Luc Rotenberg, Gregory Lenczner ULTRASOUND GUIDED VENOUS ACCESS CHEST PORT IMPLANTATION

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Chest port implantation by
venous access with US Guidance
Luc Rotenberg, Gregory Lenczner
Clinique Hartmann – Ambroise Paré
26-27 bd Victor Hugo, 92200 Neuilly Sur Seine – France
www.radiologieparisouest.com
dr.rotenberg@radiologieparisouest.com
Nanjing-China June 24th 2017

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S  358 000 cancers cases/year
S  145 000 ports
S  50 000 PICC Lines
Ports implantation in France
private/public Potential ports
APHP 10 000
CHU 26 000
Public 35 000
CRLCC 17 000
Private 57 000
Total 145 000

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Hartmann Clinic
Built in 1904
Prof Henri Hartmann

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In the 1920’s… Radioherapy in Hartmann Clinic

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First Cobalt bomb
HARTMANN
1955

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S  ISHH = 700 ports / year
S  Radiologists
S  Surgeon
S  Non dedicated or dedicated operating session
S  Mean of 5 implants/session
S  300 ablations
!

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Clinical Pathway
Balistic preoperative consultation
§  Report Study
§  Interrogatory (risk factors…)
§  Balistic approch
§  Targeted
§  Device and guidance technique choice
§  Patient explanation of :
§  Intervention
§  complications
§  Possible results and implications
§  Pricing
§  Written informed consent is required before all interventions +++

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Clinical Pathway
S  Ambulatory
S  Short delay : 0 to10 days
S  Mean delay : 5 days
S  No delay in case of emmergency

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Quality of life
S  Before intervention
S  Ports implantation
S  During chimotherapy
S  After treatment

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US guidance
S  Venous direct
puncture US guided
S  100 % access SCV
S  Difficult cases
S  Asepsia +++
S  Steril pouch
S  protection for patient
S  protection for probe
S  Steril gel

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§ non ionizing radiation
§ multiples access
§ real time control
US Guidance

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ULTRASOUNDS REVIEWS
S  Skolnick ML : The role of sonography in the placement and management of jugular and
subclavian central venous catheters. Am J Roentgenol. 1994; 163:291-5
« US improve safety, speed, comfort »
S  Randolph AG, Cook DJ, Gonzales CA, Pribble CG : Ultrasound guidance for placement of
central venous catheters: a meta-analysis of the literature. Crit Care Med 1996; 24:2053-8
« US increase probability of successful placement, reduce complications, decrease
multiple attempts »
S  Hind D, Calvert N, McWilliams R et all : Ultrasonic locating devices for central venous
cannulation: meta-analysis. . BMJ. 2003, 16; 327(7411):361
« US decrease failures, reduce complications, decrease failure at 1rst attempt,
decrease Nb of attempts, decrease Nb of seconds for successful catheterization »
S  Cavanna, Luigi, et al. "Ultrasound-guided central venous catheterization in cancer
patients improves the success rate of cannulation and reduces mechanical
complications: a prospective observational study of 1,978 consecutive catheterizations."
World journal of surgical oncology 8.1 (2010): 1.
« US-improves the success rate of cannulation and reduces mechanical complications »

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n Before intervention
n End point venous access
n Local structures:
§  pleura
§ sub clavian artery
§  clavicle
n feasability
US checking venous access

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S  Installation +++
S  Fast intervention
S  Start with easy access
S  Phantom training
Key point

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Puncture technique
Access/ / long probe axis
S  Out plane : Perpendicular to the major axis of the probe
S  In plane : In the longitudinal axis of the probe

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In Plane Access
Longitudinal

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INTERNAL JUGULAR VEIN 
direct puncture

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HOW ?
JUGULAR VEIN APPROACH:
UltraSounds locating is more reliable than
anatomical landmarks
HIND Br Med J 2003:361
MAC GEEN N Eng J Med 2003:1123

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In plane approach
Courtesy of Dr Eric Desruennes

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INTERNAL JUGULAR  
« in short » 
 
tunneling the catheter

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INTERNAL JUGULAR  
 
in PAEDIATRICS

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Sub Clavian chest port
S  In recent years, the surgical approach to the subclavian
vein by sub clavicular "classic" was partially abandoned in
favor of the internal jugular, supposedly safer.
S  The addition of ultrasound guidance helps restore its
credentials in this way, more functional and aesthetic
avoiding many of the previous complications of « blind »
puncture.
S  Surroundings 5000 procedures were performed in our
institute since 2007, with this technique and this way
without first pneumothorax, arterial puncture or pinch off
syndrome.

