A prospective evaluation on external jugular vein cut-down approach for TIVAD implantation

Background Totally implantable venous access devices can be implanted both by percutaneous approaches and by surgical approaches with cephalic vein or external jugular vein cut-down techniques that are related to low intraoperative complication rates. The authors report a prospective evaluation of 83 consecutive external jugular vein cut-down approaches for totally implantable venous access devices implantation. Methods Eighty three consecutive patients (28 M, 55 F, mean age 54.2) suffering from solid tumors (58) or hematologic diseases (25) were consecutively submitted to totally implantable venous access devices insertion through external jugular vein cut-down approach (75 on right side, 8 on left side). Results All devices were surgically implanted; no instances of intraoperative complications were detected. After a minimum follow-up of 150 days, only one case of wound hematoma and one case of device malfunction due to incorrect catheter angulation were noted. Postoperative patient satisfaction was evaluated by the use of specific questionnaire that demonstrated a good satisfaction and compliance (92.8 %) of patients with implanted devices. Conclusions Despite the lack of controlled studies comparing external jugular vein cut-down approach vs other approaches, this approach should be considered as a tool for long-term central vein catheters positioning, both as an alternative and for primary approach.


Background
Totally implantable venous access devices (TIVADs) are usually inserted and utilized in case of long-term therapies and nutritional support in oncologic patients [1,2]. These devices can typically be implanted through different ways. The percutaneous approach is the most used technique and can be performed under ultrasound guidance or "blind" puncture, via the subclavian or internal jugular vein (using the Seldinger technique) [1]; nevertheless, this approach is still affected by several and potentially severe complications, like pneumothorax, hemothorax, vascular, or brachial plexus injuries, occurring in up to 12 % of patients [3,4]. On the other hand, cephalic vein cut-down (CVCD) technique appears to be effective and not affected by these severe complications [3][4][5] but is reported to fail in 6-30 % of cases, mainly due to anatomic variations in cephalic vein course or caliber. In such cases, several authors report high success rates in positioning TIVAD via the external jugular vein (EJV) by cut-down approach [3][4][5].
The authors report a prospective evaluation of 83 consecutive EJV cut-down (EJV-CD) approach procedures for TIVAD implantation, evaluating success rates, intraoperative and postoperative complications, and patient satisfaction.
All patients received single-shot preoperative antibiotic prophylaxy 30 min before surgery.

Implantation technique
All procedures were performed by the same surgeon (GC) having large experience in TIVAD implantation.
All devices were implanted in the operating theater under fluoroscopic control, and patients were treated and monitored in a day hospital setting. Seventy five TIVADs were inserted on the right side, and, due to right breast or lung cancer or to previous TIVAD or other central venous catheter implantation on the right side, the other eight were implanted on the left side. The route of the external jugular vein was identified and marked by a permanent marker prior to surgery, by placing the patient in mild Trendelemburg position and using the Valsalva maneuver (Fig. 1a). After local anesthesia (2 % solution of mepivacaine hydrocloride), 1.5-cm skin incision was performed on the neck skin. After careful dissection of subcutaneous space, the EJV was identified and exposed ( Fig. 1b) Then, the catheter was inserted ( Fig. 1c) into the vein for about 15 cm. The correct positioning of the catheter tip was controlled by fluoroscopy (Fig. 1d). So the catheter was connected to the port (placed in a subfascial pocket on the pectoralis muscle) through a subcutaneous tunnel (using the specific device present in the TIVAD sterile package). In 14 cases (16.9 %), due to difficult progression of the catheter through the vein lumen, a J-tip guidewire inserted into the catheter lumen was used to facilitate the progression. At the end of the procedure, a test puncture was performed to check patency and flow through the system with sodium heparin solution (5000 IU in 10 ml of 0.9 % saline solution).

Results
Intraoperative and postoperative results and complications are summarized in Table 2. All TIVADs were surgically implanted, with no need of percutaneous access to sublcavian or internal jugular veins. We found no differences in operative time between left and right side. No instances of intraoperative complications, such as pneumothorax, hemotorax, injuries to great vessels, or brachial plexus were detected. After a minimum follow-up of 150 days only one case of wound hematoma and one case of device malfunction due to excessive catheter angulation requiring surgical revision of the catheter were noted. No cases of deep venous thrombosis or catheter rupture were noted. Postoperative patients satisfaction was evaluated by the use of specific questionnaire on postoperative satisfaction after TIVAD implantation (Table 3) [6]. The reported results demonstrated a good satisfaction about the surgical procedure and outcome and a good compliance (92.8 %) of patients with implanted devices.
Nevertheless, only few reports dealing EJV approach for TIVAD implantation exist.
However, a recent literature review [23] and other previous studies [3,24] support the evidence that approaches to the EJV (both cut-down and percutaneous) are safe and effective even for TIVAD implantation.
The present prospective study on 83 primary EJV-CD approaches for TIVAD implantation report a 100 % success rate and a very low incidence of complications (2.4 %); furthermore, only one of these complications appears related to the specific technique itself and specifically to an incorrect angulation of the catheter when entering the EJV. This low incidence of complications is due to a totally surgical approach, with no direct vein puncture, and to the easy dissection and identification of the vein that runs superficially and can be easily detected preoperatively, by placing the patient in mild Trendelemburg position and after Valsalva maneuver.
In 14 patients, due to a difficult progression of the catheter from the EJV to the right atrium, we used a J-tip guidewire to ensure the correct catheter positioning. Difficulties in catheter progression through the vein route are mainly due to a sharp angulation between the EJV and the subclavian vein, occurring in about 12 % of patients, as recently demonstrated by radiological evaluations [25,26]. However, the simple use of the guidewire within the catheter lumen allowed a correct progression of the catheter until the right atrium.
Despite the high success and low complication rates reported by this prospective evaluation, as well as by previous studies, there are still several controversies   about the potential role of EJV-CD as primary choice for TIVAD implantation. First, the need to perform two separate incisions (one for EJV catheterization and one for the subfascial pocket for the Port) and second, the need to make a subcutaneous tunnel for the catheter and the consequent risk to create an obstacle (angulation) to the catheter flow, just near the EJV inlet. This occurrence can be avoided by creating a "gentle" shape to the catheter curve near the EJV inlet, and actually, there is no evidence that the subcutaneous tunnel itself may be related to any complication or TIVAD malfunction. Another criticism related to the presence of the tunneled catheter is the possible discomfort of patients about the presence of the catheter in subcutaneous tissues of the neck and above the clavicule that can give a "foreign body" sensation and perceived as not esthetic. For these reasons, we proposed, 30 days after surgery, a specific patient satisfaction questionnaire designed for TIVAD implantation [6]. Results of this questionnaire, summarized in Table 3, reflect a good patient satisfaction and compliance (in 92.8 % of cases) with TIVAD implanted through the EJV, thus encouraging us to continue in this experience.

Conclusions
In conclusion, this prospective evaluation reports a 100 % success rate in TIVAD implantation through EJV-CD approach, with very low incidence of complications and high levels of patient satisfaction, demonstrated by a dedicated questionnaire. So, despite the lack of controlled studies comparing EJV-CD approach vs other approaches that cannot lead to definitive conclusions about the "gold standard" technique, we can say that this approach should be considered at least as a tool for long-term central vein catheters positioning, both as an alternative and for primary approach.