Application of port helps to maintain good shoulder function, and the displacement range of the catheter tip is less affected (compared to PICC) by shoulder adduction and abduction
The majority of patients with malignant bone and soft tissue tumors of the lower limbs also experience lower-limb movement disorders. Some amputees require walkers or axillary canes to assist their daily life activities, meaning, for such patients, upper-limb function is highly important for the performance of such activities. Thus, such patients have high requirements in terms of shoulder joint function.
The effect of limb movement, especially the movement of the catheterization-side shoulder joint, on the position of the central catheter tip remains debated. Most studies have found that for patients with PICC, in a 90° abduction of the shoulder joint, the catheter tip tends to move towards the right atrium; meanwhile, when the shoulder joint goes past a 90° abduction, the catheter tip tends to move towards the superior vena cava. Finally, if the abduction is continued and reaches 110–180°, the catheter tip moves back towards the right atrium [10, 11].In our study, we found that for patients with PICC, when the catheterization-side shoulder joint was abducted 180°, the catheter tended to move towards the right atrium, with an average displacement distance of > 1.5 cm; meanwhile, for patients implanted with venous ports in the internal jugular vein, the location of the catheter tip was less affected by shoulder joint adduction and abduction, showing an average displacement distance of < 0.5 cm (towards the right atrium). There was a statistically significant difference between the two groups in this regard. Thus, when providing guidance in regard to functional exercise movements to patients who have received PICC, the patients should be informed that they should minimize 180° abduction of the catheterization-side shoulder joint; this is in order to prevent arrhythmia and even endocardial necrosis and perforation caused by downward displacement of the catheter [12].
In our study, we found no significant difference between the PICC group and the port group regarding CMS score for the catheterization-side shoulder at one month post-catheterization. However, at six months post-catheterization, the patients in the PICC group scored significantly lower than the patients in the port group; this may have been caused by limitations regarding active movement of the catheterization-side shoulder joint after catheterization. Most medical staff do not provide sufficient post-catheterization guidance to patients regarding functional exercise for the shoulder joint [13]. Additionally, patients with PICC showed shoulder-joint adhesion on the catheterization side at six months after catheterization, meaning they had a small range of motion in the shoulder joint in question and, thus, a lower CMS score on the catheterization side. This adhesion may have been caused by the adoption of an abnormal position due to unusual shoulder joint activity or their own fear of catheter prolapse. At three months after extubation, there was no statistically significant difference between the two groups regarding CMS scores. Concurrently, focusing solely on the PICC group, there was no significant difference in CMS scores for the catheterization-side shoulder between one month after catheterization and three months after extubation.For the patients in the port group, there was no significant difference in CMS score for the catheterization side across the time points of one month after implantation, six months after implantation, and three months after extubation, respectively, which further confirmed the superiority of venous port implantation in regard to optimizing shoulder joint function.
Thus, although, for patients who receive PICC, activity of the catheterization-side shoulder joint will affect the position of the catheter tip, medical staff should guide these patients to perform upper limb functional exercise within a safe range (180° abduction of shoulder should be avoided); this guidance should be tailored to the actual situation of each patient, and should allow the patients to maintain good shoulder joint function and good quality of life throughout their treatment.
Port is more advantageous than PICC in terms of catheter indwelling time
Chemotherapy for bone tumors and soft tissue sarcomas can be characterized by long cycles and high dosages, this means higher requirements in regard to infusion access. In the present study, patients with PICC were extubated within two weeks of their completion of chemotherapy (the average extubation time for patients with soft tissue sarcomas was 233.35 ± 10.43 days, and the average extubation time for patients with malignant bone tumors was 349.54 ± 15.08 days). For patients in the port group, their ports were removed if no abnormality was found at a re-examination conducted three months after completion of chemotherapy (the average extubation time for patients with soft tissue sarcomas was 323.90 ± 7.77 days, and the average extubation time for patients with malignant bone tumors was 450.13 ± 13.56 days). Thus, ports have more advantages than PICC regarding the long-term retention of catheters.
Incidence of port-related complications is relatively low
Of 30 patients who had soft tissue sarcomas and received PICC, eight experienced infusion inflammation; of 38 patients who had bone tumors and received PICC, six experienced infusion inflammation and two experienced prolapse and relocation; of 35 patients who had soft tissue sarcomas and received ports, two experienced catheter folding and readjustment; of 30 patients who had bone tumors and received ports, two developed venous thrombosis. The overall incidence of complications in the port group was significantly lower than that in the PICC group. The risk of catheter related complications in PICC group was 4.88 times that in PORT group, the difference was statistically significant (χ2 = 4.200,P = 0.04).Therefore, when compared with PICC, port has the advantages of a longer possible indwelling time and a lower risk of chemotherapy-related complications for both soft tissue sarcomas and bone tumors.
