Totally implantable venous access devices (TIVADs) consist of a central venous catheter (made of silicone rubber or polyurethane) and a subcutaneously-implanted injection port made of titanium or plastic, providing a simple, safe, and permanent means of accessing the vascular system for intravenous delivery of drugs and fluids.1,2  The main advantages of these systems are to preserve peripheral vessels and to allow the patient unrestricted mobility and freedom in choice of activities.3  This situation has led to increasing use of these systems, particularly for long-term oncologic therapies.46  TIVADs can usually be implanted through 2 different ways: subclavian or external jugular vein puncture, by Seldinger technique, eventually under ultrasound (US) guidance; or surgical approach by vein cut-down (VCD) technique.1114  TIVADs insertion can be accompanied by intraoperative or early postoperative severe complications, such as pneumothorax, hemothorax, arterial, or brachial plexus injuries, deep venous thrombosis and pinch-off syndrome, which seem to be more frequent in cases of direct vein puncture than during surgical approach.710,1518  A recent meta-analysis showed a similar success rate and operating time, as well as complication rates, when comparing vein puncture and surgical approach, even if serious complications such as pneumothorax were higher after vein puncture.19  The authors present a comparative prospective study evaluating both VCD and US-guided Seldinger technique for TIVAD implantation, focusing on surgical outcome, intra and postoperative complications in 298 consecutive patients with a minimum follow-up of 180 days.

From December 2012 to September 2013, 298 patients (161 females, 137 males, mean age) were consecutively submitted, in a day-hospital setting, to TIVAD implantation in order to perform chemotherapy for solid tumor or hematologic disease, and were prospectively evaluated. Patients were divided in 2 groups, depending on TIVAD implantation technique. Group A patients (147) received TIVAD implantation by US-guided vein puncture, and group B (151) patients received TIVAD implantation by cephalic vein cut-down (CVCD) technique. TIVAD implantations were performed by 2 different teams, who were respectively skilled in percutaneous vein puncture and in CVCD technique. Patients' demographics, neoplastic disease, and comorbidities are expressed in Table 1. All TIVADs used were BardPort (Bard Access Systems, Salt Lake City, Utah, USA), with 6.5 French polyurethane catheter. All patients received single-shot preoperative antibiotic prophylaxis 30 minutes before surgery. Comparing the 2 groups, we considered the following variables: success rate, operating time, incidence, and type of complications. Continuous data (e.g., age, operating time) were expressed as arithmetic mean +/− standard deviation, while data representing rare occurrence (such as complications) were expressed as numeric value and percentage in each group. Fisher's exact test was used for comparison between groups, considering significant a P value < 0.05.

Intraoperative and postoperative results and complications are summarized in Table 2. In Group A patients, 121 TIVADs were implanted through the subclavian vein (11 left, 110 right) and 26 through the internal jugular vein (5 left, 21 right). The first approach was the subclavian vein in all cases, while the access to the internal jugular vein was obtained only in case of unsuccessful subclavian vein puncture. In 4 cases (2.7%), due to unsuccessful subclavian or internal jugular vein catheterization (despite US guidance), the catheter was inserted through external jugular vein cut-down technique. In 17 cases postoperative chest scan was performed in order to identify the presence of pneumothorax due to difficult subclavian vein puncture. In group B patients, 134 TIVADs were implanted through the cephalic (114, 24 left and 90 right) or coracobrachial (20, 3 left and 17 right) vein using the same skin incision used for the port insertion, while, in case of absence or nonsuitability of cephalic or coracobrachial vein, the catheter was inserted through the ipsilateral external jugular vein always by cut-down technique. No conversion to percutaneous vein puncture or contralateral approach, or postoperative chest scan, were needed. Mean operative time was 39.5 +/− 12.1 minutes for percutaneous vein puncture and 34.8 +/− 7.7 for vein cut-down approach, and these data showed no significant difference. Complication rate was 4.08% in Group A patients (5 cases with 2 cases of pneumothorax needing chest drain and 3 days hospitalization and 1 case of deep venous thrombosis treated with anticoagulation and subsequent TIVAD removal) and 1.98% in group B (3 cases, no pneumothorax). In 4 cases (2 of Group A, 2 of Group B), TIVAD was removed, due to wound infection, catheter tip dislocation, or deep venous thrombosis.

