Perioperative management - TIVAD implantation

Anatomy Perioperative management Technique Complications Evidence Total Video

Indications
- Long-term parenteral nutrition
- Intravenous chemotherapy (when peripheral venous access is not possible)
- Long-term infusion regimen
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)
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
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
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