Vascular Access in Oncology Patients

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)
Vascular Access in Oncology Patients
Maurizio Gallieni, Mauro Pittiruti and Roberto Biffi
CA Cancer J Clin 2008;58;323-346; originally published online Oct 29, 2008;
DOI: 10.3322/CA.2008.0015
This information is current as of April 6, 2009
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CA Cancer J Clin 2008;58:323–346

Maurizio Gallieni, MD; Mauro Pittiruti, MD; Roberto Biffi, MD
ABSTRACT Adequate vascular access is of paramount importance in oncology patients. It is Dr. Gallieni is Coordinating Editor,
important in the initial phase of surgical treatment or chemotherapy, as well as in the chronic man- The Journal of Vascular Access; Re-
searcher, University of Milano, School
agement of advanced cancer and in the palliative care setting. We present an overview of the
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of Medicine; and Vice-Director, Renal
available vascular access devices and of the most relevant issues regarding insertion and man- Unit, San Paolo Hospital, Milan, Italy.
agement of vascular access. Particular emphasis is given to the use of ultrasound guidance Dr. Pittiruti is Researcher, Italian Na-
tional Research Council; and Depart-
as the preferred technique of insertion, which has dramatically decreased insertion-related ment of Surgery, Catholic University,
complications. Vascular access management has considerably improved after the publication Rome, Italy.
of effective guidelines for the appropriate nursing of the vascular device, which has reduced Dr. Biffi is Director, Division of Abdomino-
Pelvic Surgery, European Institute of
the risk of late complications, such as catheter-related bloodstream infection. However, many Oncology, Milan, Italy.
areas of clinical practice are still lacking an evidence-based background, such as the choice of Published online through CA First Look
the most appropriate vascular access device in each clinical situation, as well as prevention at http://CAonline.AmCancerSoc.org.
and treatment of thrombosis. We suggest an approach to the choice of the most appropriate doi:10.3322/CA.2008.0015
vascular access device for the oncology patient, based on the literature available to date. (CA
Cancer J Clin 2008;58:323–346.) © American Cancer Society, Inc., 2008.
To earn free CME credit or nursing contact hours for successfully completing the online quiz based on this article, go to http://CME.AmCancerSoc.org.
INTRODUCTION
The use of vascular access devices (VADs) is an integral aspect of health care for neonates, children, and adults and
has moved beyond the acute care setting to chronic, long-term care. VADs have a paramount role throughout the
management of the oncology patient, as they are needed in the initial phases for surgery or chemotherapy, in the
advanced stages for chronic treatment, and in the last stages for palliative measures.
According to US data,1 approximately 150 million intravenous catheters are purchased, and at least 5 million cen-
tral venous catheters (CVCs) are inserted every year. It is difficult to estimate how many of these VADs are actually
used for oncology patients. However, it is reasonable to assume that the proportion is high, as most surgery, chemother-
apy, and radiotherapy protocols for the management of neoplastic disease require intravenous infusions, including
even those for palliative care, for which a long-term VAD usually is the best route of administration.
Data from a study commissioned by the Food and Drug Administration in the 1990s2 showed that the use of VADs
is associated with a high complication rate (10% to 25% of all patients with VADs) and a morbidity of at least 10%;
52% of the reported complications were directly related to insufficient information (for nurses, patients, and other
people dedicated to the care of the device) or inappropriate technique of VAD placement and nursing care.
In this review, we will summarize data indicating that at present, in 2008, technological developments; a new
patient-oriented, cost-effective approach to the selection of procedures and techniques; and closer attention to the impor-
tant issue of health practitioner education have decreased the complication rate, especially in the area of oncology
and palliative care. In particular, the introduction of ultrasound guidance has dramatically decreased insertion-related
complications, and the new, updated nursing guidelines related to VAD care have proved to be effective in reducing
the risk of late complications, such as catheter-related bloodstream infection.
However, at least 2 issues are still reason for concern:
(A) There is no evidence-based guide to the selection of the most appropriate VAD for each clinical situation, notwith-
standing the broad range of VADs available, both in terms of features and performance. Moreover, there is little
Disclosure: The authors report no conflicts of interest.
Volume 58 • Number 6 • November/December 2008 323

TABLE 1 Features, Advantages, and Disadvantages of Different Types of Vascular Access Devices
Tip Technical VAD Expected Type Ideal Main Main

Position Feature Material Duration of Use Setting Advantage Disadvantage
Short-term VADs
Short peripheral
cannulas Peripheral Nontunneled Teflon, silicone 72 to 96 hours Continuous Hospital Low cost Short duration
Short-term CVCs Central Nontunneled Polyurethane 1 to 3 weeks Continuous Hospital Low cost High risk for
CRBSI

Medium-term VADs
Midline catheters Peripheral Nontunneled Polyurethane, <2 to 3 months Discontinuous Hospital Low risk of Peripheral route
silicone and/or CRBSI
outpatient
PICCs Central Nontunneled Polyurethane, 3 to 12 (?) Discontinuous Hospital No risk at Low flow
silicone months and/or insertion
outpatient
Hohn Central Nontunneled Silicone <2 to 3 months Discontinuous Hospital Low risk of Risk of
and/or thrombosis dislocation
outpatient
Long-term VADs
Tunneled catheters Central Tunneled Polyurethane, Months to Discontinuous Outpatient Indefinite High cost
(Groshong, silicone years duration
Hickman, Broviac)
Ports Central Totally Polyurethane, Months to Discontinuous Outpatient Indefinite High cost
implanted silicone years duration
Abbreviations: CRBSI, catheter-related blood stream infection; CVC, central venous catheter; PICC, peripherally inserted central catheter;
VAD, vascular access device.
guidance addressing the problem of the therapy costs.7 However, most patients who
choice of the best VAD for the oncology require intravenous therapy for longer than
patient—a consequence of the scarcity of 1 week are not routinely assessed for inter-
randomized trials in this area. A few clear- mediate dwelling VADs. In addition, patient
cut indications come from the guidelines of satisfaction about long-term VADs has rarely
the Registered Nurses’ Association of been addressed.8,9
Ontario,3 from the guidelines of the British
Committee for Standards in Haematology,4
CLASSIFICATION AND FEATURES
and from the Standards for Infusion Therapy OF VENOUS VADS
of the Royal College of Nursing (RCN)5
and of the Infusion Nurses Society (INS).6 Venous VADs can be classified as short-term,
(B) Patients and their families still currently play intermediate (medium-term), and long-term
a minor role in the selection of VAD at the accesses. They can also be classified as central (when
onset of treatment, notwithstanding the evi- the tip of the catheter lies in the lower third of
dence showing that patient involvement is the superior vena cava [SVC], in the atrium, or in
associated with greater patient satisfaction, the upper portion of the inferior vena cava) or
fewer delays in therapy related to loss of vas- peripheral (in all the other instances). Table 1
cular access, fewer device complications, summarizes features, advantages, and disadvan-
preservation of peripheral veins, less nurs- tages of different types of VADs, which will be
ing time spent attempting to gain vascular analyzed in this review. Central venous access is
access, shorter hospital stays, fewer emer- mandatory for a number of specific solutions for
gency room visits, and decreased infusion infusion, such as those containing vesicant drugs.
324 CA A Cancer Journal for Clinicians

Short-term Venous VADs insertion; stabilization of the VAD; patient com-

pliance; and, most importantly, nurse compe-
Short-term peripheral venous VADs are usu- tence in the maintenance of the device.
ally 35- to 52-mm–long Teflon cannulas. They PICCs are usually inserted at the bedside by
are the most commonly used VADs in daily clin- trained physicians or nurses either resorting to the
ical practice and are inserted into superficial veins “blind” technique via the antecubital vein or
of the arms of adult patients or into any super- the cephalic vein or to ultrasound guidance via
ficial vein of children and neonates. a deep vein in the midarm (basilic or brachial
Short-term CVCs are nontunneled, 20- to vein); they are available with one or more lumens.

30-cm–long polyurethane catheters inserted into In the hematology-oncology setting, they are
a central vein (subclavian, internal jugular, innom- well suited for ambulatory or outpatient ther-
inate, axillary, or femoral vein), preferably resort- apy12 because they can be safely used even in
ing to ultrasound guidance. They may have a patients with extremely low platelet counts or
single lumen or multiple lumens, and they should at high risk of hemorrhage.4
be used only for hospitalized patients.10 They Materials (silicone versus polyurethane) may
are designed for continuous, short-term infu- influence the risk of complications since some
sions (1 to 3 weeks). types of polyurethane may be associated with a
higher incidence of thrombosis.13 Sometimes
Intermediate Venous VADs polyurethane PICCs may be preferable because
they have thinner lumen walls and larger inter-
Intermediate venous VADs are nontunneled, nal diameters; these features significantly increase
central venous devices specifically designed for flow rates and reduce the risk of breakage and
prolonged intermittent use; they include midline complete rupture of the catheter. This may be
catheters, peripherally inserted central catheters an advantage in hematology patients, who often
(PICCs), and Hohn catheters. Midline catheters require blood and platelet infusions. On the
are nontunneled, peripheral VADs inserted other hand, pump-driven or low-flow intra-
through a peripheral vein of the arm (antecu- venous infusions—as in chemotherapy treat-
bital, basilic, brachial, or cephalic vein), using ments for solid tumors—can easily be delivered
either a “blind” technique or ultrasound guid- by either silicone or polyurethane PICCs; silicone
ance; they are 15- to 30-cm long and are usually is associated with better biocompatibility and
made of silicone or second-third generation durability than most types of polyurethane and
polyurethane. By definition, their tip is not “cen- thus seems more suitable for long-term use. In
tral,” ie, is not located in the SVC but in the axil- the United Kingdom, most chemotherapy treat-
lary vein or in the subclavian vein. PICCs are ments are delivered through PICCs, which are
nontunneled, central catheters inserted through increasingly inserted using ultrasound guidance.
a peripheral vein of the arm; they are 50- to 60- There is no evidence of significant advan-
cm long and are usually made of silicone or tages or disadvantages of PICCs over CVCs in
second-third generation polyurethane. Hohn hospitalized patients. A few studies suggest that
catheters are nontunneled, 20-cm long, centrally PICCs may be preferable because they are asso-
inserted silicone catheters.11 Both PICCs and ciated with fewer mechanical complications at
Hohn catheters can be used for prolonged con- insertion, lower costs (since they are mainly
tinuous or intermittent infusion therapies (up inserted by nurses at the bedside), and a lower
to 3 months) both in hospitalized patients and in infection rate.1,11,14 The latter issue has recently
patients treated as outpatients, in a hospice, or been challenged,15 and it has been suggested that
at home.10 The use of PICCs is approved by the infection control and prevention programs should
Food and Drug Administration for up to 12 be consistently implemented whenever any type
months; although most PICCs may stay in place of VAD is used.16 However, it is accepted that
and in use for several months, there is growing placement in the antecubital fossa or at midarm
evidence that their actual duration depends on carries the important advantage of moving the
many factors: type of material; technique of exit site of the catheter away from endotracheal,

