for repeated administration of chemotherapeutic agents , intravenous hydration , or parenteral nutrition to cancer patients or chronically ill patients , the role of the totally implantable central venous port ( ticvp ) system is greatly increasing to address concerns about quality of life . annually , more than 5 million central catheters are implanted in the us , and the proportion of implantable catheter systems has been increasing since niederhuber et al .   first reported this system .
surgeons cut down or percutaneously puncture the cephalic , subclavian , or jugular vein , whereas interventional radiologists access the subclavian or jugular vein with the guidance of venography , ultrasound , or fluoroscopy .
recently , ultrasound - guided access to the vein , especially the internal jugular vein , and fluoroscope - guided positioning of the catheter have become widely accepted to reduce complications such as pneumothorax , pinch - off phenomenon , hematoma , or malposition of the catheter tip . however ,
because thoracic surgeons are familiar with the percutaneous puncture technique , cut down insertion of the central catheter , and the anatomy of the chest and neck vasculature , they can detect complications and manage them promptly and accurately .
they can also create a pocket port easily , given their training in pacemaker pocket creation .
in keimyung university dongsan medical center , the ticvp system has been provided by a thoracic surgeon since march 2009 .
all of the procedures were performed with one small skin incision and subcutaneous puncture of a subclavian vein . in this article , we summarize our experience of the ticvp system and present the success and complication rate of this surgical method .
the purpose of this study is to determine whether implanting a ticvp system with surgical methods is as safe as performing it with radiologic guidance .
between march 2009 and december 2010 , 245 port systems were implanted into 242 patients by thoracic surgeons .
the patients ' age , sex , underlying diseases , indications of the implantable port system , immediate and delayed complications , and total period of implantation of the port system were evaluated .
all of the study protocols were accepted by the institutional review board of keimyung university dongsan medical center . before performing the procedure , the patient 's coagulation status including prothrombin time , activated partial thromboplastin time , and platelet count were checked .
in the operating room , intravenous sedation was not performed and the patient was monitored with electrocardiography , pulse oximetry , and automatic cuff blood pressure . the neck and whole chest was prepared and draped .
a circulating nurse was positioned near the patient 's head and constantly checked the patient 's condition during the operation . as a port site ,
however , if the patient had received mastectomy or radiation therapy on the right side , or had a previous port scar , the left anterior chest was chosen .
after subcutaneous injection of 1% lidocaine for local anesthesia , a 3 cm transverse incision was made just 2 cm distal to the lower margin of the clavicle at the deltopectoral groove level .
gentle dissection of the subcutaneous tissue was done with electrocautery until the fascia layer was reached . at this layer ,
a pocket for the port was created with blunt and sharp dissection . to prevent skin tightness or necrosis , sufficient space for the port
was provided with minor bleeding control . after preparing the port site , an additional subcutaneous injection of lidocaine
an introducer needle was inserted at the deltoid tuberosity level while gently withdrawing the plunger of the syringe . because the needle was inserted through previously dissected subcutaneous tissue , no additional incision was needed .
then the needle was inserted under and along the inferior border of the clavicle , making certain that the needle was virtually horizontal to the chest wall .
once under the clavicle , the needle was advanced toward the suprasternal notch until it entered the vein .
when we failed infraclavicular subclavian vein access , we converted to a supraclavicular subclavian vein puncture just lateral to the sternocleidomastoid muscle ( fig .
1 ) . after insertion of a j - tip wire , a groshong catheter ( bardport ; bard
, salt lake , ut , usa ) was introduced through the peel off sheath .
after checking the venous return through the catheter and ensuring adequate heparinization , the catheter was cut to connect with the port ( bardport ) .
the catheter was inserted to a depth of 13 to 16 cm of the catheter length through the subcutaneous puncture site ( fig .
two anchoring sutures between the port hole and subcutaneous tissue were made to fix the port .
after checking the patency of the port and flushing it with heparin , the wound was closed with tight obliteration of the dead space to prevent hematoma . after returning from the operating room ,
a routine chest x - ray was obtained to check the catheter position and to rule out postoperative complications like pneumothorax .
