinum hematoma,
and pinch-off syndrome may occur in the puncture to
cause catheter breakage [9, 10]. When the catheter
passes through the interval between the clavicle and the
first rib, poor transfusion, thrombus, breakage, and per-
foration may occur, and the catheter may even rupture
because of pressure. The broken end may flow into the
heart or lung along with the blood flow to cause
arrhythmia or pulmonary embolism. In this study, three
patients had a pinch-off syndrome in the subclavian vein
group (1.8 %), including two patients requiring emer-
gency surgery for the removal of the broken end due to
In the postoperative complications, the incidence of
infection in the upper arm vein group (0.9 %) is lower
than that in the jugular vein group and subclavian vein
group. The study did not record any significant differ-
ence in the infection rates of arm port and subclavian
venous port [11, 12]. In the long-term maintenance of
ports, phlebothrombosis is another severe complication.
Patients and port implantation may increase the risk of
phlebothrombosis . The retrospective study shows
that the incidence of thromboembolism related to the
Table 3 Complications after port implantation
Complications Upper arm
Foundation exposure 2 (1.9) 1 (1.4) 0 (0) 0.23
Seepage on foundation 1 (0.9) 1 (1.4) 1 (0.6) 0.82
Thrombus 1 (0.9) 3 (4.3) 6 (3.6) 0.03
Infection 1 (0.9) 2 (2.9) 6 (3.6) 0.40
Poor transfusion 1 (0.9) 5 (7.1) 12 (7.2) 0.01
Catheter breakage 0 (0) 0 (0) 2 (1.2) 0.34
Pinch-off syndrome 0 (0) 0 (0) 3 (1.8) 0.20
Patients with pump
3 (2.8) 5 (7.1) 13 (7.8) 0.23
Data in parenthesis is a percentage
Table 4 Comparison of postoperative comfort after port
Items Upper arm
Appearance 0 (0) 5 (7.1) 5 (2.9) 0.006
Concern of catheter
3 (2.8) 4 (5.7) 18 (10.7) 0.19
Sleep influence 1 (0.9) 3 (4.2) 18 (10.7) 0.003
Influence on daily life 0 (0) 0 (0) 2 (1.1) 0.26
Data in parenthesis is percentage
Li et al. World Journal of Surgical Oncology (2016) 14:251 Page 4 of 6
catheter is up to 12–64 %, but the anticoagulant for rou-
tine prevention is not recommended , even though
one study indicates that the incidence of deep venous
thrombosis in the arm port is higher than that in the
chest port .
The other significant advantages of the upper arm port
are that the postoperative comfort level and life quality
of patients are high. The foundation embedded in the
upper arm is concealed, and the invisibility of the punc-
ture point and operation scar in the neck and chest
renders it esthetically applicable for patients.
Moreover, in fluid replacement therapy, patients do
not require upper body undressing, which avoids embar-
rassment and discomfort, especially in women . Goltz
et al.  found that the satisfaction and life quality of
patients receiving arm port implantation were signifi-
cantly higher than those of chest port implantation.
Compared with the forearm port, the upper arm port
has no difference in the infection rate, deep venous
thrombosis, catheter misplacement, or stoppage. The
embedded position of an upper arm port is high; short
sleeves can cover the injection foundation without the
subcutaneous tunnel, through chelidon. Therefore, we
think the patients’quality of life with the upper arm port
The limitation of this study is that the type assessment
of perioperative period and postoperative complications
in the retrospective analysis is not quite comprehensive.
Moreover, this is a study conducted by a single center,
and patients in the three groups are not randomized.
Also, the learning curve should be accomplished at an
early stage after introducing the upper arm port into the
hospital, to prevent the high incidences of catheter mis-
placement. However, few relevant studies on the upper
arm are conducted in China, but several occur abroad.
The current study provided evidence to assess the safety
of clinical application of the upper arm port.
In conclusion, the operation of the upper arm venous
port is safe such that severe puncture complications,
such as pneumothorax, hemothorax, and pinch-off syn-
drome, are avoided. The incidence of postoperative com-
plications is lower than that in jugular venous access
port and subclavian access port, and the discomfort level
and patients’quality of life is better. Therefore, the
upper arm venous port implantation method might be a
good choice in clinical applications.
CVP: Central venous ports; PICC: Peripherally inserted central catheter
The study was supported by the China National Natural Science Foundation
(No. 81472249) and a Guangzhou Scientific Grant (2014J2200059).
