The Bethesda Handbook of Clinical Oncology

Peter A. Zmijewski and Hannah W. Hazard-Jenkins

INTRODUCTION

Once the diagnosis of cancer has been made, the patient will go through a rigorous staging process resulting in the development of a plan of care for the newly diagnosed. Typically, blood tests are drawn to help facilitate the staging and treatment of the patient’s disease. Additionally, tests are performed to document the patient’s clinical well-being and monitor the progress of his or her treatment. Added to this is the potential for a rigorous venous sampling schedule and the use of contrast agents during radiologic imaging studies performed for staging purposes. Most of these studies can be instituted without establishment of a long-term venous access device; however, it is prudent to assess the need for central venous access early in treatment to avoid any delays. Chemotherapy administration for the cancer patient may be delivered over a more prolonged schedule with the placement of a long-term, central venous access device (CVAD). Moreover, these devices have facilitated the implementation of increasingly complex treatment regimens at home.

The rationale for placing CVADs is derived from the caustic properties of chemotherapeutic agents and the consequences of repeated venipuncture on the peripheral veins. The innermost layer of a vein is known as the tunica intima. It is this layer that becomes damaged with the repeated trauma associated with peripheral venipuncture. This damaged endothelium results in exposure of the underlying thrombogenic layer, the tunica media, which results in platelet aggregation and subsequent thrombosis. Implanted venous access devices are either tunneled through the periphery or bypass the periphery altogether and are directly implanted in the central venous system. In both circumstances, trauma to the peripheral veins is reduced. The instillation of potentially damaging substances is more tolerable in the central veins, as they have a much larger volume of blood flow and thicker vein walls. Once the decision has been made to place a CVAD, various factors must be taken into consideration. These factors may include specific patient characteristics and preferences, patient history and associated comorbidities, and specific infusion needs. The many options for venous access can then be considered in a cooperative fashion.

The initial interaction with the patient should be used to evaluate the level of care they will be capable of providing for whichever vascular device is ultimately selected. Moreover, lifestyle, habits, and activities should be taken into account during the selection process. Patients may prefer to have devices placed on their nondominant side to facilitate care. Devices implanted in the chest may be positioned low to assist in hiding them under garments and to provide for easy visualization without the need of a mirror. Consideration should be given in females to the position of bra straps and modifying placement accordingly. Additionally, patients who partake in certain recreational activities such as firearm shooting may prefer to have an implanted port positioned away from the shoulder in which the firearm rests.

A history of previous venous device placement also must be assessed as this could modify the preferred site of catheter insertion. Preoperative ultrasound evaluation of the upper extremities, jugular, and central veins may be beneficial in patients with a history of multiple central venous accesses. Moreover, any surgical interventions or currently placed devices such as automated implantable cardioverter defibrillators and pacemakers should be noted. The presence of inferior vena cava (IVC) filter devices should also be noted as this may require the use of an alternate type of access wire (i.e., straight wires instead of J-curved wires). Patient allergies need to be documented as well and the device and surgical equipment modified accordingly. Finally, the physical examination is also a key part of the preoperative patient assessment. The skin at the insertion and final placement sites should be assessed for adequacy. Patients with underlying skin conditions or prior surgical sites may dictate location of implantable device. Moreover, evidence of dilated superficial veins may herald an undisclosed central venous stenosis that may complicate catheter placement and initiate further evaluation before operative intervention.

Ultimately, the type of infusion agent and the frequency needed may dictate the type of access device used. Patients in need of chronic and continuous infusion may best benefit from tunneled devices, whereas subcutaneous ports are ideal devices for patients who will only need accessed intermittently. The type of infusates used and their relative compatibilities may also be a consideration in deciding the number of lumens that may be needed in a particular device.

