Myung Gyu Song

Incidence and Risk Factors of Infectious Complications Related to Implantable Venous-Access Ports

Objective The purpose of this study was to determine the incidence and risk factors of infections associated with implantable venous access ports (IVAPs). Materials and Methods From August 2003 through November 2011, 1747 IVAPs were placed in our interventional radiology suite. One hundred forty four IVAPs were inserted in patients with hematologic malignancy and 1603 IVAPs in patients with solid tumors. Among them, 40 ports (23 women and 17 men; mean age, 57.1 years; range, 13-83) were removed to treat port-related infections. We evaluated the incidence of port-related infection, patient characteristics, bacteriologic data, and patient progress. Univariable analyses (t test, chi-square test, and Fishers exact test) and multiple logistic regression analyses were used to determine the risk factors for IVAP related infection. Results Overall, 40 (2.3%) of 1747 ports were removed for symptoms of infection with an incidence rate of 0.067 events/1000 catheter-days. According to the univariable study, the incidences of infection were seemingly higher in the patients who received the procedure during inpatient treatment (p = 0.016), the patients with hematologic malignancy (p = 0.041), and the patients receiving palliative chemotherapy (p = 0.022). From the multiple binary logistic regression, the adjusted odds ratios of infection in patients with hematologic malignancies and those receiving palliative chemotherapy were 7.769 (p = 0.001) and 4.863 (p = 0.003), respectively. Microorganisms were isolated from 26 (65%) blood samples, and two of the most causative organisms were found to be Staphylococcus (n = 10) and Candida species (n = 7). Conclusion The underlying hematologic malignancy and the state of receiving palliative chemotherapy were the independent risk factors of IVAP-related infection.

A Single-Incision Technique for Placement of Implantable Venous Access Ports via the Axillary Vein

PURPOSE To evaluate the technical feasibility and safety of a single-incision technique for placement of implantable venous access ports via the axillary vein. MATERIALS AND METHODS Ports were placed in 216 patients between May and October 2012 using a single-incision technique via the axillary vein. Patients included 112 men and 104 women with a mean age of 58.2 years. After making a single vertical incision without subcutaneous tunneling, ports were placed via the left axillary vein in 172 patients and via the right axillary vein in 44 patients. Axillary vein punctures were directed medially at the incision site under ultrasound guidance. We retrospectively reviewed success rates, technical difficulties, procedure times, and immediate and delayed complications of the procedure. RESULTS All single-incision port placements were technically successful. Technical difficulties occurring during the procedure included advancement of the wire or catheter into an unintended vein (n = 33), kinking at the cuff-catheter junction (n = 13), bleeding via the puncture tract (n = 5), bending of the peel-away sheath (n = 3), and puncture of the axillary artery (n = 3). All technical problems were overcome with additional manipulation. The only immediate complication was puncture site hematoma in two patients. The mean follow-up period was 165.7 days, and there were no reports of port malfunction. Axillary vein thrombosis was observed in one patient. CONCLUSIONS The single-incision technique for placing ports via the axillary vein was a feasible and safe procedure with high technical success and low risk of complications.

Innominate vein stenosis in breast cancer patients after totally implantable venous access port placement

Purpose To evaluate the risk factors for central vein stenosis after placement of the totally implantable venous access ports (TIVPs) and the clinical relevance of this condition in breast cancer patients. Materials and methods TIVPs were placed in 191 women with breast cancer via the internal jugular vein (IJV) from January 2009 to December 2012 (mean age, 51.42 years) by left-side (n = 102) and right-side (n = 89) approaches. Medical records were retrospectively reviewed. The presence of significant central vein stenosis, tip location of the catheter and retrosternal space were evaluated on chest computed tomography images. Statistical analysis was performed. Results Central vein stenosis developed in 1 and 14 patients after placement via the right and left IJV, respectively. Differences in the cumulative incidence of central vein stenosis were statistically significant between left- and right-side approach groups (log rank test p-value: 0.009). In Cox regression analysis, the hazard ratio for central vein stenosis was 9.441 (p = 0.031) in the left-side approach. The distance between the sternum and the left innominate vein was found to be significantly and independently related to the development of central vein stenosis (p = 0.026). The hazard ratio of distances between the sternum and left innominate vein <16 mm was 10.133 (1.319-77.841). Conclusions The incidence of central vein stenosis in breast cancer patients was higher after placement of TIVPs via the left IJV. When left-side TIVP placement is required in a patient with right-side breast cancer, the possibilities of left innominate vein stenosis should be considered.

