Chest port implant access and techniques. Luc Rotenberg 2018

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C h e s t p o r t i m p l a n t a t i o n b y
venous access with US Guidance
Luc Rotenberg, RPO, ISHH
Clinique Hartmann – CMC Ambroise Paré
26-27 bd Victor Hugo, 92200 Neuilly Sur Seine – France
www.radiologieparisouest.com
dr.rotenberg@radiologieparisouest.com
Johannesburg, Oct 4th 2018

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1.  PERCUTANEOUS CHEST PORT IMPLANT
2.  US GUIDED CHEST PORT IMPLANT
3.  CATHETER TIP POSITIONING

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Hartmann Clinic
Built in 1904
Prof Henri Hartmann

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Marie Curie and her daughter Irène at the Hoogstade Hospital in Belgium, 1915. Radiographic
equipment is installed.
Copyright © Association Curie Joliot-Curie
Nobel Prize in Physics 1903
Pierre et Marie Curie et Antoine Henri
Becquerel
In recognition of the extraordinary services he has rendered by his
discovery of spontaneous radioactivity", the other half jointly to Pierre
Curie and Marie Curie, née Sklodowska "in recognition of the
extraordinary services they have rendered by their joint researches on the
radiation phenomena discovered by Professor Henri Becquerel".

Nobel Prize in Chemistry 1911
Marie Curie, née Sklodowska
In recognition of her services to the advancement of chemistry by the
discovery of the elements radium and polonium, by the isolation of radium
and the study of the nature and compounds of this remarkable element

Nobel Prize in Chemistry 1935 Frédéric et
Irène Joliot-Curie
in recognition of their synthesis of new radioactive elements

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In the 1920’s… Radioherapy in Hartmann Clinic

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First Cobalt bomb
HARTMANN
1955

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•  358 000 cancers cases/year
•  145 000 ports
•  50 000 PICC Lines
Ports implantation in France
private/public
Potential ports
APHP
10 000
CHU
26 000
Public
35 000
CRLCC
17 000
Private
57 000
Total
145 000

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•  ISHH = 700 ports / year

–  Radiologists

–  Surgeon

–  Non dedicated or dedicated operating session
–  Mean of 5 implants/session
–  300 ablations

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Haematology, acute
leukemia,
HSCT, GM
Endocarditis
(bones, cellulitis, joints…)
Cystic ﬁbrosis,
bronchiectiasis, numerous
cures
Continuous
> 15 days
Cyclic,
prolonged…
Palliative patient,
undernourished
Infection >6months
(bones, joints...)
Choice of central venous access and device
Chemotherapy
Antibiotic treatment
Parenteral Nutrition
Others
Venous insufﬁciency
Sickle-cell anaemia
Transfusion,
Haemophilia
Prolonged IV
analgesics
Haematology, NHL, HL,
myeloma, myelodysplasia…
Hemodialysis

Chronic
Cytapheresis
Plasmapheresis
Long term central venous
access indications
Solid tumor

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Contraindications to implantable port ? (1)
< 3 months
> 3 months
Tunneled CVC with or without
cuff:
- Onco-haematology intensive
care
- Marrow transplant
- Leukemia induction…
Shared decision(2)
Neediness of high ﬂow rate perfusion ?
YES
NO
Indication
Length of treatment ?
Tunneled CVC
± cuff
PICC
Speciﬁc Catheters:
-cytapheresis,
-plasmapheresis, -
haemodialysis.
Implantable Port
NO
Tunneled CVC
± cuff
Continuous Tt.
Intermittent Tt.
Shared decision(3)
YES
Tunneled CVC
± cuff
Shared decision
PICC
Implantable Port

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(1)  Implantable Port contraindications :
-  Thrombopenia (<50000), hemostasis disorders, DIVC ;
-  Implantation site infection, systemic infection or non controlled bacteriemia ;
-  Major tumor inﬁltration of implantation site.

Remark: Mediastinal compression, superior vena cava thrombosis or sclerosis are contraindications to central catheters
implementation in the superior vena cava area : Port, PICC, tunneled catheter with or without cuff.

(2) When a patient rejects an emerging catheter and wants instead an implantable port : to negociate.

