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Bast RC Jr, Kufe DW, Pollock RE, et al., editors. Holland-Frei Cancer Medicine. 5th edition. Hamilton (ON): BC Decker; 2000.

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Holland-Frei Cancer Medicine. 5th edition.

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Chapter 33Vascular Access in Cancer Patients

, MD.

The management of patients with cancer has evolved rapidly in the second half of this century. Extensive surgical procedures have become safer and easier to undertake, mainly due to increase in knowledge and applications of supportive treatment. Central vessels have been cannulated for monitoring of physiologic parameters and delivery of medications, fluids, blood products, and nutrition. The expansion of parenteral chemotherapy stimulated research in gaining venous access. The development of total parenteral nutrition also contributed significantly to the search for and development of better and easier access to the central veins.

Before 1970, the most commonly used catheters were made of semirigid materials, such as polyvinyl chloride, and were introduced through a cut-down on the cephalic or basilic veins or through subclavian punctures. These catheters were not tunnelized and had to be removed after no more than a week because of the risk of infection and thrombosis. In 1973, Broviac pioneered the use of a barium-impregnated silicone-rubber catheter for insertion in the right atrium through a subcutaneous tunnel for prolonged parenteral hyperalimentation.1 This technique revolutionized long-term central venous access, as this catheter proved to be less thrombogenic. The segment of catheter in the subcutaneous tunnel between the skin entry site and the venous insertion site contains a Dacron cuff that allows fibroblastic ingrowth from the surrounding fat, thus blocking free passage from the skin along the path of the catheter to the deeper tissues, decreasing the risk of infection. These two characteristics allow the catheter to remain in the central venous system for prolonged periods, sometimes years. The first modification to the Broviac catheter was introduced by Hickman, who developed a catheter of larger internal diameter, allowing higher infusion flow rates for bone marrow transplantation patients.2 Shortly thereafter, we reported the simultaneous use of two catheters of different lengths, to allow synchronous access for hyperalimentation through one dedicated line and administration of other fluids and medications through the second line3 (Fig. 33.1). The next advance occurred with the introduction of double- and triple-lumen catheters contained in one sheath, but with separate external ports. Thus, multiple medications, solutions, and blood products may be administered simultaneously without risking precipitation in the lumina of the catheter.

Figure 33.1. Position of staggered catheter tips.

Figure 33.1

Position of staggered catheter tips.

Subsequently, a totally implantable system was developed, in which a catheter similar to the Broviac/Hickman was connected to a reservoir that is positioned in continuity in a subcutaneous pocket. Such devices must be accessed through a noncoring needle; thus, they do not easily permit as high-flow infusions as do the external catheters. However, they clearly demonstrate the advantage of a system that has no external component; and once healed, the incision sites are aesthetically more appealing. Niederhuber reported the initial series, demonstrating the practicality of this technique in cancer patients.4 More recently, double-lumen catheter port systems have been developed, with the catheter tips in close vicinity or staggered 3 cm apart, in order to allow continuous infusion through both lumina, minimizing contact between solutions.

A larger double-lumen catheter (Permcath®), initially intended for hemodialysis, has found its application in oncology. This is a more rigid staggered-tipped double-lumen external device that allows high flow as part of a cytapheresis apparatus. It has become very useful for peripheral stem cell collection prior to chemotherapy and for cytapheresis in hematologic malignancies.

Lastly, thinner polyurethane catheters attached to a small port (P.A.S.-PORT®) have been utilized. These catheters can be placed through the basilic or cephalic veins and tracked with an electromagnetic unit, thus avoiding fluoroscopy during insertion and permitting the placement at the bedside or in the office or clinic.5 An external version without a port has been incorporated more recently (PiccCatheter®); it represents a new variety of semirigid, less thrombogenic central catheter that can be placed through a peripheral vein and may be useful for patients who require short- or medium-term central venous access, or for patients in whom a surgical implantation of a port is particularly difficult (e.g., massive chest wall tumor, tracheostomy).

