Port Catheter Placement Without Imaging: A Feasible Solution for Low-Resource Settings

A port catheter is a crucial instrument, particularly for chemotherapy patients. It is preferred due to its relatively simple placement, ease of maintenance, significant benefits for the patient, and prolonged usability with proper care. Under normal circumstances, venipuncture is ideally performed using imaging techniques, and catheter placement is confirmed via fluoroscopy. However, economic constraints may limit access to these resources. In such cases, blind port catheter placement becomes a viable alternative, and its feasibility is well established (1). 

In this study, the authors aimed to explore the technique of port catheter placement using anatomical landmark guidance in a blind fashion. Additionally, the authors introduce a novel suturing technique designed to keep the port reservoir away from the incision site. 

Operative Steps 

The patient was placed in the Trendelenburg position, and the procedural site was marked, disinfected, and draped appropriately.  

Local anesthesia was administered at the marked jugular vein access site, followed by venous puncture using a puncture needle. A guidewire was advanced through the needle into the jugular vein.

The needle was removed, and the guidewire entry site was enlarged by a few millimeters using a scalpel. A right-angle clamp was then used to further dilate the opening. This step aims to prevent kinking of the catheter when it is directed downward through the tunnel. 

A dilator was introduced over the guidewire, after which the guidewire was removed. The catheter was then advanced over the dilator and secured in place. Throughout this process, the tip of the dilator was kept closed to prevent potential air embolism. Local anesthesia was administered at the site where the port reservoir pocket was created, and along the planned tunnel between the pocket and the catheter entry site. 

A skin incision was made at the marked site using a scalpel, and a pocket was created through sharp and blunt dissection. Any bleeding can be controlled by suturing or direct pressure. Once the pocket was formed, the fit of the port reservoir was assessed. If necessary, the pocket can be slightly enlarged. A sterile sponge was placed inside the pocket to assist with hemostasis. 

To create the tunnel, a tunneling rod was advanced from the upper incision toward the lower incision. The catheter was attached to the tip of the rod and pulled downward to bring it into the pocket. Care was taken to prevent kinking at the upper entry site. Once the catheter was positioned within the pocket, it was secured, and a locking mechanism was placed at the junction of the port reservoir and the catheter. Special attention was given to avoid any damage to the portions of the catheter that will remain inside the body. 

While maintaining a firm grip on the catheter, it was cut at the appropriate length and quickly connected to the port reservoir. The catheter and reservoir were then locked together using the locking mechanism. The port reservoir was positioned within the pocket, and its function was tested by flushing with saline using a Huber needle attached to a syringe. 

Novel Technique 

To ensure that the port reservoir remained below the incision site and to prevent interference with needle insertions during future treatments, it was anchored downward. This was achieved by placing a horizontal subcutaneous suture that looped under the junction of the port reservoir and catheter in a U shape. Once the suture was tied, the reservoir was securely fixed in a downward position. The upper and lower incisions were sequentially closed, and the procedure was completed. 

Note 

The authors predominantly prefer the jugular vein over the subclavian vein, as port catheters placed via the subclavian route are at risk of developing pinch-off syndrome. In some cases, catheter compression between the first rib and the clavicle may lead to fracture, necessitating surgical removal (2). 

Editor’s Note 

Imaging is generally recommended as a standard practice; however, this approach presents an alternative option for insertion without imaging when necessary, particularly in resource-constrained settings.  While this procedure typically does not fall under the remit of thoracic surgery, this may not be the case in some regions of the world. 

References

1. LaBella G, Kerlakian G, Muck P, et al. Port-A-Cath placement without the aid of fluoroscopy or localizing devices: a community hospital series. Cancer J . 2005 Mar-Apr;11(2):157-9. doi: 10.1097/00130404-200503000-00012.
2. Sen CT. Two-Port VATS Technique to Retrieve a Fractured Chemo Port Catheter from the Left Pulmonary Artery. January 2022. doi:10.25373/ctsnet.19099853

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