Original Article

Use of port-a-cath in cancer patients: a single-center experience

Philomena Charlotte D’Souza1, Shiyam Kumar2, Annupam Kakaria3, Rashid Al-Sukaiti3, Khawaja Farhan
Zahid2, Muhammad Furrukh2, Ikram A Burney2, Mansour S Al-Moundhri4
1
Department of Nursing, Sultan Qaboos University Hospital, Muscat, Oman
2
Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
3
Department of Radiology Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
4
College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman

Abstract
Introduction: Central venous catheters play an important role in the management of cancer patients. Different types of devices are associated
with different patterns of complications. We report on the pattern of use and rate of complications of port-a-caths in patients diagnosed with
malignant cancer at a single institution.
Methodology: The data were collected retrospectively from patients who received the treatment for solid tumors or lymphoma through a port-
a-cath at the Sultan Qaboos University Hospital (SQUH) between January 2007 and February 2013.
Results: A total of 117 port-a-caths were inserted in 106 patients. The majority (86; 73.5%) were implanted by an interventional radiologist,
and the right internal jugular vein was accessed in 79 (67.5%) patients. Mean catheter indwelling time was 354 (range 3–1,876) days for all
patients, 252 (3–1,876) and 389 days (13–1,139) for patients with and without complications, respectively. Thirty (25.6%) port-a-caths were
removed prematurely, mainly due to infectious complications, while 17 (14.5%) were removed after completion of treatment. Staphylococcus
aureus was the most frequently isolated organism, found in 8 (6.8%) patients. Underlying diagnosis (p < 0.001), chemotherapy regimen (p <
0.001), sensitivity to antibiotics (p = 0.01), and any complication (p < 0.001) were significant factors affecting the duration of port-a-cath use.
None of these factors were significant on multivariate cox regression analysis.
Conclusions: The mean duration of port-a-cath use was almost one year. Infection was the most common complication leading to premature
removal, followed by port thrombosis.

Key words: port-a-cath; chemotherapy; infection; cancer; Oman.

J Infect Dev Ctries 2014; 8(11):1476-1482. doi:10.3855/jidc.4155

(Received 21 August 2013 – Accepted 31 January 2014)

Copyright © 2014 D’Souza et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction and catheter fracture remain important complications

Central venous catheters play an important role in associated with TIVAP [1,2,8,9]. Over the course of
the management of patients with malignancies. They the past decade, reports suggest that the complication
serve not only for safe administration of rate has decreased with improved techniques and
chemotherapy, but also for prolonged administration material [10].
of fluids, blood and blood products, antibiotics, There are different kinds of devices used for long-
parenteral nutrition, and frequent blood sampling [1- term venous access in cancer patients. Earlier, the
5]. There are different types of venous access devices, Hickman line and Broviac catheters were used; more
but totally implantable venous access ports (TIVAP) recently, port-a-caths, which are implanted
are now used most commonly because of their safety, subcutaneously, are being used more commonly due to
cosmesis, low infection rates, ease of implantation, their ease of access and lower complication rates
and use [1,3,6,7]. TIVAP can be implanted in an office [11,12]. There are many reports in the literature on the
setting under local anesthesia. Interventional increasing use of port-a-cath devices from developed
radiologists can implant the TIVAP in an outpatient countries, but scant data have been reported from
setting, offsetting the costs [8]. However, the developing countries on the use of such devices, which
procedure and its subsequent maintenance are not free may be due to unavailability of the technique, cost,
of side effects; infections, hematoma, malpositioning, and/or patient unwillingness.
pneumothorax, thrombosis/blockage, embolization,
D’Souza et al. – Port-a-cath in cancer patients J Infect Dev Ctries 2014; 8(11):1476-1482.

