Wednesday, December 23, 2009

Portacath Insertion Technique



(Via Medscape)
There's an article in the British Journal of Surgery this month comparing two techniques of portacath insertion; the Seldinger technique vs. the venous cutdown. Portacaths are the little subcutaneous thingies that are used for chemotherapy infusions. Instead of having all your arm veins ravaged by the toxic chemicals of adjuvant chemotherapy, one can choose to have a port placed, thereby facilitating access to one of the main central veins.

Traditionally portacaths are placed as an outpatient surgical procedure using some IV sedation and local anesthetic. The majority of them are placed using the Seldinger technique whereby you jam a big fat needle into either the internal jugular in the neck or under the clavicle and into the subclavian vein, slide a guidewire through the bore of the needle and then advance the catheter to the SVC over the wire. The catheter is then tunneled subcutaneously for a bit and hooked up to a port, usually situated somewhere on the upper chest wall.

I generally don't do mine that way. Most of the time (95%) I utilize the venous cutdown method. I make a small incision over the deltopectoral groove, dissect out the cephalic vein, make a venotomy, and directly insert the catheter into the vein. The rest follows as per the Seldinger technique. It takes me about 10-20 minutes, usually. I do it without an assistant. There's no need for a CXR afterwards in the PACU. It's an elegant procedure when all goes perfectly.

Why do I choose to cutdown? Well, anytime you start jabbing large bored needles into someone's neck or chest wall, you assume a certain amount of risk; specifically pneumothorax, hemothorax, accessing the artery rather than the vein, etc. Granted, these complications don't occur very often (1-3% risk is usually quoted), but a typical general surgeons accumulates enough numbers over a career that inevitably he/she will have to deal with them at some point.

The cutdown eliminates the possibility of a lot of these complications. I don't have to worry about pneumothoraces. I don't have to worry that the blood I draw back on my needle stick is maybe arterial blood rather than venous (is it too red???). And it doesn't take me any longer than the guys who do the Seldinger technique.

The article alluded to seems to suggest that the cutdown is an inferior technique. And it's a decent article---randomized controlled trial and all that jazz. The data, the science, seems to suggest that the cutdown isn't any safer and, furthermore, it takes longer to perform. So what do I do with that information? Do I change my technique, to better accomodate myself to the "best available evidence"? Am I making myself liable if one of my ports becomes infected or gets clogged after a few months?

I can do a subclavian stick. I put central lines in quite a bit for post op sick patients and as a favor for my medicine colleagues. I prefer the subclavian over the jugular. I'm not afraid of the procedure. I think I'm adept at the technique. But for an elective case on a patient who has enough to worry about (recent diagnosis of cancer, uncertainty of the side effects of the anticipated chemotherapy) I want to use the technique that completely eliminates the possibility that a major complication could occur. Science be damned...

13 comments:

Frank Drackman said...

You da Man!!!
I realized I wasn't "Cut" out to be a Surgeon when I nearly bled a poor laboratory dog to death trying to do a simple cutdown in ATLS... Then there was that guy where I expertly canulated his Tibialis Anterior tendon...Thought I was da Man after my first 20 or so subclavians till I aspirated bright clear air instead of the red stuff...
Now I just do the girly man IJ's and as a lefty I'm more contorted than the President (Peace be upon Him) explaining his stance on Don't Ask, Don't Smell...

Mr. Condescending said...

I bet the patient would prefer your preferred method. I know I would.

hightechsurgeon said...

Personally, I have adopted ultrasound guided placement. Now, let me say that I have placed an uncountable number of CVCs using the standard Seldinger technique without the ultrasound. However, now I just can't see any reason not to use the technology. Using ultrasound allows effortless, safe access to the IJ. One stick. No chance of PTx. Elegant. Fast.

However, that all being said. If you are going to access a rather peripheral vein, then why should it even be done by cutdown? Why do it in the O.R.? Personally (God help me for saying so) I find it easier, faster, cheaper to have interventional radiology place it in the upper arm.

Quite frankly, O.R. time is too expensive. It is too hard to get people on the schedule. They have to jump through too dang many hoops. Interventionalists do it much more efficiently. I know this is blasphemy. I know. But, I personally took my Father-In-Law to my friends in Radiology. The experience was much better than we could offer for standard surgical procedures.

All that being said, the oncologists still send their patients to me for Ports. I don't complain. :)

Anonymous said...

Buckeye, I hope you have a great holiday weekend!
-SCNS

Anonymous said...

Why not get a CXR anyway just to make sure the catheter isn't too deep, or do you do it under fluoro?

Buckeye Surgeon said...

anon- I use fluoro in the OR.

Ben said...

pardon my 4th year med student ignorance, as i've never seen one of these procedures (where i'm at all they do is the seldinger technique to the subclavian with fluoro, as far as i know) - but where do you put the port when you do a cutdown to the cephalic? still in a pocket over the pec major? does the course of the catheter look any different?

radinc said...

I second the ultrasound technique. easy, fast and accurate.

maybe we shouldn't let you surgeons get a hold of ultrasound, you'll start wanting to do all our biopsies. but I'm sure there's a 2-day cme in tahoe or orlando for this.

with ultrasound you see the needle go right into the vein. stick to stitches in 15 minutes.

later,
radinc

Buckeye Surgeon said...

ben-
port in pocket over the pec muscle.

Kellie (GeneralSurgeon) said...

I do all mine with ultrasound and seldinger. Didn't used to do ultrasound, but we've got it and it makes it much more elegant.

As a surgeon who does dialysis access I would prefer to NOT use the cephalic vein cutdown or a subclavian access.

Chunda said...

I understand. Question if you did it the Seldinger way at the point that it is in the SVC would you then use Floro to comfirm placement? Also if so, would it be noted in your operative notes?

Anonymous said...

No comparison between the cut down and ultrasound guided placement. The ultrasound technique is at least a 100 times safer and superior. Using jugular approach also avoids pinching of the catheter between the clavicle and first rib which you see with subclavian puncture.

Anonymous said...

Hi Byckeye Surgeon, Have you had problems such as the catheter going to axillary vein tributary in this cephalic vein cut down technique?, recently It happened to me twice,any advice?