oral, and nasal secretions.17 Moreover, ultrasound- The choice between a tunneled catheter and
guided placement of PICCs at midarm is asso- a port depends on many factors, mainly related
ciated with optimal nursing management of the to patient compliance, experience of the nurs-
exit site.18 ing staff, and frequency of venous access. Accord-
ing to US Centers for Disease Control and
Long-term VADs Prevention (CDC) Guidelines, 22 totally im-
plantable access devices should be reserved for
Prolonged intravenous treatment (⬎3 months) patients who require long-term, intermittent
requires a long-term venous VAD, such as a tun- vascular access. A tunneled CVC is preferable

neled central catheter or a totally implanted port. for patients requiring continuous access. Thus,
Tunneled catheters are usually made of silicone oncology patients who need chemotherapy treat-
rubber, with or without Dacron anchoring cuffs; ment scheduled on a weekly or monthly basis
the variety with the cuffs is strongly recom- should benefit from a totally implanted port,
mended, as it is more stable.19 The cuffs also while those who need daily infusions of pallia-
induce an inflammatory reaction within the sub- tive treatment (analgesics, hydration, nutrition, etc.)
cutaneous (SC) tunnel, leading to fibrosis and should benefit from an external catheter.
consequent catheter fixation, usually within 3 Medium-term and long-term venous devices
to 4 weeks after insertion. Tunneled catheters are both adequate for outpatients. The use of
have been shown to be associated with lower short-term CVCs for nonhospitalized patients
infection rates than nontunneled catheters.16,20 should be discouraged, considering their high
Valved catheters have the advantage of not requir- susceptibility to infection and the risk of obstruc-
ing heparin flushes but may need pressurized tion of the device, dislocation, and catheter-
infusions for the administration of blood prod- related venous thrombosis.22
ucts and also tend to be more expensive. In a
controlled trial, they were not superior to a tra- PERIPHERAL VERSUS CENTRAL VENOUS ACCESS
ditional, open-ended device in terms of catheter
efficacy and early and late complications.21 Thus, According to Registered Nurses’ Association
there is little evidence to support one type of of Ontario Guidelines,3 INS standards,4 and
catheter over another. RCN standards,5 a central venous access is in-
Totally implanted ports consist of a reservoir dicated in the following conditions: admini-
(usually made of titanium and/or plastic polymers) stration of solutions with pH ⬍5 or pH ⬎9;
connected to a CVC (usually made of silicone), administration of drugs with osmolarity ⬎600
which may or may not be valved. Ports have mOsm/L4 or 500 mOsm/L3; parenteral nutrition
lower reported rates of catheter-related blood- with solutions containing ⱖ10% glucose or 5%
stream infections than both tunneled and non- amino acids because of their high osmolarity;
tunneled CVCs.16 Most ports have only one administration of vesicant drugs or other drugs
lumen, which makes them best suited for long- associated with vascular intimal damage; need
term intermittent chemotherapy, especially in for multiple-lumen intravenous treatment; need
patients with solid tumors. Double-lumen ports for dialysis or apheresis; need for central venous
are used for specific purposes, as in patients under- pressure monitoring; and venous access needed
going bone marrow transplantation and in patients for more than 3 months.
who require infusion of noncompatible med- Thus, in the oncology patient undergoing
ications and fluids, which necessitate a second chemotherapy, the ideal venous access is central
intravenous access. Ports allow better bathing rather than peripheral since many antineoplastic
and swimming, which are restricted with exter- drugs are notoriously vesicant. Despite the fact
nal VAD, and they may appeal to patients con- that many oncology units still deliver chemother-
cerned about the psychological implications of apy mainly by the peripheral route,it is commonly
the presence of visible nonimplanted catheters. accepted that the infusion of vesicant drugs into a
They are more expensive to purchase, insert, and peripheral vein is potentially dangerous because
remove, and they leave larger scars. it is associated with a high risk of extravasation,

infiltration, phlebitis, local tissue damage, and pro- and/or subsequent venous stenosis.25 This is par-
gressive loss of available peripheral veins. The INS ticularly true for PICCs,26 although it may be
standards for infusion therapy4 recommend a cen- difficult to administer blood products or high-
tral venous access (including PICC) for the admin- flow hydration with a very narrow lumen. When
istration of boluses of vesicant medications; if a a totally implanted port is used, choosing a
peripheral access is used, a new access site should catheter caliber larger than 6 to 7 French does not
be used for each administration, and its site should carry significant advantages since the main lim-
be documented to avoid repeated use. However, itation to flow is the caliber of the Huber nee-
continuous infusion of vesicants should be per- dle used to access the port.

formed exclusively by a central route. As regards the material, most central VADs
On the other hand, when the oncologic patient are made of silicone or polyurethane, which have
is on a palliative care program, most of the infu- different features. Silicone rubber chemical struc-
sions (analgesics, hydration, or nutrition) may be ture is composed of adjacent polymer chains
safely delivered by a peripheral route. However, cross-linked to each other. Its physical properties
peripheral parenteral nutrition (given through vary according to the degree of cross-linking.
a short peripheral cannula or through a midline Surface-active additives can be mixed with the
catheter) should be used only for a limited period polymer or added to the ends of the polymer
of time and exclusively when the osmolarity of chain to modify its surface properties, which can
the nutrient solutions, which may contain lipids, affect infection and thrombosis rates. Problems
does not exceed 800 mOsm/L. According to derived from the contact of blood with VADs
CDC guidelines,22 midline catheters should be are usually related to surface properties of the
preferred whenever intravenous therapy is base catheter material. Surface treatment processes
expected to last more than 6 days; since this is the allow coupling or incorporation of substances
case for most intrahospital parenteral nutrition to or into catheter materials. Coating with antimi-
treatments, midline catheters are bound to play crobials (silver, antiseptics, or antibiotics) may be
a major role in this setting. Also peripheral home a suitable way to prevent the development of
parenteral nutrition should be given only via catheter-associated infections, while coating with
midline catheters since short cannulas carry a antithrombotic substances may prevent throm-
high risk of dislocation and infiltration. bosis. However, there are some controversial
reports on the potential of adverse reactions due
CATHETER DESIGN AND MATERIALS
to silver- and antiseptic-coated catheters.27
Polyurethanes are a class of materials with a
All central VADs may have single or multi- broad spectrum of physical and chemical prop-
ple lumens and can be open-ended or valved. erties. Their commonality is the urethane link-
Multiple-lumen catheters are advantageous in age between “hard” and “soft” polymer chains
patients undergoing stem cell transplantation or (segments). For catheter applications, polyether
chemotherapy that involves the simultaneous and polycarbonate soft segments are used.
infusion of a number of agents and blood prod- Polyurethanes with polycarbonate soft segments
ucts. Blood products may be administered con- are more resistant to attack by biological enzymes
currently with another drug/infusion through and hydrolysis than those made of polyethers.
a dual-bore catheter. Although multiple-lumen Material properties have some clinical impli-
catheters are generally associated with increased cations that may influence catheter selection. The
morbidity, particularly infections, 23,24 in the main biological issue for catheters is hemocom-
hematology setting, the increased risk is likely patability and, to a lesser extent, compatibility
to be offset by their convenience, thereby justi- with tissue contacted to access the vessel lumen.
fying their use. If total parenteral nutrition is Hemocompatibility of a VAD refers to the abil-
being administered, a dedicated central route ity of the device to carry out its intended func-
should be used exclusively for this purpose.17 tion within flowing blood, with minimal
VADs of small caliber should be employed to interaction between device and blood that ad-
minimize the risk of catheter-related thrombosis versely affects device performance and without

inducing uncontrolled activation of cellular or inner diameters, are more easily blocked by pre-
plasma protein cascades. Hemocompatibility is cipitates. However, polyurethane is more prone
a complex issue: depending on how it is defined, to degradation if alcohol or other solvents are
on the patient population, disease state, catheter used to dissolve the precipitate. The patency of
entrance site, and other factors, one catheter mate- the catheters is also related to their kink-resistance
rial can be said to perform better or worse than (the ability of the catheter to maintain an open
another. For short-term applications, in general, lumen when it is bent): silicone catheters bend
there are no noticeable differences between more easily, but kink with less applied force than
polyurethane and silicone catheters. For longer- polyurethane catheters. However,silicone catheters

