Totally implantable venous access ports (TIVAPs) provide patients with a safe and permanent access to a vein. They are often used in patients who need continuous administration of intravenous drugs, such as those receiving chemotherapy. TIVAPs are also used when regular intravenous medications, transfusion of blood products, or parenteral nutrition needs to be given, or if regular periodic blood sampling is required.
There are two methods for the insertion or implantation of a TIVAP: the surgical venous cutdown technique is an open surgical procedure where the cephalic vein is opened and accessed, and the Seldinger technique uses a percutaneous access (through the skin without having to surgically prepare the vein) of either the subclavian or the internal jugular (IJ) vein. Examined the available evidence from randomised controlled trials for the effectiveness and safety of different TIVAP techniques, comparing them in terms of success rate and complications.
The main approaches to placement of a TIVAP are the venous cutdown, the Seldinger, and a recently described modified Seldinger technique. The venous cutdown technique uses the cephalic vein and requires skin incision and surgical dissection of the cephalic vein. Venotomy is then performed to allow catheter insertion. The modified Seldinger technique is similar to the venous cutdown technique with the addition of a guidewire and peel?away vein dilator sheath featured to further assist in catheter insertion and placement.
Randomised or quasi?randomised controlled clinical trials comparing the venous cutdown technique with the Seldinger technique and the modified Seldinger technique for implantation of TIVAPs.
Seldinger group: a percutaneous technique with use of either the subclavian vein or internal jugular vein.
Venous cutdown group: a surgical technique which uses the cephalic vein.
Modified Seldinger group: a hybrid surgical technique which also uses the cephalic vein.
Comparison 1: Seldinger versus venous cutdown
Data presented in the analysis tables and forest plots represent the numbers of primary implantation failures in each group. This means that the number of events in the table for a 100% success rate of primary implantation would be 0. An effect estimate on the left side of the equipose (effect estimate of 1) therefore indicates an effect in favour of the Seldinger group, whereas an effect estimate on the right side indicates an effect in favour of the venous cutdown group. Hence, odds ratios less than 1 favour the Seldinger group, and odds ratios greater than 1 favour the venous cutdown group.
Comparison 2: Modified Seldinger versus venous cutdown
Identified only one trial using the modified Seldinger technique. ITT analysis of 164 participants showed no difference in primary implantation success rate between the modified Seldinger technique (69/82, 84%) and venous cutdown technique (66/82, 80%), P = 0.686. No difference in infection rate between the modified Seldinger technique (1/82) and venous cutdown technique (3/82) was reported. No cases of pneumothorax were reported. Catheter?related complications and thrombosis rates were similar in the modified Seldinger technique (2/82) and the venous cutdown technique (3/82).
Comparison 3: Seldinger technique (subclavian vein) versus Seldinger technique (internal jugular vein)
One study in children and adolescents compared the effectiveness and safety of using a Seldinger technique in the subclavian versus the internal jugular vein. The primary success rate for the initial attempt at implantation was 84% (37/44) for puncture in the subclavian vein and 74% (29/39) for the internal jugular vein. Six participants (7%) were excluded from the study because of procedure failure at both sites. Alternative techniques were used, which included catheter implanted by dissection (four participants), femoral vein by puncture (one participant), and one did not have any implantation. Among the excluded participants, three cases (3.6%) presented with early complications: one case with haemothorax, one with pneumothorax, and one with cervical haematoma. The authors made no mention of complications in participants with successful initial implantation. There was a difference in overall complication rate in the subclavian group (48%) versus the jugular group (23%), P = 0.02. However, when specific complications were compared individually, no differences were found between the groups.
The primary success rate for TIVAP placement is higher with the Seldinger technique than with the venous cutdown technique. The majority of included trials reporting on the Seldinger technique used the subclavian vein for access, while the internal jugular vein was used less frequently. Additional analyses showed that the Seldinger group using subclavian vein access was more successful in TIVAP insertion than the venous cutdown technique, while no difference was found between the Seldinger group using the internal jugular vein access and the venous cutdown technique. However, this can be attributed to the small number of participants in the internal jugular vein access group.
There was no difference in overall complication rates between the two techniques. Analysis per access vein used in the Seldinger technique versus the venous cutdown technique showed that the Seldinger technique using the subclavian vein has a greater rate of catheter?related complications compared to the venous cutdown group. The remaining outcomes, infections, pneumothorax, and other complications, did not show differences between the groups.
Identified only one trial for each of the comparisons modified Seldinger technique (cephalic vein) versus venous cutdown (cephalic vein), and Seldinger (subclavian vein access) versus Seldinger (internal jugular vein access), thus a definitive conclusion cannot be drawn for these comparisons and further research is recommended.