Central venous port system associated thromboses: outcome in 3498 implantations and literature review

000042 Review Article Central venous port system associated thromboses: outcome in 3498 implantations and literature review Thrombosehäufigkeit bei zentralvenösen Portsystemen: Erfahrungsbericht über 3498 Portimplantationen im Literaturvergleich Schumacher Schumacher Martina M

Klinik für Gefäß- und Thoraxchirurgie, Klinikum Ernst von Bergmann gGmbH, Potsdam, Deutschland

mschumacher@klinikumevb.de author Wagner Wagner Roland H. RH PD Dr. med.

Zentrum der Chirurgie, Klinik für Gefäß- und Thoraxchirurgie, Klinikum Ernst von Bergmann gGmbH, Charlottenstr. 72, 14467 PotsdamKlinik für Gefäß- und Thoraxchirurgie, Klinikum Ernst von Bergmann gGmbH, Potsdam, Deutschland

rwagner@klinikumevb.de author German Medical Science GMS Publishing House

Düsseldorf

ADOLESCENT ADULT AGED AGED, 80 AND OVER ANESTHESIA, LOCAL CATHETERIZATION adverse effects methods CATHETERS, INDWELLING adverse effects FEMALE HUMANS INFECTION etiology therapy MALE MIDDLE AGED PNEUMOTHORAX etiology therapy POSTOPERATIVE HEMORRHAGE etiology surgery THROMBOSIS etiology therapy TREATMENT OUTCOME 610 central venous port systems associated thromboses zentralvenöse Portsysteme Thrombosehäufigkeit 20070307 20070809 20070903 engl 1612-3174 5 GMS German Medical Science GMS Ger Med Sci 06 Methoden: Vom 01.07.1995 bis 31.06.2006 haben wir 3498 zentralvenöse Portsysteme implantiert. In über 99% der Fälle war die Indikation ein dauerhafter, verlässlicher Zugang zur Chemotherapie. Ergebnisse: Wir sahen 199 Komplikationen (5,7%), davon 85 Infektionen (2,4%) und 63 Thrombosen (1,8%). Schlussfolgerung: Die Implantation zentralvenöser Portkatheter ist zum Standard beim Management von Patienten geworden, die einer Chemotherapie bedürfen. Aufgrund der Weiterentwicklung von Material und Design während der letzten zwanzig Jahre konnte die Rate an technischen Komplikationen signifikant gesenkt werden. Zu den am häufigsten auftretenden medizinischen Komplikationen zählen Infektionen und Thrombosen. Um diese Nachteile weiter zu reduzieren, haben wir einen „Best Practices“-Standard aus eigenen Daten und aktuellen Studien entwickelt. Methods: From 1 July 1995 to 31 June 2006 we implanted 3498 intravenous port systems. In nearly all cases the indication was vascular access for chemotherapy. Results: We registered 199 complications (5.7%), mostly infections (n=85 i.e. 2.4%) and thromboses (n=63 i.e. 1.8%). Conclusions: Permanent central venous catheters have become standard in the management of patients with malignancies. Because of the improvement of material and design during the past twenty years technical complications have been reduced significantly. The most frequent occurring medical complications are infection and thromboses. In order to further minimize these disadvantages we developed a “best practices“ standard for port implantation combining own data with recent studies. Introduction Implanted central venous port catheter systems (CVC) is today an important component in the management of oncology patients. The system provides a safe vascular access with a low complication rate whereas infections as well as catheter associated thromboses are the most common observed findings . However, thrombosis is a potential complication which can cause serious morbidity. In the present study we assembled and analysed the incidences of catheter-related venous thromboses among our patients. In order to further minimize the already low complication rate we summarized our experience compared to recent studies with the aim to develop a “best practices” standard for port implantation. Material and methods In the period between 1 July 1995 and 31 June 2006 a total of 3498 patients at the Clinic for Vascular and Thoracic Surgery at the Klinikum Ernst von Bergmann gGmbH Potsdam underwent implantation of a CVC in an outpatient as well as inpatient setting. Out of these patients, 1889 were female and 1609 male, with an average age of 57 years (16-89 years) (Table 1 ). The main indication for port implantation was in 99 per cent of cases intravenous chemotherapy for patients with malignant tumours. All patients were observed and followed postoperatively as well as during the course of their inpatient stay at the clinic. Outpatients were followed at the oncology day clinic. Three port systems manufactured by the companies Braun (Celsite® silicon catheter: 6.5F/8.5F), Arrow (A-port® silicon catheter: 8.4F/9.6F) and Vygon (Vygon® silicon catheter: 6.6F/9.6F) were used. The preferred site of implantation was the right cephalic vein accessed through a surgical cutdown approach under local anaesthesia. The exact catheter tip position was checked intraoperatively under radiographic screening. If the implantation was impossible or not indicated on the right hand side due to lung or breast cancer the left cephalic vein was used. In case of an inapt cephalic vein we punctured the subclavian vein from the incision using Seldinger technique (n=106) or cutdown (n=196) during the same session. In the event of an impaired central venous drainage we selected in one case to implant via the right femoral vein and in another case we used the left basilic vein. In no case a port catheter insertion using the jugular vein was performed. Administering contrast injection containing iodine was unnecessary giving the problem-free venous port implantation and the intraoperative monitoring of the function of the port. At the end of the operation the CVC was flushed and locked with heparinized saline (200 IE UFH/ml). A general thromboprophylaxis was not given. A chest x-ray in exspiration was routinely performed at the end of the procedure. The ports were available for use immediately after implantation. Care and maintenance of the device were carried out according to the recommendations outlined in Table 2 by an experienced nursing staff. Results Between July 1995 and June 2006, 3498 venous port implantations were carried out on adult patients with malignant disease (Figure 1 , Table 1 ). A total of 199 complications occurred listed in Table 3 . The most frequently encountered complications were infections (n=85) and thromboses (n=63). We determined thromboembolic complications, all clinically relevant occlusions of central veins as well as catheter-related thrombosis demonstrated by color Duplex ultrasonography. The clinical symptomes spanned the spectrum from local problems like arm swelling, pain, malfunction of the port systems to the appearance of collateral circulation and dyspnea. A fatal pulmonary embolism or postphlebitic syndrome did not occur. Discussion Infections and thromboses were the most often seen complications following a port implantation. A correlation of the two has been suspected by many authors . Therefore we have retrospectively compared our incidence of thrombosis in CVC with recent studies. Only studies with a sufficient patient population (n>200) summarized in Table 4 qualified for our analysis. We found a considerably high variation of the occurrence of thrombembolic complications in port systems (range between 1.4 per cent and 9.2 per cent) , . This prompted us to work out possible risk factors in port-associated thrombosis listed in Table 5 as well as their prevention. Implantation techniques, material, time of port insertion, experience and postoperative handling can be directly influenced by the implantation team, i.e. prevention is possible. Nontheless, there are important risk factors outside of the team’s control: type of malignancies, chemotherapy agents, and general risk factors (e.g. obesity, smoking, immobility, age). 1. Risk factor implantation techniques Venous thromboembolic complications occur more often in peripherally implanted venous ports than in venous chest ports. Numerous studies have shown that thoracic wall implanted ports are less prone to thrombotic episodes than armports. The stabile position, the shorter feeding path, less foreign material and a more favourable implantation procedure combined with a large lumen access vessel will reduce the incidence of thrombosis , , , , , , , , , , , . There was further evidence that endothelial damage due to the traumatization of the Seldinger puncture wire with the vessel wall enhances the risk for thrombosis , , , , , . This supports the open surgical port implantation procedure in contrast to the subcutaneous vein puncture technique , . Hall et al. demonstrated that catheter occlusion is more common following inexact location of the tip of the catheter in the superior vena cava. He suspected as cause an unfavourable rate of flow in addition to the danger of blood flushing the catheter. Thus, the exact catheter tip position should be checked intraoperatively under radiographic screening. 2. Risk factor material Some current data suggest that polyurethane catheter have a lower risk for thrombosis than silicon catheter. Polyurethane catheter have a smooth surface which diminishes the adhesion of thrombocytes , . Other studies have shown no significant difference in respect to complication rates , . Due to lack of significant data, for the authors this question still remains open. 3. Risk factor experience of the implantation team and postoperative care It is indisputable that a versed implantation team contributes to the reduction of the risk profile. Expedient venous cutdown and less trauma to the vein will result in a significant long term reduction of the risks of thrombosis. Furthermore, the safe handling of the CVC is greatly enhanced by utilization of a limited number of established catheter systems. Experienced and well-trained maintenance following strict adherence to the application of care instructions (Table 2 ) will likewise reduce the rate of complications as many studies have shown , , , , , , . 4. Risk factor time of port implantation The port implantation should be done as early as possible. At best it should be carried out at the beginning of chemotherapy. Multiple venous punctures harm the veins. Phlebothrombosis as well as already elapsed thrombotic episodes will increase the risk for thrombosis . 