Hence, here we present our experience with the Technique

use of port-a-cath in patients with solid tumors at a After 2010, all procedures were performed in the
university hospital in Oman. To the best of our radiology department using the Vital Port power
knowledge, this is the largest data set on the port-a- injectable system with a 7.5F catheter (Cook Medical,
cath-associated side effects reported from this region. Bloomigton, Indiana, USA). Prior to 2010, the cases
Our aim was to determine the total length of were performed sporadically and patients received
stay/indwelling time and reasons for premature different ports depending on availability. The standard
removal. procedure is here described.
Sultan Qaboos University Hospital (SQUH) is The skin puncture site at the root of the neck is
450-bed tertiary referral center and is one of the two infiltrated using 2% lignocaine. The internal jugular
hospitals in the country providing cancer care services. vein is accessed, and a 0.018 guide wire is passed
The section of medical oncology consists of three through the needle and its position is confirmed by
consultants, two senior registrars, two registrars, four fluoroscopy. Subsequently, the track is dilated using
rotating interns, and two cancer care nurses. The the Seldinger technique and the peel-away sheath is
senior registrars and cancer care nurses are responsible inserted. A skin incision is made in the lateral part of
for port-a-cath care and are appropriately trained. The the anterior chest wall, parallel to the clavicle. The
port-a-caths are placed by an interventional incision is deepened through the fascial layers until
radiologist. All the patients receive a detailed subcutaneous fat is reached. A pocket is created in the
explanation of the procedure by a consultant or a subcutaneous fat using blunt dissection. A track is
senior registrar. created connecting the mid part of the skin incision to
the puncture site in the neck using the tunneling
Methodology device. The port is assembled, connecting the catheter
The data were collected retrospectively on to the port. The catheter is connected to the tunneling
consecutive adult patients (> 14 years of age) who device and pulled through the track. The port is
received a port-a-cath between January 2007 and inserted in the pocket. The catheter is cut to
February 2013 at the SQUH, Muscat, Oman. appropriate length using fluoroscopic guidance. The
Information regarding patient’s age, gender, BMI, catheter is inserted into the central vein through the
diagnosis, operator, date of insertion and removal, peel-away sheath and the sheath is removed. The
indication for implantation, complications, duration of pocket created for the port is closed in layers.
port in place, and patient’s current status (alive or Waterproof dressing is applied at both sites. The port
dead) was gathered from electronic patient medical can be used immediately after the procedure. Routine
records. The duration of port-a-cath use was calculated prophylactic antibiotics are not prescribed [4,8].
from the time of insertion to removal due to any cause
(complication, removed after completion of planned Results
chemotherapy), death, or on February 28, 2013, Out of 117 port-a-caths, 18 (15.4%) were placed at
whichever came first. hospitals abroad, as these patients traveled to seek
All the implanted port-a-caths were single lumen. medical advice outside the country. The remaining 99
All the devices were implanted under local anesthesia; (84.6%) port-a-caths were placed at SQUH, 84
only two patients received post-procedure prophylactic (71.8%) by the three interventional radiologists, 12
antibiotics, and none of the patients received anti- (10.3%) by anesthetists, and 3 (2.6%) by a general
coagulation therapy. surgeon.
Access to the port-a-cath was limited to trained One hundred and six patients (106) had 117 port-a-
oncology specialist nurses or doctors (senior registrar caths inserted; 11 (9.4%) had it inserted a second time,
level) to minimize the chances of infection, and as the first port-a-cath was removed due to
aseptic measures were observed while the port-a-cath complications. The majority of patients were females
was accessed for administration of chemotherapy or (82 patients, 70.1%), with a mean duration of use of
other fluids. 354 days (range 3–1876 days). Median BMI was 27
Log rank univariate analysis was performed using KG/M2 (range 12–49); 39 (33.3%) had a BMI between
indwelling time of port-a-cath as the dependent factor. 21 and 25 KG/M2, while the majority of population
The Kaplan-Meier method was used to calculate the were either overweight or obese. Results are shown in
duration of port-a-cath use. The study was approved Table 1.
by the hospital’s medical research ethics committee.

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Table 1. Patient characteristics and diagnosis

Characteristics N (%)
Male 35 (29.9)
Female 82 (70.1)
BMI
Underweight (<18.5) 11 (9.4)
Normal weight (18.5–24.9) 39 (33.3)
Overweight (25–30) 29 (24.8)
Obese (>30) 38 (32.5)
Diagnosis
Breast cancer 52 (44.2)
Colon cancer 25 (21.4)
Gastric cancer 10 (8.5)
Hodgkin’s lymphoma 6 (5.1)
Non-Hodgkin’s lymphoma 4 (3.4)
Ovarian cancer 4 (3.4)
Others 20 (17.0)
Interventionist
Interventional radiologist 86 (73.5)
Abroad 16 (13.7)
Anesthetist 12 (10.3)
Surgeon 3 (2.6)
Treatment intention
Curative 12 (10.3)
Adjuvant 33 (28.2)
Palliative 72 (61.5)

Table 2. Time port-a-cath in place and reason for removal

Mean time port-a-cath in place (all patients) 354 days, range 3–1,876
Mean time port-a-cath in place (patients with complication) 252 days, range 3–1,876
Reason for removal
Complication 30 (25.6%)
Infection 19 (16.2%)
Infection + blocked 2 (1.7%)
Blocked 4 (3.4%)
Skin rupture 4 (3.4%)
Catheter fracture 1 (0.9%)
Completed chemotherapy 17 (14.5%)
Organism isolated
Staphylococcus aureus 8 (6.8%)
Acinetobacter 1 (0.9%)
E. coli 1 (0.9%)
Staphylococcus hemolyticus 1 (0.9%)
No organism isolated 8 (6.8%)
Chemotherapy regimen
*AC  D±T 25 (21.4%)
Multiple lines (no bevacizumab) 39 (33.3%)
Multiple lines with bevacizumab 18 (15.4%)
**FOLFOX4 2 (1.7%)
*AC: doxorubicin and cyclophosphamide; D: docetaxel; T: trastuzumab; ** FOLFOX-4: folinic acid, 5FU, oxaliplatin (total infusion time 48 hours)