Indications for Central Venous Access in Oncology

Several factors must be considered before the cancer patient receives a central venous access device. If a major surgical procedure is contemplated, a percutaneously placed, short-term catheter with one, two or three lumina is indicated. Such a catheter permits rapid fluid resuscitation, transfusion of blood and blood products, and administration of multiple medications, as well as the monitoring of central venous pressure during surgery. Postoperatively, all fluids can be administered through this catheter, avoiding the need for multiple peripheral venous punctures.

In the nonsurgical context, the patient’s age and type of cancer influence the choice of catheter. Pediatric patients tend to tolerate an external catheter better than a port, as all connections are external and there is no need for skin punctures to access it. In a child, the aesthetics of an external catheter is not usually an important problem, but the repeated needle puncture of a subcutaneous port might become unbearable. A child may, however, inadvertently pull on an external catheter and accidentally remove it or mechanically disrupt it. Consequently, in a child, it is important to make the tunnel sufficiently long and to secure the catheter to the skin at the exit site, to avoid dislodgment or breakage.

In the adult patient, several questions must be asked before determining the type of catheter to be used. (1) Does the patient have a severe hematologic malignancy (e.g., acute leukemia)? If so, this patient will require at least a double-lumen catheter, preferably of the external type, since the treatment will necessitate multiple simultaneous routes of venous access for drugs, fluids, and transfusions of blood products. (2) Does the patient require only intermittent central venous access (e.g., for adjuvant chemotherapy of breast or colon cancer)? If so, a totally implanted port catheter system is preferable, since such a device is easier to care for, is aesthetically more appealing, and requires use for short, small-volume infusions. (3) Does the patient require peripheral cell harvesting and/or bone marrow transplantation and intensive chemotherapy (e.g., for aggressive lymphoma, recurring after prior treatment)? Such a patient will benefit from a larger, double-lumen, hemodialysis-type catheter (Permcath®) because this catheter allows blood withdrawal at a rapid rate for cytapheresis and rapid infusion of large volumes of fluids, if necessary. (4) Does the patient require long-term access for opiates for palliation of terminal disease? In this clinical situation, any type of catheter may be used, and the decision is made on the basis of individual circumstances. For instance, if the patient will be cared for at home, an external catheter may be easier, as a family member can be taught to manage the catheter. If the patient is to be cared for in a nursing home or a hospice, any catheter is acceptable, including a thin one placed in the upper extremity vein, with or without a small subcutaneous port (P.A.S.-PORT® or Picc®).

A particular indication for long-term access in a patient with adequate peripheral veins is the anticipated use of doxorubicin or other vesicant drugs because of major damage that can occur in the peripheral veins, or worse, to the surrounding tissues, if the drug is extravasated.

Other indications are for patients with difficult venous access because of small veins, prior phlebitis from earlier chemotherapy, or obesity.

For patients with needle phobia, an external catheter may be the ideal access, as no further skin punctures will be necessary. An implanted port can also be a successful alternative when extensive denervation of the skin around the port pocket is performed, thus allowing an almost painless access of the port with a noncoring needle. This technique is advantageous, and patients have minimal discomfort in the hypesthetic area.

When continuous infusion of chemotherapy with a portable pump is indicated, long-term access is ideal, which allows for freedom of the upper extremities that would otherwise be the site of angiocaths.

Techniques for Placement of Central Venous Access Catheters

A variety of approaches are possible, and the decision must be made on the basis of the patient’s age, loco-regional pathology at the prospective catheter site, the patient’s general medical condition (e.g., the ability to tolerate transportation to an operating room, to tolerate intravenous sedation, and/or general anesthesia, if necessary [particularly, in the pediatric patient], and the patient’s and surgeon’s preferences of different techniques).

Some catheters may be placed safely at the bedside or in the office, without the need for an operating room. An example is the young patient in excellent general condition and performance status, whose antecubital veins have not been used repeatedly and who requires intermittent small-volume chemotherapy administration; P.A.S.-PORT® or a Picc® can be safely placed in such a patient. A hospitalized patient who requires a central line for a short period may have a Picc® line placed at the bedside.

