Port Placement

Question 1

Indications

Answer 1

Long-term central venous access, chemotherapy, parenteral nutrition (TPN), frequent blood draws or infusions, chronic illness requiring long-term IV therapy

Question 2

Absolute contraindications

Answer 2

uncorrected coagulopathy (INR over 1.5, platelets over 50,000), severe sepsis or bacteremia, extensive local infection or skin breakdown at insertion site

Question 3

relative contraindications

Answer 3

prior radiation therapy or surgery at the access site, or thrombosis, stenosis, or occlusion of the intended vein, and severe chronic kidney disease (consider preserving veins for future dialysis access)

Question 4

What imaging and sterile equipment is required?

Answer 4

ultrasound machine with sterile probe cover, fluoroscopy unit, sterile drapes, gloves, gown, mask and a cap

Question 5

what vascular access kit is needed?

Answer 5

18 or 21G needle, 0.035in guidewire, micro-introducer kit, vascular dilators (5-9Fr), and port catheter (9,6Fr or smaller, single or dual lumen)

Question 6

Port and tunneling materials that are needed?

Answer 6

Totally implantable venous access port (titanium or plastic), port catheter (polyurethane or silicone, cuffed or non-cuffed), and tunneling device (peel-away or tenneler rod)

Question 7

Pre-procedural protocol

Answer 7

Identify internal jugular (IJ) or subclavian vein patency, measure vein diameter (over 7mm), evaluate for thrombosis, stenosis, or anatomical anomalies

Fluroscopy for central venous mapping if needed includes confirm SVC patency, detect venous anomalies or prior stenosis, plan optimal catheter trajectory

Question 7

Closure and dressing materials needed?

Answer 7

absorbable sutures (3-0 or 4-0 Vicryl, or subcutaneous sutures for port pocket), non-absorbable sutures (3-0 Nylon for skin closure, or dermabond adhesive), sterile transparent dressing (tegaderm or opsite)

Question 8

Intraoperative Imaging protocol

Answer 8

Real-time ultrasound guidance is used for vein puncture and guidewire placement. It minimizes arterial puncture risk.

Fluorosocopy for guidewire & catheter positioning is used to ensure guidewire follows correct venous path, confirm dilator and catheter placement, verify port catheter tip

Question 9

Where should the port catheter tip be located?

Answer 9

Lower third of the superior vena cava (SVC) near the cavo-arterial junction (CAJ)

Question 10

If the jugular vein is small or thrombosed, what do you do?

Answer 10

use subclavian or femoral approach

Question 11

If there was a prior central venous occlusion what do you do?

Answer 11

Consider brachiocephalic or translumbar access

Question 12

What do you do if you have difficulty tunneling due to obesity or scar tissue?

Answer 12

Use alternative pocket locations

Question 13

What do you use if there is tortuosity of the vein?

Answer 13

use a soft, flexible guidewire

Question 14

What do you do if there is a prior clot formation?

Answer 14

Use angioplasty or stenting before placement

Question 15

What do you do if there are radiation fibrosis of tissues?

Answer 15

Adjust tunneling technique

Question 16

How do you prevent arterial puncture of the carotid or subclavian puncture?

Answer 16

use ultrasound guidance, confirm venous blood return

Question 17

How do you prevent hematoma formation due to poor needle positioning?

Answer 17

apply direct pressure, use hemostatic agents

Question 18

how do you prevent pneumothroax caused by needle misplacement into lung pleura?

Answer 18

use real-time ultrasound and fluoroscopy

Question 19

How do you prevent infection due to bacterial contamination?

Answer 19

Strict sterile technique, antibiotic prophylaxis if needed

Question 20

How do you prevent thrombosis due to clot formation at catheter tip?

Answer 20

Use antithrombotic flushes (heparin or saline lock)

Question 21

How do you cause catheter malposition due to migration due to movement?

Answer 21

confirm final placement with fluoroscopy

Question 22

What position do you place patient in to reduce air embolism risk?

Answer 22

Trendelenburg for IJ placement

Question 23

For subclavian approach how is the patient positioned?

Answer 23

supine with arm abducted

Question 24

What anesthesia is used?

Answer 24

local 1% lidocaine at access and port pocket sites, moderate conscious sedation (if required)

Question 25

What does step one (venous access) include?

Answer 25

use ultrasound guided puncture of the IJ or subclavian vein insert guidewire and confirm placement with fluoro

Question 26

What does step two include (pocket creation)?

Answer 26

Create a 2-3 cm incision in the upper chest (subcutaneous tissue pocket) Use tunneler to create subcutaneous tunnel from vein entry to pocket

Question 27

What does step three (catheter insertion and confirmation) include?

Answer 27

insert port catheter over guidewire into the SVC

Question 28

What does step four (port attachment and suturing) include?

Answer 28

secure port reservoir in the subcutaneous pocket secure port to deep fascia for stability

Question 29

What does step five (final imaging and flushing) include?

Answer 29

Confirm final catheter placement on fluoroscopy and flush with heparinized saline to prevent clotting

Question 30

What does step six (wound closure and dressing) include?

Answer 30

Close incision with subcutaneous Vicryl & skin sutures and cover with sterile dressing

Question 31

How do you confirm a functional port?

Answer 31

aspirate venous blood to confirm patency and flush with heparinized saline to prevent clotting

Question 32

What should be monitored for immediate complications?

Answer 32

Hematoma, swelling, or pain at the incision site. Symptoms of pneumothorax (SOB and Chest pain)

Question 33

What should the patient be educated on for post procedural care?

Answer 33

Avoid heavy lifting for 1-2 weeks Keep dressing dry and clean Report redness, fever, or drainage (infection sign)