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Venous Cutdown Versus the Seldinger Technique for Placement of Totally Implantable Venous Access Ports (Protocol)

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Venous Cutdown Versus the Seldinger Technique for Placement of Totally Implantable Venous Access Ports (Protocol) Cochrane Database of Systematic Reviews Venous cutdown versus the Seldinger technique for placement of totally implantable venous access ports (Protocol) Hsu CCT, Kwan GNC, van Driel ML, Rophael JA Hsu CCT, Kwan GNC, van Driel ML, Rophael JA. Venous cutdown versus the Seldinger technique for placement of totally implantable venous access ports. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD008942. DOI: 10.1002/14651858.CD008942. www.cochranelibrary.com Venous cutdown versus the Seldinger technique for placement of totally implantable venous access ports (Protocol) Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 BACKGROUND .................................... 1 OBJECTIVES ..................................... 3 METHODS ...................................... 3 REFERENCES ..................................... 5 CONTRIBUTIONSOFAUTHORS . 6 DECLARATIONSOFINTEREST . 6 SOURCESOFSUPPORT . 6 Venous cutdown versus the Seldinger technique for placement of totally implantable venous access ports (Protocol) i Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. [Intervention Protocol] Venous cutdown versus the Seldinger technique for placement of totally implantable venous access ports Charlie C-T Hsu1, Gigi NC Kwan2, Mieke L van Driel3, John A Rophael4 1The Alfred Hospital, Prahran, Australia. 2Box Hill Hospital, Box Hill, Australia. 3Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia. 4Department of Surgery - St Vincent’s Hospital, University of Melbourne, Fitzroy, Australia Contact address: Charlie C-T Hsu, The Alfred Hospital, Commercial Road, Prahran, Victoria, 3181, Australia. [email protected]. Editorial group: Cochrane Vascular Group. Publication status and date: New, published in Issue 1, 2011. Citation: Hsu CCT, Kwan GNC, van Driel ML, Rophael JA. Venous cutdown versus the Seldinger technique for placement of totally implantable venous access ports. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD008942. DOI: 10.1002/14651858.CD008942. Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT This is the protocol for a review and there is no abstract. The objectives are as follows: The review aims to compare the success rate and safety of three commonly used techniques for implanting totally implantable venous access ports (TIVAPs); the venous cutdown technique, the Seldinger technique and the newly described modified Seldinger technique. The review will include studies that use doppler or real time two-dimensional ultrasonography for locating the vein in the Seldinger technique. BACKGROUND requiring external dressing, and they are associated with reduced access-related anxiety, pain and discomfort (Bow 1999). TIVAPs Totally implantable venous access ports (TIVAPs) are devices po- are maintained through regular flushing with heparinised saline sitioned beneath the skin with a reservoir port covered with sili- as well as following administration of chemotherapeutic agents to cone rubber. The port is attached to a catheter that enters a cen- maintain patency of the catheter lumen. tral vein. The port is accessed by needle puncture through the pa- tient’s skin and into the port reservoir. TIVAPs have become an important tool for patients undergoing chemotherapeutic inter- Description of the intervention ventions for malignancies. TIVAPS are commonly placed in pa- tients commencing chemotherapy to provide central venous ac- The main approaches to placement of a TIVAP are the venous cess and to reduced the risk of phlebitis, infection and extravasa- cutdown technique, the Seldinger technique and the modified tion of chemotherapeutic agents (Ng 2007). Other applications of Seldinger technique. The cephalic vein is most commonly used in TIVAPs include administration of medications, parenteral nutri- the venous cutdown technique, followed by the external jugular tion, transfusion of blood products and periodic blood sampling. vein and less commonly the internal jugular vein and basilic vein. TIVAPs are positioned subcutaneously thus providing several ad- The Seldinger technique involves percutaneous puncture with the vantages over externalised indwelling catheter systems, such as not right internal jugular vein being the ideal site for venous access fol- Venous cutdown versus the Seldinger technique for placement of totally implantable venous access ports (Protocol) 1 Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. lowed by the subclavian or external jugular vein. The right internal anaesthetic. The use of real time ultrasound