a series of 245 port systems were implanted into 242 patients , including 82 men and 160 women , with an age range of 14 to 86 years ( mean , 55.74 ) . in 240 of the patients ,
the ticvp system was implanted for chemotherapy and other oncologic management , while in 2 noncancerous patients , the system was implanted for parenteral nutrition or to secure an intravenous route .
the pocket sites for the port were created on the right side of the chest wall in 203cases ( 85.3% ) . in 42 cases ( 14.7% ) , the left side of the chest wall was used due to previous scarring or wound problems in 10 , right side mastectomy in 9 , the patient 's preference for the left side in 9 , failure of right side subclavian venous puncture in 4 , pain or edema in the right arm in 4 , and other reasons in 6 .
two patients ( 0.82% ) underwent supraclavicular access of the subclavian vein after failure of infraclavicular access .
secondary insertion of the port system was performed in 6 patients , including 3 after it was surgically inserted with this method , 2 after radiology - guided insertion , and 1 inserted at another institution .
the mean operating time was 22.611.5 minutes ( range , 10 to 80 minutes ) .
accidental arterial puncture occurred in some cases , but there was no hematoma or hemothorax occurrence .
early complications within 30 days of surgery occurred in 11 patients ( 4.49% ) , including malposition of the catheter tip in 6 , malfunction of the catheter in 3 , and port site infection in 2 . among patients who experienced malposition of the catheter tip
, 2 were explanted , but the others refused to remove the catheter ( fig .
there was no evidence of venous thrombosis during their catheter indwelling . at the time of chart review ,
late complications occurred in 12 patients ( 4.90% ) including venous thrombosis in 4 , fever of unknown origin in 4 , skin necrosis in 3 , and sepsis in 1 patient .
we performed explantations in 25 patients ( 10.2% ) including 6 explantations after completion of chemotherapy . during explantation
compression of the puncture site for a while and complete obliteration of the port site dead space was performed .
the median duration of the ticvp system was 287.2 days , ranging from 3 to 980 days .
a totally implantable port system has been used increasingly since its introduction by niederhuber et al . .
the types of access vein and port site have varied according to the surgeon 's preference .
with cut down procedures , the cephalic vein or external jugular vein was preferred , while for percutaneous access , the subclavian or internal jugular vein approach was more frequently used . nowadays , to reduce perioperative complications and for accurate positioning of a catheter , ultrasound- , venography- , or fluoroscope - guided access
interventional radiologists prefer the sonographic approach using the internal jugular vein than the external landmark - guided technique [ 6 - 8 ] .
some surgeons prefer the cut down procedure to the cephalic vein instead of the percutaneous approach of the subclavian vein to avoid the risk of pneumothorax .
however , for a long period of time , the subclavian vein has been a preferred route for placement of the central venous catheter .
this route provides a lower chance of infection and good stability on the chest wall . because the left innominate vein forms an acute angle from the vena cava , and has the possibility of damaging the thoracic duct , the right subclavian vein is preferred over the left .
pneumothorax occurs at a rate of 1% to 2.5% incidence after interventional radiologic placement of the chest port [ 6 - 8 ] , while occurring at an incidence of 2.4% to 4.3% after implantation by a surgeon .
found that there was no difference in early complications among the internal jugular , subclavian , and cephalic veins in their comparison of central venous insertion sites .
they also found that ultrasound - guided subclavian insertion showed the lowest proportion of failure .
meanwhile teichgraber et al .   reported no incidence of pneumothorax after 3,160 cases with an ultrasound - guided internal jugular vein approach . in our study ,
if surgeons are very familiar with chest and neck vasculature , and have good hands with subclavian vein access , the incidence of pneumothorax will decrease .
in addition , if the needle should proceed toward the sternal notch slowly and directly without changing the axis , the chance of pneumothorax would be rare .
however , the slow and gentle advance of the needle during venipuncture , accurate checking on the venous blood return to the syringe , and rapid withdrawal of the needle after puncturing the artery can prevent these events . in our experience , even after arterial puncture , rapid removal of the puncture needle and compression of the adjacent soft tissue for 1 or 2 minutes could prevent hematoma formation in every event . in early insertion periods ( march to may , 2009 ) ,
when puncture through right subclavian access failed , the insertion site was changed to the left side . as a skin incision on the right anterior chest had already been made , an additional incision and pocket making was needed in the left side .