All other catheters and ports should be placed in the operating room or under sterile conditions in an interventional radiology unit. The standard approach is by cut-down of an adequately sized vein in relation to the size of the catheter. For single- and double-lumen catheters, less than 9 French in diameter, the cephalic vein in the deltopectoral groove or the external jugular vein are usually used successfully. If a larger catheter (e.g., Permcath® or double-lumen port system) is to be employed, a larger vein, such as the internal jugular, may need to be accessed (Fig. 33.2). The surgical cut-down of these veins is possible under local anesthesia and requires only a short incision.6 This technique is safe, and in the experience of the author, has never been complicated by hemothorax or pneumothorax. The catheter exit site or the port pocket location is placed on the anterior chest wall in a position comfortable for the patient (e.g., where the chest wall is flat and where the catheter or the port pocket does not interfere with clothing). For a woman, it is particularly important to avoid the line of the brassiere straps and/or to allow the catheter or the port to be covered by the bra, to permit the use of open collared blouses or dresses (Fig. 33.3).

Figure 33.2. Vein access markings.

Figure 33.2

Vein access markings.

Figure 33.3. Port/catheter exit site position avoiding bra strap.

Figure 33.3

Port/catheter exit site position avoiding bra strap.

An alternative modality, much in vogue lately, is to place the catheter in the subclavian vein through a percutaneous puncture, followed by the Seldinger technique—dilating the site over a guide wire and inserting the catheter through a peel-away sheath.7 This technique still requires a second incision for the placement of the port or for the exit site of the catheter; the incidence of hemothorax and/or pneumothorax following this approach is 1 to 3%. Vascular injury can also occur with the wire, leading to fatal complications.8 Pneumothorax has been reported in 6% of all central venous catheterizations, representing 30% of all catheterization complications.9,10 Cases of delayed pneumothorax have been reported, emphasizing the need for close monitoring of the patient after a subclavian approach.11 It appears that this technique is indicated primarily when access through the other veins is not possible.

For breast cancer patients who have undergone modified radical mastectomy or partial mastectomy with axillary dissection, it is preferable to access the contralateral side, to decrease the risk of edema of the upper extremity, should axillary or subclavian vein thrombosis occur.

If a patient has had many prior venous accesses in the upper trunk and neck, the brachial veins may be approached proximal to the antecubital fossa, tunneling the catheter and/or the port to the anterior chest wall or upper arm. If there are mechanical difficulties secondary to cervical/mediastinal tumors, tracheostomy, massive chest wall tumors, or marked fibrosis secondary to radiation, it may be necessary to approach the inferior vena cava for access. The simplest route is through a saphenous vein cut-down or the femoral vein percutaneous Seldinger technique; the drawback of such an approach is that if thrombosis of the inferior vena cava occurs, significant edema of the lower extremities results. Moreover, the inguinal-femoral area is more difficult to maintain sterile, and the incidence of infection is higher.12 Consequently, this anatomic route should be used only when there is no better alternative. Patients who have undergone repeated catheterizations and who may also present with extensive loco-regional tumors that render use of the more common veins impractical may need to be approached through less accessible veins, such as the azygos, or intercostals.13 Central approaches directly into the superior vena cava or the right atrium have been described.14 These techniques have limited applications; they should be considered at the time of thoracotomy for the primary tumor. Other approaches, such as of the inferior epigastric,15 gonadal,16 lumbar veins,17 or renal vein18 have been described, as well as direct catheterization of the inferior vena cava when no other vein is utilizable.19 All these techniques are clearly more invasive than the more conventional techniques and should be reserved for rare patients in whom the benefit of such a procedure outweighs the risks and complications. For emergency blood and short-time infusion needs, in the absence of venous access, a marrow needle may be placed in the iliac or sternal marrow in adults, or the proximal tibia in children.20

