A total of 200 consecutive patients who had undergone central venous port implantations were evaluated in our study (Table 1). Group 1 had 57 male and 43 female patients and 56 of them are international, came from abroad for health tourism. The right jugular vein was preferred in 91 of these patients. The gastrointestinal system was found to be the most common site of primary cancer followed by the pancreaticobiliary system and the breast (Table 2). In this group, single agent chemotherapy protocols were used the most. The mean duration of follow-up was calculated to be 12.3 months.
Table 1
Demographic characteristics of 200 central venous port implanted patients.
| Min-Max | Median | Mean ± SD | n | % |
Age | 20–84 | 62 | 59.6 ± 12.1 | 200 | 100 |
Duration of port use (months) | 0–93 | 8 | 13.5 ± 15.7 | 200 | 100 |
Sex | Female | 99 | 49.5 |
Male | 101 | 50.5 |
Side | Right | 186 | 93 |
Left | 14 | 7 |
Number of chemotherapeutic drug(s) | 1 | 87 | 43.5 |
2 | 83 | 41.5 |
3 | 30 | 15 |
Complication | Present | 21 | 10.5 |
Absent | 179 | 89.5 |
Dindo- Clavien severity classification | 0 | 179 | 89.5 |
II | 7 | 3.5 |
III | 14 | 7.0 |
Table 2
Primary diagnosis of 200 central venous port implanted patients.
Primary diagnosis | n | % |
Gastrointestinal system cancers | 115 | 57.5 |
Breast cancers | 28 | 14 |
Pancreaticobiliary system cancers | 26 | 13 |
Head and neck cancers | 11 | 5 |
Gynecologic cancers | 9 | 4.5 |
Soft tissue sarcomas | 4 | 2 |
Lung cancers | 3 | 1.5 |
Lymphomas | 2 | 1 |
Renal cell cancer | 1 | 0.5 |
Adenocancer of unknown origin | 1 | 0.5 |
Group 2 had 56 female and 44 male patients and 53 of them are international, came from abroad for health tourism. The right subclavian vein was preferred in 95 patients. The gastrointestinal system was found to be the most common site of primary cancer followed by breast and the pancreaticobiliary system. Single agent chemotherapy protocols were used in 41 patients, two chemotherapy agents in 41 patients and three agents were used in 18 patients. The mean duration of follow-up was calculated to be 14.6 months.
There was no statistically significant difference between Group 1 and Group 2 patients regarding to age, gender, side, number of drugs used for chemotherapy and the duration of port usage (p > 0.05) (Table 3).
Table 3
Comparison of central venous port implanted patients according to access method. Patients for whom jugular veins were used are assigned as Group 1 (100 patients) and patients for whom we used the subclavian veins are assigned as Group 2 (100 patients).
| Group 1 | Group 2 | P* |
Mean ± SD | Median | Mean ± SD | Median |
Age | 58.2 ± 11.3 | 61.0 | 60.9 ± 12.7 | 63.5 | 0.060m |
Port use duration (months) | 12.3 ± 9.9 | 9.5 | 14.7 ± 19.8 | 8.0 | 0.355m |
| n (%) | n (%) | |
Sex | Female | 43 (43) | 56 (56) | 0,066x2 |
Male | 57 (57) | 44 (44) |
Side | Right | 91 (91) | 95 (95) | 0.268x2 |
Left | 9 (9) | 5 (5) |
Number of chemotherapy drug(s) | I | 46 (46) | 41 (41) | 0.473x2 |
II | 42 (42) | 41 (41) |
III | 12 (12) | 18 (18) |
Complication | Present | 2 (2) | 19 (19) | 0.000x2 |
Absent | 98 (98) | 81 (81) |
Dindo Clavien complication severity classification | 0 | 98 (98) | 81 (81) | 0.000x2 |
II | 1 (1) | 6 (6) |
III | 1 (1) | 13 (13) |
*Statistical analysis: m: Mann-Whitney U test; x2: Chi Square test. |
Two complications were developed in Group 1 patients in whom the jugular vein was used. According to the Dindo Clavien classification, one of the complication was Category 2 and the other one was Category 3b. Nineteen complications were developed in Group 2 patients in whom subclavian vein was used. According to the Dindo Clavien classification, six of those complications were Category 2, two of them were Category 3a, and eleven of them were Category 3b. When the complication rates and the severity of those complications according to the Dindo Clavien classification were compared, Group 2 was found to have a higher rate of complications and those complications were also found to be severe when compared with Group 1 patients (p < 0.05) (Table 3).