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Breast cancer was the most common diagnosis, Figure 1. Duration of port-a-cath use by the Kaplan-Meier
followed by colon cancer, gastric cancer, and method
Hodgkin’s lymphoma (Table 1). Almost half of the
patients (57 patients, 48.7%) received more than one
line of chemotherapy through the same port-a-cath,
while the remaining patients were treated with only
one line of chemotherapy.
The right internal jugular vein was accessed in 79
(67.5%) patients, while in 38 (32.5%) patients, port-a-
caths were was implanted in the left internal jugular
vein. Choice of site of port-a-cath implantation was
interventionist dependent; however, in 18 patients with
breast cancer, the left internal jugular vein was
accessed because the right breast was affected. The tip
of the port-a-cath was found to be placed in the
superior vena cava in 73 (62.3%) patients, while in 36
(30.7%) patients, it was in the right atrium; the data for
the remaining 8 (6.8%) patients was missing.
A total of 30 (25.6%) port-a-caths were removed
prematurely due to complications, while 17 (14.5%)
were removed after completion of planned adjuvant or
curative treatment (Table 2). The mean duration of use including bevacizumab in 4 patients. Of these patients,
of port-a-cath was 354.4 days (range 3–1,876); for 7 had complications associated with the port-a-cath.
patients with a complication, it was 253 days (range 3– Almost one-fifth (25 patients, 21.4%) of the
1,876) for patients with no complications, mean patients had colorectal cancers; all of them received
duration of use was 389 days (range 13–1,139) (Figure oxaliplatin, leucovorin and 5-fluorouracil (FOLFOX4)
1). Of the 30 ports requiring removal secondary to regimen in the adjuvant setting or the same regimen
complication, 19 were placed by an interventional with bevacizumab in the metastatic setting. Out of 25
radiologist while 6, 2 and 3 were placed by an patients, 11 developed complications (9 had infections
anesthetist, surgeon or in a different institution while 1 had catheter thrombosis and 1 had skin
respectively. None of the patients died of dehiscence); 9 of those 11 patients received
complications secondary to the port-a-cath. bevacizumab as part of the chemotherapy regimen. Of
Infection was the major reason for removal (19 the 25 patients, 6 were treated with FOLFOX-4 alone
patients, 16.2%) followed by catheter blockage (4 (5 in the adjuvant setting and 1 with metastatic
patients, 3.4%) and skin dehiscence (4 patients, 3.4%), disease), and the remaining 19 patients received
infection and catheter block (2 patients each, 1.7%), bevacizumab along with a backbone of FOLFOX-4
and catheter fracture (1 patient, 0.6%). Staphylococcus chemotherapy. The most commonly used
aureus was the most common isolated organism (8 chemotherapeutic regimens were AC followed by
patients, 6.8%), while in 8 (6.8%) patients, no docetaxel + trastuzumab for breast cancer in the
organisms could be isolated. Out of 8 Staphylococcus adjuvant setting (25 patients, 21.4%), while different
aureus isolates, 3 were resistant to methicillin, and chemotherapy regimens were used for patient with
hence those patients were treated with vancomycin stage IV breast cancer (Table 2). Patients with colon
(Table 2). cancer received FOLFOX-4 + bevacizumb followed
None of the patients developed pneumothorax, by irinotecan, leucovorin, and 5-fluorouracil
arterial puncture, or acute bleeding after the procedure. (FOLFIRI) + bevacizumab or cetuximb (25 patients,
A little less than half of the patients (52, 44.4%) were 21.4%), while patients with metastatic gastric cancer
diagnosed with breast cancer; out of those, 23 patients were also treated with FOLFOX4-based therapy.
received adjuvant chemotherapy with doxorubicin + Patients with Hodgkin’s lymphoma or non-Hodgkin’s
cyclophosphamide (AC) followed by docetaxel + lymphoma were treated with the standard Adriamycin,
trastuzumab, while patients with metastatic disease bleomycin, vincristine and dacarbazine (ABVD), or
were treated with multiple lines of chemotherapy, rituximab, cyclophosphamide, vincristine and
prednisolone (R-CHOP) regimens. A total of 20