Complications of Long-term Central Venous Access

Complications related to these foreign bodies implanted for variable periods of time are of a mechanical and/or infectious nature. Because a central venous catheter floats freely in a large vein, thrombosis around the catheter can occur as a result of inflammatory reaction. When thrombosis takes place, secondary infection can easily start. Intraluminal occlusion of the catheter can occur due to thrombosis, intravenous solution precipitate, or inadequate flow. It follows that the nursing care of central venous access devices is of paramount importance; insufficient flow through the catheter, incompatible drug admixture, excessively thick fluid administration (e.g., lipids, undiluted packed cells), or interruption of flow through the catheter may lead to occlusion, which invites a cascade of complications. Major right atrial thrombosis and pulmonary emboli have been reported in patients receiving long-term total parenteral nutrition.21 Stenosis of the subclavian vein can occur in up to 50% of patients, as documented by venograms. Spontaneous recanalization of subclavian vein thrombosis has been reported in 45% of cases. Catheter-related infections are a major cause of late subclavian vein stenosis.22

Other mechanical complications may occur due to the length and flexibility of the catheter; the tip may become displaced and, secondary to pressure changes in the mediastinum, the catheter tip may flip outside of the right atrium or superior vena cava into the contralateral subclavian or internal jugular vein. On occasion, the catheter tip intimately apposes itself to the wall of the superior vena cava, producing withdrawal occlusion, a situation in which infusion is possible but no blood can be withdrawn; this problem can also occur if a fibrin sheath forms around the tip of the catheter, occluding the tip when suction is applied. Withdrawal occlusion is not infrequent and can often be managed by positioning the patient in the Trendelenburg position and/or by withdrawing blood during deep inspiration and other positional changes (elevation of arms, lateral decubitus) to attempt mobilization of the tip of the catheter. Extravasation can occur secondary to thrombosis (Fig. 33.4). If the catheter tip lies in the upper half of the superior vena cava, rather than in its distal portion or in the right atrium, the risk of thrombosis is much higher.23 A rare complication, catheter fracture and embolization during strenuous exercise, has been reported.24

Figure 33.4. Extravasation of vesicant agent secondary to venous thrombosis.

Figure 33.4

Extravasation of vesicant agent secondary to venous thrombosis.

Significant bleeding may occur during implantation of a central venous device in thrombocytopenic patients. It is essential to transfuse platelets pre- and intraoperatively in such patients, to maintain adequate local hemostasis. If necessary, vitamin K and fresh-frozen plasma are to be administered perioperatively to normalize coagulation parameters.

Catheter-related sepsis is a common occurrence in the cancer patient, in whom immunodepression and bacteremia are often present after therapy. Infections are either (1) primary in the catheter or its surgical implantation area, occurring perioperatively or at a later date due to contamination, or (2) secondary to infection in other areas of the body with bacteremia and subsequent seeding of the catheter.

Primary infection of the catheter site(s) is usually easy to diagnose; there is new onset of pain and/or tenderness, erythema, increase of skin temperature, and swelling of the catheter area (these are cardinal signs of any infection: calor-rubor-dolor-tumor). There may be serous or purulent discharge around the subcutaneous tunnel exit site or the port (Fig. 33.5). Staphylococcus epidermidis is the most frequent organism causing these primary infections,25 although more virulent pathogens such as Staphylococcus aureus can also be responsible.26

Figure 33.5. Skin and subcutaneous infection of port site.

Figure 33.5

Skin and subcutaneous infection of port site.

If the external catheter site infection extends to the intravenous portion of the catheter, or if there is seeding of the intravenous portion by bacteria originating at a distant focus, a potentially much more serious clinical picture arises. Long-term catheters are often surrounded by a fibrinous, reactive sheath, or by a wide nonoccluding thrombus. These structures are a fertile ground for bacterial proliferation;27,28 if this phenomenon occurs, the clinical picture and management will be different. An infected device can give origin to disseminated foci of infection.29 Internal port systems have been reported to be five times less frequently infected than external catheters.30

The differential diagnosis of fever in the patient with a central catheter requires blood cultures through the catheter and from a peripheral vein. If the catheter is the source of infection, there will be a more than five-fold greater yield of bacterial colonies from the catheter blood, compared with the peripheral one.31 In the absence of these bacteriologic counts, clinical suspicion of catheter-line infection is provided by chills and fever spikes that are associated with flushing the catheter or infusing medications through it. Catheter sepsis should always be considered when entertaining the diagnosis of drug fever.