5. Risk factor tumour disease Patients with a malignant primary disease are for a plethora of reasons subject to a higher risk of venous thromboembolism. Many factors are thought to contribute to the risk of thrombosis. These include the continuous release of blood coagulation tissue factor, changes in the composition of the haemostatic parameters (elevated fibrinogen, Factor VIII, and the PAI-Level) and damage to the endothelium . Broad-based investigations demonstrated that the increased risk for venous thromboembolism is associated with different kinds of malignant diseases. Kakkar et al. showed in a study based on a survey of 3891clinicians worldwide who responded to a questionnaire that tumours of the central nervous system as well as the gastrointestinal system especially the pancreas carry a higher risk for thrombosis compared to other primary malignancies. Levitan et al. analysed a patient population of 1.2 million with malignant disease and discovered that the highest risk for thrombosis is found in patients with uterine, ovarian, brain and pancreatic malignancies as well as leukaemia. 6. Risk factor chemotherapy The varied tumourgenicity of different chemotherapeutic agents have already been investigated. Nanninga and Pritchard found a significant increase in the risk for thrombosis in patients treated with CMF-chemotherapy. Doxorubicin likewise elevates the risk of thromboembolism . 7. General risk factors Age above 60 years, obesity, varicose, smoking, surgical procedures and immobility are all known risk factors in the occurrence of thromboembolic complications. 8. Thromboprophylaxis Because of the potentially dangerous effects of port-associated thrombosis many authors discussed preventive approaches utilising anticoagulants while avoiding to increase the already high risk of bleeding in tumour patients. Various studies analysed whether a low-dose of a cumarin-derivative or a low molecular weight heparin (LMWH)</PlainText></TextGroup> provides enough protection against thrombosis. The results as shown in Table 6 <ImgLink imgNo="6" imgType="table"/> are controversial. Currently, a consensus exists to not recommend a general thromboprophylaxis after CVC implantation <TextLink reference="10"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="38"></TextLink>. Further prospective investigations must be carried out to clarify this issue.</Pgraph> </TextBlock> <TextBlock linked="yes" name="Conclusions"> <MainHeadline>Conclusions</MainHeadline> <Pgraph>Subcutaneous venous port devices provide a considerable facility in the care of oncology patients. The rate of complications must be acceptable even for patients in a poor state of bodily health. Through the improvement of material and design of the port catheter in the last twenty years a significant reduction of technical complications could be achieved. The task remains to diminish the most often occurring medical complications. With the inclusion of literature reviews we worked out an approach to reduce such complications even though the multifactorial genesis of the venous thromboembolism in oncology patients exacerbated the effort. Regardless factors capable of being influenced to reduce the incidence of catheter-associated thrombosis were worked on with the aim to develop a “best practices” standard for port implantation.</Pgraph> <Pgraph>The preferred vascular access for port catheter implantation should be via the right cephalic vein followed by the right subclavian vein. The reasons are a sufficient large lumen of the venous access, the shortest and most favourable course of implantation and the most stabile position in the area of the thoracic wall. This will contribute to a considerable reduction in the risk of thrombosis compared to armports.</Pgraph> <Pgraph>Furthermore, we recommend to use an open surgical approach in CVC implantation carried out by well-trained staff. This will result in shorter operating time and avoids damage to the endothelium through the manipulation and perforation of the wire as well as better hemostasis and avoidance of hematoma with accompanied infections.</Pgraph> <Pgraph>A more interdisciplinary teamwork between vascular surgeons and oncologists as well as regular training of doctors, nursing staff and patients in the handling of port systems are another important element in minimizing the complication rate.</Pgraph> <Pgraph>The individual specification of a thromboprophylaxis according to the risk profile could likewise reduce the incidence of catheter-associated thrombosis. For that we need more standard prospective studies which build on the already existing management recommendations in the treatment of catheter-associated complications.</Pgraph> </TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline> <SubHeadline>Conflicts of interest </SubHeadline> <Pgraph>None declared.