‘Pinholes in my arms’: The vicious cycle of vascular access

Background: Vascular access devices (VADs) are essential for delivery of intravenous therapies. There are notable gaps in the literature regarding a focus on patient experience and meaning-making related to living with a VAD, specifically a central venous access device (CVAD). Aims: To explore how patients make sense of living with a CVAD. Methods: This study followed an interpretive phenomenological analysis (IPA) approach. Purposive sampling was used to identify 11 cancer patients who had a CVAD in situ. One-to-one semi-structured interviews were performed. Interviews were digitally recorded, transcribed and analysed by the lead author. Findings: Four superordinate themes were identified: the self under attack; being rescued/being robbed; protection of others/protection of self; bewilderment and dismay at lack of staff competence. Conclusion: Having a CVAD affects the psychological, social, and personal self and impacts on self-esteem and self-image. Despite this, CVADs are accepted by patients and are eventually ‘embodied’ by them.

Totally Implantable Venous Access Device (Chemoport) in Oncology: Study of 168 Polyurethane Chemoport Catheter System

Background Chemoport (totally implantable venous access device) and its catheter system are used to administer long-term chemotherapy in cancer patients. The objective of this study was to analyze the complications associated with chemoport insertion in various cancer patients. Material and Methods A total number of 168 chemoports along with polyurethane catheters were inserted in various cancer patients over a period of 3 years. 9.6 F polyurethane catheters were put by a team of surgical oncologists in operation theater under general or local anesthesia. Analysis of the complications was done until the chemoport was removed due to any reason. Results Out of 168 patients, 30 (17.85%) developed complications. Complications included arterial puncture, malposition of the catheter tip, pneumothorax, hematoma, seroma, deep vein thrombosis, fracture of the catheter, a reversal of port, infections, and thrombosis of the catheter. Only a few required premature port and catheter removal. Conclusion There was a low rate of complications associated with chemoport using a polyurethane type of catheter system. However, infection-related complications were comparatively more common in our series. Chemoport requires expert handling, patient education, strict follow-up, and dedicated teamwork to minimize complications.

Oral Minocycline As Systemic Therapy for Uncomplicated Venous Access Device-Related Bloodstream Infection with Coagulase-Negative Staphylococci in Patients after Allogeneic Hematopoietic Cell Transplantation

Venous access device-related bloodstream infections (VAD-BSIs) with coagulase-negative staphylococci (CoNS) are common complications after allogeneic hematopoietic cell transplantation (alloHCT). So far, the standard systemic antimicrobial therapy for uncomplicated VAD-BSIs with methicillin-resistant CoNS consisted of intravenous (IV) vancomycin (vanco). This approach requires hospitalization, necessitates new competent venous access, exposes patients to potential (mainly renal) toxicity and increases the risk of commensal flora dysbiosis with selection of vanco-resistant enterococci. Patients after alloHCT are particularly at risk of iatrogenic and nosocomial complications. In addition, repeated hospitalizations can impact autonomy and quality of life and are associated with significant costs. Minocycline (mino) is an oral antimicrobial agent that has strong in vitro effects on most Gram positive bacteria and potential anti-biofilm activity, and can be used in the clinic for some CoNS infections. Our infectious disease specialists proposed that systemic therapy with oral mino could be used for the management of uncomplicated VAD-BSIs, primarily when the reference treatment with IV vanco was not possible (renal failure or allergy) or when hospitalization was refused by patients. We retrospectively analyzed the results of this mino-based approach. From January 2012 to December 2020, we treated 24 uncomplicated VAD-BSIs with CoNS in 23 alloHCT patients aged 17-72y with oral mino. Uncomplicated VAD-BSIs were defined as 2 or more blood cultures positive for the same CoNS drawn consecutively peripherally and through the VAD, in patients without signs of sepsis, cellulitis or suppurative thrombophlebitis and without endovascular implant or orthopedic material. VAD were implantable ports (n=17), tunneled catheter (n=1) or PICC-lines (n=6). Pathogens were S. epidermidis (n= 21) or S. haemolyticus (n=3). CoNS were in vitro susceptible to mino according to EUCAST guidelines (with MIC <= 0.5mg/L, predominantly). Mino was administered at a dose of 100 mg BID for 7-14 days. For 8 VAD-BSIs, patients were initially treated with IV vanco for the first 1-3 days followed by oral mino, while 16 VAD-SIBs were managed with oral mino alone. VAD management consisted of catheter removal (for tunneled and PICC-lines, n=7) or antibiotic locks with vanco (n=15) or gentamicin (n=2) administered at least every other day for 14 days (for ports). Overall, clearance of bacteremia (as assessed by negativity of surveillance peripheral blood cultures with the same CoNS drawn between d+3 and +30 after initiation of systemic therapy) was achieved in all but 1 patient (with port, treated with mino alone) who had persistent bacteremia at day +9. No complication such as suppurative thrombophlebitis, endocarditis or metastatic foci of infection was observed in any patient during the 3-month period after initiation of treatment. Among the 17 patients for whom VAD salvage was attempted, VAD decontamination was successful in 10 cases while 4 patients experienced persistently positive VAD-derived blood cultures during the early (d+3 to +14) surveillance period and 3 patients experienced delayed relapse of VAD-BSIs with the same CoNS 1-3 months later (with 1 patient with cellulitis). All these events led to VAD removal. Treatment with mino was well tolerated with the exception of mild skin rash in one patient. Our results in this retrospective cohort suggest that oral mino can be a promising alternative to standard IV vanco for systemic therapy in VAD-BSIs with CoNS and that a strategy combining oral mino and antibiotic locks may salvage VAD in approximately half of the cases. This remains to be confirmed in prospective studies. Disclosures No relevant conflicts of interest to declare.

