AJR 2001; 176:991-994
© American Roentgen Ray Society
Radiologic Placement of Implantable Chest Ports in Pediatric Patients
Jonathan M. Lorenz1,
Brian Funaki,
Thuong Van Ha and
Jeffrey A. Leef
1
All authors: Department of Radiology, The University of Chicago Hospitals,
5841 S. Maryland Ave., MC 2026, Chicago, IL 60637.
Received July 12, 2000;
accepted after revision September 25, 2000.
Address correspondence to J. M. Lorenz.
Abstract
OBJECTIVE. We evaluated the technical success and complications
associated with radiologic placement of implantable chest ports in children
for long-term central venous access.
MATERIALS AND METHODS. Between May 1, 1996 and January 11, 2000, 29
chest ports were placed in 28 children (15 girls, 13 boys; age range, 2-17
years; mean, 11.7 years). The patient's right internal jugular vein was used
for access in 93% (27/29) of the procedures, and a collateral neck vein was
used as a conduit to recanalize the central veins in two procedures because of
bilateral jugular and subclavian vein occlusion. All procedures were performed
in interventional radiology suites. Both real-time sonography and fluoroscopy
were used to guide venipuncture and port insertion. Follow-up data were
obtained through the clinical examination and electronic review of charts.
RESULTS. Technical success was 100%. Fourteen percent of the
catheters were removed prematurely, including one catheter removed 17 days
after placement because the patient's blood cultures were positive for
Candida albicans. No patients experienced hematoma, symptomatic air
embolism, symptomatic central venous thrombosis, catheter malposition, or
pneumothorax. The median number of days for catheter use by patients was 280
days (total, 9043 days; range, 17-869 days). The rate of confirmed
catheter-related infection was 14% or 0.04 per 100 venous access days. One
catheter occluded after 132 days.
CONCLUSION. In pediatric patients, radiologists can insert
implantable chest ports using real-time sonographic and fluoroscopic guidance
with high rates of technical success and low rates of complication.
Introduction
Radiologic placement of subcutaneous, implantable chest ports in adults is
now widely accepted
[1,2,3].
However, at our hospital, there has been delayed acceptance of radiologic port
placement in the pediatric population, and these procedures are often referred
to pediatric surgery rather than interventional radiology. Although surgical
placement of chest ports in pediatric patients has been documented in the
literature [4,
5], radiologic placement of
chest ports in pediatric patients has not been addressed. In adult patients,
the use of real-time sonographic and fluoroscopic guidance by radiologists
during chest port placement results in rates of safety and success that are
equal to or better than the rates achieved using surgical placement
[1]. The same techniques of
imaging guidance can be applied to routine port placement in children and
offer several advantages over "blind" placement, particularly in
children with limited central venous access. The purpose of this study was to
establish the safety and efficacy of chest port placement in children by
interventional radiologists.
Materials and Methods
Patients
Between May 1, 1996, and January 11, 2000, we performed 29 consecutive
chest port implantations in 28 children (15 girls, 13 boys; age range, 2-17
years, mean 11.7 years). The indications for chest port placement in a patient
included malignancy requiring chemotherapy (26 procedures), short-bowel
syndrome requiring chronic parenteral nutrition (two procedures), and
meningitis requiring long-term antibiotics (one procedure). A retrospective
review of these procedures, including all relevant operative notes, discharge
reports, pathology reports, cultures, and laboratory data, was performed. We
defined early catheter-related infections as those occurring within 1 month of
the procedure. We defined premature catheter removal as removal of the
catheter that was due to catheter-related infection or catheter
thrombosis.