</Pgraph> </TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Aitken DR</RefAuthor> <RefAuthor>Minton JP</RefAuthor> <RefTitle>The "pinch-off sign": a warning of impending problems with permanent subclavian catheters</RefTitle> <RefYear>1984</RefYear> <RefJournal>Am J Surg</RefJournal> <RefPage>633-6</RefPage> <RefTotal>Aitken DR, Minton JP. The "pinch-off sign": a warning of impending problems with permanent subclavian catheters. Am J Surg. 1984;148(5):633-6.</RefTotal> </Reference> <Reference refNo="2"> <RefAuthor>Barrios CH</RefAuthor> <RefAuthor>Zuke JE</RefAuthor> <RefAuthor>Blaes B</RefAuthor> <RefAuthor>Hirsch JD</RefAuthor> <RefAuthor>Lyss AP</RefAuthor> <RefTitle>Evaluation of an implantable venous access system in a general oncology population</RefTitle> <RefYear>1992</RefYear> <RefJournal>Oncology</RefJournal> <RefPage>474-8</RefPage> <RefTotal>Barrios CH, Zuke JE, Blaes B, Hirsch JD, Lyss AP. Evaluation of an implantable venous access system in a general oncology population. Oncology. 1992;49(6):474-8.</RefTotal> </Reference> <Reference refNo="3"> <RefAuthor>Biffi R</RefAuthor> <RefAuthor>De Braud F</RefAuthor> <RefAuthor>Orsi F</RefAuthor> <RefAuthor>Pozzi S</RefAuthor> <RefAuthor>Arnaldi P</RefAuthor> <RefAuthor>Goldhirsch A</RefAuthor> <RefAuthor>Rotmensz N</RefAuthor> <RefAuthor>Robertson C</RefAuthor> <RefAuthor>Bellomi M</RefAuthor> <RefAuthor>Andreoni B</RefAuthor> <RefTitle>A randomized, prospective trial of central venous ports connected to standard open-ended or Groshong catheters in adult oncology patients</RefTitle> <RefYear>2001</RefYear> <RefJournal>Cancer</RefJournal> <RefPage>1204-12</RefPage> <RefTotal>Biffi R, De Braud F, Orsi F, Pozzi S, Arnaldi P, Goldhirsch A, Rotmensz N, Robertson C, Bellomi M, Andreoni B. A randomized, prospective trial of central venous ports connected to standard open-ended or Groshong catheters in adult oncology patients. Cancer. 2001;92(5):1204-12.</RefTotal> </Reference> <Reference refNo="4"> <RefAuthor>Boraks P</RefAuthor> <RefAuthor>Seale J</RefAuthor> <RefAuthor>Price J</RefAuthor> <RefAuthor>Bass G</RefAuthor> <RefAuthor>Ethell M</RefAuthor> <RefAuthor>Keeling D</RefAuthor> <RefAuthor>Mahendra P</RefAuthor> <RefAuthor>Baglin T</RefAuthor> <RefAuthor>Marcus R</RefAuthor> <RefTitle>Prevention of central venous catheter associated thrombosis using minidose warfarin in patients with haematological malignancies</RefTitle> <RefYear>1998</RefYear> <RefJournal>Br J Haematol</RefJournal> <RefPage>483-6</RefPage> <RefTotal>Boraks P, Seale J, Price J, Bass G, Ethell M, Keeling D, Mahendra P, Baglin T, Marcus R. Prevention of central venous catheter associated thrombosis using minidose warfarin in patients with haematological malignancies. Br J Haematol. 1998;101(3):483-6.</RefTotal> </Reference> <Reference refNo="5"> <RefAuthor>Brothers TE</RefAuthor> <RefAuthor>Von Moll LK</RefAuthor> <RefAuthor>Niederhuber JE</RefAuthor> <RefAuthor>Roberts JA</RefAuthor> <RefAuthor>Walker-Andrews S</RefAuthor> <RefAuthor>Ensminger WD</RefAuthor> <RefTitle>Experience with subcutaneous infusion ports in three hundred patients</RefTitle> <RefYear>1988</RefYear> <RefJournal>Surg Gynecol Obstet</RefJournal> <RefPage>295-301</RefPage> <RefTotal>Brothers TE, Von Moll LK, Niederhuber JE, Roberts JA, Walker-Andrews S, Ensminger WD. Experience with subcutaneous infusion ports in three hundred patients. Surg Gynecol Obstet. 1988;166(4):295-301.</RefTotal> </Reference> <Reference refNo="6"> <RefAuthor>De Gregorio MA</RefAuthor> <RefAuthor>Miguelena JM</RefAuthor> <RefAuthor>Fernandez JA</RefAuthor> <RefAuthor>de Gregorio C</RefAuthor> <RefAuthor>Tres A</RefAuthor> <RefAuthor>Alfonso ER</RefAuthor> <RefTitle>Subcutaneous ports in the radiology suite: an effective and safe procedure for care in cancer patients</RefTitle> <RefYear>1996</RefYear> <RefJournal>Eur Radiol</RefJournal> <RefPage>748-52</RefPage> <RefTotal>De Gregorio MA, Miguelena JM, Fernandez JA, de Gregorio C, Tres A, Alfonso ER. Subcutaneous ports in the radiology suite: an effective and safe procedure for care in cancer patients. Eur Radiol. 1996;6(5):748-52.</RefTotal> </Reference> <Reference refNo="7"> <RefAuthor>Foley MJ</RefAuthor> <RefTitle>Radiologic placement of long-term central venous peripheral access system ports (PAS Port): results in 150 patients</RefTitle> <RefYear>1995</RefYear> <RefJournal>J Vasc Interv Radiol</RefJournal> <RefPage>255-62</RefPage> <RefTotal>Foley MJ. Radiologic placement of long-term central venous peripheral access system ports (PAS Port): results in 150 patients. J Vasc Interv Radiol. 1995;6(2):255-62.</RefTotal> </Reference> <Reference refNo="8"> <RefAuthor>Hall P</RefAuthor> <RefAuthor>Cedermark B</RefAuthor> <RefAuthor>Swedenborg J</RefAuthor> <RefTitle>Implantable catheter system for long-term intravenous chemotherapy</RefTitle> <RefYear>1989</RefYear> <RefJournal>J Surg Oncol</RefJournal> <RefPage>39-41</RefPage> <RefTotal>Hall P, Cedermark B, Swedenborg J. Implantable catheter system for long-term intravenous chemotherapy. J Surg Oncol. 1989;41(1):39-41.