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

2. Disclosures
Bard
BBraun

3. 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

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

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

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

7. 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 ?

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

9. 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

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

11. Primary success rate 2. Venous cutdown: External jugular
120 TIVAD
420 TIVAD
95 CV %
391 CV ,1% %
,9 %
17 to small
8 abscent
27 to small
2 abscent

12. 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

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

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

15. 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

16. Primary success rate 3. Venous cutdown: Guiding

17. 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%

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

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

20. 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

21. 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 %
Retro-pectoral vein 1 %
External jugular vein 10 6 % %
10 TIVAD 5%

22. 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%
Subclavian vein 1
,5% %
Reason
VC to small, VJE impossible 1
No VC, no VJE cutdown 3
Catheter mal insertion 2
No cutdown
No VC, No VJE

23. 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
,5%
DVT %
Extremity swelling
(No DVT: US confirmed)
Thromboflebitis
Catheter malfunction %
No pneumothorax
No hemothorax
No arterial puncture
No plexus injury
No hemoptesis
No pinch off

24. 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

25. 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

26. 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

27. 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

28. Observing the patient: radiography

29. 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 No radiography
162: CT or X-Ray thorax neg CT, 46 neg X-Ray
Radiography
Total of 162 CT
Mediastinal mass, no obstruction
,7%
Mediastinal mass, obstruction
,6%
PLVCS
,2%
Venous obstruction
X-Ray
Pleural effusion
6,7%

30. 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!!