Procedure
Before all procedures, patients with a prothrombin time greater than 17 sec
or a platelet count less than 50,000/mm3 received blood products to
correct deficiencies. If patients were already receiving broad-spectrum
antibiotics providing adequate coverage of skin flora, they received no
antibiotics before the procedure. Most patients received IV cefazolin sodium
(Ancef; SmithKline Beecham Pharmaceuticals, Philadelphia, PA) 1 hr before the
procedure. Subcutaneous 1% lidocaine was administered as local anesthesia. At
the discretion of the interventional radiologist, procedures were performed
with the patient under either general anesthesia or conscious sedation with
fentanyl citrate (Sublimaze; Abbott Laboratories, North Chicago, IL) and
midazolam hydrochloride (Versed; Hoffman-LaRoche, Nutley, NJ). If conscious
sedation was used, it was administered by radiology department nurses under
the direction of the interventional radiologist. House staff of the requesting
pediatric service assisted with sedation of younger children (<10 years).
Seventy-six percent (22/29) of the procedures were performed with the patient
(age range, 2-16 years; mean, 10.5 years) under general anesthesia.
Twenty-four percent (7/29) of the procedures were performed with the patient
(age range, 12-17 years; mean, 15.6 years) under conscious sedation. All
procedures were performed in a standard angiography suite in the radiology
department. Each patient was placed in the supine position, and a sterile
surgical scrub was performed (EZ Prep 270 kit; Becton Dickinson, Franklin
Lakes, NJ) using iodophor detergent and povidone-iodine. For each patient, an
area from the angle of the mandible to the nipple line was scrubbed. During
each procedure, radiologists wore masks and caps and followed guidelines for
standard surgical scrub
[6].
In older children, we placed dual-lumen 10-French or single-lumen 8-French
chest ports (Bard, Salt Lake City, UT). In infants and younger children, we
placed slim titanium low-profile 6-French chest ports (SIMS Deltec, St. Paul,
MN). Sixteen dual-lumen and 13 single-lumen ports were placed (Figs.
1 and
2). The catheter placement
technique is illustrated in Figure
3A,3B,3C,3D,3E.
We used the right internal jugular vein for access, if possible. In all
patients, punctures were made with a 21-gauge needle (Micropuncture System;
Cook, Bloomington, IN) under real-time sonographic guidance. A 2- to 3-cm
incision was made approximately 2 cm caudad to the clavicle. We used blunt
dissection to create a subcutaneous pocket large enough for the port
reservoir. A battery-operated cautery device (Aaron-Ram ophthalmic cautery
fine tip; Aaron Medical Industries, St. Petersburg, FL) was available in all
cases. Cautery was necessary in only one patient because of minor persistent
bleeding.
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Fig. 3D. —Method of chest port placement. Photograph shows subcutaneous
tissues closed with interrupted, inverted 3.0 Vicryl sutures (Ethicon,
Somerville, NJ) and overlying skin closed with interrupted 3.0 Ethilon
mattress sutures (Ethicon).
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Using the tunneling device provided with the port, we passed the catheter
subcutaneously to the jugular vein puncture site. We measured the catheter
using fluoroscopy, shortened it appropriately, attached it to the port, and
inserted it intravenously through a peel-away sheath until the tip was at the
junction of the superior vena cava and right atrium. We used fluoroscopy to
monitor insertion of the peel-away sheath. The subcutaneous tissues were
closed with interrupted, inverted 3.0 Vicryl sutures (Ethicon, Somerville,
NJ), and the overlying skin was closed with interrupted 3.0 Ethilon mattress
sutures (Ethicon). We placed iodophor ointment on the incision site. If the
patient was scheduled for immediate chemotherapy, we accessed the port with
needles. Sutures were removed 2 weeks after the procedure.
In 93% (27/29) of the procedures, the internal jugular vein was used for
access. In two procedures on a single patient with bilateral central venous
occlusion, we placed the chest port via small collateral veins and
recanalization of occluded central veins
[7]. We performed the
recanalization procedures using an antegrade technique. We obtained a venogram
by injecting a peripheral IV to verify occlusion and to select a small
collateral neck or chest vein for antegrade puncture (Fig.