INDICATIONS

Indications for venous access placement in the oncology patient are guided by complex factors that evolve during the transition from diagnosis to treatment and finally into remission. Consideration is given to the composition of the infusates being administered, the frequency of treatment (monthly, weekly, and daily), the size or number of lumens required, the patient’s ability to provide self-care of the device, and patient’s preference (which may be influenced by vanity, an appropriate consideration in the decision-making process). Additional factors to consider are the potential for daily maintenance needs such as flushes and dressing changes that may or may not be covered by insurance and patients may not be able to do on their own. For example, a bone marrow transplant patient may require a large-bore multichannel catheter for stem cell collection initially, but will also need a long-term catheter for the remainder of the transplant process.

CONTRAINDICATIONS

The placement of various CVADs is associated with very few contraindications. Patients with uncontrolled coagulopathy are at risk for developing hematomas at sites of surgical dissection (port pocket sites, cephalic vein cut-down) and around percutaneous catheter insertion sites. Every effort should be made to correct coagulopathy before a CVAD is placed. It is also important to realize that the subclavian vein is essentially non-compressible due to the overlying clavicle and direct pressure may not work to control catheter site bleeding. For coagulopathy patients, a more compressible vessel, such as the internal jugular may be preferable for access. Attempted access in specific vessels with known thrombosis, diagnosed by ultrasound or contrasted imaging, is a contraindication and only patent vessels should be attempted to be accessed. A bloodstream infection, as demonstrated by positive blood cultures, is also a contraindication for long-term CVADs due to the high colonization rates and thus requiring subsequent removal. The CVAD may be placed once the infection has been adequately treated and negative blood cultures are documented.

Certain CVADs require the positioning of a device in the subcutaneous tissue of the chest, may not be appropriate options in some situations or certain types of tumors. Moreover, certain patients, such as those with cystic fibrosis, may require constant chest percussive therapy making a secondary site of placement a more viable option. These sites include the upper arm or a part of the abdomen. In addition to port placement, it is also necessary to understand the position of the catheter. For instance, in patients with head and neck cancer, presence of an internal jugular catheter may interfere with radiation and future surgical exploration. For these patients, subclavian or contralateral internal jugular access may be more appropriate.

INFUSION DEVICES

Venous access devices can be categorized into five groups based on the mechanism of insertion and catheter dwell potentials. These categories include peripheral angiocatheters, peripherally inserted central catheters (PICCs), percutaneous non-tunneled central catheters, tunneled central catheters, and implanted ports. Each category is then further defined by device-specific characteristics such as flow rates, lumen size, catheter tip location, and dwell time. In utilizing this process, it is easier to identify which catheter meets the specific needs of the patient in Table 41.1.

While not a CVAD, it is worth mentioning the peripheral intravenous angiocatheter (PIV), as it is simplest access to utilize. The angiocatheters are relatively easy to insert and remove, specialized training or certification is not required for insertions and most practitioners are qualified to place a PIV. These catheters come in a variety of gauges and lengths to accommodate patients as well as large-bore peripheral catheters preferred for rapid infusion of large volumes such as venous contrast or blood products. Intermittent nonvesicant chemotherapy can be administered via peripheral access. However, reliability of obtaining access during each treatment session may be unpredictable and if unsuccessful, may delay treatment. Therapeutic agents with extremes of pH (normal pH = 7.35 to 7.45) or osmolarity (normal 280 to 295 mOsm/L) should not be administered through peripheral access as the concentration of material infused can lead to patient discomfort, infiltration, clotting, and infection. One exception is parenteral nutrition in which dextrose contents are under 10% and the osmolarities >500 mOsm/L (INS). In this case, it is considered safe to administer this therapy peripherally. Limitations of PIV catheters include short dwell time (1 to 3 days), high thrombophlebitis rates, thrombosis and shear of the vessel, infiltration into the surrounding tissue, cellulitis, and pain with infusions. As a result of these limitations, PIVs are reserved primarily for hospital/clinic use and management by health-care professionals.