term applications, durability may be more impor- also recover more readily and are not permanently
tant than biocompatibility. deformed as easily as are polyurethane catheters.
Ease of insertion is influenced by catheter stiff- Clotting and thrombosis are influenced by the
ness and wall thickness, as well as frictional prop- chemical as well as the physical properties of the
erties of the catheter surface; in general, silicone material. Catheters with a rough surface are more
catheters are more difficult to advance over guide thrombogenic than those with a smooth surface
wire than polyurethane catheters of similar size. (radiopaque barium sulfate filler can have an
The risk of mechanical phlebitis is influenced influence). Some studies29,30 suggest that sili-
by catheter stiffness and size. Given the same cone may be less thrombogenic than some spe-
lumen size, silicone catheters are larger and poten- cific types of polyurethane. Polycarbonate-based
tially cause more mechanical phlebitis, but sili- polyurethane is more stable and less thrombo-
cone is less stiff and, therefore, less traumatic to genic than polyether-based polyurethane.
the vascular endothelium. Since silicone has lower Stability and durability are affected by the
tensile and burst strength than polyurethane response of catheters to infusates (including sol-
catheters of equal dimensions, the wall thickness ubilizing agents), disinfectants, and cleaning solu-
of silicone catheters is increased to provide ade- tions, as well as by the biologic environment.
quate strength. Consequently, for the same catheter Polyurethane is inherently stronger due to higher
French size (outer diameter), silicone catheters burst and tensile strength, but it is more suscep-
have a smaller lumen and lower flow rate than tible to in vivo degradation and attack by sol-
polyurethane catheters. Flow is proportional to vents. Silicone is less prone to stress cracking
radius at the fourth power, so very small changes than polyurethane because it is cross-linked.
in inside diameter—especially of narrow cath- Vascular damage is a function of catheter stiff-
eters—have a very large effect on flow rates. ness, especially of its tip. Thicker catheters are
Infusate compatibility is a function of catheter stiffer than thinner catheters. In general, silicone
composition and structure. Catheters are not is softer and less traumatic than polyurethane.
attacked by drugs, but they are by the solvents With regard to catheter maintenance requirements,
necessary to put them into solution or to pre- polyether polyurethanes are subject to degrada-
serve them. In general, silicone is more compat- tion by alcohols and disinfectants, especially oint-
ible with infusates because it is cross-linked and ments in a PEG (polyethylene glycol) base.
hydrophobic. Alcohols, in particular, can per- Silicone is more resistant to attack by cleaning and
meate polyurethane catheters (especially those disinfecting agents but is more easily torn. Silicone
with polyether soft segments) and carry solubi- is also more resistant to solvents in general because
lized drugs with them.28 it is cross-linked. Silicone catheters may swell
The risk of extravasation of infusates is influ- but don’t break in most solvents, and their
enced by catheter stiffness, as stiffer catheters can hydrophobicity limits the attack by water.
damage the vessel. Silicone is less stiff than Radiopacity is a function of the amount of
polyurethane. radiopaque material in the catheter. Smaller
Catheter occlusion caused by precipitates usually diameter catheters or catheters loaded with a
depends on the administration of incompatible lower concentration of radiopaque agent will
infusates rather than on catheter material prop- have a dimmer fluoroscopic image. Radiopaque
erties. Again, silicone catheters, having smaller agents (ie, BaSO4) weaken catheter materials.

Teflon, silicone, and polyurethane have been Multiple Versus Single Lumen
associated with fewer catheter-related infections CVCs with multiple lumens may be associated
than polyvinyl chloride or polyethylene. However, with higher infection rates than single-lumen
all available CVCs are made either of polyure- CVCs, as shown by several randomized con-
thane or silicone, and there is no specific recom- trolled trials (RCTs) and stated by CDC guide-
mendation regarding materials for clinical practice.17 lines22; nonetheless, this contention has been
questioned by recent papers. Two recent sys-
CHOICE OF THE VAD AND RISK OF INFECTION tematic reviews and quantitative meta-analyses
have focused on the risk of CR-BSI and catheter

The type and the design of the catheter itself colonization in multilumen catheters compared
may significantly affect the risk of catheter-related with single-lumen catheters. The first one con-
infection, as shown by Maki in an important sys- cluded that multiple lumens are not a significant
tematic review of 200 prospective studies.16 risk factor for increased CR-BSI or local catheter
Tunneling and Total Implantation colonization compared with a single lumen.23
The second one concluded that there is some
Tunneled catheters and totally implanted evidence from 5 RCTs with data on 530 cen-
VADs are associated with a lower rate of infec- tral VADs that for every 20 single-lumen catheters
tion since they are specifically protected from inserted, one CR-BSI will be avoided that would
extraluminal contamination. On the other hand, have occurred had multilumen catheters been
tunneling and SC implantation require a minor used.32 Although further research is warranted,
surgical procedure, which is contraindicated in in the meantime it may be reasonable to recom-
patients with low platelet counts or coagulation mend a single-lumen catheter unless multiple
abnormalities.4 ports are essential for patient management.
Coating with Antiseptic Drugs Moreover, if a multilumen catheter is used, one
port should be identified and designated exclu-
Short-term CVCs coated with chlorhexidine/ sively for parenteral nutrition because the inter-
sulfadiazine or coated with rifampicin/minocy- action of parenteral nutrition solutions with
cline have a significantly lower infection rate.16 drugs and solutions of different pH increases
In a recent systematic review and economic eval- rates of thrombosis and, consequently, rates of
uation conducted by the Liverpool Reviews and infection. In addition, the larger lumen of dou-
Implementation Group,31 the authors conclude ble ports should be used for parenteral nutrition
that rates of catheter-related bloodstream infec- to reduce the tendency to obstruction.17 Of
tion (CR-BSI) are significantly reduced by course, all lumens must be handled with the same
catheters coated with rifampicin/minocycline meticulous attention to aseptic techniques.
or internally and externally coated with chlorhex- Compared with central venous catheters,
idine/silver sulfadiazine. Statistical significance was PICCs appear to be associated with a lower risk
not seen with catheters only coated externally. of infection, most probably because of the exit site
Thus, as suggested by Evidence-based Practice on the arm, which is less prone to be contami-
in Infection Control guidelines,17 the use of a nated by nasal and oral secretions1; however, no
VAD coated with an antimicrobial is to be con- RCTs have proven such contention to date.17 At
sidered for adult patients who require short-term present, it is reasonable to consider PICC inser-
central venous catheterization and who are at tion (a) in patients with tracheostomy; (b) in
high risk for CR-BSI if the facility infection patients with severe anatomic abnormalities of
rates remain high despite the implementation neck and thorax, which may be associated with
of a comprehensive strategy to control them. difficult positioning and nursing of a centrally
It is important to stress that most evidence in placed CVC; and (c) in patients who need intra-
this area concerns short-term, nontunneled, cen- venous access for prolonged periods of time
tral venous access. There is no evidence to sup- (months). On the other hand, PICCs are not
port the use of PICCs or tunneled catheters advisable in patients with renal failure and impend-
coated with antiseptic drugs. ing need for dialysis, in whom preservation of

upper-extremity veins is needed for fistula or quite obvious. The CDC recommends not to
graft implantation. Anyway, the assumption that use routinely venous cut-down procedures as a
PICCs are safer than conventional CVCs with method to insert catheters, even for long-term
regard to the risk of infection is in question; the ones, because percutaneously placed catheters
issue should be addressed by a larger, adequately are associated with a lower infection rate than
powered RCT assessing peripheral vein throm- surgically implanted ones.22 However, in neonates
bophlebitis, PICC-related thrombosis, and pre- and in children, not routinely but in selected
mature dislodgment, as well as CR-BSI.15 cases, venous cut-down might be the safest choice.
Recognition of risk factors for difficult catheter-

CATHETER PLACEMENT
ization is essential, and all patients should be eval-
uated for conditions that might increase the
Insertion Technique: State of the Art difficulty of catheter insertion, such as skeletal
Choice of Venous Access and Role deformity, presence of scars, obesity, or previous
surgery at insertion site. An alternative that may
of Ultrasound Guidance
reduce the incidence of pneumothorax (the most
With the exception of PICCs, all long-term frequent complication of central venous cannu-
catheters for oncology treatments require an lation by subclavian route) is the preferential use
access through tributary branches of the vena of the internal jugular vein35 for the percutaneous
cava so that their tip is placed correctly in the “blind” (based on anatomic landmarks) approach
central venous district. for central venous cannulation. Nonetheless, this
PICCs are usually inserted at the antecubital may not always be possible due to anatomic abnor-
site. The procedure is performed by a nurse or a malities, dehydration, operator inexperience, or
physician, usually in a blind fashion. It is associated disease-related alterations; in such conditions, the
with a high risk of local phlebitis, patient discom- operator may be forced to resort to subclavian
fort, and venous thrombosis,33 especially in pa- venipuncture and expose the patient to the risk of
tients with hematological malignancies34; on the pneumothorax. The issue, which is associated
contrary, in our experience PICC insertion by with additional costs, has been addressed by devel-
ultrasound-guided venipuncture of deep veins at oping a number of imaging techniques to access
midarm is associated with a low risk of local the subclavian and/or internal jugular vein under
complications and negligible patient discomfort. guidance (simple Doppler, echo-color Doppler,
The percutaneous approach to the subclavian digital venography, and others).
or internal jugular vein currently is the most The only procedure that has been evaluated
popular procedure for placing catheters in the in RCTs, which have been pooled in 3 meta-
SVC, both for short-term (no more than 6 to 8 analyses,36–38 is the ultrasound-guided placement
weeks) and long-ter m use. Such venous of central venous access (technique adopted for
approaches were made possible in the 1970s by both the subclavian and internal jugular vein).
the development of specific tools, like the According to this technique, an ultrasound probe
Seldinger j-wire and the peel-away introducer- is used to locate the vein, and the introducer nee-
dilator, formerly not available. These technolog- dle is guided through the skin and into the ves-
ical instruments offer the option to avoid open sel. During internal jugular venous catheterization,
surgical vein cannulation, which at that time was ultrasound guidance (both 2-dimensional [2D]
necessary for the placement of the silicone and ultrasound- and Doppler-guided methods) clearly
polyurethane catheters required for long-term reduces the number of complications, failures,
access. The great flexibility of percutaneous can- and time required for insertion.36 Conversely, its
nulation, the short duration of the procedure in use for subclavian venous catheterization has
most situations, and the possibility to switch from yielded inconsistent results in a small number of
a procedure that requires an operating theater trials36,39,40: limited evidence favored 2D ultra-
to a less demanding (especially cost-wise) out- sound guidance for subclavian vein procedures
patient or even bed-side procedure have made the in adults (relative risk 0.14; 95% confidence inter-
superiority of percutaneous central vein access val, 0.04 to 0.57). The landmark Vascular Access

