D'Angelo F, Ramacciato G, Caramitti A, Aurello P, Lauro S, Bordin F, Della Casa U
Istituto di I Clinica Chirurgica, Università degli Studi di Roma, La Sapienza.
Minerva Chir. 1997 Jul-Aug;52(7-8):937-42.
Totally implantable central venous access devices (Port-a-Cath, PaC) allow better treatment of cancer patients, with safe administration of chemotherapeutic agents, and are well accepted by the patients. The aim of the present paper is to analyze the complications of the different implant techniques on the basis of a personal experience of 92 central venous access devices.
A total of 92 PaC (Port-a-Cath, Pharmacia: Celsite Braun) have been implanted in 88 patients between August 1992 and June 1995 for cancer treatment. Age ranged between 19 and 79 years (median 52 years), 56 were male and 32 women. PaC have been implanted by percutaneous cannulation of the subclavian vein, with Seldinger technique, in 34 cases; by venous cutdown respectively on the cephalic vein in 46 cases, the jugular vein in 7 cases, the basilar vein in 4 and the saphenous vein in 1 case. Four patients experienced a double implant. In 84 cases the implant was done under local anesthesia, while in 8 required general anesthesia, during operation for the primary neoplasm.
A total of 7 complications were experienced (7.6%, 7/92): 4 sepsis and 3 mechanical. No cases of pnx were observed. Sepsis occurred after 29, 45, 64, 401 days of implantation respectively, and culture demonstrated S. aureus in 2 cases, and E. coli and Klebsiella oxytoca in 1 case each. Mechanical complication comprehends 2 cases of catheter dislodgement and 1 case of port rotation. No complications were noticed in case of implant during surgery for primary cancer (8 cases). In 7 cases the procedure has been converted from cephalic vein cutdown to percutaneous cannulation of the subclavian vein due to anatomic reasons (13.2%, 7/53). Five PaC have been explanted for complications.
On the basis of the personal experience we think that PaC are of easy implant, with few complications and of good acceptance from the patients. We prefer venous cutdown on cephalic vein as implant technique because of avoidance of pnx or bleeding complications. Percutaneous puncture of subclavian vein is useful for implantation during major surgery, because less time consuming, and in case of anatomical anomalies fo the cephalic vein. Basilic vein cutdown has been utilized exclusively for esthetic reason in young people, to avoid the scar in the upper thoracic region. Alternative implant techniques has been employed in special conditions, such as catheter position in the inferior v.cava, or early in our experience (internal jugular vein). A total of 7 complication have been reported (7.6%), 4 sepsis and 3 mechanical (2 dislodgement, 1 rotation). Sepsis were not related to implant technique, presenting on day 29, 45, 64 and 401 respectively; all required the explant of the PaC as a treatment. Mechanical complications are related to surgical technique; all required re-exploration with 1 explant and 2 reposition of the PaC. In PaC positioning during surgery for primary cancer (8 cases) no morbidity has been reported. All but the 5 PaC explanted were functioning until patient's need; maximum length reported is 42 months.
完全植入式中心静脉通路装置（Port-a-Cath，PaC）能更好地治疗癌症患者，可安全地给予化疗药物，且患者接受度良好。本文旨在基于92例中心静脉通路装置的个人经验，分析不同植入技术的并发症。
1992年8月至1995年6月期间，共为88例患者植入了92个PaC（Port-a-Cath，法玛西亚：Celsite Braun）用于癌症治疗。年龄在19岁至79岁之间（中位数52岁），男性56例，女性32例。34例采用经皮锁骨下静脉穿刺，Seldinger技术植入PaC；46例分别经头静脉、7例经颈静脉、4例经基底静脉、1例经大隐静脉进行静脉切开植入。4例患者进行了双次植入。84例植入在局部麻醉下进行，8例在原发性肿瘤手术期间需要全身麻醉。
共发生7例并发症（7.6%，7/92）：4例败血症和3例机械性并发症。未观察到气胸病例。败血症分别在植入后29天、45天、64天、401天发生，培养显示2例为金黄色葡萄球菌，1例为大肠杆菌，1例为产酸克雷伯菌。机械性并发症包括2例导管移位和1例端口旋转。原发性癌症手术期间植入（8例）未出现并发症。7例因解剖原因（13.2%，7/53）手术过程从经头静脉切开转换为经皮锁骨下静脉穿刺。5个PaC因并发症被取出。
基于个人经验，我们认为PaC易于植入，并发症少，患者接受度良好。我们更倾向于经头静脉切开作为植入技术，因为可避免气胸或出血并发症。锁骨下静脉经皮穿刺在大手术期间植入很有用，因为耗时少，且适用于头静脉解剖异常的情况。仅因美观原因在年轻人中采用基底静脉切开，以避免胸部上方区域的瘢痕。在特殊情况下采用了替代植入技术，如导管置于下腔静脉或在我们经验早期（颈内静脉）。共报告7例并发症（7.6%），4例败血症和3例机械性并发症（2例移位，1例旋转）。败血症与植入技术无关，分别在第29天、45天、64天和401天出现；所有均需要取出PaC作为治疗。机械性并发症与手术技术有关；所有均需要再次手术，1例取出，2例重新定位PaC。原发性癌症手术期间PaC定位（8例）未报告发病率。除5个被取出的PaC外，所有装置在患者需要时均能正常工作；报告的最长使用时间为42个月。