Effectiveness of breast fixation to reduce migration of the tip of a totally implantable venous access port in women

Purpose To evaluate effectiveness of breast fixation to reduce migration of the catheter tip of a totally implantable venous access port (TIVP) in women. Materials and Methods TIVPs were placed in 129 women via the right axillary vein from July 2012 to December 2014, with a final study population of 118 patients (mean age, 55.3 ± 13.8 years; range, 21-91 years). The patients were divided into two groups according to breast fixation during TIVP placement. A total of 56 patients received TIVP placement without breast fixation (Group 1); the remaining 62 received TIVP placement in the supine position after fixation of the ipsilateral breast on the abdominal wall in the sitting position (Group 2). Medical records were retrospectively reviewed for age, weight, height, body mass index, and underlying malignancy. We evaluated the difference in distance ratios between the port chamber and the catheter tip on supine chest and erect chest radiographs, respectively. Statistical analysis was performed using Students t test. Results Differences in all parameters between Group 1 and Group 2 were not statistically significant. Mean distance ratio between the port chamber and the catheter tip was 1.95 ± 0.97 in Group 1 and 1.33 ± 0.59 in Group 2. Differences in distance ratios between the port chamber and the catheter tip were statistically significant between Group 1 and Group 2 (p = 0.001). Conclusions Breast fixation seems to be effective in reducing migration of the port chamber and catheter tip with position changes in female patients during TIVP placement.

Factors Causing Loss of Normal Doppler Waveform of the Left Internal Jugular Vein: Evaluation on Chest Computed Tomography

Purpose To evaluate the presence and causes of left brachiocephalic vein (LBCV) steno-occlusive lesions in patients with loss of normal waveform in Doppler ultrasound of the left internal jugular vein (LIJV). Materials and Methods We performed Doppler ultrasound of both internal jugular veins in 1912 patients who received an implantable venous access port from August 2013 to January 2016. Among them, 106 patients showed loss of normal Doppler waveforms of the LIJV (56 men and 50 women; mean age, 61.4 ± 11.6 years). We retrospectively analyzed the presence and causes of the LBCV steno-occlusive lesions on contrast-enhanced chest computed tomography (CT) images. Results LBCV steno-occlusive lesions were present in 82 patients (77.4%). The causes of these lesions were anatomic structures (n = 70, 85.4%), tumorous lesions (n = 11, 13.4%), and thrombus (n = 1, 1.2%). The anterior anatomic structures to the LBCV causing stenosis were bony structures (n = 50), right upper lobe (n = 11), and mediastinal fat (n = 9). The posterior anatomic structures to the LBCV resulting in stenosis were right brachiocephalic artery (n = 58), left common carotid artery (n = 7), and aortic arch (n = 5). The tumorous lesions resulting in stenosis were mediastinal lymph node (n = 5), thymic lesions (n = 3), lymphoma (n = 1), lung cancer (n = 1), and bone tumor (n = 1). Conclusions It is necessary to suspect steno-occlusive lesion of the LBCV from various causes and to use caution when performing central venous catheterization in cases with loss of a normal Doppler waveform.

Prophylactic Placement of an Inferior Vena Cava Filter During Aspiration Thrombectomy for Acute Deep Venous Thrombosis of the Lower Extremity.