Since the first implant described in 1982,1  TIVADs have increasingly been used for long-term intravenous nutrition and drug delivery. TIVADs achieve a permanent, safe and less painful vascular access, facilitate treatment of many medical disorders, and improve patients' quality of life by giving them unrestricted mobility and freedom in their activities.2,11  TIVADs can be implanted through either percutaneous or surgical approach.714  Percutaneous access consists of a direct deep vein puncture of internal jugular vein or subclavian vein (eventually axillary vein), better under US guidance, and catheter insertion using the Seldinger technique.1517  This approach is the same used in cases of short-term central venous catheter or dialysis catheter implantation, and is still the most used worldwide.7,10,1520  Percutaneous approach has the risks of severe intraoperative complications, such as pneumothorax, hemothorax, arterial, or brachial plexus injuries, which can affect patients' outcomes. Data in the literature show that the aforementioned complications may occur in up to 12% of patients.7,15,16,21  The use of ultrasound guidance has been demonstrated to reduce, but not to completely avoid this risk.15,2225  On the other hand, surgical approach with peripheral vein cut-down technique (cephalic vein coracobrachial vein or even external jugular vein), which has shown an overall risk of complication similar to percutaneous approach, is obviously not affected by risk of hemothorax and pneumothorax, due to the absence of deep vein puncture.1426  In about 10−12% of cases,13,14,18  cephalic vein is not suitable for catheterization, due to anatomic variations or vein damage. In these cases we have different options: try to identify the coracobrachial vein deeper in the Morenheim fossa or place the catheter in the ipsilateral external jugular vein. This vein is superficial, quite large, and rectilineous, and it is easy to check,14,27  placing the patient in mild Trendelenburg position. So, the combined success rate of the cephalic vein and coracobrachial/external jugular vein cut-down approach is about 100% in literature as well as in the present study.13,14,18,19,27  Results from the present prospective study show no differences in operative time, as well as mid- and long-term results between the two groups, while there was a slightly higher incidence of complications in Group A (not statistically relevant) due to specific complications of direct vein puncture.

In conclusion, peripheral veins cut-down approaches for TIVAD placement are fast and safe and have a very high success rate with very low risk of complications when compared to percutaneous approach. So, this approach should be considered as a valid alternative to vein puncture approach, and the first choice in selected cases.