(3) Intermittent treatment: when no use between treatments, parenteral nutrition 5/7 days = rather a port.
Continuous treatment: parenteral nutrition 7/7 days, palliative care, PCA morphinic = rather an emerging catheter.
Comments

Clinical Pathway
Balistic preoperative consultation
§  Report Study
§  Interrogatory (risk factors…)
§  Balistic approch
§  Targeted
§  Device and guidance technique choice
§  Patient explanation of :
§  Intervention
§  complications
§  Possible results and implications
§  Pricing
§  Written informed consent is required before all interventions +++
临床综合治疗模式
术前靶向方案

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Clinical Pathway
•  Ambulatory
•  Short delay : 0 to10 days
– Mean delay : 5 days
– No delay in case of emmergency

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Quality of life
•  Before intervention
•  Ports implantation
•  During chimotherapy
•  After treatment
生活质量

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Key point
•  Installation +++
•  Fast intervention
–  Start with easy access
–  Phantom training

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INTERNAL JUGULAR  
« in short » 
 
tunneling the catheter

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INTERNAL JUGULAR  
 
in PAEDIATRICS

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Sub Clavian chest port
•  In recent years, the surgical approach to the subclavian vein by sub
clavicular "classic" was partially abandoned in favor of the internal
jugular, supposedly safer.
•  The addition of ultrasound guidance helps restore its credentials in this
way, more functional and aesthetic avoiding many of the previous
complications of « blind » puncture.
•  Surroundings 10.000 procedures were performed in our institute since
2007, with this technique and this way without ﬁrst pneumothorax,
arterial puncture or pinch off syndrome.

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US guidance
ultrasound guidance with sterile pouch allows direct puncture of the subclavian vein and avoids the tunneling

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BRACHIAL VEIN
by BASILIC approach

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EXTERNAL JUGULAR VEIN
…exceptionnal

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FEMORAL VEIN

…exceptionnal

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In all cases
Plain Chest XRAY control
•  Ports position
•  Reference imaging

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SEESITE®
Radiopaque marking + Ultrasound guided venipuncture set

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4 AVAILABLE SETS
• Surgical Set POLYSITE®
(port, catheter, connection rings, vein
pick, syringe, straight Huber needle,
catheter rinse)
  Percutaneous Set
POLYSITE® ISP
(Surgical set + puncture needle, peel
away sheath introducer, J guidewire,
tunneling device)
  Combine CT port marked +
  Ultrasound guided venipuncture set
(Percutaneous set + echogenic puncture needle,
marqued J guidewire, Bulb Raulerson system,
dressing including sterile gel, a protective sheath
for ultrasound probe and 2 elastics)
  All Sets includes
•  Patient diary to give to the
patient
•  Instruction for use
•  8 identification stickers
•  1 patient card
•  1 Medical alert sheet
  Ultrasound guided
venipuncture set
  POLYSITE® Echo

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Product characteristics
Silicone filled suture holes
Radiopaque marking
detectable by X-ray
SEESITE® port SEESITE® kit
1 graduation
=
1mL/sec
5 mL/sec 3 mL/sec 1 mL/sec
POLYSITE ® Echo kit
accessories

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  Unique and innovative radiopaque marking for easy
identification of maximum flow rate injection (graduation)
First Key argument
identification
5 mL/sec 3 mL/sec 1 mL/sec
Benefit :
àPatient safety

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First Key argument
Identification
Clearly identifiable, our marking allows a better visibility under
X-ray than competitors ports (only ports with CT making)
SEESITE®POWER
PORT®
BARD
Smiths

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Second Key argument
Port position
–  Allows to detect if the port is flipped
Correct position of the port
Marking has a « C » shape
like in “Correct”
Flipped port
Marking has a
reverse « C »
shape
C C
Risks of complication:
- Cytotoxic product Extravasations
(cutaneous necrosis)
- Edema, inflammation for non
cytotoxic products
- blunted needle, painful withdrawal
for patient
- Postponed treatment
- Cost increase
Benefit :
àPatient safety

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Third Key argument
adaptable with medical practices
–  Unique range of pressure injectable port with RX marking offering :
•  7F and 8F silicone catheters
•  Catheter size inferior to 7F à 5F silicone (1 ml/sec, useful for paediatric use and
MRI exams)
SEESITE® range is compatible with doctors practices and habits (not the
opposite) :
o Silicone versus PU,
o Paediatric use,
o Catheters diameter Benefit :
àNo changes in doctors practices
àdoctors comfort
  Usual injections flow rate for scanner and MRI
procedures : from 1 to 3 mL/sec.
5 mL/sec injections are rarely used (see table) and not
recommended for risky cases (catheter motions).