Prevention of Complications

Adequate surgical techniques and care of the operative areas and the catheter are of paramount importance in the long-term success of these venous access devices. Placement of central venous catheters must be performed aseptically, whether in the operating room, in the invasive radiology unit, or at the bedside. The patient’s hygiene is also important, since thus it is possible to minimize bacterial contamination. It is difficult to sterilize the operative field in a few seconds; patients should wash themselves with bactericidal soap preoperatively and after implantation of the access device.

Surgical technique must be meticulous, and painstaking hemostasis must be accomplished; if a hematoma should develop, the risk of infection with the foreign body is high. The placement of the catheter in the subcutaneous tunnel must be sufficiently deep, in order to avoid skin compression and possible necrosis with catheter extrusion (Fig. 33.6). A deep position of the catheter in the subcutaneous fat also prevents trauma to it and makes it less visible, thus more aesthetically appealing. If a port is placed, the flap of skin overlying it must be of sufficiently homogeneous thickness to permit easy palpation and access. Once the catheter is placed, a chest film or fluoroscopy is essential to confirm good central positioning. Ideally, the catheter should be in the distal superior vena cava or the right atrium. This position allows for the tip of the catheter to float in a high-flow wide area and minimizes the chances of thrombosis around it. A lower extremity catheter should have its tip in the upper inferior vena cava. Immediately after placement, the catheter should be flushed with 10 to 20 mL of normal saline to clear it of small amounts of blood. The entire catheter and/or port system is then filled immediately with heparin. The concentration of heparin varies in different protocols. It seems important to use concentrated heparin (i.e., 1,000 or 5,000 U/mL) in a volume equal to the capacity of the system in use; this avoids excess heparin in the systemic circulation and allows impregnation or adhesion of heparin to the catheter wall, which reduces the risk of intraluminal thrombosis.32 Every time the catheter is to be used, the heparin must be withdrawn and discarded. When the catheter is utilized for prolonged periods of time, a small dose of heparin can be incorporated in the solution (i.e., in total parenteral nutrition) to reduce thrombosis.33 An alternative method to minimize thrombosis is the daily administration of low-dose warfarin (i.e., 1 mg/d), which has been reported to decrease significantly the number of symptomatic thromboses, without altering the systemic coagulation parameters.34 However, a prospective trial to assess the benefits of urokinase as adjuvant treatment of proven Hickman catheter sepsis failed to demonstrate benefit in the salvage of infected catheters.35

Figure 33.6. Broviac catheter extrusion through tunnel skin.

Figure 33.6

Broviac catheter extrusion through tunnel skin.

The prevention of infection is critical in the management of these devices. Continuous, reiterative education at all levels is essential. All physicians, nurses, patients, and family members who may at any time be involved with the use of the venous access device must know all aspects of care: strict aseptic technique in dressing, changes of needles, connection of intravenous solutions, flushing, and changes of caps. Totally occlusive dressings around the exit site of external catheters and around the port when it is accessed are mandatory to decrease external contamination. Transparent sterile dressings have become popular as they allow continuous inspection of the site and create a totally occlusive dressing by self-adhesion in the shape of a mesentery around the catheter or the Huber needle tubing (Fig. 33.7). General medical, nursing, and mechanical common sense is essential. All external tubing, whether permanent or temporary during treatments, must be strongly secured by tape (with redundant loops) to avoid accidental dislodgment, trauma, or traction. It is preferable that the patient does not lie on the side of the accessed vein with the extremity bent since this can impair flow and may increase the incidence of thrombosis. When the catheter is not in use and the patient takes a bath, shower, or swim, it is important to change the dressing around the exit site of an external catheter and to maintain the skin overlying a port totally clean.36

Figure 33.7. Transparent occlusive dressing for implanted accessed port.