</RefTotal> </Reference> <Reference refNo="9"> <RefAuthor>Heaton DC</RefAuthor> <RefAuthor>Han DY</RefAuthor> <RefAuthor>Inder A</RefAuthor> <RefTitle>Minidose (1 mg) warfarin as prophylaxis for central vein catheter thrombosis</RefTitle> <RefYear>2002</RefYear> <RefJournal>Intern Med J</RefJournal> <RefPage>84-8</RefPage> <RefTotal>Heaton DC, Han DY, Inder A. Minidose (1 mg) warfarin as prophylaxis for central vein catheter thrombosis. Intern Med J. 2002;32(3):84-8.</RefTotal> </Reference> <Reference refNo="10"> <RefAuthor>Hiller E</RefAuthor> <RefTitle>Venöse Thromboembolien bei Tumorpatienten. Prophylaxe und Therapie</RefTitle> <RefYear>2006</RefYear> <RefJournal>Arzneimitteltherapie</RefJournal> <RefPage>35-42</RefPage> <RefTotal>Hiller E. Venöse Thromboembolien bei Tumorpatienten. Prophylaxe und Therapie. Arzneimitteltherapie. 2006;24:35-42.</RefTotal> </Reference> <Reference refNo="11"> <RefAuthor>Hinke DH</RefAuthor> <RefAuthor>Zandt-Stastny DA</RefAuthor> <RefAuthor>Goodman LR</RefAuthor> <RefAuthor>Quebbeman EJ</RefAuthor> <RefAuthor>Krzywda EA</RefAuthor> <RefAuthor>Andris DA</RefAuthor> <RefTitle>Pinch-off syndrome: a complication of implantable subclavian venous access devices</RefTitle> <RefYear>1990</RefYear> <RefJournal>Radiology</RefJournal> <RefPage>353-6</RefPage> <RefTotal>Hinke DH, Zandt-Stastny DA, Goodman LR, Quebbeman EJ, Krzywda EA, Andris DA. Pinch-off syndrome: a complication of implantable subclavian venous access devices. Radiology. 1990;177(2):353-6.</RefTotal> </Reference> <Reference refNo="12"> <RefAuthor>Hofmann HAF</RefAuthor> <RefTitle></RefTitle> <RefYear>2004</RefYear> <RefBookTitle>Ports, Pumpen und Katheter: Artikel über Portimplantationen für das KV-Heft</RefBookTitle> <RefPage></RefPage> <RefTotal>Hofmann HAF. Ports, Pumpen und Katheter: Artikel über Portimplantationen für das KV-Heft [letter]. Berlin; 2004. Available from: http://www.dr-hofmann-chirurgie.de/20026/presse/20026_presse_kv.pdf</RefTotal> <RefLink>http://www.dr-hofmann-chirurgie.de/20026/presse/20026_presse_kv</RefLink> </Reference> <Reference refNo="13"> <RefAuthor>Kakkar AK</RefAuthor> <RefAuthor>Levine M</RefAuthor> <RefAuthor>Pinedo HM</RefAuthor> <RefAuthor>Wolff R</RefAuthor> <RefAuthor>Wong J</RefAuthor> <RefTitle>Venous thrombosis in cancer patients: insights from the FRONTLINE survey</RefTitle> <RefYear>2003</RefYear> <RefJournal>Oncologist</RefJournal> <RefPage>381-8</RefPage> <RefTotal>Kakkar AK, Levine M, Pinedo HM, Wolff R, Wong J. Venous thrombosis in cancer patients: insights from the FRONTLINE survey. Oncologist. 2003;8(4):381-8.</RefTotal> </Reference> <Reference refNo="14"> <RefAuthor>Kawasaki R</RefAuthor> <RefAuthor>Morita S</RefAuthor> <RefAuthor>Hisa N</RefAuthor> <RefAuthor>Tsuji A</RefAuthor> <RefAuthor>Noda Y</RefAuthor> <RefTitle>[Evaluation of 389 cases with a central venous access device inserted peripherally in the forearm]</RefTitle> <RefYear>1999</RefYear> <RefJournal>Gan To Kagaku Ryoho</RefJournal> <RefPage>2055-60</RefPage> <RefTotal>Kawasaki R, Morita S, Hisa N, Tsuji A, Noda Y. [Evaluation of 389 cases with a central venous access device inserted peripherally in the forearm]. Gan To Kagaku Ryoho. 1999;26(13):2055-60.</RefTotal> </Reference> <Reference refNo="15"> <RefAuthor>Kock HJ</RefAuthor> <RefAuthor>Pietsch M</RefAuthor> <RefAuthor>Krause U</RefAuthor> <RefAuthor>Wilke H</RefAuthor> <RefAuthor>Eigler FW</RefAuthor> <RefTitle>Implantable vascular access systems: experience in 1500 patients with totally implanted central venous port systems</RefTitle> <RefYear>1998</RefYear> <RefJournal>World J Surg</RefJournal> <RefPage>12-6</RefPage> <RefTotal>Kock HJ, Pietsch M, Krause U, Wilke H, Eigler FW. Implantable vascular access systems: experience in 1500 patients with totally implanted central venous port systems. World J Surg. 1998;22(1):12-6.</RefTotal> </Reference> <Reference refNo="16"> <RefAuthor>Laffer U</RefAuthor> <RefAuthor>Durig M</RefAuthor> <RefAuthor>Bloch HR</RefAuthor> <RefAuthor>Zuber M</RefAuthor> <RefAuthor>Stoll HR</RefAuthor> <RefTitle>Implantierbare Kathetersysteme. Erfahrungen mit 205 Patienten</RefTitle> <RefYear>1989</RefYear> <RefJournal>Dtsch Med Wochenschr</RefJournal> <RefPage>655-8</RefPage> <RefTotal>Laffer U, Durig M, Bloch HR, Zuber M, Stoll HR. Implantierbare Kathetersysteme. Erfahrungen mit 205 Patienten. Dtsch Med Wochenschr. 1989;114(17):655-8.</RefTotal> </Reference> <Reference refNo="17"> <RefAuthor>Ledgerwood AM</RefAuthor> <RefAuthor>Saxe JM</RefAuthor> <RefAuthor>Lucas CE</RefAuthor> <RefTitle>Venous access devices: a review</RefTitle> <RefYear>1993</RefYear> <RefJournal>Surg Annu</RefJournal> <RefPage>45-57</RefPage> <RefTotal>Ledgerwood AM, Saxe JM, Lucas CE. Venous access devices: a review. Surg Annu. 1993;25 Pt 2:45-57.