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US and SUBCLAV.VEIN
S  Laméris JS, Post PJ, Zonderland HM et all : Percutaneous placement of
Hickman catheters: comparison of sonographically guided and blind techniques. AJR
Am J Roentgenol. 1990; 155(5):1097-9
radiologist vs surgeon
pneumo/hemothorax: US 0% vs Landmarks 10%
S  Gualtieri E, Deppe SA, Sipperly ME, Thompson DR :Subclavian venous
catheterization: greater success rate for less experienced operators using ultrasound
guidance. Crit Care Med. 1995; 23(4):692-7
less experienced Drs
success rate: US 92% vs Landmarks 44%
S  Pirotte T, Veyckemans F : Ultrasound-guided subclavian vein cannulation in
infants and children: a novel approach. Br J Anaesth. 2007; 98(4):509-14
(successive/children < 10kg): exp Dr
success rate: 1rst attempt 84%, 2nd attempt 100%

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Longitudinale approach
In plane way
Courtesy of Dr Eric Desruennes

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US guidance
ultrasound guidance with sterile pouch allows direct puncture of the
subclavian vein and avoids the tunneling

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Puncture of the subclavian vein is always distant from the clavicle :
2-4 cm up of the costovertebral joint), and not crossing over.
Compression and ponction scv
Orthogonal approach
Out plane way

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CEPHALIC VEIN 
surgical procedure 
at chest level

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CEPHALIC VEIN « in short »

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BRACHIAL VEIN 
by BASILIC approach

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AXILLARY VEIN « in short »

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EXTERNAL JUGULAR VEIN 
 
…exceptionnal

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FEMORAL VEIN
…exceptionnal

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In all cases
Plain Chest XRAY control
•  Ports position
•  Reference
imaging

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« the Chest Port horror show »
What not suppose to do

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Never in the decollete

!

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Surgical approach
§  surgical approach by the healthy side
§  prevent disease areas
§  radiotherapy

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Esthetic
respect neckline
and decollete
(BUNODIERE 2001)
Criteria for selection of
surgical approach

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Good result
•  Small scar (1 to 2 cm)
•  Oblique or vertical scar by deltopectoral groove
approach
•  invisible suture by a buried overlock and/or biological glue

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Discreet or invisible scare in
deltopectoral groove

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Almost invisible scar in deltopectoral groove

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Preventing complications of central venous catheterization 
McGee N Engl J Med 2003; 348:1123-33

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Injuries and liability related to central vascular catheters:  
a closed claims analysis  
Domino Anesthesiology 2004; 100:1411-8

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conclusion :
patient opinion
0
10
20
30
40
50
60
70
80
90
100
Before After
Favorable
Not Favorable
Retrospective study
100 consecutive women
Hartmann 2005
n  Satisfaction 97 %
n  Gratefull for
preserving the
cleavage 64 %

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WHAT IS GOOD FOR THE PATIENT
…IS GOOD FOR THE DOCTOR
THE REVERSE MAY BE WRONG !
Dr Michel BUNODIERE, 2001

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Take home :
US guidance ports access
1.  Technique
1.  US guidance scv ponction
2.  Verticale or oblique scare in deltopectoral groove, 1 to 2 cm
3.  Direct SCV ponction through the ports hole : no tunelisation
4.  Xray intervention guidance
5.  Deep point with vicryl 3.0 and intradermal surjet monocryl 4.0 and/or
biological glue
2.  Advantages / misadvantages
1.  Esthetic
2.  Fonctionnal
3.  Fast
4.  Few complication since 10 years: pneumothorax = 0, pinch-off = 0
5.  Operating dependant

Luc Rotenberg, Gregory Lenczner ULTRASOUND GUIDED VENOUS ACCESS CHEST PORT IMPLANTATION

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Luc Rotenberg, Gregory Lenczner ULTRASOUND GUIDED VENOUS ACCESS CHEST PORT IMPLANTATION