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      Perioperative and Postoperative Complications of Supraclavicular, Ultrasound-Guided, Totally Implantable Venous Access Port via the Brachiocephalic Vein in Adult Patients: A Retrospective Multicentre Study

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          The totally implantable venous access port (TIVAP) provides patients with safe, effective and long-term convenient venous access for the administration of medications such as chemotherapy drugs. The implantation and long-term use of TIVAP are related to thrombosis, infection and other complications. In this study, the medical records of multicentre patients were collected, and the perioperative and postoperative complications were retrospectively analysed to objectively evaluate the safety of the implantation of supraclavicular, ultrasound-guided TIVAP via the brachiocephalic vein (BCV).

          Patients and Methods

          We retrospectively analysed the clinical data of 433 adult patients who had undergone ultrasound-guided TIVAP implantation via the BCV at four hospitals in China from March 2018 to May 2019. The success rates of the first puncture, operation time, and perioperative and postoperative complications were analysed.


          All the TIVAPs were implanted successfully (100%). The average TIVAP carrying time was 318.15 ±44.22 days (range: 38–502 days) for a total of 197,694 catheter days. The success rate of the first puncture was 94.92% (411/433), and the average operation time was 29.66 ±7.45 min (range: 18–60 min). The perioperative complications included arterial puncture in 4 patients and pneumothorax in 1 patient. The incidence of postoperative complications was 5.08% (22/433), including poor incision healing (n = 2), catheter-related infection (n = 3), port infection (n = 6), thrombosis (n = 2) and fibrin sheath formation (n = 8). Another patient had infusion disturbance 2 days after the operation, and chest X-ray showed bending at the connection between the catheter and port. No other serious complications occurred, such as catheter rupture and drug leakage. The total incidence of complications was 6.24% (27/433).


          This study showed excellent tolerance of supraclavicular, ultrasound-guided BCV puncture to implant TIVAP and a low incidence of complications. As a safe and effective method of TIVAP implantation, it can provide a new choice for clinicians.

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          Most cited references 33

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          Complications of central venous catheters: internal jugular versus subclavian access--a systematic review.

          To test whether complications happen more often with the internal jugular or the subclavian central venous approach. Systematic search (MEDLINE, Cochrane Library, EMBASE, bibliographies) up to June 30, 2000, with no language restriction. Reports on prospective comparisons of internal jugular vs. subclavian catheter insertion, with dichotomous data on complications. No valid randomized trials were found. Seventeen prospective comparative trials with data on 2,085 jugular and 2,428 subclavian catheters were analyzed. Meta-analyses were performed with relative risk (RR) and 95% confidence interval (CI), using fixed and random effects models. In six trials (2,010 catheters), there were significantly more arterial punctures with jugular catheters compared with subclavian (3.0% vs. 0.5%, RR 4.70 [95% CI, 2.05-10.77]). In six trials (1,299 catheters), there were significantly less malpositions with the jugular access (5.3% vs. 9.3%, RR 0.66 [0.44-0.99]). In three trials (707 catheters), the incidence of bloodstream infection was 8.6% with the jugular access and 4.0% with the subclavian access (RR 2.24 [0.62-8.09]). In ten trials (3,420 catheters), the incidence of hemato- or pneumothorax was 1.3% vs. 1.5% (RR 0.76 [0.43--1.33]). In four trials (899), the incidence of vessel occlusion was 0% vs. 1.2% (RR 0.29 [0.07-1.33]). There are more arterial punctures but less catheter malpositions with the internal jugular compared with the subclavian access. There is no evidence of any difference in the incidence of hemato- or pneumothorax and vessel occlusion. Data on bloodstream infection are scarce. These data are from nonrandomized studies; selection bias cannot be ruled out. In terms of risk, the data most likely represent a best case scenario. For rational decision-making, randomized trials are needed.
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            Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study.