One subclass of peripheral angiocatheters is the midline catheter. With the guidance of a handheld ultrasound device, these catheters are usually inserted at the antecubital fossa or into the brachial veins. The catheter is approximately 20 cm in length and typically is placed with the tip near or in the axillary vein. In this position, the catheter is not considered central and should be treated as a peripheral angiocatheter with regard to infusates. However, since the catheter tip is in a larger vessel with increased blood flow, the risk of phlebitis and infiltration is decreased as compared to peripheral angiocatheters. Typical dwell time for midline catheters is 2 to 4 weeks with careful monitoring for complications. In addition to extended dwell time, the midline catheter, unlike the PICC, does not need radiographic verification for tip placement, since it is not advanced centrally. As a result, this is a less costly means of access and simplifies positioning. Phlebitis and thrombosis are also less likely to occur with midline catheters as compared to central venous lines. Midlines are particularly beneficial in patients who would otherwise require serial placements of short PIVs and do not need the long-term access or a PICC line. Midline catheters can also be used when there is a relative contraindication to PICC access such as in patients with end-stage renal disease where the central veins should be accessed as minimally as possible.

Midline catheters do have limitations. First, their tips do not reside centrally so infusates are limited to those that are safe for PIVs. Since the axillary vein lies deep in the axillary region, it may be difficult to identify early phlebitis, infiltration, or infection. Frequently, a blood return is not achieved for confirmation of vascular patency or specimen collection. The short intravenous catheter length compared to the external component yields increased risk of dislodgement. Midline catheters require daily flushing to maintain patency and dressing changes at least weekly, which may require home health services. Moreover, catheter-related bloodstream infection rates are similar to those of PICCs.

TABLE 41.1Venous Access Devices

Type of Catheter	Indications	Limitations
Peripheral angiocatheters	Hydration, PPN, short-term access	Frequent infiltration/phlebitis, easily dislodged, short dwell time (up to 72 hours) cannot be used for solutions with extreme pH or osmolarity, not for at home patients
Midline catheters	Hydration, PPN, short-term access	Less frequent infiltration/phlebitis than angiocatheters, 2–4 week dwell time, cannot be used for solutions with extreme pH or osmolarity, not for at home patients
Peripherally inserted central catheters (PICCs)	Hydration, antibiotic, blood transfusions, venous sampling, chemotherapy, medication administration	Requires weekly dressing change and flushing, must keep dry at all times, limited flow rates, visible, potential for easily dislodgement, higher occlusion rate, avoid placement if potential dialysis in future, up to 12 month dwell time
Nontunneled central venous catheters: a. Central lines b. Temporary dialysis or pheresis catheters	a. Acute-care medication, large-bore access, hydration, all IV medication, CVP measurements b. Hemodialysis, stem cell collection and transplant requiring only double-lumen access, plasmapheresis treatment	Short dwell time: 7–14 days for central lines, 1–4 weeks for pheresis catheters, higher risk of infection than tunneled catheter, increased risk of dislodgement, highly visible, increased risk for pneumothorax, not typically used for at home patients
Tunneled central venous catheters: a. Traditional tunneled catheter b. Tunneled dialysis catheters c. Hybrid triple-lumen tunneled catheters	a. Long-term IV medication, hydration, chemotherapy b. Hemodialysis, plasmapheresis, stem cell collection/double-lumen transplant access c. Stem cell collection, transplantation requiring triple lumen	Requires routine dressing changes and flushing, must keep site dry at all times, may be visible to others, lower risk of infection than non-tunneled catheters
Implantable ports a. Chest ports b. Arm ports	Intermittent IV access, chemotherapy, hydration, antibiotics, lab draws	Requires needle stick to access, difficult to access in obese patients, port may rotate and become difficult to access, typically requires OR procedure for placement and removal

Peripherally Inserted Central Catheters (PICC)