</RefTotal> </Reference> <Reference refNo="18"> <RefAuthor>Lee AY</RefAuthor> <RefAuthor>Levine MN</RefAuthor> <RefAuthor>Butler G</RefAuthor> <RefAuthor>Webb C</RefAuthor> <RefAuthor>Costantini L</RefAuthor> <RefAuthor>Gu C</RefAuthor> <RefAuthor>Julian JA</RefAuthor> <RefTitle>Incidence, risk factors, and outcomes of catheter-related thrombosis in adult patients with cancer</RefTitle> <RefYear>2006</RefYear> <RefJournal>J Clin Oncol</RefJournal> <RefPage>1404-8</RefPage> <RefTotal>Lee AY, Levine MN, Butler G, Webb C, Costantini L, Gu C, Julian JA. Incidence, risk factors, and outcomes of catheter-related thrombosis in adult patients with cancer. J Clin Oncol. 2006;24(9):1404-8.</RefTotal> </Reference> <Reference refNo="20"> <RefAuthor>Lersch C</RefAuthor> <RefAuthor>Kotowa W</RefAuthor> <RefAuthor>Fung S</RefAuthor> <RefAuthor>Janssen D</RefAuthor> <RefTitle>Prophylaxis of port system-associated thromboses in advanced oncology patients using heparin flushing</RefTitle> <RefYear>2004</RefYear> <RefJournal>J Cancer Res Clin Oncol</RefJournal> <RefPage>235-41</RefPage> <RefTotal>Lersch C, Kotowa W, Fung S, Janssen D. Prophylaxis of port system-associated thromboses in advanced oncology patients using heparin flushing. J Cancer Res Clin Oncol. 2004;130(4):235-41.</RefTotal> </Reference> <Reference refNo="19"> <RefAuthor>Lersch C</RefAuthor> <RefAuthor>Eckel F</RefAuthor> <RefAuthor>Sader R</RefAuthor> <RefAuthor>Paschalidis M</RefAuthor> <RefAuthor>Zeilhofer F</RefAuthor> <RefAuthor>Schulte-Frohlinde E</RefAuthor> <RefAuthor>Theiss W</RefAuthor> <RefTitle>Initial experience with Healthport miniMax® and other peripheral arm ports in patients with advanced gastrointestinal malignancy</RefTitle> <RefYear>1999</RefYear> <RefJournal>Oncology</RefJournal> <RefPage>269-75</RefPage> <RefTotal>Lersch C, Eckel F, Sader R, Paschalidis M, Zeilhofer F, Schulte-Frohlinde E, Theiss W. Initial experience with Healthport miniMax® and other peripheral arm ports in patients with advanced gastrointestinal malignancy. Oncology. 1999;57(4):269-75.</RefTotal> </Reference> <Reference refNo="21"> <RefAuthor>Levitan N</RefAuthor> <RefAuthor>Dowlati A</RefAuthor> <RefAuthor>Remick SC</RefAuthor> <RefAuthor>Tahsildar HI</RefAuthor> <RefAuthor>Sivinski LD</RefAuthor> <RefAuthor>Beyth R</RefAuthor> <RefAuthor>Rimm AA</RefAuthor> <RefTitle>Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Risk analysis using Medicare claims data</RefTitle> <RefYear>1999</RefYear> <RefJournal>Medicine (Baltimore)</RefJournal> <RefPage>285-91</RefPage> <RefTotal>Levitan N, Dowlati A, Remick SC, Tahsildar HI, Sivinski LD, Beyth R, Rimm AA. Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Risk analysis using Medicare claims data. Medicine (Baltimore). 1999;78(5):285-91.</RefTotal> </Reference> <Reference refNo="22"> <RefAuthor>Linder LE</RefAuthor> <RefAuthor>Curelaru I</RefAuthor> <RefAuthor>Gustavsson B</RefAuthor> <RefAuthor>Hansson HA</RefAuthor> <RefAuthor>Stenqvist O</RefAuthor> <RefAuthor>Wojciechowski J</RefAuthor> <RefTitle>Material thrombogenicity in central venous catheterization: a comparison between soft, antebrachial catheters of silicone elastomer and polyurethane</RefTitle> <RefYear>1984</RefYear> <RefJournal>JPEN J Parenter Enteral Nutr</RefJournal> <RefPage>399-406</RefPage> <RefTotal>Linder LE, Curelaru I, Gustavsson B, Hansson HA, Stenqvist O, Wojciechowski J. Material thrombogenicity in central venous catheterization: a comparison between soft, antebrachial catheters of silicone elastomer and polyurethane. JPEN J Parenter Enteral Nutr. 1984;8(4):399-406.</RefTotal> </Reference> <Reference refNo="23"> <RefAuthor>Lokich JJ</RefAuthor> <RefAuthor>Bothe A Jr</RefAuthor> <RefAuthor>Benotti P</RefAuthor> <RefAuthor>Moore C</RefAuthor> <RefTitle>Complications and management of implanted venous access catheters</RefTitle> <RefYear>1985</RefYear> <RefJournal>J Clin Oncol</RefJournal> <RefPage>710-7</RefPage> <RefTotal>Lokich JJ, Bothe A Jr, Benotti P, Moore C. Complications and management of implanted venous access catheters. J Clin Oncol. 1985;3(5):710-7.</RefTotal> </Reference> <Reference refNo="24"> <RefAuthor>Masci G</RefAuthor> <RefAuthor>Magagnoli M</RefAuthor> <RefAuthor>Zucali PA</RefAuthor> <RefAuthor>Castagna L</RefAuthor> <RefAuthor>Carnaghi C</RefAuthor> <RefAuthor>Sarina B</RefAuthor> <RefAuthor>Pedicini V</RefAuthor> <RefAuthor>Fallini M</RefAuthor> <RefAuthor>Santoro A</RefAuthor> <RefTitle>Minidose warfarin prophylaxis for catheter-associated thrombosis in cancer patients: can it be safely associated with fluorouracil-based chemotherapy?</RefTitle> <RefYear>2003</RefYear> <RefJournal>J Clin Oncol</RefJournal> <RefPage>736-9</RefPage> <RefTotal>Masci G, Magagnoli M, Zucali PA, Castagna L, Carnaghi C, Sarina B, Pedicini V,Fallini M, Santoro A. Minidose warfarin prophylaxis for catheter-associated thrombosis in cancer patients: can it be safely associated with fluorouracil-based chemotherapy? J Clin Oncol. 2003;21(4):736-9.</RefTotal> </Reference> <Reference refNo="26"> <RefAuthor>Monreal M</RefAuthor> <RefAuthor>Davant E</RefAuthor> <RefTitle>Thrombotic complications of central venous catheters in cancer patients</RefTitle> <RefYear>2001</RefYear> <RefJournal>Acta Haematol</RefJournal> <RefPage>69-72</RefPage> <RefTotal>Monreal M, Davant E. Thrombotic complications of central venous catheters in cancer patients. Acta Haematol. 