supraclavicular needle puncture to the subclavian vein just lateral to the sternocleidomastoid muscle was performed . with this route , the surgeon did not need to change the original patient 's right side position . when trying to access the internal jugular vein , the surgeon should change position to the patient 's head side .
two operations ( 0.82% ) were performed and no occurrence of pneumothorax with this method was observed .
lin et al .   reported their experience using external jugular vein cut down , when the cephalic vein approach failed .
below the cutdown site of the cephalic vein , they made a pocket for the port , where a new external jugular vein provided an excellent alternative route .
for secure and long - term maintenance of a ticvp system , the catheter tip position is crucial .
the united states food and drug administration has stated that the catheter tip should not be placed in or allowed to migrate into the heart . when the catheter is positioned in the right atrium
, it may cause cardiac - related complications such as perforation , tamponade , arrhythmia , or cardiac thrombosis .
furthermore , catheter tips placed in the superior vena cava ( svc ) may cause port malfunction .
many authors agree with positioning the tip at the svc - right atrial junction . on standard chest radiograph , because the upper border of the svc is at the level of the inferior border of the clavicle , or the angle of the right main bronchus and trachea , the catheter tip should be located below this level .
the svc - right atrium junction level on chest radiograph is somewhat different according to different authors .
defalque and campbell   have mentioned that the ideal tip position is between the fifth and sixth thoracic vertebrae , whereas rutherford et al
.   mentioned that it is between the right lateral margin of the svc and superior border of the cardiac silhouette , while another author described it as 1 cm inferior to the right superior cardiac border . with preliminary evaluation of the optimal catheter tip length under fluoroscopic guidance prior to the operation
, we attempted to keep the catheter length 13 to 16 cm from the subcutaneous insertion site in the operative field .
as our procedures were performed without radiologic guidance , we tried to keep the catheter tip from entering the svc area by a j - tip wire heading caudally , slowly proceeding the catheter , and checking cardiac ectopy on the monitor .
however , we found a malpositioned catheter tip located in the internal jugular or contralateral innominate vein in 6 patients ( 2.45% ) .
in this situation , we could have changed the tip position by the endovascular snaring technique or by reinsertion of the catheter in the operating room . but no patient wanted these procedures .
1 ) since all of the procedures are performed in the operating room , the risk of infection will be lower than procedures done in the angiographic suite .
2 ) because we form the pocket and perform subcutaneous cannulation of the catheter with one small skin incision , no additional incisions or subcutaneous tunneling is needed .
3 ) because the implanted catheter length is short , the risk of catheter - associated complications like lumen occlusion and infection might decrease .
however , since we did not perform a comparative study with a radiology assisted port insertion group , we have a limited ability to test these advantages . for a surgically implanted system using a subclavian vein , complication rates of 5% to 24.6%
have been reported and those radiologically implanted at the same site show a lower complication rate up to 20.7% .
however , considering the high incidence of malposition of the catheter tip , complementary cooperation with a radiologist would be needed .
surgical insertion of a ticvp system with percutaneous subclavian venous access is a safe procedure with a lower complication rate and many clinical benefits .
 backgroundthe role of totally implantable central venous port ( ticvp ) system is increasing . implantation performed by radiologist with ultrasound - guided access of vein and fluoroscope - guided positioning of catheter 
 is widely accepted nowadays . in this article 
 , we summarized our experience of ticvp system by surgeon and present the success and complication rate of this surgical method.materials and methodsbetween march 2009 and december 2010 , 245 ports were implanted in 242 patients by surgeon . 
 these procedures were performed with one small skin incision and subcutaneous puncture of subclavian vein . 
 patient 's profiles , indications of port system , early and delayed complications , and implanted period were evaluated.resultsthere were 82 men and 160 women with mean age of 55.74 . port system was implanted on right chest in 203 , and left chest in 42 patients . 
 there was no intraoperative complication . 
 early complications occurred in 11 patients ( 4.49% ) including malposition of catheter tip in 6 , malfunction of catheter in 3 , and port site infection in 2 . 
 late complication occurred in 12 patients ( 4.90%).conclusionsurgical insertion of ticvp system with percutaneous subclavian venous access is safe procedures with lower complications . 
 careful insertion of system and skilled management would decrease complication incidence . 