G. Debonnaire, MD Belgium Insertion of central venous ports: is there still a role for venous cutdown? G. Debonnaire, MD Belgium

Disclosures Bard BBraun

Introduction Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion The implantation of a TIVAD* can be performed by various techniques Percutaneous TIVAD insertion has gained popularity, and is now commonly used by non-surgical clinicians Role of venous cutdown? Preferred technique? * Totally implantable venous access devices

Literature Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion

Literature Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion

Literature Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion

BUT IS IT REALLY ? Literature Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion Ultrasound guided venous access is golden standard BUT IS IT REALLY ?

Reviewing the data Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion

Primary success rate 1. Venous cutdown: Anatomy 95% cephalic vein present 80% Lateral superficial 20% Deep inferior to deltoid 70-84% cephalic vein is found

Primary success rate 1. Venous cutdown: Anatomy Veins: Cephalic vein External jugular vein Retro-pectoral veins/ Coraco-brachial vein

Primary success rate 2. Venous cutdown: External jugular 120 TIVAD 420 TIVAD 95 CV 79% 391 CV 93,1% 25 21% 29 6,9 % 17 to small 8 abscent 27 to small 2 abscent

Primary success rate 2. Venous cutdown: External jugular 25 TIVAD (no CV) 29 TIVAD (no CV) 7 CI for VJE 18 TIVAD 20 VJE Success 9 VJE Fail SC puncture 17 VJE 1 Contralateral 4 VJI cutdown 3 AV cutdown 2 coracobrachial vein

Primary success rate 2. Venous cutdown: External jugular CV CV + VJE Povoski 79,1% 94,1% Di carlo 93,1% 97,9%

Primary success rate 4. Venous cutdown: Retro-pectoral veins Open approach Guidewire

Primary success rate 3. Venous cutdown: Guiding In various retrospective studies and a few single center randomized controlled trials the median primary success rates for the open approach range from 71% to 94%,and from 90% to 99% for puncture of a central vein

Primary success rate 3. Venous cutdown: Guiding

Primary success rate 3. Venous cutdown: Guiding PORTAS 1 164 patients 82 CV 82 Modified Seldinger 66 succesful CV 81% 69 succesful CV 84% With modified Seldinger 94%

Reviewing the data Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion

Reviewing the data Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion

Results Máxima Medical Center (Veldhoven, the Netherlands) Standardisation of preoperative assessment, insertion technique and postoperative care provides low complication rates in totally implantable venous access devices (TIVAD): a cohort study of 200 cases. G. Debonnaire, M. Bender, G.Vreugdenhil, M. Scheltinga Aim: lowering complication rate by standardisation of insertion technique Open approach, maximizing primary succes rate using different veins ( CV, VJE, retropectoral veins) and modified seldinger

Results Máxima Medical Center (Veldhoven, the Netherlands) Standardisation of preoperative assessment, insertion technique and postoperative care provides low complication rates in totally implantable venous access devices (TIVAD): a cohort study of 200 cases. G. Debonnaire, M. Bender, G.Vreugdenhil, M. Scheltinga Insertion technique Venous cutdown Right Left Total Cephalic vein 103 71 174 87% Retro-pectoral vein 1 2 1% External jugular vein 10 6 16 8% 192 96% 10 TIVAD 5%

Results Máxima Medical Center (Veldhoven, the Netherlands) Standardisation of preoperative assessment, insertion technique and postoperative care provides low complication rates in totally implantable venous access devices (TIVAD): a cohort study of 200 cases. G. Debonnaire, M. Bender, G.Vreugdenhil, M. Scheltinga Insertion technique Puncture +/- US Right Left Total Internal jugular vein 2 3 5 2,5% Subclavian vein 1 3 1,5% 8 4% Reason VC to small, VJE impossible 1 No VC, no VJE cutdown 3 Catheter mal insertion 2 No cutdown No VC, No VJE

Results Máxima Medical Center (Veldhoven, the Netherlands) Standardisation of preoperative assessment, insertion technique and postoperative care provides low complication rates in totally implantable venous access devices (TIVAD): a cohort study of 200 cases. G. Debonnaire, M. Bender, G.Vreugdenhil, M. Scheltinga Early complication <30 days Complication Hematoma 1 0,5% DVT 2 1% Extremity swelling (No DVT: US confirmed) Thromboflebitis Catheter malfunction 4 2% No pneumothorax No hemothorax No arterial puncture No plexus injury No hemoptesis No pinch off

There is no golden standard Literature Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion Which technique is the best? There is no golden standard Complementary

Refrasing the question Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion Which technique is the best for my patient? venous cutdown or puncture

Observing the patient Observe your patient Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion Observe your patient Acquired abnormalities of the central veins are more common than congenital abnormalities. The predominant acquired abnormality is a partial or complete obstruction or stenosis of a central vein, leading to difficulties or a failure Observe radiography

Trendelenburg position Safer via venous cutdown Observing the patient Severe orthopnea Pulmonary hypertension Pulmonary emphysema / COPD Cardiac failure Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion Trendelenburg position Safer via venous cutdown Previous catheters Previous surgery shoulder, neck, thorax

Observing the patient: radiography

Results Máxima Medical Center (Veldhoven, the Netherlands) Standardisation of preoperative assessment, insertion technique and postoperative care provides low complication rates in totally implantable venous access devices (TIVAD): a cohort study of 200 cases. G. Debonnaire, M. Bender, G.Vreugdenhil, M. Scheltinga Preoperative radiography revison 200 TIVAD 38 No radiography 162: CT or X-Ray thorax 104 neg CT, 46 neg X-Ray Radiography Total of 162 CT Mediastinal mass, no obstruction 6 3,7% Mediastinal mass, obstruction 1 0,6% PLVCS 2 1,2% Venous obstruction X-Ray Pleural effusion 6,7%

Conclusion Venous cutdown has the lowest complication rate Introduction Literature Primary succes rate Complications Results MMC Observing the patient Conclusion Venous cutdown has the lowest complication rate Maximize the primary success rate by anatomical knowledge, several possible target veins and guidewire technique Venous cutdown and puncture are complementery techniques All comes down to observing the patient!! geoffreydebonnaire@yahoo.com