1
Niederhuber
JE
,
Ensminger
RW
,
Gyves
JW
,
Liepman
M
,
Doan
K
,
Cozzi
RN
.
Totally implanted venous and arterial access system to replace external catheters in cancer treatment
.
Surgery
1982
;
92
(
4
):
706
711
2
Damascelli
B
,
Patelli
G
,
Frigerio
LF
,
Lanocita
R
,
Garbagnati
F
,
Marchianò
A
et al
.
Placement of long-term central venous catheters in outpatients: study of 134 patients over 24,596 catheter days
.
AJR Am J Roentgenol
1997
;
168
(
5
):
1235
1239
3
Kock
HJ
,
Pietsch
M
,
Krause
U
,
Wilke
H
,
Eigler
FW
.
Implantable vascular access systems: experience in 1500 patients with totally implanted central venous systems
.
World J Surg
1998
;
22
(
1
):
12
16
4
Bow
EJ
,
Kilpatrick
MG
,
Clinch
JJ
.
Totally implantable venous access ports systems for patients receiving chemotherapy for solid tissue malignancies: a randomized controlled trial examining the safety, efficacy, costs, and impact on quality of life
.
J Clin Oncol
1999
;
17
(
4
):
1267
5
Schwarz
RE
,
Groeger
JS
,
Coit
DG
.
Subcutaneously implanted central venous access in cancer patients: a prospective analysis
.
Cancer
1997
;
79
(
8
):
1635
1640
6
Nightingale
CE
,
Norman
A
,
Cunningham
D
,
Young
J
,
Webb
A
,
Filshie
J
.
A prospective analysis of 949 long-term central venous access catheters for ambulatory chemotherapy in patients with gastrointestinal malignancy
.
Eur J Cancer
1997
;
33
(
3
):
398
403
7
Biffi
R
,
de Braud
F
,
Orsi
F
,
Pozzi
S
,
Mauri
S
,
Goldhirsch
A
et al
.
Totally implantable central venous access ports for long-term chemotherapy. A prospective study analyzing complications and costs of 333 devices with a minimum follow-up of 180 days
.
Ann Oncol
1998
;
9
(
7
):
767
773
8
Sarzo
G
,
Finco
C
,
Parise
P
,
Savastano
S
,
Vecchiato
M
,
Degregori
S
et al
.
Insertion of prolonged venous access device: a comparison between surgical cutdown and percutaneous techniques
.
Chir Ital
2004
;
56
(
3
):
437
442
9
Mansfield
PF
,
Hohn
DC
,
Fornage
BD
,
Gregurich
MA
,
Ota
DM
.
Complications and failures of subclavian vein catheterization
.
N Engl J Med
1994
;
331
(
26
):
1735
1738
10
Kincaid
EH
,
Davis
PW
,
Chang
MC
,
Fenstermarker
JM
,
Pennell
TC
.
Blind placement of long-term central venous access devices: report of 589 consecutive procedures
.
Am Surg
1999
;
65
(
6
):
520
524
11
Di Carlo
I
,
Cordio
S
,
La Greca
G
,
Privitera
G
,
Russello
D
,
Puleo
S
et al
.
Totally implantable venous access devices implanted surgically: a retrospective study on early and late complications
.
Arch Surg
2001
;
136
(
9
):
1050
1053
12
Chang
HM
,
Hsieh
CB
,
Hsieh
HF
,
Chen
TW
,
Chen
CJ
,
Chan
DC
et al
.
An alternative technique for totally implantable central venous access devices. A retrospective study of 1311 cases
.
Eur J Surg Oncol
2006
;
32
(
1
):
90
93
13
Jablon
LK
,
Ugolini
KR
,
Nahmias
NC
.
Cephalic vein cut-down verses percutaneous access: a retrospective study of complications of implantable venous access devices
.
Am J Surg
2006
;
192
(
1
):
63
67
14
Povoski
SP
.
A prospective analysis of the cephalic vein cutdown approach for chronic indwelling central venous access in 100 consecutive cancer patients
.
Ann Surg Oncol
2000
;
7
(
7
):
496
502
15
Zaghal
A
,
Khalife
M
,
Mukherji
D
,
El Majzoub
N
,
Shamseddine
A
,
Hoballah
J
et al
.
Surg Oncol
2012
;
21
(
3
):
207
215
16
Aldrighetti
L
,
Paganelli
M
,
Caterini
R
,
Catena
M
,
Ronzoni
M
,
Ferla
G
.
Safety and efficiency of totally implantable devices for prolonged venous access: a prospective study
.
J Chemother
1996
;
8
(
1
):
393
396
17
Covey
AM
,
Toro-Pape
FW
,
Thornton
RH
,
Son
C
,
Erinjeri
J
,
Sofocleous
CT
et al
.
Totally implantable venous access device placement by interventional radiologists: are prophylactic antibiotics necessary?
J Vasc Interv Radiol
2012
;
23
(
3
):
358
362
18
Cavallaro
G
,
Iorio
O
,
Iossa
A
,
Rizzello
M
,
Silecchia
G
,
De Toma
G
.
Surgical approach for totally implantable venous access devices (TIVADs). Consideration after 753 consecutive procedures
.
Am Surg
(
in press
).
19
Orci
LA
,
Meier
RP
,
Morel
P
,
Staszewicz
W
,
Toso
C
.
Systematic review and meta-analysis of percutaneous subclavian vein puncture versus surgical venous cutdown for the insertion of a totally implantable venous access device
.
Br J Surg
2014
;
101
(
2
):
8
16
20
Lin
CP
,
Wang
YC
,
Lin
FS
,
Huang
CH
,
Sun
WZ
.
Ultrasound-assisted percutaneous catheterization of the axillary vein for totally implantable venous access device
.
Eur J Surg Oncol
2011
;
37
(
5
):
448
451
21
Di Carlo
I
,
Pulvirenti
E
,
Mannino
M
,
Toro
A
.
Increased use of percutaneous technique for totally implantable venous access devices. Is it real progress? A 27-year comprehensive review on early complications
.
Ann Surg Oncol
2010
;
17
(
6
):
1649
1656
22
Wu
SY
,
Ling
Q
,
Cao
LH
,
Wang
J
,
Xu
MX
,
Zeng
WA
.
Real-time two-dimensional ultrasound guidance for central venous cannulation: a meta-analysis
.
Anesthesiology
2013
;
118
(
2
):
361
375
23
Fragou
M
,
Gravvanis
A
,
Dimitriou
V
,
Papalois
A
,
Kouraklis
G
,
Karabinis
A
et al
.
Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study
.
Crit Care Med
2011
;
39
(
7
):
1607
1612
24
Hind
D
,
Calvert
N
,
McWilliams
R
,
Davidson
A
,
Paisley
S
,
Beverley
C
et al
.
Ultrasonic locating devices for central venous cannulation: meta-analysis
.
BMJ
2003
;
327
(
7411
):
361
25
Gualtieri
E
,
Deppe
SA
,
Sipperly
ME
,
Thompson
DR
.
Subclavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance
.
Crit Care Med
1995
;
23
(
4
):
692
697
26
Chang
HM
,
Hsieh
CB
,
Hsieh
HF
,
Chen
TW
,
Chen
CJ
,
Chan
DC
et al
.
An alternative technique for totally implantable central venous access devices. A retrospective study of 1311 cases
.
Eur J Surg Oncol
2006
;
32
(
1
):
90
93
27
Di Carlo
I
,
Barbagallo
F
,
Toro
A
,
Sofia
M
,
Lombardo
R
,
Cordio
S
.
External jugular vein cutdown approach, a useful alternative, supports the choice of the cephalic vein for totally implantable access device placement
.
Ann Surg Oncol
2005
;
12
(
7
)
1
4