European Journal of Cardiovascular Medicine

Appearing in the 1990s, the implantable chamber catheter (ICC) quickly established itself as an essential medical device in the management of patients requiring long-term iterative intravenous treatments (chemotherapy, immunotherapy, targeted therapy, antibiotic therapy, etc.). The benefits are multiple because its use provides undeniable safety and comfort, both for the patient and for the healthcare team. The indications are mainly therapeutic and most frequently concern chemotherapy, long-term antibiotic therapy, longer than three months, parenteral nutrition or repeated blood transfusions (sickle cell disease, hemophilia). At the same time, it is also possible to take blood samples. There are several contraindications. They concern major hemostasis disorders such as thrombocytopenia less than 50,000/mm3, septic shock, a history of axillo-subclavian thrombosis, infected or burned skin areas, areas previously irradiated or soon to be irradiated, areas near skin metastases and the presence of a mediastinal tumor. Furthermore, imaging is essential before implantation of these intravenous devices, in order to avoid caval syndrome.

We present a series of patients followed in the medical oncology department at Bejaia University Hospital for cancer pathologies in collaboration with the intensive care unit. medical, the aim of our article is to expose the advantages as well as the disadvantages of our experience, and to define the patient's circuit upon receipt to plan the implantation of the intravenous device.

A series of 23 patients was collected in the Intensive Care Department of Bejaia University Hospital. The patients are referred by the medical oncology team for the installation of an implantable port for IV chemotherapy. The protocol consists, after verifying its feasibility, of preparation of the patient, Simplified explanation of the procedure, Installation of equipment with monitoring, Titrated ambulatory sedation, based on ketamine associated or not with midazolam, Local anesthesia based on lidocaine injectable, placement of the implant after ultrasound-guided catheterization. End of the procedure, dressing and resumption of contact of the patient with his companion. This protocol made it possible to optimize the use of awake sedation drugs, putting the patient in comfort and making the procedure safer by ultrasound guidance.

Patient preparation and installation

• information + oral or signed informed consent. And VVP with hydration at the SSI and antibiotic prophylaxis if necessary
• installation in DD, arms alongside the body, head in slight extension turned to the opposite side of the puncture site (S/C Right)
• ECG, BP and oximetry monitoring for monitoring vital parameters - Operator to the right of the patient, the assistant opposite.
• Wide disinfection around the site setting up sterile fields
• preparation of the material on a table (scissors, N11 cold scalpel, dissecting forceps, needle holder, absorbable thread, hemostatic forceps and sterile compresses) (figure 1)
• The Kit (puncture needle mounted on a syringe, metal guide, vascular dilator, graduated Cath, box, and Hubert needle) (Figure 1)
• 10 CC syringes with SSI + heparin, 2.5 cc syringe with AL (xylocaine 1%)

Technique itself:

• Trendelenberg position at 15° Infiltration with 1% xylocaine next to the future cervical puncture site, and the future port insertion site, and along the future subcutaneous tunneling route of the catheter.
• Puncture at 1TDD under the clavicle at the junction of the 1/3 int and 1/3 middle of the bone. And insert the needle (22G) 3-5 cm deep next to the suprasternal hollow, always using light suction until the vein is located, then disconnect the syringe (figure 2)

(Be careful, the presence of pulsatile flow and bright red blood indicates an arterial puncture. In this case, quickly remove the needle and compress for five to ten minutes.)

• Under ECG monitoring, advance the metal guide through the puncture needle and advance approximately 20 cm (figure 3)
• Make sure that the first curved part (“J”) of the guide is oriented towards the heart.
• Only minimal resistance should be encountered during advancement.
• Once the guide is in place, the needle can be removed and after widening the puncture opening with a scalpel, the dilator can be slid over the metal guide in order to dilate the subcutaneous tissues (figure 4)
• ideal distance to advance the catheter can be estimated by placing the catheter on the patient's chest (figure 5).
• A study has measured that this distance is generally 16.5 cm for an adult of average size(2), (we use 20cm on average)
• Once the catheter is in place, the guide and the vascular dilator are removed. completely, and skin closure (figure 6)
• After placement of the subclavian catheter, a control chest x-ray is systematically performed. requested •to exclude complications and to confirm correct positioning of the CVC in the superior vena cava above the right atrium

A series of 22 patients was collected in the Intensive Care Department of Bejaia University Hospital. The patients are referred by the medical oncology team for the installation of an implantable port for IV chemotherapy. The protocol consists, after having verified its feasibility, of preparation of the patient, The deadlines are 1 to 5 days for the appointment to install the prosthesis, Protocol designed for the use of awake sedation drugs, by putting the patient in comfort and securing the gesture by ultrasound guidance.

Figure 1: Material Required for Installing the Chambers

Figure 2: Ultrasound-Guided Identification of the Central Vein

Figure 3: Ultrasound Control after Placement of the Implantable Port

Figure 4: Placement of the Intravenous Catheter

Figure 5: Control by Telethorax

Our study involves 22 consecutive patients. Analysis of our series shows us that 71% of patients are men. The average age is 59.8 years (36-90). The origin of the patients is distributed as follows: 100% oncology. For 21 patients, the puncture was performed in the internal jugular and for a single tracheostomized patient with laryngeal cancer, the puncture was performed in the subclavian. In 86% of cases, the insertion took place on the right compared to 14% on the left (at the request of the original service or the patient himself). The average duration of application (from infiltration with xylocaine to skin closure) was 30 minutes (20-60). Venipuncture, whether jugular or subclavian, on the right or left, was obtained during the first attempt in 100% of cases, without iterative puncture. No intraoperative complications related to the procedure (arterial puncture, hematoma, pneumothorax) were noted. Over the entire study period, overall morbidity of 7.8% with four infectious complications occurring two months after placement of the implantable port (3.9%) and four thromboembolic complications (3.9%) including one at one month, the second at 14 months and the last two at 17 months from the initial procedure.