Figure 33.7

Transparent occlusive dressing for implanted accessed port.

A common complication is nonthrombotic occlusion of the catheter due to mixtures of incompatible solutions or medications. It is important to avoid concomitant infusions of solutions that are possibly incompatible, even through separate lumina of the catheter, unless their tips are staggered to allow dilution by the flowing blood. If tips are co-terminous, precipitation may occur (Fig. 33.8).

Figure 33.8. Catheter occlusion with skin necrosis.

Figure 33.8

Catheter occlusion with skin necrosis.

When a vesicant solution is to be administered, a rapid infusion of normal saline should be given initially to assure that there is no extravasation or resistance to the flow. Then, it is sound practice to administer the drug through a side port (piggyback). If a subcutaneous extravasation occurs, severe necrosis can ensue with consequent loss of the device and major morbidity.

Treatment of Complications

The nature of a complication determines the treatment. Thrombosis of the catheter lumen is a common occurrence, most frequently due to interruption of infusion for more than 1 minute or with a slow infusion of a thick solution. If the diagnosis is made promptly, intermittent withdrawal and injection of normal saline may be successful. If thrombosis is established within the catheter lumen, concentrated heparin may be useful but usually is not. Thrombolytic agents, such as urokinase, can be successful: 1 or 2 mL of 5,000 U/mL can be gently injected into the port or catheter and left in situ for 20 or 30 minutes. Frequently, a relatively recent clot will dissolve and catheter patency can be restored. If unsuccessful, a second dose may be given and left for 12 to 24 hours before attempting catheter use. The majority of catheters become patent with this treatment.37–39 The availability of urokinase has ceased, as reo-viruses were discovered in some lots. Because urokinase is produced from cultures of kidney cells obtained post mortem from human neonates, possible risks of viral transmission became a concern; to date, no infections have been documented secondary to urokinase use. An alternative thrombolytic enzyme is Alteplase that can be used in doses of 1 mg/mL.40

A more serious complication occurs when a major vein thromboses around the catheter. High percentages of subclavian vein thromboses have been reported,41 but the majority remain asymptomatic unless pulmonary emboli occur. Diagnostic tests are helpful in patients who develop edema of the arm and shoulder, pain along the axillary-subclavian vein, and collateral circulation. The most precise test is a venogram through a distal peripheral vein (not through the catheter, since the thrombosis can spare the distal catheter).22,42 Duplex Doppler studies, magnetic resonance imaging, nuclear angiography, and sometimes computed tomographic studies can assist in establishing the extent of thrombosis.43

Once the diagnosis of major venous thrombosis is established in the symptomatic patient, several therapeutic options exist. The safest standard approach is to remove the catheter, after which the flow may be re-established through the catheter channel. Anticoagulation will diminish spread of the thrombosis and allow spontaneous lysis at the periphery of the thrombosed segment.44 In an attempt to salvage the catheter, particularly in patients with difficult access, treatment with arm elevation and anticoagulation, without removal of the catheter, has been reported as successful.45 The successful use of urokinase in a peripheral vein infusion has also been reported,46 but the risk of hemorrhage may not justify its use. Streptokinase and recombinant plasminogen activator are of known value for other intravascular thromboses. The risks and benefits of thrombolytic therapy must be evaluated for each patient.

By far the most severe complications are of infectious nature. A frequent occurrence is an exit site infection usually due to S. epidermidis, for which local care and antibiotics are usually successful, conserving the catheter in situ.47 If the infection is due to S. aureus, the catheter must be removed because of the virulence of this organism.26

Tunnel or port-pocket cellulitis-like infection without overt purulent contents may be treated with intravenous antibiotics and local care (see Fig. 33.5). If no improvement is seen within 1 or 2 days, however, or if systemic symptoms develop, the catheter must be removed. On occasion, débridement of the area may become necessary. Of all the catheter-related sepses, the most difficult to manage is of fungal origin, particularly in children.48 It is unusual to manage successfully a patient with a fungus-contaminated catheter without removing it, in addition to using antifungal antibiotics, such as amphotericin B. Prophylactic antifungal treatment is not usually justified, however. When a catheter has been removed because it is a source of sepsis, it is advisable to treat the patient with antibiotics for several days until blood cultures become negative and all signs and symptoms disappear. Many of these patients, however, have poor venous peripheral access; after sepsis is cured, it is important to maintain only a temporary peripheral or central access until a new long-term access can be placed.

