TIVAPs are widely used in the clinic because they require no external dressing, allow patient activity, and improve the life of patients, especially in patients with breast cancer who require frequent chemotherapy and blood sampling [11]. At present, surgical cutdown of the cephalic vein and percutaneous puncture for TIVAP implantation via IJV and SCV are the most widely used for their high success rate and low complications [3, 12, 13].
However, the IJV and SCV may not be the best option for many clinical situations. The high puncture point seems to be one of the shortcomings of the IJV approach, the large angle of the fold of the catheter due to the high puncture point may lead to catheter discount, clogging, and fracture [14]. Larger angle and longer catheterization pathway are important factors in the reduction of patient comfort and may cause an unattractive appearance for patients with breast cancer after TIVAP placement [15]. The puncture point of SCV approach is lower, which is more convenient and comfortable than IJV, but the occurrence of pinch-off syndrome (POS) may lead to dysfunction of the catheter. POS is the main cause of catheter rupture or fracture for the SCV approach [14].
In 1982, Niederhuber et al. of MD Anderson Cancer Center in the USA, first applied the TIVAP surgical technique to the central vein through the cephalic vein [16]. Studies showed that, compared with the SCV approach, the incidence of complications of the INV approach using surgical techniques for TIVAP is low, and it is considered superior to the SCV approach [17]. Koketsu et al. [18, 19] also believed that TIVAP could provide safe and feasible infusion channels for patients through INV, which is worthy of promotion and application. However, surgical incision and implantation of TIVAPs also have the disadvantages of long operation time, low success rate, and great trauma [20].
With the development of ultrasound technology, however, ultrasound-guided INV catheterization has been gradually applied in clinical practice, and many studies have confirmed its safety and effectiveness [5,6,7,8,9]. However, ultrasound-guided puncture of INV for TIVAPs is rarely reported and is still overlooked.
The IJV merges with the SCV behind the sternoclavicular joint to form the INV, and the bilateral INVs converge to form the superior vena cava (SVC). We know that the INV is relatively fixed and has a larger diameter than the IJV and SCV; this provides the possibility of ultrasound-guided puncture of INV safely and effectively [21].
In this preliminary study, the right INV approach was obtained only, as the thoracic duct afflux into the central vein is via left INV, so the right INV approach was preferred to avoid thoracic duct damage. But in Beccaria’s study [9], 78 patients with left INV catheterization did not have thoracic duct injury. Another study showed that left INV catheterization was safe and feasible in children [22]. The safety and feasibility of left INV approach of TIVAPs for patients need to be studied further.
Beccaria et al. conducted a comparative study between CVC via the INV and IJV approach. The study indicates that the US-guided CVC via INV approach is safe and easy to operate, and it is a reasonable alternative to IJV approach in adults [9]. In our study, right INV approach was adopted in 67 cases, the success rate of the first puncture was 95.52% (64/67), similar to the results of 90.18% (257/285) reported by Beccaria et al [9]
One study showed that the success rate of catheterization of the left INV was higher than that of the right in newborns and children [23].
In this study, the rate of perioperative complications was 1.50% (1/67), consisting of one case of self-limited arterial puncture, visualized as SCV by ultrasound. The second puncture was successful, and there was no hematoma formation.
The overall postoperative complication rate in this study was 4.48% (3/67), which was lower than that in most other studies [12, 24]. Catheter-related infections were found in 1 case 5 weeks after surgery. The blood culture showed Staphylococcus aureus. Fibrin sheath formation was found by digital subtraction angiography (DSA) in 2 cases. They all led to unplanned port withdrawal after active anti-infection and failure of thrombolytic therapy. It remained important to avoid unplanned port withdrawal by standardizing the operation and paying attention to the maintenance and management of the catheter.
Lin et al. [25] reported 2620 cases of patients with the SCV puncture route. The incidence of catheter fracture was 2.6%, highlighting that POS is the main cause of catheter rupture. In this study, supraclavicular puncture of right INV was used to avoid the occurrence of POS by crossing above the clavicle, and no catheter fracture was found. In addition, none of the patients had catheter malposition after the procedure, which might be related to the fact that the range of catheter activity by INV approach was small, and the location of the catheter was accurately positioned by DSA fluoroscopy during the operation.
Given the preliminary results reported here (the study was retrospective and the cases were limited), there is a clear need for a randomized controlled study to confirm the feasibility and safety of the ultrasound-guided right INV approach for TIVAPs. It may stimulate future research in this area.