4A,4B).
We selected a collateral vein that would most likely communicate directly with
the occluded central veins (on the basis of orientation or vascular blush),
marked the skin overlying this vein, and punctured using real-time sonographic
guidance. Recanalization was performed using hydrophilic guidewires
(Radiofocus Glidewire; Medi-Tech, Watertown, MA) and 5-French endhole
catheters (Radiofocus Glidecath; Medi-Tech) under real-time fluoroscopic
guidance. Central venous access was verified by injection of contrast
material. A tract was created with serial dilators, and the 8-French peel-away
sheath was advanced to the right atrium, allowing advancement of the
single-lumen 8-French catheter.
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Fig. 4A. —6-year-old boy with short-bowel syndrome and history of
multiple central venous catheters. Venogram shows total occlusion of right
subclavian and jugular veins and multiple small collateral veins. Left
subclavian and jugular veins were also occluded (not shown). Small occluded
collateral vein (arrowheads) was accessed using real-time sonography
and used as conduit to recanalize central veins and place chest port.
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Results
The technical success rate for chest port placement was 100%. During the
study period, 90% (26/29) of the catheters were removed and 10% (3/29)
remained in place. Median follow-up time was at 280 days of catheter use
(total, 9043 days; range, 17-869 days). No patients were lost to follow-up.
Confirmed catheter-related infection rate was 14% (4/29) or 0.04 per 100
venous access days. One catheter occluded after 132 days. No instances of
catheter malposition, symptomatic central venous thrombosis, pneumothorax,
skin dehiscence, symptomatic air embolism, or hematoma were observed. Fourteen
percent (4/29) of the catheters were removed prematurely, including one
catheter removed 17 days after placement as a result of an early
catheter-related infection. The remainder of the catheters were removed when
they were no longer required.
The patient with the early catheter-related infection was a 2-year-old boy
with short-bowel syndrome who required long-term parenteral nutrition. He had
a history of external-line infections caused by Candida albicans, but
blood cultures performed on the patient before line placement revealed
negative findings. Because the patient had a history of multiple accidental
line removals, the clinical service requested an implantable chest port. The
patient presented to the hospital 2 weeks after the procedure with
intermittent fevers; blood cultures performed at that time showed positive
findings for C. albicans. The chest port was removed, and the
incision was closed because there were no signs of inflammation at the port
site. The wound healed without complication.
Late catheter-related infections occurred in three patients at 209, 336,
and 639 days after placement. In one patient, blood cultures were positive for
coagulase-negative Staphylococcus organisms, and the chest port was
the presumed source despite the absence of signs of inflammation at the port
site. The infection was treated with antibiotics, the bacteremia resolved, and
the port was not removed. In the remaining two patients, blood cultures were
positive for Pseudomonas aeruginosa and Serratia marescens,
respectively. As in the first patient, these patients had no signs of
inflammation at the port sites. Both ports were removed, and the incisions
were closed. The patients were treated with antibiotics, the bacteremia
resolved, and wound healing occurred without complication.
Discussion
Despite a large population of pediatric oncology patients in our hospital,
few children are referred to interventional radiology for placement of
implantable chest ports. Discussions with the pediatric staff have revealed
persistent concerns about potential complications associated with radiologic
port placement. As a result, pediatric surgeons usually perform these
procedures. One contributing factor to the concerns may be the absence of
published literature establishing the safety of radiologic port placement in
children. Hundreds of adult patients are referred to our radiology department
for chest port placement every year. Radiologic port placement in adults is
performed with safety and success rates at or exceeding those of surgical
placement [1]. Ironically, the
most difficult cases involving placement of central lines in patients with
occluded central veins are often referred to interventional radiology by
pediatric surgery. The same techniques of direct imaging guidance used in
adult port placement can be applied to placement in pediatric patients to
maintain high technical success rates and low complication rates.
