Evidence - TIVAD implantation - general and visceral surgery
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Literature summary
A totally implantable venous acces device provides subcutaneous access most often to the central venous system and is designed for long-term use. Substances with a higher osmolarity (cytostatic drugs, nutritional solutions, blood constituents) can be administered via the TIVAD over a prolonged period of time. Other benefits include its entirely subcutaneous position, which reduces the risk of infection compared to catheters inserted percutaneously, and the improved quality of life for patients in terms of personal hygiene and physical activity.
The first TIVAD systems were first described in 1982 [1, 2] and quickly became increasingly important as permanent and safe central venous access options, particularly in oncology, due to their excellent clinical performance.
The available venous access routes for catheter placement include the cephalic vein, external and internal jugular vein, subclavian vein in the anterior chest and shoulder region, and the basilic vein.[3] A randomized controlled trial from 2009 established that the technique of implantation, access route, and the implant site do not affect early and late complications.[4] However, studies have found that left-sided catheter positions and the position of the catheter tip in the upper part of the superior vena cava carry a higher risk of thrombotic events.[5, 6]
Intraoperative complications are quite rare and account for less than 2%.[7] Most problems develop in the long run. In addition to risk factors inherent to the patient, improper handling of the TIVAD plays a particularly important role in terms of infections. TIVAD infections are among the most common complications and are therefore also the most frequent reason for explantation.[8, 9] The spectrum of pathogens is dominated by gram-positive pathogens of the skin such as s. epidermidis, s. aureus and various streptococci. An increasing number of candida-related infections have been reported.[10, 11] According to a study by Gaillard et al., colonization with s. epidermidis can be successfully eliminated by the intraluminal administration of vancomycin.[12] In their meta-analysis, Safdar et al. described a catheter block with vancomycin as reducing catheter-related bacteremia in high-risk patients.[13] Bissling et al. demonstrated a significant reduction in catheter infections by blocking the catheter with taurolidine.[14]
Prophylactic medication for catheter-related thrombosis is a topic of intense discussion. Monreal et al. demonstrated the benefit of thrombosoprophylaxis,[15] while more recent randomized trials and a meta-analysis failed to show a significant effect of central venous catheter systems on the reduction of thromboembolic events.[16–19] Consequently, regular TIVAD irrigation with heparin solution is also controversial.[20] According to the IFUs of various manufacturers, regular TIVAD irrigation with heparine-saline is recommended, but there is no evidence of benefit compared to standard saline. Heparin-related side effects in the event of overdosage (bleeding, heparin-induced thrombocytopenia) and the unclear legal situation regarding the IV application of drugs by outpatient nursing services are arguments against standardized irrigation of the TIVAD system with heparin-saline. Corresponding information can be found in the guidelines of the German Nutrition Society.[21, 22]
Ongoing trials on this topic
Possible literature on this topic
1.Niederhuber JE, Ensminger W, Gyves JW et al (1982) Totally implanted venous and arterial access system to replace external catheters in cancer treatment. Surgery 92(4):706–712
2.Niederhuber J, Gyves J, Ensminger W et al (1982) Totally implanted system for intravenous chemotherapy in patients with cancer. Am J Med. 73(6):841–845
3.Lenhart M, Schätzler S, Manke C, Strotzer M et al (2010) Radiologische Implantation zentralvenöser Portsysteme am Unterarm – Implantationsergebnisse und Langzeit-Follow-up bei 391 Patienten. Fortschr Röntgenstr 182:20–28
4.Biffi R, Orsi F, Pozzi S et al (2009) Best choice of central venous insertion site for the prevention of catheter-related complications in adult patients who need cancer therapy: a randomized trial. Ann Oncol 20:935-940
5.Ignatov A, Hoffmann O, Smith B, Fahlke J et al (2009) Ann 11 year retrospective study of totally implanted central venous access ports: complications and patient satisfaction. Eur J Surg Oncol 35:241–246
6.Puel V, Caudry M et al (1993) Superior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted ports. Cancer 72(7):2248–2252
7.Hofmann HAF (2008) Die Portimplantation. Chirurgische Praxis 69:695–708
8.Teichgräber UK, Pfitzmann R, Hofmann HA (2011) Central venous port systems as an integral part of chemotherapy. Dtsch Ärztebl Int 108(9):147–154
9.Fischer L, Knebel P, Schröder S et al (2008) Reasons for explantation of totally implantable access ports: a multivariate analysis of 385 consecutive patients. Ann Surg Oncol. 15(4):1124–1129
10.Clarke DE, Raffin TA (1990) Infectious complications of indwelling long term central venous catheters. Chest 97:966–972
11. Newman N, Issa A, Greenberg D et al (2012) Central venous catheter-associated bloodstream infections. Pediatr Blood Cancer 59(2):410–414
12.Gaillard JL, Merlino R, Pajot N, Goulet O, Fauchere JL, Ricour C, Veron M. Conventional and nonconventional modes of vancomycin administration to decontaminate the internal surface of catheters colonized with coagulase-negative staphylococci. JPEN J Parenter Enteral Nutr. 1990 Nov-Dec;14(6):593-7.