in Oncology Patients method was more success- settings, such as the intensive care unit, emer-
ful than Doppler-guided cannulation for subcla- gency room,43–45 oncology,46 pediatrics,47 and
vian vein procedures (1.48; 1.03 to 2.14). An dialysis,48 leading to the conclusion that ultra-
indirect comparison of relative risks suggested sound guidance improves the success rate of vein
that 2D ultrasonography would be more success- cannulation, reducing the number of attempts,
ful than Doppler guidance for subclavian vein complications, and failures. Concerns have been
procedures in adults (0.09; 0.02 to 0.38). expressed with respect to training, as the novel
The meta-analyses have shown that ultra- techniques should be incorporated into the ultra-
sound guidance reduces complications relative sound courses that are currently being set up for

to percutaneous accesses performed with the radiologists, anesthesiologists, and surgeons.
standard “landmark” technique, especially when Moreover, the landmark method would remain
the operators have little experience with the important for emergencies when ultrasound
landmark method. In many studies the control equipment and/or expertise might not be imme-
arm (unguided percutaneous access) often had diately available.
unusually high complication and unsuccessful Cost analysis is a key issue. Calculations should
rates (over 40%), whereas most prospective series be precise and also include costs for ultrasound
report early complication rates for experienced devices and operator training. Calvert et al38 com-
operators usually under 5%. pared the economics of using 2D-ultrasound
National Institute for Clinical Excellence- locating devices and more traditional landmark
UK made the following recommendations in methods for central venous cannulation. They
200241: reached the conclusions that the cost of using
(A) 2D-imaging ultrasound guidance should be ultrasound for central venous cannulation was
the preferred method when a CVC is in- less than 10 pounds sterling (corresponding to
serted into the internal jugular vein of adults about 20 USD) per procedure and that the intro-
and children in “elective situations.” duction of 2D ultrasound for central venous can-
(B) 2D-imaging ultrasound guidance should nulation would save the United Kingdom–
be considered in most clinical situations National Health Service money (£2,000 for
where CVC insertion is necessary, inde- every 1,000 procedures). However, some criti-
pendently of the situation (elective or emer- cism derived from the incidence of arterial punc-
gency procedure). ture that the authors used in their analysis. Based
(C) Everyone who uses 2D-imaging ultrasound on experience and published data, a 12% inci-
guidance to insert CVCs should be appro- dence of arterial puncture using the landmark
priately trained so that they can use the approach was judged almost an order of magni-
technique competently. tude too high. Using a significantly lower and
The implementation of National Institute for more realistic arterial puncture incidence reduces
Clinical Excellence-UK guidelines has been the cost of the landmark technique and may
associated with a significant reduction in com- change the cost-effectiveness calculation to the
plication rates in a UK tertiary referral center.42 point where the ultrasound choice may no longer
Similar recommendations, based on the pub- be dominant, meaning that while ultrasound is
lished data of RCT meta-analyses, have been more effective, it also costs more. Finally, since
made by several scientific societies.4,6,17 Most the reference is internal jugular vein cannulation
recently, the Association for Vascular Access has in the operating theater, the question of whether
drafted a position statement on the use of real- the results can be extrapolated to other central
time imaging for placement of central VADs venous cannulations performed outside that set-
(available at www.avainfo.org) advocating the ting was not addressed.38
use of ultrasound guidance for all nonemergent In conclusion, the present state of central
central vascular access procedures, including venous long-term cannulation, especially for
insertion of PICCs. CVCs and ports used in oncology, remains quite
Other prospective studies, some of which were controversial. These procedures are widespread,
RCTs, have addressed this issue in a number of and most operators tend to rely on personal

TABLE 2 Frequency of Early Complications (Expressed in % of Cases), According to the Insertion Site,
Using Anatomic Landmark Percutaneous Techniques*
Internal Jugular Subclavian Femoral
Arterial puncture 6.3 to 9.4 3.1 to 4.9 9.0 to 15.0

Local bleeding <0.1 to 2.2 1.2 to 2.1 3.8 to 4.4
Hemothorax NA 0.4 to 0.6 NA
Pneumothorax <0.1 to 0.2 1.5 to 3.1 NA
Total 6.3 to 11.8 6.2 to 10.7 12.8 to 19.4
*Adapted from Hamilton HC, Foxcroft DR.49

Abbreviation: NA, not applicable.
experience and professional education when systematically verify position by fluoroscopy after
they choose an approach, the most important implantation; recently, an electrocardiography-
factor being their degree of familiarity with the derived method has been proposed as a radiation-
various options. While many RCTs have clearly free alternative, with initial encouraging results.52
shown that ultrasound guidance is superior to
the landmark technique—at least in terms of COMPLICATIONS OF CENTRAL VENOUS
immediate outcome—for internal jugular vein CATHETERS
cannulation in a variety of clinical settings, doubts
still persist for the subclavian insertion site, and The complications of CVCs can be classified
more studies are needed to address long-term into 2 main categories: (A) early (intraoperative
benefits and cost-effectiveness. Adequately pow- and postimplantation period to first use) and (B)
ered prospective RCTs are still lacking on sev- late complications.
eral issues, especially late complications of central
Early Complications
venous long-term accesses; for example, the
impact of different techniques and access routes Early complications are related to central
on infection and thrombosis rates in the oncol- venipuncture for catheter insertion. They include
ogy patient population is still unknown. No trial pneumothorax, hemothorax, primary malposi-
comparing the subclavian versus internal jugu- tion, arrhythmias, air embolism, and arterial per-
lar vascular access in this patient population has foration causing clinically relevant bleeding.
been published so far, although an objective need Published rates of specific complications are
for such a trial is clear.49 highly dependent on patient selection and are
based on series of several hundred patients53;
Catheter Tip Position
early complications occur in approximately 6.2%
The position of the catheter in the vascular to 11.7% of patients (Table 2). Arterial punc-
system is a major determinant of CVC-related ture and hematoma are the most common
thrombosis, and tip position has emerged as the mechanical complications during the insertion
main independent prognostic factor for mal- of CVCs, with similar rates for internal jugular
function and reduced duration of the device. and subclavian catheterization.54
Placement of the catheter tip high in the SVC Pneumothorax continues to be reported in
results in a higher incidence of thrombosis than many prospective series, while no case of signif-
low placement in the SVC or at the atriocaval icant hemorrhage related to catheter placement
junction. 50 Therefore, at least in oncology has been reported recently in the literature.
patients, the atriocaval junction appears to be
Pneumothorax
the optimal position; hemodialysis could require
full atrial positioning of the catheter tip, at least Pneumothorax is described as the most fre-
for cuffed devices.51 Thrombosis also seems to quent complication of percutaneous central ven-
be more common when catheters are inserted ous cannulation. Its prevalence is 0.5% to 12%,
entering the left subclavian vein. Many centers depending on differences in clinical features,

access site, and operator experience; this last vari- however, the routine use of this imaging tech-
able is considered by (almost) all authors as the nique does not improve the diagnostic yield.58
key deter minant of pneumothorax rate. Treatment of iatrogenic pneumothorax aims at
Consequently, the operator learning curve (maybe evacuating air from the pleural space and re-
up to 50 implants) has a major impact on com- expanding the lung. Available therapeutic options
plication rate and should be borne in mind when include simple observation; aspiration with a
the complication prevalence is assessed: inser- catheter, with or without immediate removal of
tion of a catheter by a physician who has per- the catheter after pleural air is evacuated; and
formed 50 or more catheterizations is half as insertion of a chest tube or tube-thoracostomy.59

