Port-a-cath became increasingly popular for the management of cancer patients since their outcome is comparable to the tunneled central lines with low risk of infection . In our facility, we prefer the port-a-cath over the tunnel central line or peripherally inserted central lines as long-term venous access because of the ease of use for families and healthcare professionals.
In this study, we aimed to analyze our experience with the insertion of port-a-cath, report its complications in pediatric patients, and compare both techniques of insertion. Patients with neoplasms, hematologic disorders, and patients that require long-term supplements require long-term venous access, and IVADs helped to improve the quality of care in those patients. Most children with oncological diseases in our facility had port-a-cath insertion as the standard of care
In our study, the majority of the port-a-cath inserted were placed percutaneously in the left subclavian vein because of the ease of implantation. Additionally, it provides long intravascular length, which is very important in small infants because as they grow, the catheter can be pulled out before they finish their treatment. Visualization of the central vein at the time of insertion of the venous catheter is important in reducing the rate of failure and complications relating to damage to adjacent structures. Therefore, we inserted most of the catheters under ultrasound guidance. A study reported that the port-a-cath implantation method without guidance was less effective than ultrasound-guided .
The average duration of the catheter in our study was 14 months and is consistent with the published series, which ranged between 12 and 22 months . The use of IVADs may be associated with complications, most of which can be effectively controlled without the removal of the catheter. Insertion and maintenance are important to minimize iatrogenic injuries and reduce complications related to the catheter. Infection was the most common complication in our series, followed by thrombosis. Thrombosis and infection were reported in associated with hematological malignancy, which could be attributed to abnormal immune response and viscosity of the blood, making the central venous catheter susceptible to thrombosis and, subsequently, infections .
Prior central line insertions, more than one device insertion, and a long duration of the catheter were risk factors for infection . In our study, 94 (16.5%) catheters were removed because of infection. The education and training programs for the patients and healthcare providers involved in the insertion and care of catheters will help reduce the infection rate. Our study showed that catheters malfunction and thrombosis, which required ports replacements was 7%, which is consistent with what was reported in the literature (5%) . Catheter blockage is suspected when there is a failure in infusion, or the catheter fails to withdraw blood.
Most of the complications have been related to insertion, and scarce data were published about the complications associated with their removal. The detection and treatment of complications related to the extraction of central venous catheters should be emphasized. We had 4 cases who developed dislodgement of a catheter in the right atrium and right pulmonary artery. The causes could be a poor connection to the port, catheter damage at the pinching point below the clavicle, or incorrect catheter position. The dislodgment rate of port-a-catheters reported in the literature was 1.4 to 3.6% [15, 16] with an average of 2.4% . This rate is higher than what was reported in adults, which ranged from 0.3 to 1.5% [13, 18] Most catheters were broken at the site of connection . This could be attributed to the manual assembly of the catheters to the port by the surgeon in the operating room or because of the hyperactivity of patients in this age group. Surprisingly, patients with dislodged catheter did not present with respiratory symptoms and did not require supplementary treatment pre or post removal of the dislodged catheter. However, most dislodgements present with only irrigation resistance or even without symptoms or signs .
Long-term use of central venous catheters is known to have peri-catheter adhesions and calcifications. These factors can result in stuck catheters that are difficult to remove. The incidence of stuck catheters is not exactly known, and different results have been reported with an incidence ranged from 0.3 to 2.2% . The long duration of the catheter was the main predisposing factor to this complication [22, 23]. To facilitate removal, a second incision was required in 4 patients and venotomy in 2 patients. Inserting a guidewire into the catheter allows greater traction to be applied to the stuck catheter without fracturing it [24, 25]. Two cases failed this technique, which required removal by venotomy of the left internal jugular vein. Others advocate using the endoluminal dilatation technique to remove stuck port-a-cath [26,27,28]. We reported one patient with embed distal part of the catheter in the superior vena cava, and it was discovered later after the removal of the port-a-cath.
In our experience, the best management of a retained fragment, if it is free-floating, is to remove it by the help of interventional radiologists or cardiologists. However, if it is fixed to the wall of the major vascular structure, it is wise to leave the catheter in place because removal may lead to fatal complications such as hemorrhage and the need for a major surgery like sternotomy with pulmonary arteriotomy . As soon as the catheter becomes unnecessary, it is crucial to be removed with caution to avoid complications related to its extraction, such as bleeding, infection, air embolism, and catheter embolism. As a safety measure, we try to remove all the ports after 2 years of placement.
In comparing both approaches for port-a-cath insertion, we did not find a significant difference between both techniques in insertion and removal complications. This indicates that both approaches are safe, and the choice of the approach should be tailored according to the patients’ characteristics.
Limitations of the study
The limitations of our study were the retrospective nature and single-centered study. Additionally, there was loss of data during the study period. However, the study presents a large experience in the management of pediatric patients with port-a-cath.