Hoshal first described the peripherally inserted central venous catheter (CVC) in 1975. In a case series, he described threading 61 cm silicone catheters into the SVC through the basilic or cephalic veins. Thirty of 36 catheters lasted the entire duration of treatment (up to 56 days) of total parenteral nutrition and thus successful application of the concept of central access. In current practice, a PICC is a long, flexible catheter inserted into a peripheral vein and advanced into the central circulation, typically placed in a vein of the upper arm. Alternative access sites can include the internal or external jugular veins, the long or short saphenous veins, the temporal vein, or the posterior auricular veins. The saphenous, temporal, and posterior auricular veins are typically reserved for pediatric patients. Once the vein is cannulated, the catheter is advanced until its distal tip resides in the superior vena cava (SVC) or the IVC, depending on originating vein. The tip location of the PICC is desired in the lower third of the SVC, preferably at the junction of the right atrium with either the SVC or the IVC. The external component is secured to skin, preferably with a removable locking device or sutures. One advantage of a PICC line is there is minimal risk to chest organs as compared to catheters placed directly in the central venous system.

PICCs come in single, dual, or triple lumens and a variety of luminal sizes. The catheters have a small outer diameter allowing for initial insertion into smaller vessels prior to advancement centrally and are radio-opaque for visualization of catheter tip placement on chest radiograph. The length of these devices can be modified to accommodate different patient body habitus.

PICCs are used for patients with poor venous access that need infusions of solutions with extreme pH or osmolarity, extended intravenous medications use (1 week to several months in duration), intermittent blood sampling, and as a respite from long-term catheters. For these purposes, PICCs are associated with greater ease and safety with insertion when compared with conventional CVCs. Moreover, PICCs also help minimize the pain associated with repeated venipuncture whether for replacement IVs or lab draws. Power-injectable PICCs may be utilized in patients where frequent contrasted imaging studies are likely. Certified nurses can perform insertions during inpatient hospitalization, in outpatient settings, and in the home.

There are a few potentially negative factors to take into consideration when contemplating the placement of a PICC line. PICC lines have relatively small lumen(s) and the long length of the catheter results in decreased flow rates. This is especially so with infusions of viscous solutions such as blood products and intravenous nutrition therapy. PICC lines often cannot be used for gravity-driven infusions as is frequently used in a home settings. Frequent flushing of the catheter with normal saline and/or heparin lock, and dressing changes weekly or more frequently may be challenging for some patients. In addition, careful attention is required to protect the exposed catheter exit site from contamination or damage and a patient’s modesty may be compromised due to visibility of the external component. There are activity limitations with PICC catheters that include but are not limited to any straining maneuvers such as heavy lifting or straining that could elevate the intra-thoracic pressure leading to catheter malposition. Malpositioning can even occur with physiologic pressure changes during cough or forceful emesis. Submersion of the extremity in water when bathing in pools or hot tubs is forbidden secondary to increased infection risks. Patients may not be candidates for PICCs if they have had surgical alteration of vascular anatomy, lymphedema, ipsilateral radiation to the chest or arm, loss of skin integrity at the anticipated insertion site, or anticipate future dialysis access needs. Finally, due to their small caliber, these lines are not considered adequate intravenous access for resuscitation in the setting of hemodynamic compromise.

However minimal, PICC-related complications should be recognized. These include infection, phlebitis, vein thrombosis, catheter occlusion, catheter fracture and leak, and inadvertent removal prior to completion of therapy (Table 41.2). At a baseline, oncology patients are at increased risk for venous thrombus formation secondary to their malignancy, treatment regimen, and the trauma of catheter insertion. Improper final tip positioning and subclavian access as opposed internal jugular access may also contribute to thrombosis. However, in cancer patients, PICCs have been shown to have less incidence of deep venous thrombosis than tunneled catheters used for the same purpose.