guidance is a necessity jugular vein runs a straight course to the superior vena cava thus with internal jugular vein puncture. Successful needle entry into minimizing catheter contact with the vessel wall and is of some dis- the vein can be verified by easy flow of blood into the syringe. A tance away from the lung apices. For these reasons internal jugular flexible guidewire is advanced through the hub of the venipunc- vein puncture is associated with a lower risk of catheter malposi- ture needle and passed into the SVC. The needle is withdrawn tion, thrombosis and pneumothorax (presence of air in the pleu- and removed when the guidewire is securely in the SVC. Vein ral cavity) and/or haemothorax (presence of blood in the pleural dilators and a peel-away sheath are used to insert the catheter.A cavity). The anatomy of the external jugular vein is such that both catheter is threaded through the vein dilator sheath into the SVC sides of the vein open into the subclavian at close to right angles, under fluoroscopic guidance so that the correct tip positioning is which can potentially complicate catheter placement and provoke achieved. The vein dilator sheath is constructed so that it tears subclavian vein stenosis and thrombosis. More recently, Knebel et away as it is pulled out of the vein. In contrast to the cephalic vein al described the use of a modified Seldinger technique that employs cutdown technique, two small skin incisions are required. One is attributes of both venous cutdown and the Seldinger technique in- at the guidewire exit site and the second is for implantation of volving the cephalic vein (Knebel 2009). Potential complications the port reservoir in a port pocket created 8 cm from the catheter of these techniques include stenosis, kinking or dislodgement of exist site. The catheter is passed through a subcutaneous tunnel the catheter, subcutaneous haematoma, nerve palsy, thoracic duct to connect to the reservoir port. Finally, the functionality of the injury and wound infection (Di Carlo 2001). The Seldinger tech- TIVAP system is checked by flushing the lumen with heparinised nique in particular reference to subclavian vein puncture is associ- saline solution and an upright chest radiograph is taken to check ated with complications such as pneumothorax, haemothorax and for pneumothorax (Nocito 2009). potential injuries to the great vessels (Di Carlo 2010). Over the Traditionally the Seldinger technique described percutaneous past two decades, there has been a shift in practice towards the puncture using anatomical landmarks. Increasingly ultrasound is Seldinger technique over the venous cutdown technique because used to guide percutaneous vascular access. Real time ultrasonog- surgical expertise is not required (Di Carlo 2010). Another factor raphy generates a two dimensional image to locate the blood vessel that may contribute to the change in practice is that the Seldinger and Doppler ultrasonography generates an audible sound from technique is more cost effective with a shorter turnaround times flowing venous blood. A meta-analysis by Hind et al found that than traditional cutdown technique which requires access to op- real time ultrasound for internal jugular vein procedures in adults erating theatre. resulted in fewer failed catheter placements, fewer complications with catheter placement and a lower failure rate on first attempt (Hind 2003). On the other hand, the use of Doppler ultrasound Venous cutdown technique guidance was less successful and more time consuming than us- An incision is made under local anaesthesia along the deltopectoral ing the anatomical landmark method (Hind 2003). The benefit groove; the cephalic vein is located then dissected out circumfer- of real time ultrasonography in guiding percutaneous puncture of entially. Two separate sutures are placed around the cephalic vein, the subclavian vein, cephalic vein, basilic vein or the axillary vein one proximal and one distal. The suture placed distally around is uncertain as current evidence is sparse. the cephalic vein is securely tied down. The cephalic vein is then partially transected in a transverse fashion along its midportion. A catheter is passed proximally into the lumen of the partially Modified Seldinger technique transected cephalic vein and advanced centrally into the superior vena cava (SVC). The catheter is manipulated under fluoroscopic The modified Seldinger technique involves surgical dissection of guidance until it reaches the desired position above the atrial-caval the cephalic vein with the use of the guidewire and peel away junction. To prevent catheter migration, the suture placed prox- vein dilator sheath featured in the Seldinger technique. The ini- imally around the catheter and the proximal
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