Figure 1.
Appearance of the upper arms after CV port implantation.
Arrows indicate implanted ports in the upper arm. It generally takes less effort to roll up a sleeve to provide access to the upper arm port than to completely remove a shirt for access to the subclavian port.
Table 1.
Characteristics of the Patients.
Table 2.
Proportion of Success and Complications.
Figure 2.
Examples of anticipated preoperative difficulties with the procedure confirmed on CT scan images.
(A) SVC syndrome. Arrow indicates the excluded SVC by a tumor. (B) Tortuous collateral blood circulation. Arrows indicate the contrast-enhanced tortuous collateral blood circulation attributable to a modification caused by surgery, radiation, or spontaneous occlusion.
Figure 3.
(A) Minimum specific materials for the procedure. In this kit, a CV port/catheter, a dilator sheath, and a guide wire are supplied. For venipuncture, we use common peripheral intravenous catheters with appropriate lengths and gauge sizes through which a guide wire can be passed. In this kit, an 18-gauge needle is sufficient. In case of “Seldinger technique”-based kits, a 20- or 22-gauge needle might be sufficient because those guide wires are usually thinner than “peel-off sheath”-based kits. Further, commonly used materials such as surgical caps, masks, eye protection, sterile gloves, gowns, drapes, disinfectant sponges, gauzes, sutures with needles, scalpels, anesthetic syringes, and 1% or 2% lidocaine anesthetic solutions are also required (not shown). (B) Arm position. The patient should be asked to lie down in the supine position, which allows the upper limb to abduct, upper arm to rotate outward, forearm to supinate, and medial side of the arm to be upward for better demonstration of the basilic vein. The elbow should not be bent, and the forearm should not be pronated. (C) Tips for applying the probe with the correct angle. The probe should be applied at the correct angle.
Figure 4.
How to distinguish the artery and vein.
(A) Typical appearance of artery. An artery is rounded, pulsing, and accompanied by thin high brightness of the intima beneath the adventitial circle. (B) Venous stasis and valve. Gray slightly high-echoic venous stasis is seen in the lumen and, depending on the site, in venous valves. (C) Typical cross-section view of the upper arm. A brachial artery, two accompanying brachial veins, and a basilic vein located medially far from the others are shown. (D) Imaging the vessel course pattern by sweeping. If the vein runs as B, its section will stay at the center of the monitor during sweeping. If the vein runs as A or C, it will move to the left or right on the monitor during sweeping. In this case, turn the probe orthogonal to the line (A or C). After imaging and adjustment, a 90° turn of the probe will result in a clear longitudinal view of the vein.
Figure 5.
Real-time ultrasound-guided venipuncture.
(A) “Two-person method” and “one-person method.” With the “two-person method,” the ultrasound-guidance step and the puncturing step are assigned separately to two operators. This can increase the success rate for beginners. (B) Tips for puncture with the correct angle. The axes between the probe and needle must be kept in one line.
Figure 6.
(A) Skin incision. A scalpel should be used to make a skin incision from 2 cm to the right to 2 cm to the left of the puncture point. This incision should be used later as the entrance for making a subcutaneous pocket with a forceps. (B) Making a slit between the skin and wire. The connective tissues between the skin and wire should be cut with a scalpel to make a slit a few millimeters long over the wire in the puncture point. (C) The purpose of a slit. Without this step, the catheter route will be shallower from the skin surface; subsequently, the risk of catheter exteriorization will increase.
Figure 7.
Images of postprocedural complications that could be prevented with an upper arm CV port.
(A) Catheter pinch-off syndrome and fracture. Arrow indicates a “pinched-off” and fractured site of a catheter. Arrowheads indicate the fractured distal catheter fragments that had migrated into the pulmonary artery through the heart. (B) Catheter inversion. Left panel, Arrow indicates a normal catheter placed centrally. Note that there is a sweep turning point at this puncture site that may cause tension derived from an elastic restoring force. Right panel, Arrowheads indicate the peripherally inverted distal portion of a catheter for the same case.