            Subclavian vein catheterization may cause various complications. We compared the real-time ultrasound-guided subclavian vein cannulation vs. the landmark method in critical care patients. Prospective randomized study. Medical intensive care unit of a tertiary medical center. Four hundred sixty-three mechanically ventilated patients enrolled in a randomized controlled ISRCTN-registered trial (ISRCTN-61258470). We compared the ultrasound-guided subclavian vein cannulation (200 patients) vs. the landmark method (201 patients) using an infraclavicular needle insertion point in all cases. Catheterization was performed under nonemergency conditions in the intensive care unit. Randomization was performed by means of a computer-generated random-numbers table and patients were stratified with regard to age, gender, and body mass index. No significant differences in the presence of risk factors for difficult cannulation between the two groups of patients were recorded. Subclavian vein cannulation was achieved in 100% of patients in the ultrasound group as compared with 87.5% in the landmark one (p < .05). Average access time and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < .05). In the landmark group, artery puncture and hematoma occurred in 5.4% of patients, respectively, hemothorax in 4.4%, pneumothorax in 4.9%, brachial plexus injury in 2.9%, phrenic nerve injury in 1.5%, and cardiac tamponade in 0.5%, which were all increased compared with the ultrasound group (p < .05). Catheter misplacements did not differ between groups. In this study, the real-time ultrasound method was rated on a semiquantitative scale as technically difficult by the participating physicians. The present data suggested that ultrasound-guided cannulation of the subclavian vein in critical care patients is superior to the landmark method and should be the method of choice in these patients.
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              Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice

              The use of ultrasound (US) has been proposed to reduce the number of complications and to increase the safety and quality of central venous catheter (CVC) placement. In this review, we describe the rationale for the use of US during CVC placement, the basic principles of this technique, and the current evidence and existing guidelines for its use. In addition, we recommend a structured approach for US-guided central venous access for clinical practice. Static and real-time US can be used to visualize the anatomy and patency of the target vein in a short-axis and a long-axis view. US-guided needle advancement can be performed in an "out-of-plane" and an "in-plane" technique. There is clear evidence that US offers gains in safety and quality during CVC placement in the internal jugular vein. For the subclavian and femoral veins, US offers small gains in safety and quality. Based on the available evidence from clinical studies, several guidelines from medical societies strongly recommend the use of US for CVC placement in the internal jugular vein. Data from survey studies show that there is still a gap between the existing evidence and guidelines and the use of US in clinical practice. For clinical practice, we recommend a six-step systematic approach for US-guided central venous access that includes assessing the target vein (anatomy and vessel localization, vessel patency), using real-time US guidance for puncture of the vein, and confirming the correct needle, wire, and catheter position in the vein. To achieve the best skill level for CVC placement the knowledge from anatomic landmark techniques and the knowledge from US-guided CVC placement need to be combined and integrated.

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                04 February 2021
                : 17
                : 137-144
                [1 ]Department of Intervention, The Second Affiliated Hospital of Soochow University , Suzhou, 215004, Jiangsu, People’s Republic of China
                [2 ]Department of Intervention, Wuxi People’s Hospital Affiliated to Nanjing Medical University , Wuxi, 214023, Jiangsu Province, People’s Republic of China
                [3 ]Department of General Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine , Changshu, 215500, Jiangsu, People’s Republic of China
                [4 ]Department of Anesthesiology, Bazhong Central Hospital , Bazhong, Sichuan, 636000, People’s Republic of China
                [5 ]Department of Radiology, The First Affiliated Hospital of Soochow University , Suzhou, 215004, Jiangsu, People’s Republic of China
                Author notes
                Correspondence: Yong Jin Department of Intervention, The Second Affiliated Hospital of Soochow University , Suzhou, 215004, Jiangsu, People’s Republic of ChinaTel +86 13776097707 Email 578898234@qq.com
                Ling Wen Department of Radiology, The First Affiliated Hospital of Soochow University , Suzhou, 215004, Jiangsu, People’s Republic of China Email wenling@suda.edu.cn

                These authors contributed equally to this work

                © 2021 Yu et al.

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                Page count
                Figures: 2, Tables: 2, References: 34, Pages: 8
                Original Research


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