Subcutaneous venous port systems play an important role in the management of patients that require intermitting longterm infusion

therapy, especially since they are durable, warrant patient comfort, and have low infection rates.1,2 The usage of ports for a wide variety of indications has also brought a wide spectrum of complications that are well documented in the existing literature.15 With this article, we want to report two rare complications of the port-a-cath and propose a method of working that may decrease the possibility of recurrence of these complications.

Materials and methods

Retrospective chart analysis was performed on 178 patients, who received a subcutaneous port catheter between 2002 and 2007. Among these, the ones with complications that were not common in the literature are presented.

Results
All port catheter implantations were performed by either an anesthetist or pediatric surgeon. The mean age of the patients was 43 years (range 5 days78 years). The catheters were inserted via the subclavian vein using the infraclavicular approach with intravenous sedation in 155 adults and under general anesthesia in 23 children. Prophylactic sefazolin sodium was administered 30 minutes in advance. Rare complications included two catheter fractures and embolisations and one port deformation. Two catheters were found to be fractured during an elective removal. Both patients with split catheters were radiologically examined in the operation theatre to locate the distal part of the catheter. One of them was located in the inferior vena cava and the other in the sinus coronarius.

Both catheter tips were removed under angiographic guidance by a snare that was introduced through the right femoral vein by the cardiologist and interventional radiologist. Another catheter was removed due to malfunction and appeared to be deformed, probably due to improper usage of the port needles. The deformed port is seen in Figures 1 and 2. Figures 1 and 2. Lateral and ventral views of the deformed port catheter which was removed because of nonfunctioning

Discussion
The need to obtain reliable long-term access to the vascular system encouraged researchers to design the subcutaneous catheters. Placing these devices completely under the skin allows the patient to continue a normal life without special care, other than monthly heparinised serum infusion. The introduction of any foreign object into the body, however, is accompanied by technical difficulties and the risk of developing complications. Aitken and Minton were the first to document a case of catheter fracturing and embolising secondary to a pinching effect of the clavicle and the first rib.6 They proposed that mechanical compression between the clavicle and the first rib could lead to fracturing of the catheter.6 From than on, several cases have been reported with a wide range of symptoms, ranging from minimal to life-threatening.3,6 Our cases are especially worth mentioning, since they were both asymptomatic. Additionally, since the patients therapy

had come to an end, we did not encounter an inability to flush or draw from the catheter. It is not evident whether the catheters fractured during the removal or before, since pre-removal chest X-rays had not been taken. Once embolisation of the catheter is diagnosed, removal of the catheter is indicated.3 The commonly accepted management of catheter embolisation is transcutaneous retrieval through a femoral approach; however, a case requiring thoracotomy for a centrally embolised catheter, has also been reported.3,7 A more lateral introduction of the catheter has been proposed to prevent this complication. The catheter enters the vein more laterally from the clavicular-first rib angle, thus providing a wider space to minimise the pinching effect.3,6 Hienke et al graded the severity of pinch off by radiographic criteria and recommended to remove the catheters with evidence of compression. 8 This urges us to look for signs of compression of catheters on routine chest X-rays and perform chest X-rays before the routine removal of the catheters. This could help prevent startling situations and timely alert the physician to consult a capable specialist for intravascular removal. Another reported solution to prevent pinch off mechanism may be more proper placing of the catheter using imaging guidance. An ultrasound guided port placement may eliminate the other procedure related complications, such as pneumothorax, hemothorax, arterial injury, and catheter malpositioning.2,9 Also, placing the catheter through the internal jugular vein may lead to a lower risk of thrombosis by minimising the contact with the vessel wall, besides this

route may prevent the compression between the clavicle and the 1st rib.2 Ultrasound-guided port placement, using the internal jugular vein, is not in the current insertion technique, but for small children the authors are planning to use this technique soon. After the start, it will be possible to compare the results and to conclude the on imaging-guided catheter insertion. The images in Figures 1 and 2 clearly show that the deformity seen would be hard to elicit. The plastic needle site would hardly come off, unless pulled by a needle with a bended tip. This bended tip could be the result of a strong push to the metal bottom of the port. The answer to prevent this complication lies in educating the medical personnel. Concluding, chest X-rays should be performed before removing the port catheters. Fractured and embolised catheters should be removed in institutions with specialists like interventional radiologist or cardiologist, well capable of removing the distal tip. After removal, the ports should be examined to detect any possible deformities and medical personnel like oncology nurses, should be informed on how to use and take care of the port catheters.
Competing interests: None known.

Author information: Egemen Erolu, Pediatric Surgeon; Erhan Bulutu, Anesthesiologist;, mr Erelen, Anesthesiologist; VKF American Hospital, Istanbul, Turkey Correspondence: Dr Egemen Erolu, Amerikan Hastanesi ocuk Cerrahisi, Gzelbahe Sok. No:20 34365 Nianta, Istanbul, Turkey. Email: egemene@amerikanhastanesi.org References:

1. Krupski G, FroschieGW, Weh FJ, Schlosser GA. Central venous access devices in treatment of patients with malignant tumors: venous port, central venous catheter and Hickmann catheter. Cost benefit analysis bsed on a critical review of the literature, personl experiences with 135 port implantations and patient attitude. Chirurgie. 1995;66:202 7. 2. il BE, Canyiit M, Peynirciolu B, et al. Subcutaneous venous port implantation in adult patients: a single center experience. Giagn Interv Radiol. 2006;12:93 8. 3. Denny MA, Frank LR. Ventricuar tachycardia secondry to port-a-cath fracture and embolization. J Emerg Med. 2003;24:2934. 4. Dysarz FA, Fiorillo MA, Davidson PG. Complications ofsubcutaneous injection ports. Mt Sinai J Med. 1998;65:28991. 5. Malm T, Eliasson H, Johansson S, et al.Tricuspid valve stenosisa serious complication of port-a-cath. Lakartidningen. 2005;102:331821. 6. Aitken DR, Minton JP. The pich-off sign: a warning of impending probems with permanent subclavian catheters. Am J Surg. 1984;148:6336. 7. Doering RB, Stemmer EA, Connoly JE. Complications of indwelling venous catheters. AmJ Surg. 1967;114:259 66. 8. Hienke DH, Zandt-Stastny DA, Goodman LR, et al. Pinch off syndrome: a complication of implantable subclavian venous access devices. Radiology. 1990;177:3536. 9. Biffi R, Corrado F, Braud F, et al. Long term totally implantable central venous access ports connected to a groshong catheter for chemotherapy of solid tumors: experience from 178 cases using a single type of device. Eur J Cancer. 1997;33:11904.

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