In previous studies of patients receiving long-term chemotherapy, when compared with PICC venous port showed the advantages of a low complication rate and high patient satisfaction [14].Although PICC catheterization can have a low risk of causing damage to surrounding vital tissues and organs, the overall incidence of complications is nevertheless high; this is probably caused by: long-distance catheterization, large variations in peripheral infusion approaches, exposure of the catheterization end, and the small distance between the puncture site and the elbow joint (which has a large range of motion). Further, patients with PICC require weekly catheter care, and some patients have low compliance in this regard; this can also increase the risk of PICC complications, especially catheter-related infections and thrombosis (particularly among patients with malignant tumors) [15]. Such complications may be mainly attributed to such patients’ hypercoagulable state and reduced immune function. In contrast, the incidence of complications in patients using ports is relatively low, generally < 10%; early complications mainly include mis-penetration into the artery, pneumothorax, and arrhythmias caused by excessively deep catheterization, while late complications mainly include catheter displacement, fracture, infection, and venous thrombosis [16–19]. Among all complications, port infection and catheter-related infection are the most common [20]. However, there is controversy regarding the use of antibiotics to prevent port device infection. Johnson et al [21] conducted a meta-analysis of four studies that reviewed antibiotic prophylaxis in port placement; these four studies featured a total of 2,154 patients with port implantation, of whom 360 (16.7%) used antibiotics and 1,794 (83.3%) did not; overall, 27 (1.25%) of these patients developed infection. Of the infected patients, five were receiving antibiotic prophylaxis (1.39%) and 22 were not receiving antibiotic prophylaxis (1.23%). Consequent statistical analysis revealed that prophylactic use of antibiotics does not reduce the incidence of infection after port implantation. Additionally, the use of port may lead to a higher incidence of complications during the application of targeted drug therapy for patients with malignant tumors; the most common complications in this regard are infection and dehiscence of the port incision [22]. Therefore, to reduce the risk of related complications, before implementing targeted therapy for patients with bone tumors and soft tissue sarcomas who have received conventional chemotherapy it is recommended that the port be removed.
At present, the primary implantation sites for venous ports include the internal jugular vein, the subclavian vein, the basilic vein, and the femoral vein. However, implantation through the subclavian vein may lead to "pinch-off" syndrome [23], which is when the catheter enters the subclavian vein through the gap between the first rib and the clavicle; it is then squeezed by the first rib and the clavicle, resulting in stenosis or clamping, which can cause catheter injury or fracture in severe cases. In addition, implantation through the femoral vein may lead to deep venous thrombosis of the lower limbs [24]. Thus, these two sites are limited in terms of their clinical application, and implantation through the internal jugular vein is the most common approach. In our study, the patients mainly had bone and soft tissue tumors of the lower limbs, were relatively young, and had movement disorders of the lower limbs. A small number of amputees needed to walk and live with the help of walkers or axillary canes, meaning they had high requirements for upper limb function. Therefore, internal jugular vein implantation was the most common approach.
Study Limitations
Despite its strengths, this study has some shortcomings. Primarily, the number of cases examined was relatively small, bias could not be avoided in the statistical analysis, and the effect of patient position was not considered when examining displacement of the location of the catheter end. These shortcomings must be addressed in future clinical work.
Implications for Nursing
In clinical work, patients who have received chemotherapy for bone and soft tissue tumors of the lower limbs often have lower-limb dysfunction. Some patients who have undergone amputation need to use walkers or axillary canes to perform daily activities. They also have high requirements for upper-limb and shoulder-joint function. A PICC must be placed in the upper limb and, thus, has a certain impact on patients' upper limb activities, such as their ability to use walking aids or axillary canes; this, in turn, can affect the patients’ engagement in functional exercise and quality of life. Further, the use of walking aids or axillary canes can increase the risk of PICC tube blockage and other related complications [25].The port approach solves the above issues; the patients can use walkers or axillary canes flexibly, which improves their quality of life, and port also has the advantages of long indwelling time and low risk of complications. Thus, health-care professionals should carefully consider the optimal chemotherapy pathways for patients with lower-extremity bone and soft tissue tumors. Additionally, this study can represent a reference for nurses who are guiding patients who have received a venous port regarding the range of motion they can apply in their upper limbs and shoulder joints during daily activities.