likely to result in a mechanical complication as The selection of the approach depends on the size
insertion by a physician who has performed of the pneumothorax, the severity of symptoms,
fewer than 50 procedures.55 and whether there is a persistent air leak or not.
With the ultrasound-guided approach, pneu- According to our own data and contributions
mothorax has become extremely rare. When it in the literature, the first approach to a small
occurs, clinical presentation of iatrogenic pneu- asymptomatic pneumothorax (one involving less
mothorax complicating central venous access than 30% of the hemithorax) should be obser-
placement in cancer patients without severe vation alone, with repeated chest x-rays and sup-
underlying pulmonary disease is largely depend- plemental oxygen. The administration of oxygen
ent on the size of the pleural space involved. is able to accelerate by a factor of 4 the reab-
Individuals with a small pneumothorax (one sorption of air by the pleura, which occurs at
involving less than 30% of the hemithorax) are the rate of 2% per day in patients breathing room
usually asymptomatic and may have a normal air.60 Most physicians hospitalize patients with
physical examination. The diagnosis of iatro- a small pneumothorax, although patients who
genic pneumothorax must always be confirmed are likely to comply with treatment plans may
by the identification of a thin, visceral pleural be managed at home after 6 hours of observa-
line, which is found to be displaced from the tion and a new x-ray, provided that they have
chest wall on a posterior-anterior chest x-ray rapid access to an emergency service.61
performed with the patient in an upright posi- A pneumothorax that is large (involving 30%
tion. A confirmatory x-ray is usually obtained of the hemithorax or more) or progressive may
after implantation, immediately after the proce- be drained by simple aspiration via a plastic
dure, or a few hours later, depending on the avail- intravenous catheter, thoracentesis catheter, or
able facilities and on-site protocols. However, it small-bore (7 to 14 French) catheter or by the
has been suggested that postprocedural chest insertion of a chest tube.62 Simple aspiration is
radiographs are not routinely required after successful in 70% of patients with moderate-
image-guided (by fluoroscopy or ultrasound) sized primary spontaneous pneumothorax. No
central venous catheter insertion.56,57 A post- data are available in the medical literature regard-
procedural chest radiograph can be performed on ing the success rate of this treatment in iatro-
a case-by-case basis in symptomatic patients or genic pneumothorax complicating a CVC
when there is suspected inappropriate catheter placement. Iatrogenic pneumothorax may also be
tip position. managed with a chest tube that is left in place
As there are anecdotal reports of delayed, severe for 1 or more days. The need for a chest tube is
pneumothorax not visible on earlier x-rays occur- much more frequent in patients with severe
ring hours and even days after the procedure, emphysema, obstructive lung disease, or hyper-
particularly in oncology patients, a delayed x-ray inflation. Severe hypoxemia or hypotension may
(at least 2 hours after implantation) should be occur in patients with chronic obstructive pul-
preferred. Another chest x-ray should urgently monary disease and be life-threatening. Also,
be obtained for all patients carrying a central hypercapnia occurs often, with values of partial
venous port who develop acute respiratory symp- pressure of arterial carbon dioxide exceeding 50
toms. An x-ray obtained during expiration may mmHg. Physicians should evaluate patients care-
help in identifying a small apical pneumothorax; fully, ruling out significant pulmonary disease

before scheduling a procedure for CVC implan- are exchange over guidewire, removal (for non-
tation and taking alternative approaches into tunneled, short-term CVC), or an attempt at
consideration (eg, venous cut-down, ultrasound pharmacological disobstruction (for PICCs or
guidance, or peripherally inserted CVCs). long-term VADs). Disobstruction should always
be performed using a 10 mL syringe (or larger)
LATE COMPLICATIONS
so as to avoid inappropriately high pressure, which
may damage the catheter, and using the most
According to a general definition, late com- adequate solution for the presumed type of
plications are events that occur after the peri- obstruction (ethanol for lipid aggregates, uroki-

operative period following catheter insertion.63 nase or rTPA for clots, NaOH or HCl for drugs,
In the oncology setting, events occurring after the and sodium bicarbonate for contrast medium).
first chemotherapy course given through the Damage to the external part of the catheter
device can be considered late complications. may occur because of inappropriate nursing care
They are mechanical complications (pinch off, of the catheter exit site (eg, using scissors chang-
fractures, dislodgement, or migration); extrava- ing the dressing, chemical damage to silicone
sation injuries; infections (including phlebitis of due to inappropriate use of ether, chemical dam-
the cannulated vessel); catheter and vein throm- age to polyurethanes due to inappropriate use
bosis/occlusion (including deep vein thrombo- of ethanol, etc.).5,6 Damage to PICCs and tun-
sis, pulmonary embolism, or SVC syndrome). neled catheters is usually repaired with specific
The experience of one of the authors64 in a repair kits; for short-term, nontunneled CVCs,
large series of patients with totally implantable exchange over guide wire is more cost-effective.
access ports connected to a Groshong catheter Erosion or damage to the skin above the port
showed that the rate of late complications is low: is usually secondary to (A) errors during place-
catheter rupture and embolization 1.5% (0.063 ment (choice of a port that is too large or posi-
episodes/1,000 days of use); venous thrombo- tioning the port in an area that is too skinny because
sis 1.5% (0.063 episodes/1,000 days of use); the absence of an adequate SC tissue will increase
pocket infection 0.3% (0.012 episodes/1,000 the chance of skin necrosis due to the presence of
days of use); port-related bacteremia 2.4% (0.101 the VAD) or to (B) inappropriate nursing (ie, a
episodes/1,000 days of use). In a retrospective Huber needle left in place for more than a week).
study by Yildizeli et al,65 long-term complications Dislocation of nontunneled catheters, both
of catheter and port system placement occurred central and PICC, is usually secondary to inap-
in 6.6% of cases, namely infection (2.2%), throm- propriate securing of the catheter at the time of
bosis (1.3%), extravasation (1.3%), and catheter insertion or to inadequate nursing of the catheter
fracture (1.8%). exit site. Catheter stabilization is used to pre-
serve the integrity of the access device and to
Mechanical Complications
prevent catheter dislocation. CVCs are stabilized
The obstruction of a CVC is usually due to using a method that does not interfere with
intraluminal precipitation of lipid aggregates, assessment and monitoring of the access site or
drugs, clots, or contrast medium. It can be effec- impede vascular circulation or delivery of the
tively prevented by appropriate nursing (ensur- prescribed therapy.6
ing continuous infusion of parenteral nutrition by Different products are used to stabilize cath-
intravenous pump; following appropriate proto- eters: manufactured catheter-stabilization devices,
cols of flushing when the catheter is not in use sterile tapes, and surgical strips. Whenever fea-
or after blood withdrawal; avoiding routine use sible, a manufactured catheter-stabilization device
of the catheter for infusion of blood products, should be preferred. Stitches should not be used
blood withdrawal, or infusion of contrast medium routinely, as they increase the risk of local throm-
for radiological investigations; and avoiding direct bosis/phlebitis (in PICCs), as well as the risk of
contact between heparin and parenteral nutri- bloodstream infection (in CVCs) and the risk
tion solution containing lipids). When the catheter of dislocation and local infection of the exit site
lumen is obstructed, the most appropriate actions (in all devices).4

Dislocation of tunneled catheters should be (B) choice of the internal jugular vein rather than
prevented by positioning the cuff at least 2.5 cm the subclavian vein66,67; (C) appropriate position
inside the tunnel (or more, according to the man- of the tip of the catheter; (D) proper stabiliza-
ufacturer’s instructions) and securing the catheter, tion of the catheter (for external VADs); and (E)
preferably with a catheter-stabilization device, proper placement of the reservoir (for ports).
for at least 3 to 4 weeks.
Extravasation Injuries
The “pinch-off ” syndrome is due to com-
pression of a large-bore silicone catheter— Central VADs have greatly reduced the inci-
tunneled or connected to an implantable port— dence of extravasation injury, but this severe

between the clavicle and the first rib, typically complication may still occur in cases of catheter
secondary to “blind” percutaneous placement malfunction, such as rupture or tear in the catheter
of the catheter in the subclavian vein via the or port septum, migration of the catheter into a
infraclavicular route. Such compression may smaller vein, perforation of the SVC wall, sep-
lead to malfunction, obstruction, damage, and aration of the catheter from the reservoir, and
even fracture of the catheter, with emboliza- improper placement of the needle into the port
tion in the lung vascular bed. It is a potentially septum.68 Extravasation injury has been reported
severe complication, which is totally prevent- to occur in 0.1% to 6.5% of cases.69 Catheter
able simply by avoiding placement of silicone occlusion, which may be due to a clot within
catheters via the infraclavicular “blind” veni- the catheter lumen or to fibrin sheath forma-
puncture of the subclavian vein. tion, can be associated with extravasation because
Tip migration is a complication of silicone excessive force when flushing the catheter can
long-term catheters. It is also defined as a second- rupture its connection to the septum.
ary malposition, and it usually happens when an Extravasation of chemotherapy drugs can result
inappropriately short catheter (tip in the upper in significant tissue damage. Pain is the main warn-
third of the SVC) dislocates because of increased ing sign. If pain suggests extravasation injury, drug
thoracic pressures. It can be prevented by proper infusion should be discontinued immediately, and
positioning of the tip of the catheter. the site should be aspirated for residual drug. In
Evidence that the choice of the internal jugu- severe cases, tissue necrosis can occur. Depending
lar vein is better than the subclavian vein for on the site of extravasation, alteration in limb
VAD placement comes from a recent prospec- function and even mediastinal damage may occur.70
tive, nonrandomized, observational study in 1,201 The degree of tissue injury may be severe enough
patients.66 Immediate complications were more to necessitate surgical debridement.
frequent in the subclavian than in the internal
Infections
jugular approach (respectively, 5.0% versus 1.5%;
P ⬍.001); catheter malposition (2.3% versus Intravascular catheter-related infections are a
0.2%), venous thrombosis (2.0% versus 0.6%), major cause of morbidity and mortality in can-
catheter malfunction (9.4% versus 4.3%), and cer patients. In the hospitalized population,
long-term morbidity (15.8% versus 7.6%) were bloodstream infections are the third most fre-
also significantly more frequent in the subcla- quent type of nosocomial infection.71 A large
vian than in the internal jugular group. European, multicenter, point-prevalence study
Thus, most of the mechanical complications reported that 71% of all sepsis patients had an
are dependent on technical aspects of VAD inser- intravenous line.72 Coagulase-negative staphy-
tion (pinch-off syndrome, dislocation, tip migra- lococci, Staphylococcus aureus, aerobic Gram-
tion, erosion above the reservoir, etc.) or on negative bacilli, and Candida albicans are the
appropriateness of nursing (occlusion, disloca- pathogens most commonly involved.
tion, damage to the external tract of the VAD, ero- Infection prevention and control is a crucial
sion above the reservoir, etc.). aspect of the clinical care of patients carrying a
In particular, it appears that the cornerstones vascular access. Cancer patients are especially sus-
for effective prevention of insertion-related com- ceptible to infections because of immunodepres-
plications are (A) use of ultrasound guidance35; sion, and they should therefore be carefully