A novel strategy to prevent catheter infection in cancer patients is the development of long-term silicone catheters with incorporated antimicrobial agents.49

Results of Long-term Central Venous Catheters in Cancer Patients

The ideal result is represented by a patient who has a correctly placed catheter, properly managed by self and staff, that stays functional for the entire length of time required and allows blood samples to be drawn and medications and solutions to be administered through it, without thrombosis or infection occurring. How often does this happen?

Many series report different complications that highlight the difficulties in maintaining ideal central venous access. The first important comparison is between external catheters and ports. A randomized trial of 100 patients with solid tumors found a significantly higher removal rate for external catheters versus ports (20 versus 4%). Infection rates were significantly lower in port patients (12 versus 2.5%).50 Other retrospective studies tend to confirm the concept that implanted ports are less prone to infection than are external catheters.51,52 In children, a prospective study of 144 ports versus 130 external catheters also found superior performance of implanted ports, compared with external catheters.53

The author’s initial personal experience with external catheters in 169 patients (182 catheterizations) for hematologic malignancies and solid tumors, in which all catheters were placed by surgical incisions and all were subject to meticulous postoperative care, included 10 infections (5.9%) and 6 thromboses (3.5%). Thirteen catheters required replacement secondary to infection and/or catheter occlusion. This emphasizes the safety of external catheters, provided there is optimal long-term care54 (Table 33.1).

Table 33.1. Initial Experience of One Surgeon with External Long-Term Central Venous Catheters.

Table 33.1

Initial Experience of One Surgeon with External Long-Term Central Venous Catheters.

In the past 8 years, 410 central venous access devices have been implanted by the author and surgical residents under his direct supervision (Table 33.2). Wide acceptance of the safety and convenience of these devices has led to their increasing use in women undergoing adjuvant treatment for breast cancer as well as other diseases, particularly if vasotoxic and histotoxic drugs are to be used.

Table 33.2. One Surgeon’s 8-year Experience with Central Venous Access Devices.

Table 33.2

One Surgeon’s 8-year Experience with Central Venous Access Devices.

The quality of life for patients has improved significantly, since these devices allow avoidance of repeated peripheral venous punctures. In one study, patient satisfaction was particularly notable with implanted ports.55 Avoidance of occlusion of catheters has been reported by the use of double-lumen devices for administration of fluorouracil and leucovorin, a common regimen in gastrointestinal cancer.56

Nonmetallic ports were evaluated in one study of 78 patients with 369 treatment cycles and a total of 1,370 infusion days; there were no infections, and 87% achieved long-term function.57 Successful use of urokinase and antibiotics, when needed, maintained 94.9% of catheters functional in a prospective study of 177 pediatric oncology patients.58

The National Cancer Institute has reported its experience with catheter-related fungemia in 155 cancer patients. Of patients treated only with antifungal therapy, 82% had a poor outcome, supporting the concept that catheters should be removed early in the course of fungal infection.59 The experience of the University of Maryland Cancer Center with 690 external (Hickman®) catheters between 1978 and 1987 reported a total of 134, 273 catheter days.60 There were 438 noninfectious complications and 603 infections, the majority at the exit site. Infections and bacteremias were treated effectively without removing the catheter.

Conclusion

Long-term central venous catheterization in cancer patients has become an important aspect of management and treatment. The use of the different devices can be systematized and adapted to the needs of the individual patient. Adequate care of the catheter and patient education are essential factors in the successful longevity of the catheter; in patients with small veins, obese arms, or venous thrombosis from prior chemotherapy, the improved quality of life related to the expediency of access to the bloodstream cannot be overemphasized.

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Bookshelf ID: NBK20943
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