Purpose: To evaluate the effect of an inferior vena cava (IVC) filter during aspiration thrombectomy for acute deep vein thrombosis (DVT) in the lower extremity. Materials and Methods: From July 2004 to December 2013, a retrospective analysis of 106 patients with acute DVT was performed. All patients received an IVC filter and were treated initially with aspiration thrombectomy. Among the 106 patients, DVT extension into the IVC was noted in 27 but was not evident in 79. We evaluated the presence of trapped thrombi in the filters after the procedure. The sizes of the trapped thrombi were classified into 2 grades based on the ratio of the maximum transverse length of the trapped thrombus to the diameter of the IVC (Grades I [≤ 50%] and II [> 50%]). Results: A trapped thrombus in the filter was detected in 46 (43%) of 106 patients on final venograms. The sizes of the trapped thrombi were grade I in 12 (26.1%) patients and grade II in 34 (73.9%). Among the 27 patients with DVT extension into the IVC, 20 (74.1%) showed a trapped thrombus in the filter, 75% (15 of 20) of which were grade II. Among the 79 patients without DVT extension into the IVC, 26 (32.9%) showed a trapped thrombus in the IVC filter, 73% (19 of 26) of which were grade II. Conclusions: Thrombus migration occurred frequently during aspiration thrombectomy of patients with acute DVT in the lower extremity. However, further studies are needed to establish a standard protocol for the prophylactic placement of an IVC filter during aspiration thrombectomy.

Effect of catheter diameter on left innominate vein in breast cancer patients after totally implantable venous access port placement

The effect of catheter diameter on left innominate vein stenosis in breast cancer patients after totally implantable venous access port placement. Purpose: To evaluate the effect of catheter diameter on left innominate vein stenosis in breast cancer patients after placement of totally implantable venous access ports. Materials and methods: Totally implantable venous access ports were placed via the left internal jugular vein in 241 women with right breast cancer from January 2010 to December 2014 (mean age, 51.5 years; range, 19–83 years). There were 67 totally implantable venous access ports with a 6.5F catheter and 142 totally implantable venous access ports with an 8F catheter. Medical records were retrospectively reviewed. The presence of significant left innominate vein stenosis and tip location of the catheter was evaluated on chest computed tomography images. Statistical analysis was performed. Results: Left innominate vein stenosis developed in 1 (1.5%) and 13 (9.2%) patients after implantation with 6.5 and 8F catheters, respectively. Difference in the cumulative incidence of left innominate vein stenosis was statistically significant between the two groups (log rank test p-value: 0.002). In Cox regression analysis, the hazard ratio for left innominate vein stenosis was 20.766 (p = 0.005) for an 8F catheter. Conclusion: The incidence of left innominate vein stenosis was higher after implantation of totally implantable venous access ports with 8F catheter rather than with 6.5F catheter. Considering that using 8F catheter versus 6.5F catheter has no advantage in terms of performance of the device, the results of our study suggest that ports with catheters >7F should be avoided.

Clinical outcomes of totally implantable venous access port placement via the axillary vein in patients with head and neck malignancy

Purpose: To evaluate the clinical outcomes and complications of totally implantable venous access port implantation via the axillary vein in patients with head and neck malignancy. Materials and methods: A total of 176 totally implantable venous access ports were placed via the axillary vein in 171 patients with head and neck malignancy between May 2012 and June 2015. The patients included 133 men and 38 women, and the mean age was 58.8 years (range: 19–84 years). Medical records were retrospectively reviewed. Results: This study included a total of 93,237 totally implantable venous access port catheter-days (median 478 catheter-days, range: 13–1380 catheter-days). Of the 176 implanted totally implantable venous access port, complications developed in nine cases (5.1%), with the overall incidence of 0.097 events/1000 catheter-days. The complications were three central line-associated blood-stream infection cases, one case of keloid scar at the needling access site, and five cases of central vein stenosis or thrombosis on neck computed tomography images. The 133 cases for which neck computed tomography images were available had a total of 59,777 totally implantable venous access port catheter-days (median 399 catheter-days, range: 38–1207 catheter-days). On neck computed tomography evaluation, the incidence of central vein stenosis or thrombosis was 0.083 events/1000 catheter-days. Thrombosis developed in four cases, yielding an incidence of 0.067 events/1000 catheter-days. All four patients presented with thrombus in the axillary or subclavian vein. Stenosis occurred in one case yielding an incidence of 0.017 events/1000 catheter-days. One case was catheter-related brachiocephalic vein stenosis, and the other case was subclavian vein stenosis due to extrinsic compression by tumor progression. Of the nine complication cases, six underwent port removal. Conclusion: These data indicate that totally implantable venous access port implantation via the axillary vein in patients with head and neck malignancy is safe and feasible, with a low axillary vein access-related complication rate.