FIGURE 1 Management of Tunneled or Totally Implanted Central Venous Catheter-related Infection.
protected from this severe complication. Patient antimicrobial catheters, and antimicrobial catheter
safety can be enhanced by incorporating guide- lock solutions. Management of catheter-related
lines17,73 into daily clinical practice. infections involves deciding on catheter removal,
Most catheter-related infections arise by 2 antimicrobial catheter lock solution, and the type
mechanisms: (A) infection of the exit site, followed and duration of systemic antimicrobial therapy
by migration of the pathogen along the exter- (Figure 1). The type of catheter involved should
nal catheter surface and (B) contamination of also be taken into account. Empirical intravenous
the catheter hub, leading to intraluminal coloniza- antimicrobial therapy should be initiated after
tion and consequent seeding of the pathogen samples for appropriate cultures have been obtained.
into the circulation. In most cases of CVC-related bacteremia and
Because diagnosis is often clinical, and clini- fungemia,nontunneled CVCs should be removed.
cal diagnostic criteria are either insensitive or On the other hand, the decision to remove a tun-
nonspecific, CVC-related infections are often neled catheter or implantable device should be
overdiagnosed; this results in unnecessary and based on several factors, such as the severity of
wasteful removal of the catheter.74 Catheter- the patient’s illness and underlying condition (neu-
sparing diagnostic methods, such as differential tropenia, thrombocytopenia); proof that the VAD
quantitative blood cultures and differential time is infected; availability of other vascular access
to positivity (DTTP), have emerged as reliable sites; assessment of the specific pathogen involved;
diagnostic techniques. Paired blood cultures (aer- and presence of complications, such as endocardi-
obic and anaerobic) from a peripheral vein and tis, septic thrombosis, and tunnel infection.
the central catheter should be obtained. If the When a catheter-related infection has been
culture from the central catheter turns positive documented and a specific pathogen has been
before the peripheral sample (diagnostic cut-off: identified, systemic antimicrobial therapy should
2 hours), this so-called DTTP can help to make be targeted, and the use of antibiotic lock ther-
the diagnosis of catheter-related infection.72 apy should be considered. Specific guidelines on
Possible preventive strategies include skin diagnosis, management, and prophylaxis of CVC-
antisepsis, maximum sterile barrier, use of related infections are available.17,73,75

McGee et al53 have suggested that selection to occur in 15% to 25% of patients with CVC-
of the subclavian site appears to minimize the related vein thrombosis. Although the throm-
risk of infectious complications. However, while bosis rate is high, only a third of the thrombosed
this statement is supported by an RCT compar- CVCs become symptomatic. Nonetheless, CVC
ing the infection rates associated with the selec- thrombosis can result in clinical symptoms, the
tion of the subclavian or femoral vein, 54 no loss of catheter function, a higher rate of infec-
RCTs comparing the infection rates associated tion, postphlebitic syndrome of the upper extrem-
with internal jugular and subclavian vein can- ity, pulmonary embolism, and greater costs.
nulation are available. Moreover, a more recent However, using totally implantable access devices,

nonrandomized study comparing the subcla- we reported a low incidence of catheter-related
vian, internal jugular, and femoral sites in 657 symptomatic venous thrombosis: 1.06% (ie,
intensive care patients (the largest sample size of 0.022/1,000 days of port use).81
all CVC studies conducted) showed that the Within 24 hours of CVC insertion, a fibrin
overall incidence of CVC infection and colo- sheath, always colonized by bacteria, forms around
nization is low and does not differ both from a the catheter, but its presence does not predict
clinical and statistical standpoint among the 3 subsequent thrombosis of the vessel in which
sites, provided that optimal insertion sites are the catheter is placed. Mechanisms of CVC-
selected, experienced operators insert the cath- induced thrombosis include acute and chronic
eters, strict sterile techniques are adopted, and endothelial damage to the vein wall produced
trained intensive care unit nursing staff perform by an intravascular foreign body. Regarding the
catheter care.76 possible role of the insertion technique in induc-
ing thrombosis, prospective nonrandomized stud-
Thrombosis
ies have suggested a relationship between minimal
Catheter-related thrombosis, along with infec- insertion damage to the vein wall, as obtained
tion, is the most relevant complication in cancer with ultrasound guidance, and low rate of sub-
patients who need long-term venous access.77 sequent thrombotic events. However, no RCTs
To address this issue, the Italian Study Group for in a long-term setting have investigated the rela-
Long Term Central Venous Access promoted a tionships between insertion techniques (eg,
nationwide consensus on catheter-related cen- percutaneous versus venous cut-down, ultrasound-
tral venous thrombosis.78 The problem of throm- guided versus anatomic landmark techniques)
bosis is particularly relevant because the incidence and central venous thrombosis rate.
of venous thromboembolism is markedly higher Materials can also have an effect on throm-
in patients with cancer than in patients without bosis rates. Prospective trials have indicated an
cancer,79 as thrombosis is a direct consequence inherent superiority of silicone and second-third
of tumor growth and host inflammatory responses generation polyurethane over more rigid mate-
and an indirect consequence of cancer treat- rials like polyvinylchloride, tetrafluoroethylene,
ment, venous stasis, and direct vessel trauma. and polyethylene. In addition, a lower-diameter
Indeed, cancer and chemotherapy are recognized catheter and a single lumen might be protective
risk factors for development of central venous against the risk of central venous thrombosis.
thrombosis in patients with a CVC because of When thrombosis occurs, medical treatment
direct release of thrombogenic factors by neoplas- or catheter removal are the possible options.
tic cells, decrease of antithrombotic natural fac- Studies on the pharmacologic treatment of
tors induced by the tumor, and the procoagulant catheter-related thrombosis have focused on clin-
activity of many anticancer drugs. ically overt thromboses, reporting a rate of suc-
In a systematic review, 80 the incidence of cessful catheter preservation ranging from 45.5%
symptomatic CVC-related deep vein thrombo- to 96%.78 No clear advantages could be obtained
sis in adults varied between 0.3% and 28.3%, by catheter removal after the thrombosis was
whereas the incidence of venography-assessed established, and the clinical outcome did not seem
cases (mostly asymptomatic) ranged from 27% to be influenced by this measure. In addition, the
to 66%. Pulmonary embolism has been reported risk of embolization during or immediately after

catheter removal has been reported.82 The manda- enoxaparin 100 IU/kg) in high-risk patients,
tory indications to catheter removal in case of including those who have a family history of
thrombosis include infected thrombus, malpo- thrombotic events or previously suffered from
sition of the tip (primary or secondary to migra- idiopathic venous thrombotic events.
tion), and irreversible occlusion of the lumen. With regard to the particular type of venous
Thrombolytic drugs (urokinase or recombi- thrombosis (local or, more seldom, central), which
nant tissue plasminogen activator) should be used may occasionally be associated with PICCs, it
in acute symptomatic cases diagnosed fewer than appears to be a multifactorial phenomenon influ-
24 hours after the first symptoms. Efficacy of enced by caliber of the catheter, technique of

systemic versus local thrombolysis is still a mat- placement (ultrasound-guided versus blind), can-
ter of debate, especially for large thrombi. Chronic nulated vein (cephalic versus brachial versus basil-
symptomatic cases should be treated with a com- ica), position of the tip, stabilization technique
bination of low-molecular–weight heparin (stabilization devices versus tape versus stitches),
(LMWH) and then oral anticoagulants or with type of treatment, patient, and disease charac-
LMWH long-term alone, depending on the clin- teristics. PICC placement in the basilica vein or
ical setting. Compared with warfarin, LMWH in a brachial vein at midarm by the ultrasound
exhibits a superior safety profile and more pre- technique is recommended; catheters larger than
dictable antithrombotic effects and can usually be 4 French are to be avoided.26
given once daily in a unit dose without the need
for dose monitoring, but use in patients with Are Infections and Thrombotic Events Related?
renal failure (especially for glomerular filtration Van Rooden et al89 have shown a close asso-
rate ⬍30 mL/minute) should be cautious because ciation of CVC-related infection with throm-
even low prophylactic doses of LMWH may bosis: they found that the risk of developing
accumulate and cause bleeding. clinically manifest thrombosis increases sub-
Although some early open-label trials sug- stantially after an episode of CVC-related
gested a benefit from oral, low-dose daily war- infection (relative risk, 17.6) and is enhanced
farin 83 or daily SC dose of LMWH, 84 more by the severity of the infection. Comparing
recent double-blind, placebo-controlled RCTs patients without catheter-related infections and
did not find any advantages for either of these pre- patients with systemic catheter-related infec-
vention strategies.85–87 tion, the absolute risk of thrombosis increased
The choice to start prophylaxis against venous from 2.5% to 57.1%. Moreover, in patients hav-
thromboembolic events in all oncology patients ing 2 or more positive subsequent CVC lock
bearing a CVC, either with LMWH or with fluid cultures with identical micro-organisms,
minidose warfarin, remains unsupported by 71.4% developed thrombosis as compared with
evidence-based medicine. However, more stud- 3.3% in patients with negative or a single pos-
ies are needed to identify subsets of cancer patients itive culture.
who are at high risk of developing CVC throm-
bosis and may benefit from prophylactic systemic
CATHETER MANAGEMENT
anticoagulation. Indeed, in a recent observa-
tional study,88 compared with patients with no Catheter management is a critical issue in the
treatment, continuous antithrombotic prophy- care of cancer patients, and it is as important as
laxis administered to patients who were older catheter selection and placement. Venous access
and had a history of venous thromboembolism, can be considered a routine matter, but it can
as well as more advanced cancer, did not pre- carry serious complications, which can be main-
vent catheter-related thrombosis but significantly tained at a very low level if strict adherence to
reduced systemic venous thromboembolism a regimented protocol of surgical technique and
(8.2% versus 4%) and mortality (44% versus 25%). of catheter care is maintained.90
The Italian Study Group for Long Term Central In the early years of vascular access care,91 it
Venous Access78 suggests considering prophy- was shown that the most significant way to reduce
laxis with a single daily dose of LMWH (eg, catheter-related infections was rigorous aseptic