Our technical success rate was 100% in all patients referred for port
placement. In pediatric series, technical success rates for all patients
referred for treatment are usually lower or not reported
[4,
5]. We attribute our high
technical success rate to both sonographic and fluoroscopic guidance.
Sonographic guidance can be used for planning the procedure, performing
routine venipuncture, and identifying alternative routes of access in patients
with central venous obstruction. Before the procedure, sonography can be used
to localize appropriate-sized veins and identify occluded veins. During the
procedure, real-time sonographic guidance enables the radiologist to puncture
the small internal jugular veins of children accurately, using a single
puncture in most cases. Finally, sonography is especially important for
children with conditions requiring chronic central venous access such as
short-bowel syndrome. In these patients, jugular and subclavian routes may be
exhausted, and venous recanalization or femoral catheter placement may become
the only techniques available for central access.
To avoid complications of femoral catheter placement such as deep venous
thrombosis [8], radiologists
have developed techniques to recanalize chronically occluded neck and chest
veins to allow central line placement in patients who have lost jugular and
subclavian vein patency [7].
One child in our series was referred to interventional radiology by pediatric
surgery because of bilateral subclavian and jugular vein occlusions. On
separate occasions, two different thyrocervical collateral veins were accessed
and used as conduits to recanalize central veins so that chest ports could be
placed (Fig.
4A,4B).
Central line placement in this child was possible because real-time sonography
was used to guide puncture of the collateral veins, and venography was used to
guide the recanalization of the veins and advancement of the catheter to the
right atrium.
The procedure-related complication rate in our study compared favorably
with rates reported in published surgical studies
[4,
5]. No patient suffered an
immediate procedure-related complication. In only one patient, a presumed
catheter-related infection occurred within 1 month of chest port placement.
However, this patient may have had a preexisting occult Candida
infection; he had a long history of multiple external-line infections from the
same organism. If radiologists follow guidelines for standard surgical scrub,
rates of early infection for ports placed in the interventional radiology
suite are similar to those placed in the operating room
[1,2,3,4,5].
Fluoroscopic guidance of advancement of guidewires and sheaths virtually
eliminates inadvertent arterial injury and central venous rupture.
Complications of blind puncture such as pneumothorax or hematoma from arterial
puncture are extremely rare when real-time sonographic guidance is employed
[9]. Use of real-time
sonographic needle guidance prevents the need for venous cutdown described in
pediatric surgical series [4].
In addition, the use of imaging guidance allows routine access via the
internal jugular vein, which avoids complications associated with subclavian
vein access such as central venous thrombosis
[10,
11]. Our incidence of
symptomatic central venous thrombosis was 0%.
In our study, late catheter-related infection occurred at a rate similar to
the rates in published surgical studies
(Table 1). The infections
likely resulted from frequent chemotherapy infusions coupled with immune
suppression. In the three children requiring premature port removal for
presumed catheter infection, the incisions were closed after removal, and the
patients were treated with a full course of antibiotics. Our approach to port
infections is the same for both children and adults. In the absence of
clinical signs of inflammation at the port site or in cases of mild erythema,
we close the incision after port removal. We have found that healing of the
port site proceeds uneventfully in these patients. In patients with purulent
catheter infections, we remove the catheter, pack the wound with iodophor
gauze, and bandage with wet-to-dry dressings. Dressing changes are performed
every 2-3 days until the wound heals by secondary intention. Wound care is
managed by the interventional radiologist with the assistance of the radiology
nursing staff.
In conclusion, interventional radiologists can place implantable chest
ports in children with a high degree of technical success. Radiologists have
the unique advantage of combined, real-time sonographic and fluoroscopic
guidance to place central lines even in patients with complete central venous
occlusion. Concerns about potential complications of radiologic port placement
in children are unwarranted, as shown by the near-absence of procedure-related
complications in our study and the ability of radiologists to manage
complications such as catheter-related infections.
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Abstract
Introduction
