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]