nursing care, renewal of the dressings, and access Transparent polyurethane film is recommended
to the catheter being the sole responsibility of for catheter-site insertion dressing by the CDC
specially trained nurses. guidelines for the prevention of infections asso-
Nowadays, much nursing time is spent car- ciated with intravascular catheters.22 It has proved
ing for patients receiving intravenous therapy. to offer the advantages of excellent adhesion,
In several countries nursing care in vascular access firm support of the catheter, good tolerability,
is very advanced, as nurses select, insert, and ease of application, and fewer replacements per
remove both peripheral and central venous catheter lifetime compared with standard gauze
devices, but in all countries their role in assess- and tape dressings.95 Regarding the risk of infec-

ing the patient’s vascular access needs and in tion, recent guidelines17 suggest that transparent
maintaining the access is crucial.92,93 polyurethane films are also superior in prevent-
Many times patients and parents, rather than ing CVC-related infections.
nurses, are caring for catheters. Therefore, VAD There is no defined frequency for changing
complication rates can be viewed in different transparent dressings, but most facilities change
perspectives. However, nursing care, regardless the dressings weekly or sooner as needed. The
of the fact that the caregiver is the patient, a par- dressing must be changed if it becomes wet,
ent, or a nurse, should follow standard, high-qual- soiled, or loose. Patients who shower must pro-
ity procedures. Specific nursing aspects of vascular tect the site to prevent any water from getting
access care are beyond the scope of this review, under the dressing.
but they are very important. We refer the reader A recent meta-analysis of 8 RCTs96 found that
to available nursing guidelines.6 We only sum- chlorhexidine-impregnated dressing (a round
marize a few considerations on dressing tech- patch with a slit that allows it to be fitted around
nique, catheter flushing, and patient education. the catheter and antimicrobial action that lasts for
up to 7 days) is effective in reducing vascular and
Dressing Technique
epidural catheter bacterial colonization and is also
Clinical management of VADs requires ster- associated with a trend toward reduction in
ile technique because their correct maintenance catheter-related bloodstream or central nervous
increases the benefits to the patient and decreases system infections, suggesting the need for a large
the risk of serious complications. RCT to confir m whether chlorhexidine-
It has been shown that wearing sterile gloves impregnated dressing is cost-effective in prevent-
and disinfecting the skin with 2% chlorhexidine- ing bacterial infections related to vascular and
based preparations reduce catheter-related infec- epidural catheters or not.
tions most effectively.94 Povidone-iodine or a 70%
Catheter Flushing
alcohol solution can be used alternatively in case
of allergy to chlorhexidine. More recently,17 it has Routine catheter flushing is the most common
been suggested that the dressing of CVCs with practice to maintain patency, reducing fibrin
the use of nonsterile gloves coupled to a no-touch sheath and clot formation.63 This is a common-
technique is equivalent to the use of sterile gloves. sense practice as no studies are available in the
The port system is accessed using a special literature. Flushing protocols vary by facility and
noncoring Huber needle, which avoids damage type of VAD. In most cases flushing is carried
to the port and allows more than 2,000 punctures. out with 10 to 20 mL of normal saline, followed
The silicone port membrane needs to be punc- by 5 mL of heparin solution (10 U/mL for daily
tured vertically in order to avoid bending the flushing or 100 U/mL in case of longer intervals).
tip. During continuous use, access needles should However, some catheters are designed to pre-
be changed every 7 days, with caps and tubing vent the reflux of blood into the catheter through
changed every 2 days, but in patients treated with the presence of pressure-sensitive valves and can
total parenteral nutrition, tubing is changed every be flushed with normal saline only.
day because of a greater potential for bacterial Saline flushing should be done with 10-mL or
growth. VADs that are used intermittently should larger syringes to prevent excessive flushing force
be accessed and flushed at least once a month. that can damage the catheter. Prefilled syringes

of smaller size are available with a traditional 10- state how to contact the hospital or health care
mL syringe diameter; they generate a signifi- professional if they have concerns.98 In selected
cantly lower pressure compared with traditional cases, it may be useful to arrange for a nurse to
3-mL syringes. visit the patient at home in order to further rein-
Flushing is recommended before and after force the retention of training information.
administration of drugs, before and after trans-
fusion of blood components, after obtaining PATIENT ISSUES: VASCULAR ACCESS AND
blood specimens, and for device maintenance QUALITY OF LIFE
when not in use.

The only available publication on catheter Many patients suffering from solid tumors
flushing concerns catheter maintenance in patients require long-term central venous access for safe,
who after completion of therapy retain their cyclic delivery of chemotherapeutic agents,
ports for extended periods of time.97 Most man- transfusion of blood and blood products, and
ufacturers recommend heparin flushing of the performance of laboratory tests. It is a common
port systems at 4-week intervals, but Kuo et al experience that venous integrity is quickly com-
challenged this indication. They showed that promised by local trauma caused by the exposure
patient compliance with monthly appointments to toxic effects of the antineoplastic drugs and
is poor and that average intervals of accession repetitive cannulation and blood sampling so
among patients who had clotted catheters was that an efficient peripheral venous access becomes
79 days versus 63 days for those without any dif- progressively difficult to achieve and maintain
ficulty in flushing. They concluded that monthly over the period usually required to complete a
maintenance is excessive, inconvenient for the chemotherapy program. Moreover, some oncol-
patients, and expensive, while clinical experi- ogy patients need an indefinite venous access for
ence suggests that less frequent flushing could palliation and symptomatic therapies. In this spe-
be safe and feasible. cific clinical setting, totally implantable access
ports are usually preferred to percutaneous tun-
Patient Education neled catheters because they need no external
dressing, do not interfere with patient activities
Most long-term VADs are cared for by patients (such as personal hygiene, swimming, and sex-
at home. Therefore, patient education is of ual life), require only monthly flushes of hep-
utmost importance to reduce the occurrence arinized saline to keep the catheter patent, and
of complications. have a relatively lower incidence of infection
Patients and caregivers should understand the and malfunction. It is common practice to implant
importance of thorough hand washing, of admin- these devices at the beginning of the course of
istering medications on time, and of routine chemotherapy to avoid potential future venous
assessment of the insertion site. Teaching aids access problems and failures; however, despite
include video tapes, information booklets, and their extensive use, the pros and cons of this pol-
hands-on practice using dummy devices and icy have been evaluated in only one RCT, par-
equipment. Reinforcement of information pro- ticularly with respect to efficacy and cost-benefit
vided with lectures and written material by ratio and its impact on patient quality of life.99
demonstration and practice has been found to Descriptive and prospective nonrandomized tri-
achieve better retention of information. als have reported a number of patient benefits,
Following adequate training, the nurse should including no need for additional peripheral
establish whether the patient and/or family care- venipunctures, greater convenience, and arms
giver are ready to manage their vascular access left free for activities of daily living, whereas
at home. To do so, they should be able to describe patients generally disliked the visibility of ports
the rationale and the risks and the benefits of the and complained about site soreness.9,100
device, demonstrate care of the access to a level Clinical trials to evaluate safety, costs, and qual-
appropriate for their needs, list the signs and ity of life of central venous ports have been basi-
symptoms of catheter-related complications, and cally open-label, single-arm, Phase II studies101–103

or comparative studies with externalized tun- of use); failure of the assigned venous-access
neled systems; they have provided little infor- strategy occurred in 16 (27%) of 60 controls,
mation on quality of life and global costs, who had to cross over to receive central venous
especially when only prospective data are taken access to complete treatment. As expected, fail-
into consideration,104,105 ure was correlated with significant access-related
A paper from our group64 has provided clini- anxiety and pain according to the outcome of
cians, health care planners, and funding agencies multiple linear regression. The analysis of qual-
with data derived from a large prospective study on ity of life was based on only 92 patients com-
total cost of devices for long-term chemotherapy pleting 6 cycles of chemotherapy; although no