The placement of an implantable port is a procedure with a falsely benign reputation, it can quickly turn into a real ordeal with sometimes formidable complications [4,5]. The placement procedures and venous sites used are numerous and varied. The cephalic vein is the main vein used by surgeons. Its surgical approach offers the advantage of direct visual control but in certain cases, this vein may be too thin, difficult to find (in obese patients), non-existent or impossible to catheterize [6]. Thus, the success rate of implantable port placement by direct approach to the cephalic vein varies from 70 to 94% depending on the series [7,8]. In addition, this technique results in ligation and therefore sacrifice of the cephalic vein. The other peripheral veins are more rarely used except in radiology where the basilic vein approach is the most common. These peripheral approaches have a low injection flow rate. Indeed, the longer the catheter, the greater the resistance to flow [9]. In addition, the small difference between the diameter of the peripheral veins and that of the catheter is a factor favoring thrombosis [10,11].

The subclavian vein is often used as venous access. Theoretically simple and quick, based on anatomical landmarks, puncture of the subclavian vein carries significant risks of complications: it in fact has the highest risk of pneumothorax. Cases of sometimes fatal arterial puncture [12,13] and rupture followed by migration of catheters following compression in the costoclavicular clamp (pinch off syndrome) have also been described [14-16]. To avoid these complications, it would be preferable to reserve the subclavian route for contraindications to the internal jugular route [17,18]. Formerly considered more thrombogenic, the internal jugular vein (IJV) is currently the venous site most often recommended for placement of implantable ports [19-21]. Its large caliber and its direct route to the right heart make it a privileged venous access. A comparative study of 1201 patients showed more immediate and long-term complications during percutaneous subclavian vein punctures compared to IJV [22-27]. The choice of this internal jugular route can, however, be the cause of aesthetic discomfort for patients and its intimate anatomical relationships with cervical vasculonervous elements require a precise and optimal approach. The approaches to the IJV include percutaneous puncture or surgical approach by stripping the vein. The surgical approach offers the advantage of direct visual control, but this approach is more invasive, which increases the risk of postoperative infections and catheter thrombosis [28].

Percutaneous puncture has the advantage of being less invasive than surgical denudation of the vein with a lower risk of infection due to the absence of dissection [29]. It is also faster. However, the installation time of an implantable port is a risk factor for thrombosis; an exposure time of less than 25 minutes is associated with a significant reduction in the risk of thrombosis [30]. The analysis of our results confirms these data since our per- and postoperative morbidity rate is 7.8% while the series of surgical approach to the IJV report complication rates varying from 16 to 21% [31]. However, when it is based on anatomical landmarks alone, the so-called “blind” percutaneous puncture is more uncertain, with a failure rate of up to 19% of cases [32]. Likewise, the proximity of the carotid artery and the nerve of complications. Denys et al. demonstrated, from a study involving 200 subjects, that the IJV was outside the position predicted by the anatomical surface landmarks in 5.5% of cases [34]. Another study based on 1136 patients confirmed that the IJV was only anterolateral to the carotid artery in 54% of cases in the Sédillot triangle [35]. These anatomical variations can be the cause of repeated carotid punctures and venous punctures, which we know are directly correlated with the risk of thrombosis [3] and complications linked to the procedure [36]. Thus, accidental carotid punctures causing retropharyngeal hematoma [37] or stroke have already been described [38-41].

To address these difficulties, the use of ultrasound guidance for the placement of an implantable port by percutaneous puncture of the IJV seems entirely appropriate. Moreover, the 2008 SOR recommends ultrasound-guided placement of the central lines in the internal jugular. The advantages of ultrasound-guided puncture have been reported by numerous publications [42-48]. It allows the operator to identify the vein and its possible anatomical variations and to control the puncture needle until it penetrates the vein. It thus makes it possible to increase the success rate of the initial venipuncture, to reduce the average time of installation and iterative punctures, and above all to reduce the risks of carotid punctures or irritation of the brachial plexus. Randolph et al. showed in a meta-analysis that ultrasound guidance reduced complications by 74% in the internal jugular and 89% in the subclavian compared to so-called “blind” punctures [43]. The analysis of our results confirms this superiority of ultrasound-guided puncture compared to “blind” puncture. However, this technique requires an ultrasound machine. However, the initial investment is heavy, which constitutes one of the main limits to its use. However, studies have shown that purchasing an ultrasound machine pays off in the long run. Thus, the Health Technology Assessment program indicates that the use of ultrasound guidance in central venous line placement would save money.

The placement of implantable ports is constantly increasing, making a safe, effective, reproducible, non-iatrogenic and minimally invasive placement procedure essential. The use of ultrasound combined with the image intensifier makes it possible to meet these requirements, increase efficiency and reduce possible complications. The placement of an implantable port by ultrasound-guided percutaneous puncture in the right internal jugular seems to be the procedure most often recommended and the one to be favored. However, the choice of installation technique remains at the discretion of the practitioner, depending on the specific clinical situation of each patient and the logistics available.

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