Despite zero occlusion in Group 1, four catheters were occluded in Group 2 patients. While one patient’s problem was solved by pressurized heparin wash, in three patients the ports had to be removed and replaced because of this occlusion. The patient whose problem was solved by pressurized heparin wash was on a single agent chemotherapy because of a head and neck cancer. Two of the three patients whose ports were replaced had a breast cancer primary and the last one had a head and neck cancer. One of the patient was on single agent but the other two patients were on three-agent chemotherapy protocols. The rate of port occlusion was found to be significantly high in Group 2 when compared to Group 1 patients (p < 0.05).
In Group 1 the port had to be removed due to infection in one patient. At this patient’s port culture Candida albicans was identified. The patient was on a single agent chemotherapy due to pancreatic cancer. Infection had developed in three patients in Group 2. One of these infections was superficial surgical site infection which was successfully treated by local therapy and thus the port could be salvaged. Ports had to be removed and replaced in two patients and Enterobacter aerogenes was identified in both catheter cultures. Both patients were on three-agent chemotherapy protocols, one for breast cancer and the other for head and neck cancer. Infection rate was found to be significantly high in Group 2 compared to Group 1 patients (p < 0.05).
Catheter rupture was observed in two patients and in both patients the central venous ports had been implanted via the subclavian vein. A linear breakage was identified in one patient and a complete separation in the other. The first patient, a 61 years old woman, was treated with an alkaloid containing single-agent chemotherapy for breast primary. The port was implanted through the right subclavian vein, the intravascular and the extravascular catheter angle was above 60 degrees. In the 78th month of her treatment patient experienced a sharp pain at her shoulder after drug administration through her venous port. Due to this pain her venous port was evaluated by fluoroscopy and a contrast extravasation corresponding to the subclavicular area was identified (Fig. 1a). The port was removed and a new port was implanted through the right jugular vein. In the ex-situ examination, 9 cm distal to the port-catheter attachment point, a linear breakage of approximately 2 cm was observed (Fig. 1b). The projection of this point was predicted to be at the one third proximal part of the clavicle, just between the clavicle and the first rib. The other patient was a 46 years old male who was on a single-agent chemotherapy protocol for colon cancer. After an uneventful treatment period through his venous port for more than 29 months the fluid administered through the venous port caused shoulder pain and we couldn’t pool blood from the port. Radiological evaluation indicated a complete breakage at a point compatible with the one third distal part of the clavicle and the distal end of the catheter was found to be freely floating in the atrium (Fig. 2a). The port entrance was between the clavicle and the first rib (Fig. 2b) and interventional radiology team removed the broken distal end by an angiographic intervention. The port and the proximal part of the catheter was also extirpated and a new central venous port was implanted through the left subclavian vein. To note, the catheter angle of this patient was also above 60 degrees.
Pneumothorax is another important complication of venous port implantation. No pneumothorax was identified in Group 1 patients whose venous ports were implanted through jugular vein but in Group 2 patients a total pneumothorax requiring chest tube placement and a partial pneumothorax that improved with conservative treatment were identified in two patients.
We could not able to puncture the port in one of the patients of Group 2 and the radiological investigation revealed that the posterior, broad-based part of the port, had turned down (Fig. 3). The upturned port could be salvaged with revision.
Arrhythmia, another frequent complication of port implantation developed in one patient during the procedure. This rapid ventricular response tachyarrhythmia persisted despite the withdrawal of the guide-wire and the rhythm recovered with vagal stimulation and antiarrhythmic therapy.
We observed suture line problems in four of the Group 2 patients and at those patients skin and subcutaneous tissue overlying the port lost its integrity. When the treatment details of these patients were reviewed we noticed that two patients had received Bevacizumab for lung and colon cancer. In three patients the port catheters were removed and replaced with the new ones but in one patient we created a new space to place the port thus we managed to salvage the port.