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(17.1%) patients received the vascular endothelial one patient, which is again much better when
growth factor receptor (VEGFR) antibody compared to our study [11].
bevacizumab with chemotherapy; 18 of these patients Infection (21 port-a-caths, 17.9%) was the most
received multiple lines of chemotherapy, while 2 common complication for the premature removal of
received FOLFOX4 only. In 8 of those 20 patients, the the port-a-cath, which is much higher than other
port-a-cath was removed because of infection. studies, which ranged from 1.7% to 9.3%
On log rank analysis, underlying diagnosis (p < [1,3,6,9,10,14,18]. A total of 85 port-a-caths were
0.001), complication (p < 0.001), chemotherapy placed between 2010 and 2013, while only 14 were
regimen (p < 0.001), and sensitivity to antibiotics (p = inserted in the three preceding years, from January
0.01) were significant factors affecting the duration of 2007 through December 2009. Out of 14 port-a-caths
port-a-cath use, while gender (p = 0.40), intention of placed before, 5 (35.7%) were removed, while among
treatment (p = 0.16), site of port-a-cath placement (p = the 84 implanted during 2010–2013, 22 (26.2%)
0.33), site of tip (p = 0.33), interventionist (p = 0.17), required removal. The learning curve of the operators
BMI (p = 0.23), administration of bevacizumab (p = might explain the higher rate of infection. In a small
0.65), and single or multiple lines of chemotherapies study published from our hospital about patients with
(p = 0.24) were not significantly associated with sickle cell disease, 17/24 (70.83%) port-a-caths were
premature removal of the port-a-cath. None of these removed due to infective complications in the years
factors were significant on multivariate cox regression 1996–2011 [19]. After the documentation of
analysis. bloodstream infections associated with port-a-caths,
infections were treated with systemic intravenous
Discussion antibiotics. The port-a-cath was not removed if the
Patients with cancer require repeated venous infection was treated successfully; the port-a-cath was
access for blood sampling, administration of drugs removed only from patients with repeated infections or
(chemotherapeutic agents, antibiotics, and others), and continuous fever despite negative blood and urine
sometimes parenteral nutrition. Some cultures and despite receiving adequate antibiotic
chemotherapeutic agents are notorious for causing coverage.
thrombophlebitis or extravasations injuries. With a In a study by Sticca et al. (2009) comparing the
central line, all these complication can be reduced outcomes of central venous devices placed by an
[1,14]. Since the introduction of TIVAPs, many interventional radiologist and surgeon, there was no
studies have been published regarding their efficacy, difference in complication rates between the two
cost, and complications [1]. Though port-a-cath use is groups, and it was more expensive for the devices to
more common these days, it is also associated with be placed by the radiologist [10]. It is difficult to
short- and long-term complications, mainly arterial compare the success rate for the port-a-cath duration
puncture, pneumothorax, infections, malposition, implanted by the general surgeon and interventional
thrombosis/blockage, difficulty of access, and catheter radiologist in our study, as the vast majority of
fracture and leakage [1,4,8,9]. Our data indicate that procedures were done by the radiologist while only
port-a-cath placement is an effective route for the three devices were implanted by the surgeon, out of
administration of chemotherapy and other agents over which two were removed. Since the health system in
several days and over several courses of Oman is government supported, direct cost estimates
chemotherapy. The mean duration of use was more are difficult to assess. The vast majority of port-a-
than a year (389 days), which is similar to findings of caths were placed in the right internal jugular vein due
several other studies (range 181–596) [3,10,15-17], to ease of implantation; the left jugular vein was
though higher than what was reported by an Italian accessed in patients with right breast cancer most
study (168 days) [5]. The mean duration of use was often, but the site of implantation had no significance
much better in our study compared to a study from on the duration of use or development of
Pakistan in which port-a-caths were inserted in 55 complications (p = 0.33). This is similar to the study
patients (153 days vs. 354.4 days). However, 20% of by Stica et al. [10]. Catheter thrombosis/blockage was
the population in that study had acute leukemia and the second most common complication, seen in 6
the main reason for premature removal was device patients (5.1%), which is higher than what has been
failure. The authors did not specify the details of reported in other studies (range 0%–1.58%) [4,5,20];
device failure. The infection as a cause of premature however, the rate is lower than that reported from the
removal for the port-a-cath was mentioned for only Netherlands (9.3%) [16,21]. At our institution, we

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experience with a totally implanted system for intravenous Dr. Shiyam Kumar
chemotherapy. Cancer 57: 112-–1129. doi: 10.1002/1097- Department of Medicine, College of Medicine and Health Sciences
0142(19860315)57:6<1124::AID- Sultan Qaboos University, Al-Khoud PO Box 35
CNCR2820570611>3.0.CO;2-D. PC 123, Muscat, Oman
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