2001;106(1-2):69-72.</RefTotal> </Reference> <Reference refNo="25"> <RefAuthor>Monreal M</RefAuthor> <RefAuthor>Alastrue A</RefAuthor> <RefAuthor>Rull M</RefAuthor> <RefAuthor>Mira X</RefAuthor> <RefAuthor>Muxart J</RefAuthor> <RefAuthor>Rosell R</RefAuthor> <RefAuthor>Abad A</RefAuthor> <RefTitle>Upper extremity deep venous thrombosis in cancer patients with venous access devices - prophylaxis with a low molecular weight heparin (Fragmin)</RefTitle> <RefYear>1996</RefYear> <RefJournal>Thromb Haemost</RefJournal> <RefPage>251-3</RefPage> <RefTotal>Monreal M, Alastrue A, Rull M, Mira X, Muxart J, Rosell R, Abad A. Upper extremity deep venous thrombosis in cancer patients with venous access devices - prophylaxis with a low molecular weight heparin (Fragmin). Thromb Haemost. 1996;75(2):251-3.</RefTotal> </Reference> <Reference refNo="27"> <RefAuthor>Nanninga AG</RefAuthor> <RefAuthor>de Vries EG</RefAuthor> <RefAuthor>Willemse PH</RefAuthor> <RefAuthor>Oosterhuis BE</RefAuthor> <RefAuthor>Sleijfer DT</RefAuthor> <RefAuthor>Hoekstra HJ</RefAuthor> <RefAuthor>Mulder NH</RefAuthor> <RefTitle>Continuous infusion of chemotherapy on an outpatient basis via a totally implanted venous access port</RefTitle> <RefYear>1991</RefYear> <RefJournal>Eur J Cancer</RefJournal> <RefPage>147-9</RefPage> <RefTotal>Nanninga AG, de Vries EG, Willemse PH, Oosterhuis BE, Sleijfer DT, Hoekstra HJ, Mulder NH. Continuous infusion of chemotherapy on an outpatient basis via a totally implanted venous access port. Eur J Cancer. 1991;27(2):147-9.</RefTotal> </Reference> <Reference refNo="28"> <RefAuthor>Pettengell R</RefAuthor> <RefAuthor>Davies AJ</RefAuthor> <RefAuthor>Harvey VJ</RefAuthor> <RefTitle>Experience with an implantable venous access system for chemotherapy</RefTitle> <RefYear>1991</RefYear> <RefJournal>N Z Med J</RefJournal> <RefPage>284-5</RefPage> <RefTotal>Pettengell R, Davies AJ, Harvey VJ. Experience with an implantable venous access system for chemotherapy. N Z Med J. 1991;104(915):284-5.</RefTotal> </Reference> <Reference refNo="29"> <RefAuthor>Poorter RL</RefAuthor> <RefAuthor>Lauw FN</RefAuthor> <RefAuthor>Bemelman WA</RefAuthor> <RefAuthor>Bakker PJ</RefAuthor> <RefAuthor>Taat CW</RefAuthor> <RefAuthor>Veenhof CH</RefAuthor> <RefTitle>Complications of an implantable venous access device (Port-a-Cath) during intermittent continuous infusion of chemotherapy</RefTitle> <RefYear>1996</RefYear> <RefJournal>Eur J Cancer</RefJournal> <RefPage>2262-6</RefPage> <RefTotal>Poorter RL, Lauw FN, Bemelman WA, Bakker PJ, Taat CW, Veenhof CH. Complications of an implantable venous access device (Port-a-Cath) during intermittent continuous infusion of chemotherapy. Eur J Cancer. 1996;32A(13):2262-6.</RefTotal> </Reference> <Reference refNo="30"> <RefAuthor>Pritchard KI</RefAuthor> <RefAuthor>Paterson AH</RefAuthor> <RefAuthor>Paul NA</RefAuthor> <RefAuthor>Zee B</RefAuthor> <RefAuthor>Fine S</RefAuthor> <RefAuthor>Pater J</RefAuthor> <RefTitle>Increased thromboembolic complications with concurrent tamoxifen and chemotherapy in a randomized trial of adjuvant therapy for women with breast cancer. National Cancer Institute of Canada Clinical Trials Group Breast Cancer Site Group</RefTitle> <RefYear>1996</RefYear> <RefJournal>J Clin Oncol</RefJournal> <RefPage>2731-7</RefPage> <RefTotal>Pritchard KI, Paterson AH, Paul NA, Zee B, Fine S, Pater J. Increased thromboembolic complications with concurrent tamoxifen and chemotherapy in a randomized trial of adjuvant therapy for women with breast cancer. National Cancer Institute of Canada Clinical Trials Group Breast Cancer Site Group. J Clin Oncol. 1996;14(10):2731-7.</RefTotal> </Reference> <Reference refNo="31"> <RefAuthor>Rauthe G</RefAuthor> <RefAuthor>Altmann C</RefAuthor> <RefTitle>Complications in connection with venous port systems: prevention and therapy</RefTitle> <RefYear>1998</RefYear> <RefJournal>Eur J Surg Oncol</RefJournal> <RefPage>192-9</RefPage> <RefTotal>Rauthe G, Altmann C. Complications in connection with venous port systems: prevention and therapy. Eur J Surg Oncol. 1998;24(3):192-9.</RefTotal> </Reference> <Reference refNo="32"> <RefAuthor>Reichardt P</RefAuthor> <RefAuthor>Kretzschmar A</RefAuthor> <RefAuthor>Biakhov M</RefAuthor> <RefAuthor>Irwin D</RefAuthor> <RefAuthor>Slabber C</RefAuthor> <RefAuthor>Miller L</RefAuthor> <RefAuthor>Bowden C</RefAuthor> <RefTitle>A phase III randomized, double-blind, placebo-controlled study evaluating the efficacy and safety of daily low-molecular-weight heparin (dalteparin sodium, fragmin) in preventing catheter-related complications (CRCs) in cancer patients with central venous catheters (CVCs)</RefTitle> <RefYear>2002</RefYear> <RefJournal>Proc Am Soc Clin Oncol</RefJournal> <RefPage>abstr 1474</RefPage> <RefTotal>Reichardt P, Kretzschmar A, Biakhov M, Irwin D, Slabber C, Miller L, Bowden C. A phase III randomized, double-blind, placebo-controlled study evaluating the efficacy and safety of daily low-molecular-weight heparin (dalteparin sodium, fragmin) in preventing catheter-related complications (CRCs) in cancer patients with central venous catheters (CVCs). Proc Am Soc Clin Oncol. 