Correspondence

Importance of the Surgical Approach for TIVAD implant in 2012

Isidoro Di Carlo, Adriana Toro.

• Department of Surgical Sciences, Organ Transplantation and Advanced Technologies, University of Catania, Cannizzaro Hospital, Catania, Italy

• Submitted: January 6, 2012;
• Accepted January 14, 2012
• Published: January 15, 2012

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The Hickman-Broviac catheter has represented for many years a revolutionary support to the central venous infusion. However they needed continuous external dressing, infections occurred frequently, and the patient had his normal activities limited by catheter’s external impingement. For these reasons, since the mid-1980 we have assisted to an increase of TIVADs implantation as they considerably facilitate effective long-term chemotherapy as well as parenteral nutrition, fluid and factor replacement, and frequent blood sampling [1]. TIVADs have improved patients’ quality of life by allowing unrestricted mobility and freedom in performing daily activities. Moreover in patients affected by cancer they avoid the caustic effect of chemotherapy agents, that is a frequent cause of narrowing of peripheral vein and limit the dreadful risk of chemotherapy extravasation, frequently causing ulcers of the deep tissues

First implantation of a TIVAD, was performed in 1982 at the MD Anderson Cancer Centre in Houston by John Niederhuber, using the cephalic vein with surgical technique [2]. From 1982 the technique spreads all over the world and has been used over all by surgeons. Since the first description of the cephalic vein to insert a TIVAD many other different venous sites, using surgical technique, have been described including, external jugular vein, internal jugular vein, axillary vein, azygos vein, superior vena cava, right atrium, femoral vein, saphenous vein, inferior epigastric vein, gonadal vein, lumbar vein and inferior vena cava. In 1992 a TIVAD was successfully implanted in an angiographic unit by using a radiological guided technique. Recently the TIVADs implants have been required for different clinical conditions. Due to this increased request different specialists have begun to perform this last procedure [1]. Moreover, the belief that the percutaneous approach is easier and safer compared to the surgical one, has determined the increase of this method of implantation. As result, the surgical technique is used less frequently and the percutaneous approach has become the most used all over the word. However, with the increase of percutaneous procedures we have assisted to a concomitant raise of immediate post-procedural life-threatening complications, such as pneumothorax (Pnx) and/or emo-Pnx [3] or long term complications as the pinch-off syndrome, rupture of catheter and catheter migration.

The cephalic vein remain the most used surgical site for TIVAD implant, it permits to achieve the procedure in a percentage comprised between 70% and 94% [4]. But this approach permits, in case in which the cephalic vein is narrow or absent, to use different veins by the same approach so that the success rate reaches frequently the 100% [4] in hands of nexperienced operator [4].

The major advantage of the cephalic vein (CV) cut down approach compared to the percutaneous subclavian vein approach is the absence of risks to develop immediate complications such as Pneumothorax, hemothorax, injury to the great vessels and neural lesions at the time of catheter insertion [1].

In cases where the cephalic vein could not be visualized, is hypoplastic or fibrotic because of previous chemotherapy an external jugular vein (EJV) cut-down approach can be used [4]. The success rate of the CV cut-down approach alone is 93.09% but this value can reach 97.85% if patients underwent an ipsilateral EJV approach after CV failure.

When cephalic or external jugular vein are unsuitable because of multiple previous lines, recent line-related infection, chemotherapy or trombosis, the internal jugular vein or axillary vein or its branches can be used. The axillary vein or its branches may be used and it is preferred in thin patients. On the opposite, in fat patients the dissection of the neck for internal jugular vein is most easy in relation to the axillary vein[5].

All these veins permit an easy approach to implant a TIVAD and permit to achieve the results in 100% avoiding the fatal risk of the percutaneous approach.

When the veins flowing in the superior vena cava are unsuitable for use or the anterior chest wall does not permit to implant the reservoir, one of the veins draining in the inferior vena cava has to be used. Relative contraindications to using the superior central venous system include venous thrombosis, burns of the head and neck, previous or planned radiation therapy to the neck or mediastinum, extensive cervical or thoracic trauma, oropharyngeal fistula and tracheostomy[6].

The two veins used to the access the inferior vena cava are the femoral and the saphenous veins. The femoral is the most used vein by Seldinger technique, on the opposite saphenous vein is usually isolated by surgical technique; this last technique can be used preferentially or when femoral vein cannot be used as in the case of presence of coagulopathy.

Surgical approach is still a referenced method that can avoid the immediate and fatal complications. Moreover as the skin incision is until now mandatory to implant a TIVAD, the cephalic vein should be always attempted, leaving the percutaneous technique only for very selected cases.

Authors’ contributions

IDC and AT conceived and designed the study prepared the draft and edited the final version for publication.

Both authors approved the final version for publication.

Funding source

Nil

Conflict of Interests

The authors declare that there are no conflicts of interests.

References

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[2]. Niederhuber JE, Ensminger W, Gyves JW, Liepman M, Doan K, Cozzi E.Totally implanted venous and arterial access system to replace external catheters in cancer treatment. Surgery1982; 92:706-712

[3]. Biffi R, Pozzi S, Cenciarelli S, Zambelli M, Andreoni B. Treatment of pneumothorax as a complication of long-term central venous port placement in oncology patients. An observational study. J Vasc Access 2001;2:129-136.

[4]. Di Carlo I, Barbagallo F, Toro A, Sofia M, Lombardo R, Cordio S. External jugular vein cut down approach, as a useful alternative, supports the choice of the cephalic vein for totally implantable access device placement. Ann Surg Oncol 2005;12:570-573.

[5]. Di Carlo I, Toro A. Choise of venoussites. Surgical implant/Technique. 2012; pg 43-54. In Di Carlo I, Biffi R (Eds). Totally implantable venous access devices. Springer Editor 2012, pg 1-286.

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