TABLE 41.2Complication of Central Venous Access Devices

Complication	PICC	Non-tunneled Catheter	Tunneled Catheter	Implantable Port
Arterial puncture	Rare	Internal jugular: 6.3%–9.4% Subclavian: 3.1%–4.9% Femoral: 9.0%–15.0%	Internal jugular: 6.3%–9.4% Subclavian: 3.1%–4.9% Femoral: 9.0%–15.0%	Internal jugular: 6.3%–9.4% Subclavian: 3.1%–4.9% Femoral: 9.0%–15.0%
Malposition	10%	Right IJ: 4.3% Left IJ: 12% Right subclavian: 9.3% Left subclavian: 7.3%	Right IJ: 4.3% Left IJ: 12% Right subclavian: 9.3% Left subclavian: 7.3%	Right IJ: 4.3% Left IJ: 12% Right subclavian: 9.3% Left subclavian: 7.3%
Pneumothorax	NA	Internal jugular: 0.1%–0.2% Subclavian: 1.5%–3.1%	Internal jugular: 0.1%–0.2% Subclavian: 1.5%–3.1%	Internal jugular: 0.1%–0.2% Subclavian: 1.5%–3.1%
Bacteremia	2.1/1,000 catheter days	2.7/1,000 catheter days	1.6/1,000 catheter days	0.1/1,000 catheter days
Pocket infection	NA	NA	NA	0.7%
References	17, 24, 26	17, 23, 25	17, 23	17, 18, 23

Percutaneous Central Venous Catheters

Aubaniac was the first to describe cannulation of a central vein (the subclavian) for venous access. These CVCs, either the thin flexible or the larger rigid variety, are inserted directly into the central circulation via the subclavian vein, the external jugular vein, the internal jugular vein, or the femoral vein. Catheters included in this category include the standard CVC or temporary rigid hemodialysis/apheresis catheters. CVCs are typically used for rapid infusion, when multiple infusates are needed simultaneously or for hemodynamic monitoring (central venous pressure measurement). Thus, CVCs are for use in hospitalized patients in acute care settings only with typical dwell times of 7 to 14 days.

The rigid, non-tunneled, central catheters are typically used for acute hemodialysis, access after removal of an infected tunneled dialysis catheter, stem cell collection for autologous transplant, healthy donor collection, or for therapeutic apheresis. Certified nurse practitioners, physician assistants, or physicians can place these catheters, in a surgical suite, or in interventional radiology. Image guidance is essential. Catheter exchange at the same venous site can indefinitely maintain a single access site, which may be limited in hemodialysis patients or oncology patients due to prior access and thrombosis of other central access points, however this practice should be reserved for the patient with truly limited central venous access.

Complications related to these devices include infection, bleeding, inadvertent arterial access, air embolism, pneumothorax, hemothorax, cardiac perforation with tamponade, and cardiac dysrhythmia. The cancer patient with cachexia is at increased risk for insertion complications as are patients with large body habitus or coagulopathies. Utilization of image-guided placement with ultrasound technology for venipuncture and modified Seldinger approach helps to minimize these risks. While the catheter is in place, infections, thrombosis of the accessed vein, loss of catheter lumen patency, and dislodgment can occur and consideration should be made for removal of the device if this occurs. Frequent assessment of the catheter for integrity, dislodgment, and site evaluation is required. Flushing of each catheter lumen is performed frequently for patency. The catheter exit site must be kept dry with an intact occlusive dressing and changed biweekly to minimize infection risks. The lumens are usually given a high-dose heparin lock to maintain patency. Accidental dislodgment of the rigid catheter can occur even though sutures are placed and due to the large caliber of these devices, unrecognized dislodgement can lead to life-threatening hemorrhage. Usage of these catheters and dressing changes are typically reserved for certified technicians or nurses to provide consistent management.

Tunneled Catheters

A tunneled catheter is a larger bore catheter inserted into the central circulation followed by tunneling through the subcutaneous tissue to an exit site remote from the access site. After tunneling, the catheter is advanced into the central circulation via the jugular veins, subclavian vein, femoral vein, or lumbar vein access (only in vein-compromised patients). The tip of the catheter should terminate in the SVC/right atrial junction or IVC/right atrial junction, depending on venous access origin. A retention cuff, which causes inflammation and ingrowth into the cuff, is integrated on the catheter and the cuff is positioned approximately 1 to 2 cm within the skin insertion point. The cuff serves as a barrier to bacteria migration along the tract into the central circulation. Additionally, the cuff helps prevent inadvertent catheter dislodgement.