2002;21:abstr 1474.</RefTotal> </Reference> <Reference refNo="33"> <RefAuthor>Salem RR</RefAuthor> <RefAuthor>Ward BA</RefAuthor> <RefAuthor>Ravikumar TS</RefAuthor> <RefTitle>A new peripherally implanted subcutaneous permanent central venous access device for patients requiring chemotherapy</RefTitle> <RefYear>1993</RefYear> <RefJournal>J Clin Oncol</RefJournal> <RefPage>2181-5</RefPage> <RefTotal>Salem RR, Ward BA, Ravikumar TS. A new peripherally implanted subcutaneous permanent central venous access device for patients requiring chemotherapy. J Clin Oncol. 1993;11(11):2181-5.</RefTotal> </Reference> <Reference refNo="34"> <RefAuthor>Schauer V</RefAuthor> <RefAuthor>Weiss W</RefAuthor> <RefAuthor>Pickel P</RefAuthor> <RefAuthor>Berger H</RefAuthor> <RefTitle>Peripher-venöse Portimplantation: Ergebnisse einer prospektiv kontrollierten Studie</RefTitle> <RefYear>2002</RefYear> <RefJournal>RoeFo</RefJournal> <RefPage>VO45.3</RefPage> <RefTotal>Schauer V, Weiss W, Pickel P, Berger H. Peripher-venöse Portimplantation: Ergebnisse einer prospektiv kontrollierten Studie. RoeFo. 2002:VO45.3.</RefTotal> </Reference> <Reference refNo="35"> <RefAuthor>Starkhammar H</RefAuthor> <RefAuthor>Bengtsson M</RefAuthor> <RefAuthor>Morales O</RefAuthor> <RefTitle>Fibrin sleeve formation after long term brachial catheterisation with an implantable port device. A prospective venographic study</RefTitle> <RefYear>1992</RefYear> <RefJournal>Eur J Surg</RefJournal> <RefPage>481-4</RefPage> <RefTotal>Starkhammar H, Bengtsson M, Morales O. Fibrin sleeve formation after long term brachial catheterisation with an implantable port device. A prospective venographic study. Eur J Surg. 1992;158(9):481-4.</RefTotal> </Reference> <Reference refNo="36"> <RefAuthor>Stein M</RefAuthor> <RefAuthor>Wagner RH</RefAuthor> <RefTitle>Komplikationen zentralvenöser Portsysteme: Erfahrungsbericht über 2359 Implantationen</RefTitle> <RefYear>2005</RefYear> <RefJournal>Dtsch Med Wochenschr</RefJournal> <RefPage>1129-32</RefPage> <RefTotal>Stein M, Wagner RH. Komplikationen zentralvenöser Portsysteme: Erfahrungsbericht über 2359 Implantationen. Dtsch Med Wochenschr. 2005;130(18):1129-32.</RefTotal> </Reference> <Reference refNo="37"> <RefAuthor>Torramade JR</RefAuthor> <RefAuthor>Cienfuegos JA</RefAuthor> <RefAuthor>Hernandez JL</RefAuthor> <RefAuthor>Pardo F</RefAuthor> <RefAuthor>Benito C</RefAuthor> <RefAuthor>Gonzalez J</RefAuthor> <RefAuthor>Balen E</RefAuthor> <RefAuthor>de Villa V</RefAuthor> <RefTitle>The complications of central venous access systems: a study of 218 patients</RefTitle> <RefYear>1993</RefYear> <RefJournal>Eur J Surg</RefJournal> <RefPage>323-7</RefPage> <RefTotal>Torramade JR, Cienfuegos JA, Hernandez JL, Pardo F, Benito C, Gonzalez J,Balen E, de Villa V. The complications of central venous access systems: a study of 218 patients. Eur J Surg. 1993;159(6-7):323-7.</RefTotal> </Reference> <Reference refNo="38"> <RefAuthor>Ulrich S</RefAuthor> <RefAuthor>Taverna C</RefAuthor> <RefAuthor>Bächli E</RefAuthor> <RefTitle>Thromboseprophylaxe bei Patienten mit implantiertem Port-A-Cath - was tun? Eine nicht durchgeführte Studie</RefTitle> <RefYear>2004</RefYear> <RefJournal>Schweiz Med Forum</RefJournal> <RefPage>562-4</RefPage> <RefTotal>Ulrich S, Taverna C, Bächli E. Thromboseprophylaxe bei Patienten mit implantiertem Port-A-Cath - was tun? Eine nicht durchgeführte Studie. Schweiz Med Forum. 2004;4:562-4.</RefTotal> </Reference> </References> <Media> <Tables> <Table format="png"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption> <Pgraph> <Mark1>Table 1: Gender distribution, age and indication</Mark1> </Pgraph> </Caption> </Table> <Table format="png"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption> <Pgraph> <Mark1>Table 2: Care guidelines during port usage</Mark1> </Pgraph> </Caption> </Table> <Table format="png"> <MediaNo>3</MediaNo> <MediaID>3</MediaID> <Caption> <Pgraph> <Mark1>Table 3: Complications (n=199)</Mark1> </Pgraph> </Caption> </Table> <Table format="png"> <MediaNo>4</MediaNo> <MediaID>4</MediaID> <Caption> <Pgraph> <Mark1>Table 4: Catheter-associated thromboembolic complications in the review of recent studies</Mark1> </Pgraph> </Caption> </Table> <Table format="png"> <MediaNo>5</MediaNo> <MediaID>5</MediaID> <Caption> <Pgraph> <Mark1>Table 5: Thrombosis-related risks factors</Mark1> </Pgraph> </Caption> </Table> <Table format="png"> <MediaNo>6</MediaNo> <MediaID>6</MediaID> <Caption> <Pgraph> <Mark1>Table 6: Thromboprophylaxis</Mark1> </Pgraph> </Caption> </Table> <NoOfTables>6</NoOfTables> </Tables> <Figures> <Figure format="png" height="434" width="517"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption> <Pgraph> <Mark1>Figure 1: Port implantations 07/95-06/06 (n=3498)</Mark1> </Pgraph> </Caption> </Figure> <NoOfPictures>1</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>