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Fourth Key argument
unique complete kit
–  Complete accessories offer
•  Echo-guided venipuncture set (in
accordance with NICE
recommendations)
•  Safety Huber needle PPS® CT
–  In accordance with European directive
2010/32 on blood exposure prevention
–  Continuity for establishment already using
Polyperf Safe®
Benefit :
àPhysician comfort
Benefit :
àPrevention of catheter obstruction

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Promotional tools
1° Different Packaging
2° Brochures 2 pages

Surgical approach
S  surgical approach by the healthy side
S  prevent disease areas
S  radiotherapy

Esthetic
respect neckline
and decollete

(BUNODIERE 2001)
Criteria for selection of
surgical approach

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Good result
•  Small scar (1 to 2 cm)
•  Oblique or vertical scar by deltopectoral groove approach
•  invisible suture by a buried overlock and/or biological glue

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Discreet or invisible scare in deltopectoral groove

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Almost invisible scar in deltopectoral groove

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Lumen obstruction
Lumen obstruction by blood clot (24 % )
• Causes :

•  Lack of flush
•  Drug precipitation (incompatibility between 2 products, crystallisation)
•  Endovenous loops
•  Lipid deposits

Clinical signs
•  Discomfort or pain in thoracic cavity, neck or in scapular area, in rare cases appearance of arm oedema
•  Impossible to inject and absence of blood reflux
•  Infectious signs

Recommendations
•  X-Ray control and/or opacification (phlebography, CT scanner)
•  Urokinase lock (Actosolv) :
–  1ml with 9 ml of NaCl (dosage 5000 UI/mL) leave 1ml of the fibrinolytic solution in contact with the blood clot during 15-20min then suck up
•  Treatment of the cause (anticoagulant, thrombolytic agents, antibiotics)
•  Device removing in case of failure

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Flushing recommendations
•  Technique
–  Use a pulsatile flow when flushing
–  Use a flush with 10 × 1mL boluses with a time interval of 0.4 s between 2 boluses
–  Use the positive pressure technique when disconnecting a syringe
•  Volume
–  Use a 10mL flush for all IV catheters (except for peripheral cannulas, use 5 mL)
–  Use a 20mL flush after infusion of viscous products like blood components, parenteral
nutrition, and contrast media
•  Regimen
–  Flush with NS before and after administration of drugs of fluids
–  Flush with NS before and after blood sampling

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Flushing recommendations
3. As you come towards the last 1ml of the flush,
remove the needle from the PORT AT THE SAME TIME
AS YOU ARE FLUSHING.
2. You will now need to flush the PORT using a push
pause turbulent flush and finishing with a positive
pressure flush.
1. The needle should be correctly placed in the
septum and just touching the bottom plate

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Need of heparin ?
•  There is no data conﬁrming the need of heparin to prevent catheter
occlusion or thrombosis
•  The half life of heparin is very short

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Preventing complications of central venous catheterization
McGee N Engl J Med 2003; 348:1123-33

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Injuries and liability related to central vascular catheters:
a closed claims analysis
Domino Anesthesiology 2004; 100:1411-8

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conclusion :
patient opinion
0
10
20
30
40
50
60
70
80
90
100
Before After
Favorable
Not Favorable
Retrospective study
100 consecutive women
Hartmann 2005
n  Satisfaction 97 %
n  Gratefull for preserving the
cleavage 64 %

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WHAT IS GOOD FOR THE PATIENT
…IS GOOD FOR THE DOCTOR

THE REVERSE MAY BE WRONG !

Dr Michel BUNODIERE, 2001

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Take home :
ports access
Technique
1.  Pre opetative consultation
2.  Verticale or oblique scare in deltopectoral groove, 1 to 2 cm
3.  US puncture guidance
4.  Surgical approach
5.  PORT positioning See Site
6.  TIP positioning
7.  Management and Complication

Chest port implant access and techniques. Luc Rotenberg 2018

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Chest port implant access and techniques. Luc Rotenberg 2018