Tunneled catheters can be further divided into three types: traditional tunneled catheters, dialysis catheters, and hybrid tunneled catheters. The traditional tunneled catheters are best known as the Hickman or Broviac catheter. These are intended for patients requiring long-term central venous access use in instances such as total parenteral nutrition, chemotherapy, chronic medication administration, transfusions, and blood sampling. The second are the dialysis catheters. These are typically used for hemodialysis but they are also utilized for stem cell collection and posttransplant venous access. The final catheter type, the hybrid tunneled catheters, are most often used in transplant patients for stem cell collection, transplant access, or photophoresis treatments in graft-versus-host disease. All three of these catheters are available in single, double, or triple lumens, with a variety of lumen sizes and catheter lengths. These catheters are known for lower infection rate as compared to nontunneled catheters.

Management of tunneled catheters requires flushing protocols, weekly dressing changes, and protection from inadvertent dislodgment. In addition, the patient is restricted from submersion of the catheter during bathing or swimming. Tunneled catheters with high-dose heparin lock solution require removal of the lock prior to catheter use to prevent inadvertent systemic heparinization. Catheters containing valve devices may only require saline flushes, thus simplifying this regimen.

Complications of tunneled catheters include those associated with the insertion procedure (i.e., bleeding, air embolus, pneumothorax, hemothorax, and cardiac dysrhythmia) as well as long-term issues (i.e., infection, migration, thrombosis, and catheter shear). Most medical centers will stock catheter repair kits that allow for the salvage of cracked or leaking catheters. Extrusion of the cuff from the subcutaneous position is an indication for replacement or removal of the tunneled catheter.

Implanted Ports

Implanted ports are CVC attached to a reservoir with a self-sealing septum. The reservoir is surgically implanted into a pocket in subcutaneous tissue and the attached catheter is tunneled subcutaneously before advancement into the central venous circulation. The implanted port is ideal for patients undergoing intermittent or cyclic therapy when daily access is not required. Ports are also suited to chemotherapy administration or venous access for lab draws in vein-compromised patients requiring chronic venous access. Early identification of patients who will need ports helps to facilitate placement prior to the anticipated neutropenia, weakness, and wound healing difficulties often associated with chemotherapy. Newer models of implanted ports allow power injections of contrast material for radiologic imaging. Medical device companies also promote ports with differing flow patterns or characteristics within the reservoir chamber (i.e., “the port”) that claim to improve infusion, blood draws, and lower thrombosis rates. Compared to tunneled catheters, studies have also demonstrated up to a 10-fold advantage in long term infection rates due to the completely implanted nature of the catheter. Nevertheless, continuous access of the port will certainly defeat this advantage. Ports provide patients with improved modesty as it is not visible, especially if the port pocket is located in a discrete location. In addition, active patients may find more freedom during de-accessed periods. These catheters have an extended dwell time of several years or longer depending on number of punctures into the septum and the needs of the patient. Consideration should be given to retaining the port for a period of time after completion of therapy for use in surveillance blood testing purposes.

Patients with uncontrolled coagulopathy, bacteremia, or sepsis should have those conditions addressed prior to the placement of a new indwelling device, as with other CVADs. Some individuals with severe malnutrition or cachexia may have an extremely poor healing capacity and may be at undue risk for port erosion through the skin. These patients should undergo therapy with a PICC or other alternative until such a time when a port may be better tolerated.