Availability of data and materials
YL, YC, XG, and XY carried out the studies, participated in collecting the data,
and drafted the manuscript. JL, LK, JY, and XZ performed the statistical
analysis and participated in its design. JZ, YC, HH, MH, and YD helped to
draft the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
This study was approved by the institutional review board of The Sixth
Affiliated Hospital, Sun Yat-sen University (Guangzhou, Guangdong), and
written informed consent was obtained from every participant.
Received: 9 May 2016 Accepted: 8 September 2016
1. Sonobe M, Chen F, Fujinaga T, Sato K, Shoji T, Sakai H, et al. Use of totally
implantable central venous access port via the basilic vein in patients with
thoracic malignancies. Int J Clin Oncol. 2009;14:208–12.
2. Vardy J, Engelhardt K, Cox K, Jacquet J, McDade A, Boyer M, et al. Long-
term outcome of radiological-guided insertion of implanted central venous
access port devices (CVAPD) for the delivery of chemotherapy in cancer
patients: institutional experience and review of the literature. Br J Cancer.
3. Di Carlo I, Cordio S, La Greca G, Privitera G, Russello D, Puleo S, et al. Totally
implantable venous access devices implanted surgically: a retrospective
study on early and late complications. Arch Surg. 2001;136:1050–3.
4. Marcy PY, Magne N, Castadot P, Italiano A, Amoretti N, Bailet C, et al. Is
radiologic placement of an arm port mandatory in oncology patients?:
analysis of a large bi-institutional experience. Cancer. 2007;110:2331–8.
5. Conessa C, Talfer S, Herve S, Chollet O, Poncet JL. Cephalic vein access for
implantable venous access devices. Technique and long-term follow-up.
Rev Laryngol Otol Rhinol (Bord). 2002;123:143–8.
6. Kawamura J, Nagayama S, Nomura A, Itami A, Okabe H, Sato S, et al.
Long-term outcomes of peripheral arm ports implanted in patients with
colorectal cancer. Int J Clin Oncol. 2008;13:349–54.
7. Kelly H, Goldberg RM. Systemic therapy for metastatic colorectal cancer:
current options, current evidence. J Clin Oncol. 2005;23:4553–60.
8. Lorch H, Zwaan M, Kagel C, Weiss HD. Central venous access ports placed
by interventional radiologists: experience with 125 consecutive patients.
Cardiovasc Intervent Radiol. 2001;24:180–4.
9. Cho JB, Park IY, Sung KY, Baek JM, Lee JH, Lee DS. Pinch-off syndrome.
J Korean Surg Soc. 2013;85:139–44.
10. Mirza B, Vanek VW, Kupensky DT. Pinch-off syndrome: case report and
collective review of the literature. Am Surg. 2004;70:635–44.
11. Akahane A, Sone M, Ehara S, Kato K, Tanaka R, Nakasato T. Subclavian vein
versus arm vein for totally implantable central venous port for patients with
head and neck cancer: a retrospective comparative analysis. Cardiovasc
Intervent Radiol. 2011;34:1222–9.
12. Bodner LJ, Nosher JL, Patel KM, Siegel RL, Biswal R, Gribbin CE, et al.
Peripheral venous access ports: outcomes analysis in 109 patients.
Cardiovasc Intervent Radiol. 2000;23:187–93.
13. Sutherland DE, Weitz IC, Liebman HA. Thromboembolic complications
of cancer: epidemiology, pathogenesis, diagnosis, and treatment.
Am J Hematol. 2003;72:43–52.
14. Vescia S, Baumgartner AK, Jacobs VR, Kiechle-Bahat M, Rody A, Loibl S, et al.
Management of venous port systems in oncology: a review of current
evidence. Ann Oncol. 2008;19:9–15.
Li et al. World Journal of Surgical Oncology (2016) 14:251 Page 5 of 6
15. Kuriakose P, Colon-Otero G, Paz-Fumagalli R. Risk of deep venous
thrombosis associated with chest versus arm central venous subcutaneous
port catheters: a 5-year single-institution retrospective study. J Vasc Interv
16. Goltz JP, Petritsch B, Kirchner J, Hahn D, Kickuth R. Percutaneous
image-guided implantation of totally implantable venous access ports in
the forearm or the chest? A patients' point of view. Support Care Cancer.
• We accept pre-submission inquiries
• Our selector tool helps you to ﬁnd the most relevant journal
• We provide round the clock customer support
• Convenient online submission
• Thorough peer review
• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research
Submit your manuscript at
Submit your next manuscript to BioMed Central
and we will help you at every step:
Li et al. World Journal of Surgical Oncology (2016) 14:251 Page 6 of 6
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at