13.Safdar N, Maki DG (2006) Use of vancomycin-containing lock or flush solutions for prevention of bloodstream infections associated with central venous access devices: a meta-analysis of prospective, randomized trials. Clin Infect Dis 43:474–484
14.Bisseling TM, Willems MC, Versleijen MW et al (2010) Taurolidine lock is highly effective in preventing catheter-related bloodstream infections in patients on home parenteral nutrition: a heparincontrolled prospective trial. Clin Nutr 29:464–468
15.Monreal M, Alastrue A, Rull M et al (1995) Upper extremity deep venous thrombosis in cancer patients with venous access devices – Prophylaxis with a low molecular weight heparin (Fragmin). Thromb Haemost 75:251–253
16.Chan A, Iannucci A, Dager WE (2007) Systemic anticoagulant prophylaxis for central catheter-associated venous thrombosis in cancer patients. Ann Pharmacother 41(4):635–641
17.Karthaus M, Kretzschmar A, Kröning H et al (2006) Dalteparin for prevention of catheter-related complications in cancer patients with central venous catheters: final results of a double-blind, placebocontrolled phase III trial. Ann Oncol 17(2):289–296
18.Verso M, Agnelli G, Bertoglio S et al (2005) Enoxaparin for the prevention of venous thromboembolism associated with central vein catheter: a double-blind, placebo-controlled, randomized study in cancer patients. J Clin Oncol 23(18):4057–4062
19.Chaukiyal P, Nautiyal A et al (2008) Thromboprophylaxis in cancer patients with central venous catheters. A systematic review and meta-analysis. Thromb Haemost 99(1):38–43
20.Kanna A (2008) Heparinised saline or normal saline? J Perioper Pract 18:440–441
21.Shaffer JL, Bakker H, Bozzetti F et al (1997) A European survey on management of catheter-related complications in home parenteral nutrition. Clin Nutr 16:42
22.Jauch KW, Stanga Z et al (2007) Technik und Problem der Zugänge in der parenteralen Ernährung. Leitlinie Parenterale Ernährung der DGEM Aktuel Ernaehr Med 32(Suppl 1):41–53
Reviews
Clari M, Spoto M, Franceschi G, Acuto M, Tonella S, Caristia S, Buratti G, Gaboardi S, Rasero L, Campagna S, Busca E, Dal Molin A. Short Versus Long Timing of Flushing of Totally Implantable Venous Access Devices When Not Used Routinely: A Systematic Review and Meta-analysis. Cancer Nurs. 2021 May-Jun 01;44(3):205-213
Jiang M, Li CL, Pan CQ, Cui XW, Dietrich CF. Risk of venous thromboembolism associated with totally implantable venous access ports in cancer patients: A systematic review and meta-analysis. J Thromb Haemost. 2020 Sep;18(9):2253-2273.
Jiang M, Li CL, Pan CQ, Yu L. The risk of bloodstream infection associated with totally implantable venous access ports in cancer patient: a systematic review and meta-analysis. Support Care Cancer. 2020 Jan;28(1):361-372.
Toro A, Schembari E, Fontana EG, Di Saverio S, Di Carlo I. Forty years after the first totally implantable venous access device (TIVAD) implant: the pure surgical cut-down technique only avoids immediate complications that can be fatal. Langenbecks Arch Surg. 2021 Sep;406(6):1739-1749.
van den Bosch CH, van Woensel J, van de Wetering MD. Prophylactic antibiotics for preventing gram-positive infections associated with long-term central venous catheters in adults and children receiving treatment for cancer. Cochrane Database Syst Rev. 2021 Oct 7;10:CD003295.
Wang P, Soh KL, Ying Y, Liu Y, Huang X, Huang J. Risk of VTE associated with PORTs and PICCs in cancer patients: A systematic review and meta-analysis. Thromb Res. 2022 May;213:34-42.
Wu XH, Chen LC, Liu GL, Zhang TT, Chen XS. Heparin versus 0.9% saline solution to maintain patency of totally implanted venous access ports in cancer patients: A systematic review and meta-analysis. Int J Nurs Pract. 2021 Apr;27(2):e12913.
Xiong ZY, Zhou HM, Li SY. Prolonged flushing and locking interval for totally implantable vascular access device: A systematic review and meta-analysis. J Vasc Access. 2021 Nov;22(6):969-978.
Yeow M, Soh S, Yap R, Tay D, Low YF, Goh SSN, Yeo CS, Lo ZJ. A systematic review and network meta-analysis of randomized controlled trials on choice of central venous access device for delivery of chemotherapy. J Vasc Surg Venous Lymphat Disord. 2022 Sep;10(5):1184-1191.e8.
Zhou Y, Lan Y, Zhang Q, Song J, He J, Peng N, Peng X, Yang X. Totally implantable venous access ports: A systematic review and meta-analysis comparing subclavian and internal jugular vein punctures. Phlebology. 2022 May;37(4):279-288.
Guidelines
Onkopedia Pflege: Portkatheter 2015
Recommendation from the Commission on Hospital Hygiene and Infection Protection at the Robert Koch Institute (RKI) (Federal Health Gazette 02/2017):
literature search
Literature search on the pages of pubmed.