|Year : 2019 | Volume
| Issue : 1 | Page : 18-21
Unexpected bleed during chemoport removal: How to manage?
Ravi C Arjunan, Pavan Kumar Jonnada, Uday Karjol
Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
|Date of Web Publication||1-Oct-2019|
Dr. Pavan Kumar Jonnada
Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Chemo port is a boon for majority of cancer patients for the comfort it provides for the delivery of chemotherapy. After completion of chemotherapy, it is advisable to remove the chemo port. Removal of chemo port is less morbid procedure and complications occur very rarely. Here by we share our experience of bleeding encounter during chemo port removal and further management. A 36-year-old woman diagnosed with breast cancer underwent breast conservation in 2012. She completed post-operative chemoradiotherapy. 6 years later she presented for follow-up and with no evidence of recurrence, she was advised for chemo port removal. During removal of chemo port, bleeding was encountered from non-visualised source. She was immediately transferred to cardiovascular surgery department. A venogram was performed revealing chemo port in one of the tributaries of subclavian vein and tear in the anterior wall of subclavian vein. Tear was repaired with clips and removal of the chemo port was done ligating the tributary. Chemo port removal is a less morbid procedure and complications are very rare. However, when encountered with complications, one must be learned enough to sought with them. Interdepartmental communication and instant matured decisions will guide in preventing catastrophic events and are lifesaving.
Keywords: Bleeding, chemoport, vascular injury
|How to cite this article:|
Arjunan RC, Jonnada PK, Karjol U. Unexpected bleed during chemoport removal: How to manage?. Niger J Cardiovasc Thorac Surg 2019;4:18-21
| Introduction|| |
Chemoport is a totally implantable venous device used in oncology to deliver chemotherapy and very helpful for long-term use. There is an evident literature highlighting the benefits and complications associated with the chemoport insertion. However, scarce information is available during the complications that occur during the removal of removal, and here, in this report, we would share the experience of uncanny bleeding during the removal of chemoport and highlight the issues pertinent to the management of this complicated scenario.
| Case Report|| |
A 36-year-old premenopausal woman presented to the outpatient department of surgical oncology of our institute with the complaints of lump in her right breast. Clinical examination revealed a 3 cm × 2 cm lesion in her lower inner quadrant hard mass. Bilateral mammography showed lower inner quadrant mass lesion of 2.5 cm × 2 cm. Biopsy of the lesion was positive was mucinous carcinoma. She was counseled for breast conservation, and subsequently, she underwent breast conservation surgery in June 2012. Histopathology was suggestive of 3 cm × 2.5 cm × 3.2 cm mucinous carcinoma with free margins and reactive changes in all the 11 examined nodes. With pT2N0 status, receptor status being was estrogen receptor (8+), progesterone receptor (6+), and negative HER2/neu, she was counseled for adjuvant chemotherapy. She underwent chemoport insertion by direct puncture of subclavian vein; based on anatomic landmarks in September 2012, postoperative X-ray is shown in [Figure 1], following which she received six cycles of chemotherapy and 45 Gy in 25 fractions of radiation therapy.
She was lost for follow-up and presented to the surgical oncology outpatient clinic in 2018. She was evaluated for metastasis, and it was negative. She was advised for removal of her chemoport.
After preanesthetic evaluation for removal of chemoport, she was taken up for removal of chemoport. A 2-cm incision was given over the previous incision and dissection carried out to identify the diaphragm of the chemoport which was placed in the subcutaneous plane. After identifying the diaphragm, and its attached tubing, the diaphragm was freed all around and an initial attempt to remove the tubing was performed. Initially, after the diaphragm is freed, without resistance 2 cm of the tubing was retrieved and then resistance was encountered. An additional attempt to remove the chemoport tubing was performed; there was a gush of bleeding encountered from nonvisualized source. Further attempts to remove the chemo port tubing were abandoned and packing was done to stop the bleeding. The patient was then transferred to cardiovascular surgery department immediately.