Clinical Outcomes for Endovascular Repair of Thoracic Aortic Disease Using the Seal Thoracic Stent Graft: A Korean Multicenter Retrospective Study

PURPOSE To investigate the midterm outcomes of thoracic endovascular aneurysm repair (TEVAR) with the use of the Seal stent graft for four categories of thoracic aortic disease. MATERIALS AND METHODS This retrospective multicenter study evaluated the records of 216 Korean patients who underwent TEVAR with the Seal stent graft during 2007-2010. The study outcomes were (i) perioperative death, (ii) endoleak, (iii) repeat intervention, (iv) aortic-related death, and (v) all sudden unexplained late deaths. RESULTS The overall technical success rate was 94% (203 cases), and the disease-specific rates were 97% (88 cases) for aneurysms, 96% (71 cases) for dissections, 82% (32 cases) for traumatic aortic disease, and 100% (12 cases) for intramural hematoma and/or penetrating aortic ulcer. There were 6 acute surgical conversions (2 for aneurysms and 4 for dissections). There were 18 endoleaks, 4 retrograde ascending aortic dissections, and 6 stent graft-induced new entries. The 1-, 3-, and 5-year overall survival rates were 93% ± 3, 90% ± 4, and 90% ± 4, respectively. CONCLUSIONS TEVAR with the Seal thoracic stent graft provided a high technical success rate and low mortality and complication rates during midterm follow-up. However, additional long-term studies are needed to evaluate the durability and late complications associated with this device.

Mechanical recanalization for clot occlusion of venous access ports: experimental study using ports with clot occlusion

Purpose To test the hypothesis that mechanical injection of saline is safe and effective in restoring patency of totally implantable venous access ports (TIVAPs) with clot occlusion. We devised an experimental port model for the evaluation of mechanical TIVAP recanalization prior to its clinical application. Materials and Methods The clot TIVAP occlusion model was constructed by filling the catheter with swine blood and incubating it at 37.5°C. The model was incubated for different lengths of time ranging from 1 day to 7 days. Each incubation time point included 20 ports. Total catheter occlusion of the TIVAPs was assessed with a 10-mL saline syringe equipped with a non-coring needle. Occlusion was defined as no passage of saline through the catheter when it was aspirated and infused gently with the 10-mL saline syringe. Pressure was evaluated during recanalization with an indeflator. Histological examination was performed on the clot obtained during recanalization. Results Among the 140 total experimental ports, 65 occlusions (46.4%) were detected. Of these 65 occlusions, 56 (86.1%) were recanalized by mechanical saline pressure via the indeflator. The indeflator pressure ranged from 29 pound per square-inch (psi) to 265 psi at mechanical catheter recanalization (mean: 110 psi). Histologically, all specimens from the model ports exhibited a similar appearance; specifically, erythrocytes, cells, and fibrin were evenly scattered throughout the clot. Conclusions Our data indicate that it is feasible to generate a TIVAP clot occlusion model with swine blood. Moreover, mechanical recanalization was suitable for resolving occluded catheters without thrombolytic agents.