of solid tumors. Briefly,333 port devices,amount- statistically significant differences were detected
ing to a total of 79,178 days in situ, were placed in the total FLI-C scores between the groups, a
during a 30-month period in 328 patients (5 rise in the total scores over the course of the
patients underwent a second placement after study was observed, which was consistent with
removal of the first device), who were followed a chemotherapy-induced effect. Cost was much
prospectively for a minimum of 180 days in order higher in the ports group compared with con-
to detect device-related and overall complications. trols (2,178 ⫾ 271 versus 530 ⫾ 894 Canadian
The average purchase cost of the devices was Dollars, P ⬍.0001). This study has a number of
obtained from the hospital charges, based on the limitations: first, in spite of stratification and ran-
costs applied during the 30-month period of the domization procedures, the small sample size
study. Insertion and maintenance costs were esti- caused an uneven distribution of diagnoses
mated by obtaining the charges for an average port between the groups, which may have resulted
implant and subsequent use; costs of complica- in an imbalance of factors possibly affecting the
tion management were assessed analytically, pro- frequency of venous accesses and quality-of-life
viding the total amount of related costs when measurements; second, serial quality-of-life data
more than one case of a complication was observed. over 6 cycles of chemotherapy were available
The global cost for each device was defined as the for analysis from only 92 subjects so that the
purchase cost plus the insertion cost plus the main- study sample size had limited power to detect
tenance cost plus the cost of treating complica- clinically important quality-of-life differences
tions, if any. According to the obtained findings, derived from each of the subscale scores; finally,
the global cost per patient, treated for a 6-month ports were recommended for all venous accesses
period, was US $1,971. Although these results by the authors, but in reality they were used for
cannot be easily extended to other institutions due only 39%—the remaining 61% of venous blood
to different staff policies, observed complication samples for laboratory tests were obtained by
rates, and other factors, this single-center prospec- peripheral phlebotomy. This introduced a sys-
tive study shows that ports are associated with high tematic negative bias obscuring the quality-of-
purchase and insertion charges, low complication life benefit related to port use.
rate, and low maintenance costs. Until quite recently fluorouracil (5-FU) mono-
Bow and coworkers99 have randomly allocated therapy, usually modulated by folinic acid, used
adults with solid tumors (mainly gynecologic to be the one and only treatment option for
malignancies) and beginning a course of intra- metastatic colorectal cancer.106 A significant issue
venous chemotherapy at 2 university-affiliated for quality-of-life assessment in oncology patients
Canadian hospitals to have venous access using was the recent introduction of oral agents, like
a surgically implanted venous access port (n ⫽ capecitabine, in view of the claims that they
59) or using standard peripheral venous access mimic intravenous 5-FU, at least pharmacolog-
(n ⫽ 60). Outcome measurements included port ically,107 since open-tunneled Hickman lines or
complications, access strategy failure, access-related totally implantable access ports, which are nec-
anxiety and pain, quality of life (expressed by essary for prolonged 5-FU infusions, were found
means of the Functional Living Index-Cancer, to be potentially risky devices. Randomized tri-
FLI-C, 21-item questionnaire), and costs. Port als had previously demonstrated that 5-FU infu-
complication rates were low (0.23/1,000 days sion was the optimal approach as response rate,

progression-free survival (or time to progression), access-related anxiety and pain. It is still unclear
and overall survival—as well as toxicity—were whether these benefits outweigh the overall costs
all significantly in favor of infusion over bolus of their purchase, implant, and use for the sup-
administration.108 Significantly less diarrhea, stom- portive care of an increasing number of cancer
atitis, nausea and vomiting, alopecia, lethargy, and patients. During these times of economic restraint
neutropenia (all with P ⬍.0001) were seen with and limited health care resources, further well-
5-FU infusion in a recent large multicenter trial.109 designed and sufficiently powered RCTs are
Oral medicinal products were offered as an needed to answer the question.
alternative to “unpleasant” intravenous 5-FU in

a randomized trial by Twelves et al.110 The authors HOW TO CHOOSE THE MOST APPROPRIATE
report on the preferences of “experienced” VAD FOR THE ONCOLOGY PATIENT
patients receiving capecitabine and the biweekly
Choosing the appropriate device for the can-
intravenous 5-FU regimen (LV5FU2), which
cer patient may be cumbersome. Therefore, we
was given according to either an outpatient or an
would like to summarize here the most useful
in-patient regimen. Compared with the admin-
indications from available guidelines and reviews.
istration of intravenous 5-FU as an in-patient,
According to Registered Nurses’ Association of
patients preferred outpatient capecitabine.
Ontario Guidelines,3 INS Standards,6 and rec-
However, about 50% of those patients who pre-
ommendations of the British Committee for
ferred capecitabine as their favorite outpatient
Standards in Haematology,4 choosing the most
therapy later chose the outpatient intravenous appropriate type of vascular access device is the
5-FU regimen with which to continue treat- result of a collaborative process among nurse,
ment; this was due to the fact that intravenous 5- patient, physician, and other members of the
FU was better tolerated than capecitabine. In health care team, taking into account duration of
addition, self-reported quality of life using the prescribed therapy, anticipated supportive ther-
Functional Assessment of Cancer Therapy– apy, physical assessment, patient health history,
Colorectal questionnaire was in favor of LV5FU2 support system and resources, patient-caregiver
(outpatient). An additional concern for patients ability to care for the device, device availability,
who are already taking oral medication to con- and patient preference. The use of a structured
trol heart disease, hypertension, and/or diabetes approach is strongly suggested in order to facil-
might be to add 4 to 5 rather large tablets of itate a comprehensive assessment and the devel-
capecitabine in the morning and another 4 to 5 opment of a vascular access care plan before the
in the evening. initiation of therapy. All patients should receive
In conclusion, the cost-effectiveness of cen- clear and comprehensive verbal and written
tral venous port use in the long-term treatment information explaining the risks, benefits, and
of oncology patients has not been fully estab- care of the device.
lished. Prospective RCTs comparing ports with Many issues about the choice of the device
repetitive peripheral venous accesses can be car- are still matters of investigation, and ongoing
ried out exclusively in subjects with good periph- RCTs are expected to solve at least some of the
eral vein status and undergoing intermittent controversies. Nevertheless, there is a general
bolus chemotherapy. Patients showing poor consensus on some issues in the following list:
peripheral veins at the initial evaluation or sched- 1. Nontunneled central catheters are indicated
uled to receive infusion chemotherapeutic reg- for short-term in-hospital setting use when
imens are usually candidates for port placement peripheral venous access is impractical or not
and cannot be enrolled in these randomized tri- indicated. Peripheral access (via a short can-
als, thus limiting the feasibility of achieving con- nula or a midline catheter) should be chosen
clusive evidence-based information. At this time, only if the device will be used for nonvesicant
there is objective evidence that totally implantable drugs, nonhyperosmolar parenteral nutrition,
port systems are a safe, effective strategy for long- and solutions with pH between 5 and 9.
term venous access and that their use has resulted 2. Chemotherapy with vesicant drugs should
in an association with a reduction in peripheral be delivered by a central venous access in

order to reduce the risk of infusion-related precautions during catheter insertion, catheter-
complications (especially extravasation). site maintenance, and hub handling. New tech-
3. Tunneled CVCs are indicated for patients in nologies and materials will be available in the
whom long-term central venous access and near future, needing appropriate trials.
intensive device use are anticipated. The Thrombosis still remains a major problem.
repeated administration of chemotherapy, When VAD-related deep vein thrombosis occurs,
antibiotics, parenteral feeding, blood prod- it seriously complicates the clinical management
ucts, and frequent blood sampling are all con- of the patient because of the need for anticoag-
ditions suggesting their preferential use. ulant treatment and sometimes the need to achieve

4. Fully implanted catheters (ports) are more suit- another central line. It may be particularly trou-
able for children and long-term use (more than blesome in a patient who already has compro-
2 to 3 months) with less-frequent need for mised venous access because of multiple courses
access, especially in patients receiving inter- of chemotherapy. Future prevention studies should
mittent bolus chemotherapy for solid tumors. aim to achieve a better understanding of the risk
5. PICCs are more suited for ambulatory or factors for thrombosis, contributing to a better
outpatient-based therapy when a medium- definition of the patient population at risk; cer-
term use (3 months) is anticipated. Polyure- tain patient groups, including those with a hema-
thane PICCs allow easier infusion of blood tologic malignancy undergoing intensive
products as greater flow rates are achieved chemotherapy, as well as those with hereditary
because the thinner walls provide a larger in- thrombophilia or with a history of unprovoked
ternal diameter of the catheter. The risk of thrombosis, may have an elevated risk of devel-
PICC-related venous thrombosis is reduced oping this complication, making them reason-
by avoiding PICCs with calibers ⬎4 French able candidates for prophylaxis. Currently available
and by preferring insertion via the ultrasound prophylactic agents are not optimal for the pre-
technique. vention of thrombosis, especially in the cancer
6. The number of lumens and diameter of patient. Future studies should be adequately pow-
catheters should be kept to the minimum. ered and evaluate the effects of newer factor Xa
inhibitors, such as pentasaccharide fondaparinux,
FINAL REMARKS AND PROPOSALS FOR
or direct thrombin inhibitors, such as ximelega-
FUTURE INVESTIGATIONS tran. Early trials suggest that the former is more
effective for prophylaxis against venous throm-
Over the last decade, many changes have boembolism and is associated with less bleeding
occurred in oncology, with new chemotherapy than LMWH. The latter may be a more stable
combinations and more complex regimens oral anticoagulant than warfarin, not being affected
becoming available. VADs are now widely used by diet or antibiotics. Clearly such agents would
and have facilitated vascular access in this cate- first have to undergo evaluation in large Phase
gory of patients. Despite the availability of a vari- III trials in this clinical setting.
ety of devices, each showing different features Finally, more studies are needed to investigate
and performances, there are no definitive data the issue of patient satisfaction and quality of life
from the literature for an evidence-based guide and their relationships with the VAD adopted for
to the choice of the most appropriate device and long-term use,a topic rarely studied so far. Whereas
insertion site, particularly in terms of the reduc- patients and their families still currently play a
tion of long-term complications. Important com- minor role in the selection of a VAD at the onset
plications like thrombosis and infections are still of treatment, patient satisfaction should be a major
associated with permanent CVCs in oncology, issue in the clinical setting of cancer palliation.
sometimes leading to VAD loss, significant mor-
bidity, increased duration of hospitalization, and
ACKNOWLEDGMENT
additional medical costs. Nowadays most VAD-
related infections can be prevented. A number The authors thank Dr. Jennifer Hartwig, med-
of measures have been implemented to reduce ical writer, for her professional help in editing
the risk of infections, including maximal barrier the manuscript.

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Vascular Access in Oncology Patients

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Vascular Access in Oncology Patients

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Tip Technical VAD Expected Type Ideal Main Main

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Short-term Venous VADs insertion; stabilization of the VAD; patient com-

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Internal Jugular Subclavian Femoral

Arterial puncture 6.3 to 9.4 3.1 to 4.9 9.0 to 15.0

*Adapted from Hamilton HC, Foxcroft DR.49

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