With the suspicion of subclavian vein injury, a venogram with left transfemoral vein/left axillary vein access was taken. Wire was crossed via axillary access and the wire was snared from femoral access, across tear site, and balloon was inflated to control bleed. The chest wound was exposed directly. Proximal and distal clamps were placed across the site of bleed and tear in the anterior wall of subclavian vein was repaired with clips[Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e. Chemoport was seen in one of the tributaries of the subclavian vein, and it was retrieved ligating the tributary. Postprocedurally, the patient was stable.
|Figure 2: (a) Initial catheterization of the subclavian vein. (b) Contrast injected, but no leak. (c) Balloon inflated. (d) Leak seen. (e) Repaired with clips|
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| Discussion|| |
Chemoport is an implantable device which is commonly inserted into right subclavian vein owing to its straight course and easy accessibility. However, there are complications which are associated with chemoport, immediate postoperative or late in the long term. Aparna et al. in children showed that 11.9% chemoports were complicated by port-site infection and mechanical complications, venous thrombosis, and skin necrosis in 4.3%, 0.4%, and 0.4%, respectively. The most frequent complication associated with chemoport in adults was port-related infection (1.47%). Further complications were skin necrosis (0.21%), incision dehiscence (0.21%), broken or torn catheter (0.42%), jugular vein thrombosis (0.21%), and thrombosis of superior caval vein (0.21%).
There are reports that chemoport catheter gets fractured and distal end embolized, which were retrieved using interventional techniques. This complication is known as pinch-off syndrome reported to be 0.1%.
Biswas et al. reported a case of mediastinal hematoma following internal jugular catheterization which required emergency median sternotomy. However, bleeding during removal of chemoport is very rarely encountered.
The major important factor to be dealt during chemoport removal is when there is resistance during the pull of chemoport tubing, there is always a chance that chemoport tubing may get fractured and because of the negative intrathoracic pressure, the distal end may get embolized. The cause of this scenario could be decreased elasticity of the tubing of chemoport or adhesions of the chemoport tubing to the wall of the vein.
Nishinari et al. revealed that catheter retention does occur due to formation of the fibrocellular sheath on the external wall of tubing which is composed of fibrin and smooth muscle cells proliferation and areas of thrombi at different stages of organization, collagen, and endothelial cells, that lead the encapsulating sheath strongly adherent to the catheter and wall of vein. They suggested that chemoport catheter be fractured and ligate the stump close to the entry of vein, in the event of resistance to the removal of the catheter.
Patel et al. graded the chemoport removals with respect to the difficulty in removing them and described as in [Table 1].
It is important to identify the grade of difficulty and additional maneuvering be abandoned if there is increased resistance or bleeding and utilize necessary interventions to minimize morbidity associated with difficult removals. In general, the time taken to achieve hemostasis after pulling the chemoport catheter is hardly beyond 15 min and is seen with simple removals. However, with resistance to removal, care should be taken to identify the level of difficulty and proceed for further management.
Subclavian vein injury is a devastating complication that carries a high mortality rate more than that of arterial injury mostly because of the dangerous complication of air embolism. Subclavian arterial injury is a known complication associated with insertion of central venous catheters. Traditionally, thoracotomy was needed for the repair of the subclavian injuries. However, with the advent of endovascular techniques and availability of expertise, most of the vascular injuries can be treated by endovascular approach.
After the subclavian injury, spontaneous cessation of bleeding is rare owing to the weakened venous contractility. Angiography is the most important diagnostic tool, especially in cases with vascular injuries. In this case, venography was performed to identify the source.
During inadvertent arterial injury during chemoport insertion, there are certain guidelines and algorithm proposed by Guilbert et al., in the event of vascular injury, depicted as below in [Figure 3].
However, these same principles can be utilized in the event of suspected vascular injury during chemoport removal.
Hong  was the first to describe the breakthrough technique to remove the stuck catheter. This procedure was performed under general anesthesia in an operating room setting with balloons inserted and dilated sequentially in each lumen of the stuck catheter after the catheter hub had been removed.
There are many procedures described in the literature which are modifications of the original procedure. However, the need for thoracotomy for an iatrogenic subclavian vein injury has been declined in the current era with the advent of interventional endovascular management.
| Conclusion|| |
Chemoport removal is a minimally morbid procedure and complications are very rare. However, one must be aware that complications do occur and when encountered, one must be aware of treating the hemorrhage. Interdepartmental communication and instant matured decisions will guide us in preventing catastrophic events and are lifesaving.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images, and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]