As mentioned previously, the port is placed in a subcutaneous pocket most commonly in a location on the anterior chest wall, the arm, or thigh with the catheter advanced into the corresponding vein. Use of the port requires sterile preparation of the site and access with a non-coring, Huber needle, to prevent damage to the reservoir. As the entire system is subcutaneous, the patient may feel a needle stick as the port is being accessed, but applying topical anesthetics to the skin over the port prior to the needle stick may minimize the discomfort. While the port is accessed, it requires daily flushing and it must be flushed after each use as well. When the port is not actively being used, monthly flushes are required to help maintain patency. Complications associated with ports are rare and are divided into early and late events. Early complications in oncology patients include hematomas, malpositioning, and iatrogenic pneumothoraces. Late complications are dominated by catheter thrombosis and infection, however catheter facture and embolization can also occur.

SPECIAL CONSIDERATIONS

Power Injection Catheters

Traditional catheters have been studied in the past for safety when power injections are done for radiographic studies with mixed results. The studies found efficacy depends on the gauge, length, and material of the catheter. Incidence of inadequate flow rates and catheter rupture due to limited pounds per square inch (PSI) restrictions outlined by the manufacturers limits the use of most catheters for power injection. However, more recent products over come these limitations. Optimal contrast imaging requires uniform contrast delivery, which is best achieved by power injection at 2 mL/s. In fact, these limitations have led to current trends in catheter manufacturing resulting in some catheters capable of tolerating 300 PSI. One should consider power injection catheters for patients anticipated to have recurring contrast medium injection studies. Special equipment may be required for accessing power injection ports so as to prevent rupture or extravasation. In addition, the more rigid catheter required for power injection may lead to increased complications such as phlebitis or thrombosis.

Herts et al. studied a variety of CVCs including standard CVC, tunneled catheters, and implanted ports and found power injections are possible without harm to the patients or the catheters. Their findings suggest usage of central lines as a possible alternative to peripheral angiocatheters. Before using standard central access devices for power injection, institutional policies should be in place to address the practice as there may be additional training required of the staff prior to utilizing such devices to minimize complications.

Valve Technology

Ongoing clinical presentation of heparin allergies, specifically heparin-induced thrombocytopenia has led to the development of catheters with valve technology. The valve remains closed unless acted upon by negative (aspiration) or positive (infusion) pressure. By opposing central venous pressure and preventing the reflux of blood into the catheter tip during the cardiac cycle or changes in intrathoracic pressure that naturally occurs in everyday life, valvular technology is designed to improve patency and minimize exposure and/or need for regular flushing of the device. Additionally, removal of a syringe after flushing or de-accessing the port can facilitate negative pressure drawing blood into the catheter. Without blood in the catheter tip, the risk of catheter occlusion related to internal clotting is thought to be eliminated. Lamont et al. found the PASV (Boston Scientific Corporation, Natick, Mass) valved implanted port had a lower incidence of difficulty in obtaining a blood return than the Groshong (Bard Access System, Salt Lake City, Utah), which resulted in less nursing time trouble shooting malfunctioning or poorly functioning catheters. Valve technology has been incorporated into some catheters at the distal tip or in the proximal end piece. This technology is also available as an “add-on” device for catheters. A saline-only flush is recommended; however, heparin flushes are not a contraindication.

CONCLUSION

The diagnosis of a malignancy and the subsequent rigorous treatment regime(s) are overwhelming for most patients. If venous access for administration of treatment becomes difficult, it adds to a patients stress and anxiety during an already difficult time of their life. Central venous access devices can and often do minimize that one aspect of a patients care. However, care must be taken to ensure the device selected and placed is optimal for the type of treatment regime selected. Treatment factors to consider (but not limited to) include frequency of therapy administration, pH and osmolality of the medication, location of treatment (home vs. hospital) and duration of therapy. Patient characteristics to take into account include comorbidities, prior line placement, history of thrombosis or thrombophlebitis, and the ability and resources to care for a device. Finally, and most importantly, the patient should be able to help select the device that is most appropriate for them based on their lifestyle and personal preferences. When selected and used appropriately, central venous devices are extremely useful to the patient and the provider as they allow for adherence to treatment regimes while minimizing patient discomfort.