Tunnelless totally implantable venous access port implantation by ultrasound-guided axillary vein puncture: a retrospective analysis
Authors: Luo Haiguan , Pan Yuying , Zhu Shuchen , Huang Lihui , Dong Mingyan , Zhang Qiaohong , Piao Yicui 
Published: December 2023

Background:
Totally implantable venous access ports (TIVAPs) are widely used in oncology patients requiring intravenous chemotherapy, and the chest wall remains the preferred site for implantation of the TIVAP. However, the choice of implantation route is still more divergent. Most hospitals prefer the internal jugular vein (IJV) for puncture because of its safety and high success rate. However, the IJV approach still has more defects, such as the need to incise the neck, which increases the surgical incision, the need to make long tunnels, a wide range of surgical scope, and the presence of subcutaneous catheter shapes in the postoperative period, leading to less privacy for patients and decreased aesthetics. Thus, we chose the axillary vein approach and the removal of the step of making the tunnels, which simplifies the surgical process, reduces the number of wounds, narrows the scope of the operation, and reduces the scope of local anesthetic drug injections, and the results of the postoperative period are more aesthetic. The feasibility and safety of Tunnelless TIVAP implantation by ultrasound-guided axillary vein puncture are retrospectively analyzed, and the specific procedure is reported in detail.
METHODS:
All patients who underwent chest wall TIVAPs implantation from January 2022 to March 2023 were enrolled, and a total of 703 patients were enrolled, including 290 males and 413 females, with a mean age of 53.91±12.43 years. The axillary vein route was proposed to be preferred for all patients, of which 7 were not suitable for axillary vein puncture due to very poor axillary vein filling and severe obesity. Axillary venous puncture was successfully performed in 685 patients, and axillary vein puncture failure was performed in 11 patients. Finally, 685 patients underwent tunnelless TIVAPs implantation by axillary vein puncture, and 18 patients underwent TIVAPs implantation with tunneled IJV puncture. We collected the patients' age, sex, body weight, BMI, axillary vein diameter, depth of the axillary vein from the body surface (Fig. 1a), success rate of the surgery, operation time of the surgery, and postoperative follow-up to learn about the immediate and long-term complications of the surgery and analyzed the patients' postoperative results to demonstrate the feasibility and safety of TIVAP implantation by axillary vein puncture without a tunnel.
RESULTS:
703 patients signed the consent form for implantation of the TIVAPs, mean age of the patients was 53.91±12.43 years old, mean weight was 60.33±10.47 kg, mean BMI was 23.01±3.52, mean axillary vein diameter 8.38±1.73 mm, mean axillary vein depth was 26.31±4.51 mm, and the mean procedure time was 14.38±4.03 minutes (Table 1). All patients had a clear pathological diagnosis of malignant tumors requiring intravenous chemotherapy, and the top three diagnoses were breast Cancer (28.88%), colorectum Cancer (24.61%), and lung or bronchi cancer (13.94%), with a cumulative ratio of the top three diseases of 67.43% (Table 2). Seven patients could not prefer axillary vein puncture due to poor axillary vein filling and/or severe obesity assessed by preoperative ultrasound examination, 696 patients preferred tunnelless TIVAPs implantation by axillary vein puncture, the enrollment rate was 99%, and the implantation success rate of the enrolled axillary vein puncture group was 98.41%. Among them, 11 cases of patients who failed to puncture the axillary vein were reassigned to implantation of infusion ports by IJV puncture with an overall implantation success rate of 100%. Intraoperative ultrasound found a guidewire ectopic to the internal jugular in 47 patients, electrocardiographic localization, no hyperacute P wave was detected during localization in 14 patients, the guidewire was folded within the axillary vein in 13 patients, the axillary artery was mistakenly penetrated in 7 patients, and all of the problems were resolved appropriately (Table 3). After surgery, all TIVAPs functioned normally, with the catheter tips located in the middle and lower portions of the superior vena cava, and there were no surgery-related complications, such as pneumothorax, hemothorax, subcutaneous hematoma, wound infection, or wound disruption. The follow-up ended August 31, 2023, with 471 TIVAPs still in functional service, 128 removal of TIVAPs at the end of the treatment cycle, 68 incomplete information on mid-course visits to another hospital, 34 deaths during the follow-up period, and 2 unintended removals. Follow-up found retrograde catheterization to the IJV in 8 (1.14%), catheter blockage in 3 (0.43%), TIVAPs catheter-related infections in 2 (0.28%), catheter-related venous thrombosis in 2 (0.28%), and mild skin-pocket infection in 1 (0.14%). The mean duration of follow-up was 281.59 days (range: 1 day-721 days). There were no complications, such as TIVAP reversal, catheter fracture, TIVAP catheter tubing, or pinch-off syndrome, and no patients underwent secondary surgical adjustments. The overall immediate and long-term complication rate was 2.28%.
CONCLUSION:
The Tunnelless TIVAP implantation technique by ultrasound-guided axillary vein puncture can be used as the preferred chest wall TIVAP implantation technique. Physicians with experience in ultrasound-guided techniques for axillary vein puncture have a high success rate, good reliability, and fewer complications. Patients experienced less pain and better comfort during implantation, and the postoperative period was without neck wounds and the catheter shape under the skin, which is more aesthetically appealing and preferable to patients.