Analysis of six cancer patients with persistent left superior vena cava identified during central venous access device placement via an intracavitary electrocardiogram

Persistent left superior vena cava (PLSVC) is a rare congenital anomaly. PLSVC can be associated with clinically significant atrial septal defect (ASD) or ventricular septal defect (VSD). It is usually asymptomatic and accidentally detected during invasive procedures or imaging examinations. However, whether central venous access device (CVAD) can be placed and used in patients with PLSVC is controversial. A total of six patients were diagnosed with PLSVC and confirmed by chest CT among 3391 cancer patients who underwent CVAD placement via intracavitary electrocardiogram (IC-EKG) at the Venous Access Center (VAC) from May 2019 to December 2020. The CVADs (peripherally inserted central catheter in four patients and Ports in two patients) of these six patients were left in PLSVC. We analyzed changes in the P-wave in the IC-EKG during CVAD placement and the characteristics of the body surface electrocardiogram in these patients and discussed the catheter tip position in PLSVC. All six patients showed negative P-waves in lead II via IC-EKG from the beginning of catheterization: four patients showed negative P-waves and two showed biphasic P-waves in the body surface electrocardiogram (lead III) before catheterization. CVAD function was normal and no obvious complications were observed during the treatment of these patients. The total retention time of CVADs was 1537 days. For patients with a negative P-wave in lead II via IC-EKG during catheterization, especially in those with a negative or biphasic P-wave in lead III of the body surface electrocardiogram, PLSVC should be considered. CVAD insertion in patients with type I PLSVC is safe under certain conditions, with the proper tip position in the middle to lower part of PLSVC.

Impact of intravenous access site on attenuation for thoracic computed tomographic angiography: A time-matched, nested, case-control study

Background: The objective of this study was to evaluate whether the choice of intravenous access (IVA) site affects aortic attenuation during thoracic computed tomographic angiography (T-CTA) and any associated risks with intravenous device placement. Methods: All T-CTA exams performed between 1/1/2013 and 8/14/2015 were retrospectively reviewed to identify those performed with contrast media injection via alternative (i.e. non-antecubital) IVA ( n = 1769). Using time matching, antecubital IVA exams ( n = 1769) were selected as controls. For each exam, attenuation was measured in the ascending aorta. Patient and technical data was subsequently collected from all 3538 patients included in this study. Multiple linear regression was used to determine if IVA site affected attenuation. Lastly, data related to extravasations for the entire T-CTA cohort were collected and compared. Results: Hand/wrist, arm, and central venous access device IVA were all equivalent to antecubital IVA in terms of attenuation ( P = 0.579, P = 0.599, and P = 0.522 respectively). Forearm and intraosseous IVA had significantly higher attenuation ( P = 0.010 and P = 0.002, respectively) than antecubital IVA. Right-sided IVA was associated with a small attenuation increase of 11 Hounsfield Units ( P < 0.001) compared to left-sided IVA. In terms of extravasation, antecubital IVA was equivalent to hand/wrist, forearm, and upper arm IVA ( P = 0.778, P = 0.060, and P = 0.090 respectively). Conclusions: Satisfactory aortic attenuation achieved with non-antecubital IVA is equivalent to attenuation achieved with antecubital IVA for T-CTA imaging. The risk of contrast media extravasation in peripheral IVA devices was relatively low, however, appropriate IVA site selection should be considered an important factor for successful administration of contrast media for future imaging studies. This prevents undue harm to patients through preventable device failures when using a peripheral IV device in areas of high flexion/range of movements undergoing pressure injection for contrast media.

Secondary malposition of a PICC-port due to heavy physical exercise: A case report

Physical exercise is often encouraged in cancer patients, mainly for the purpose of rehabilitation and for its psychological benefit. Some authors also suggest that exercise—specially in patient with peripherally inserted central venous access devices—may contribute to reduce the risk of catheter-related thrombosis. Still, the impact of physical exercise on the risk of device-related complications is not yet defined. We report a case of secondary migration of the tip of an arm port, caused by high-intensity exercise in a woman undergoing chemotherapy because of ovarian cancer. Tip migration was suspected because of malfunction (persistent withdrawal occlusion) and diagnosis established after ultrasound examination and chest x-ray. Even if exercise may yield benefit in the cancer patient on chemotherapy, the risk of mechanical complication of the venous access device—such as tip migration—should be considered in the case of high-intensity exercise.

A totally implantable venous access device (TIVAD) abandoned for 5 years is re-accessed normally: A case report and literature review

Regular flushing and locking of totally implantable venous access devices (TIVADs) is recommended to maintain their patency when not in use. In this case report, a 73-year-old male patient received radical resection for rectal carcinoma in January 2010. A TIVAD was implanted in 2014 and a total of 12 rounds of chemotherapy of FOLFIRI was completed in 2015. During the period from 2015 to 2020, the patient never used or conducted the monthly infusion port flushing because of the inconvenience, the COVID-19 pandemic, and so on. On 18th April 2020, the patient was admitted to the radiotherapy department of Yiwu Central Hospital. The nurse evaluated the TIVAD upon admission, finding that the skin around the reservoir was normal without any sign of infection as erythema or induration of the skin overlying the implantable port but there was intraluminal occlusion of the devices. In order to re-access the catheter, discussion of a MDT was performed and several days of unremitting efforts were tried. Gratifyingly, the patient’s port was re-accessed successfully without any adverse reactions. This is a rare infusion port that has not been used and maintained for 5 years. For the port that has not been used and maintained for a long time up to 5 years, the medical staff should not give up easily. During the COVID-19 pandemic, prolonging the flushing interval of TIVADs can be an optimal clinical strategy without negative outcomes.

‘Pinholes in my arms’: the vicious cycle of vascular access

Background: Vascular access devices (VADs) are essential for delivery of intravenous therapies. There are notable gaps in the literature regarding a focus on patient experience and meaning-making related to living with a VAD, specifically a central venous access device (CVAD). Aims: To explore how patients make sense of living with a CVAD. Methods: This study followed an interpretive phenomenological analysis (IPA) approach. Purposive sampling was used to identify 11 cancer patients who had a CVAD in situ. One-to-one semi-structured interviews were performed. Interviews were digitally recorded, transcribed and analysed by the lead author. Findings: Four superordinate themes were identified: the self under attack; being rescued/being robbed; protection of others/protection of self; bewilderment and dismay at lack of staff competence. Conclusion: Having a CVAD affects the psychological, social, and personal self and impacts on self-esteem and self-image. Despite this, CVADs are accepted by patients and are eventually ‘embodied’ by them.