Perioperative management - TIVAD implantation

  1. Indications

    • Long-term parenteral nutrition
    • Intravenous chemotherapy (when peripheral venous access is not possible)
    • Long-term infusion regimen
  2. Contraindications

    • Systemic infection possibly involving the implant
    • Subclavian vein thrombosis
    • Contralateral pneumothorax
    • Local eczema/fungal infection
    • Previous radiotherapy with radiation-induced keloid formation
    • Major coagulation disorder (markedly pathologic plasma coagulation panel; platelets < 30 Gpts/L)
  3. Preoperative diagnostic work-up

    • Clinical examination (swollen arm, visible collateral circulation near the shoulder signifying subclavian vein thrombosis, previous dissection and radiotherapy of ipsilateral axilla, lymphedema of ipsilateral arm with positive Kaposi-Stemmer’s sign)
    • In previous punctures/catheter insertion in vessels of the neck: Preoperative duplex ultrasound
    • Lab studies in case of previous pathologic standardized coagulation panels: RBC, PT, PTT, platelet count
  4. Special preparation

    • Peripheral venous access (contralateral arm) and initiation of a venous drip
    • Shaving of chin, lateral neck triangle and chest down to the level of the nipples
    • Surgical skin prepping of lateral neck triangle from the median line to the nipple
  5. Informed consent

    • Risk of pneumothorax in about 2% of subclavian vein punctures with lung injury → chest tube insertion
    • Venous and arterial vascular injury requiring surgical revision
    • Secondary bleeding, locally and in vascular injury
    • Brachial plexus injury with persistent paresthesia and pareses
    • Wound infection with possible TIVAD infection → surgical explantation
    • TIVAD dislocation and dysfunction (kinking, puncture not possible etc.)
    • Venous air embolism during insertion, possibly with cerebral hypoperfusion and subsequent neurologic deficits
    • Arterial malinsertion with stroke
Anesthesia

The procedure is performed under local anesthetic, e.g., 1% mepivacaine 10 mL. When available, an a

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