1. Fluoroscopy of the Arm During Removal of the Cook Vital Port
Nicolette Sinclair1, Brent Burbridge1, Grant Stoneham1, Rob Otani1, Peter Szkup1
1University of Saskatchewan, Department of Medical Imaging
Scientific Exhibit Presentation at the Canadian Association of
Radiologists 76th Annual Scientific Meeting
We have no conflicts of interest to disclose ( i.e. no industry funding received or other commercial relationships).

2. Background
Reliable venous access is imperative for cancer patients to facilitate chemotherapy and phlebotomy.
Arm placement of subcutaneous venous ports by interventional radiology has become increasingly popular.
Advantages over surgically placed ports related to lower complications, enhanced technical success, and reduced cost to the healthcare system have been shown (1,2,3).
Marcy P, Magne N, Castadot P, et al. Radiological and surgical placement of port devices: a 4-year institutional analysis of
procedure performance, quality of life and cost in breast cancer patients. Breast Cancer Res Treat. 2005;92:61-67.
(2) Beheshti, MV, Protzer, WR, Tomlinson TL, et al. Long-term results of radiologic placement of a central vein access device.
AJR Am J Roentgenol. 1998;170:
(3) Burbridge B, Krieger E, Stoneham G. Arm placement of the cook titanium petite vital-port: results of radiologic placement in
125 patients with cancer. Can Assoc Radiol J 2000;51:

3. Background Inserted into basilic with fluoroscopy or US
Anchored to biceps fascia by most interventionalists
Day surgery procedure, one hour recovery
Good cosmetic result
At our institution growing number of referrals and increasingly accepted by patients and clinicians (4).
(4) Krieger E, Burbridge B. Arm placement of vein ports: a viable alternative. Canadian Medical
Radiation Technologists Journal 2000;31:12-14.

4. Recent Publications
Recently published 1.6% fracture frequency at vein entry site (5).
Postulated that wear and tear related to arm movement or a tight, fibrotic, vein entry site, resulting in ballooning of the catheter during injection may be a possible cause of catheter fracture.
Need pic from BB of fractured port
Image 1. Leakage of contrast related to catheter
fracture at vein entry site.
(5) Burbridge B, Stoneham G, Szkup P, et al. Catheter fracture and embolization associated with the cook vital port. Can Assoc
Radiol J Feb 13, 2001.

5. As catheter fracture and central venous catheter embolization exposes the patient to risk, we investigated a cohort of patients to attempt to determine a cause for this complication.
Catheter fracture of vein insertion site with central
Migration of distal fracture fragment.

6. Images 3 and 4. Central migration of fractured catheter into pulmonary arteries (black arrows) .

7. Methods
Ethics Approval was obtained from the University of Saskatchewan Biomedical Research Ethics Board.
Dynamic port system fluoroscopy and port venography was performed on 50 consecutive subjects who presented for routine arm port removal between June 2011 and June 2012.
Consent was obtained from each subject for port removal and for participation in the study.
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8. Methods
Records were kept of the following patient demographics: age, sex, arm of insertion, date of port insertion and removal, as well as total port days in situ.
Images were obtained with the patient supine with the x-ray beam at 90 degrees from the table. The integrity of the port system was assessed by the injection of intravenous contrast agent, under fluoroscopy, from the port hub to the catheter tip.
The angle of entry of the catheter into the vein in neutral anatomic position at port removal was compared to the angle on the date of port system insertion.
At port removal, the angle was also measured during elbow flexion and extension as well as with shoulder abduction and adduction under fluoroscopy.

9. Methods
Data analysis was performed by a statistician in collaboration with the University of Saskatchewan, College of Medicine, Clinical Research Support Unit.
Multiple subject variables were analysed, including patient age, sex, port days in-situ and arm inserted.
The effect of these variables on the change in angle with arm flexion was analysed using Fisher’s exact test, Mann-Whitney-U test, and chi-squared analysis.

10. Results
Of the 50 patients who presented for port removal, all were oncology patients, most with breast cancer. 45 patients were female, and 5 were male. 30 of the removed ports had been implanted in the left arm, while 20 were on the right. Port days in situ ranged from 16 to 2,967, with a mean of 477 (SD=494). The patient age at removal ranged from 25 to 84 years, with a mean of 57.5 years.

11. Results
There was no evidence of catheter ballooning or distortion with contrast injection.
There was no evidence of fibrin sheath formation.
Statistical analysis was performed to determine whether any of the gathered patient characteristics (gender, age, year of insertion, days in situ, accessed arm, neutral angle, contrast leak) resulted in a significantly different angle change.
Statistical significance was not demonstrated for any of the analyses, with p-values ranging from 0.17 to 1.0.
Insert table

12. Example of Catheter Angulation
Spot fluoroscopic images demonstrating change in catheter angulation
with elbow flexion.

13. Results
Injection of one port in the cohort demonstrated contrast leakage at a defect in the catheter at the vein entry site, consistent with a catheter rupture, resulting in a catheter fracture rate of 2%.

14. Discussion
The hypothesis of fibrosis at the vein insertion site leads to ballooning of the catheter during injection was not confirmed.
There were no statistically significant clinical parameters analyzed related to catheter angulation.
A 2% catheter fracture rate was observed; this is in keeping with the 1.6% incidence of catheter fracture in Burbridge et al.
The catheter fracture we detected was partial and without distal catheter embolization.

15. Discussion
Limitations of our study include the analysis of only 50 patients, who presented for elective port removal. Most of the patients assessed were not having trouble with their ports, nor were they experiencing any symptoms.
Also of note, the mean number of days in situ for this study group was 477 days, whereas the mean number of days documented by Burbridge et al was 682.
Therefore, a larger cohort with a longer catheter dwell time may have yielded different results, with the presumption that a longer dwell time allows results in increased wear and tear possibly leading to fracture, or a fibrotic band.

16. Discussion
The exact cause for catheter fracture at the vein insertion site remains unknown.
Our results do raise the possibility that catheter angulation may be an issue. This may be related to the technical element of suturing the port housing to the bicep muscle fascia and creating a point of fixation affected by bicep muscle shortening during arm flexion.
We hypothesize that the occurrence of a change in angle for a large number of patients may be the source of catheter failure, not necessarily the degree of angle change.
Therefore, that there is any angulation at all with flexion may be the issue related to repetitive arm flexion. Further work is needed to determine if altering insertion technique will minimize the risk of catheter fracture.

17. Future Investigation
We did not record the various chemotherapeutic agents that were infused through the port while it was in use, it is possible that the combination of chemical interaction as well as repeated angulation, however small, may lead to damage of the catheter.  
As catheter fracture and potential embolization do carry the potential for significant adverse outcomes, with an unadjusted mortality rate on 1.8% in one study, further investigation into potential causes for this with an aim to reduce these unwanted complications is warranted (6).
(6) Surov A, Wienke A, Carter JM, et al. Intravascular embolization of venous catheter-causes, clinical signs, and management:
a systematic review. Journal of Parenteral and Enteral Nutrition. 2009;33:

18. Acknowledgments & Contact
Thank you for taking the time to view our presentation.
We also gratefully acknowledge:
Rhonda Bryce, statistician, University of Saskatchewan, College of Medicine, Clinical Research Support Unit.
The CAR for giving us the opportunity to present at the 76th Annual Scientific Meeting.
Contact information:
Nicolette Sinclair: