Meta-analysis of primary open versus closed cannulation strategy for totally implantable venous access port implantation

Abstract

Background There is still no reference standard for the implantation of totally implantable venous access ports (TIVAPs). A recently published multicentre randomised controlled trial (RCT) revealed a significantly greater risk of pneumothorax after closed cannulation than after an open strategy. The aim of this meta-analysis was to provide an update of the available evidence for the safety and effectiveness of primary open versus closed cannulation strategy. Methods RCTs comparing outcomes of open cut-down of the cephalic vein and closed cannulation of the subclavian vein were sought systematically in MEDLINE, Web of Science and CENTRAL. The primary outcome was the occurrence of pneumothorax. A beta-binominal model was applied to combine the respective outcomes, and results are presented as odds ratios (OR) with 95% confidence interval (CI). Results Six RCTs with a total of 1831 patients were included in final analysis. Meta-analysis showed statistically significant superiority of the open cut-down technique regarding pneumothorax (OR 0.308, 95% CI 0.122 to 0.776), but a statistically significant higher failure of the primary technique for the open cut-down technique than for closed cannulation (OR 2.364, 95% CI 1.051 to 5.315). There were no significant differences between the two procedures regarding other morbidity endpoints. Conclusion This meta-analysis shows a general superiority of open cut-down of the cephalic vein over closed cannulation of the subclavian vein regarding the occurrence of pneumothorax. Open cut-down should be the first-line approach for TIVAP implantation. Closed cannulation should be performed with ultrasound as second-line procedure if the open technique fails. Systematic review registration PROSPERO CRD42013005180

Surgical approach for totally implantable venous access port: a full strategy to avoid the percutaneous approach complications

“…These two techniques add a small amount of time during the procedure; however, in our personal experience, neither pneumothorax nor hemothorax has been experienced [4]. Furthermore, the pieces of evidence of closed cannulation with ultrasound are not still solid [1].…”

“…We read with interest the article by Klaiber et al published online in January 2021 in the Langenbeck's Archives of Surgery [1]. The authors concluded their meta-analysis stating that the cutdown technique for totally implantable venous access port in the cephalic vein reduced the risk of pneumothorax and hemothorax when compared with closed cannulation of the subclavian vein.…”

Application of intracavitary ECG for positioning the totally implantable venous access port in the upper arm of cancer patients

“…Totally implantable venous access port (TIVAP) is a closed intravenous infusion device that may be implanted under the skin and retained in the body for a long duration ( 1 , 2 ). It mainly comprises an injection seat for puncture and an intravenous catheter system and may be used for infusion, rehydration, nutritional support and blood transfusion of various chemotherapy drugs ( 3 , 4 ). Compared with peripherally placed central venous catheter (PICC) and central venous catheter, TIVAP has obvious advantages in terms of safety, infection rate and patient satisfaction ( 5 , 6 ).…”

Response to: Surgical approach for totally implantable venous access port: a full strategy to avoid the percutaneous approach complications

“…We thank our Italian colleagues for their interest in our work [1], and we appreciate their statement in favor of surgical cutdown of the coracobrachial or external jugular vein as an alternative in case open cut-down of the cephalic vein fails. We share their opinion that this is a reasonable approach as it offers the chance to prevent puncture-associated complications such as pneumo-and hemothorax effectively.…”

“…Therefore, high-quality trials on this topic are needed to gain better evidence as a basis for practice recommendations and guidelines. The conclusion drawn from our results [1] is based on meta-analyzed data from randomized controlled trials in which venous puncture was used as secondor third-line strategy. Considering that complication rates were low in our study even when a percutaneous technique was used, our recommendations were justified and evidence based.…”