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Vascular access in cancer patients – clinical implications
Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Central venous catheters (CVC) are vital for patients receiving chemotherapy not compatible with peripheral infusion. Thousands of centrally and peripherally inserted central venous catheters are inserted into patients with cancer each year. All types of intravascular catheters are associated with complications. These complications may be divided into infectious, thrombotic, mechanical and occlusive events. All of these events have the potential to harm patients and cause additional expense for the health-care system. Furthermore, the above-mentioned complications are largely avoidable through proper patient selection, insertion technique, hygiene precautions and catheter maintenance.

Catheter-related infections and deep venous thrombosis are the two most common and feared CVC related complications. Infection in a catheter can cause lifethreatening bacteraemia, and thrombosis can lead to pulmonary embolisation, post-thrombotic syndrome and stenosis of the vessel affected. Many studies describing methods to minimise infectious complications associated with central venous catheters have been carried out. These methods appear to have been implemented in most modern advanced healthcare facilities resulting in a continual decrease in catheter-related infections over the last two decades. New implantation techniques, fewer infections and better catheter materials are likely to have contributed to the reduction in the incidence of catheter-related deep venous thrombosis (CR-DVT). Peripherally inserted central venous catheters (PICC) and subcutaneously implanted vascular access ports (PORT) are two very commonly used catheter devices for delivery of chemotherapy. International guidelines are unclear as to which device to choose due to the paucity of controlled trials.

The aim of this thesis was to study complications related to central venous access devices used over long periods of time, usually for the delivery of chemotherapy. Vascular access in cancer patients – clinical implications We prospectively studied PORT complications (Study 1) over a six-month follow- up period. In Study 2, we assessed the number of common CVC-related micro- organisms that are transferred across PORT membrane contaminated by a controlled suspension of micro-organisms when a non-coring access needle is inserted using two different techniques. In the largest randomised controlled trial published on this topic (Study 3), we compared PICC with PORT regarding CRDVT and other catheter-related complications. The economic implications of using PICC or PORT were assessed from health-care system´s perspective (Study 4), using data on adverse events and clinical factors (implantation, treatments and dwell-time) from Study 3.

Chemotherapy against various forms of cancer is very common. Implantation of PORT is one of the ten most common surgical procedures in Sweden according to the Swedish Perioperative Register. Hence, the topic in this thesis may be clinically relevant to many patients and their health care providers.

We found that the incidence of catheter-related blood stream infection was very low in the cohorts studied. In general, PICCs are associated with significantly more CR-DVTs and adverse events than PORTs. The cost to the health-care system when using PICC is higher than for PORT when complications are included. Given the choice, patients about to commence chemotherapy appear to prefer PORT to PICC. PORT implantation is more painful than PICC insertion, but PICC appears to influence activities of daily life more than PORT.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. , p. 99
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1693
National Category
Surgery
Identifiers
URN: urn:nbn:se:liu:diva-159085DOI: 10.3384/diss.diva-159085ISBN: 9789176850220 (print)OAI: oai:DiVA.org:liu-159085DiVA, id: diva2:1338642
Public defence
2019-09-06, Originalet, Qulturum, Länssjukhuset Ryhov, Jönköping, 09:00 (English)
Opponent
Supervisors
Available from: 2019-07-23 Created: 2019-07-23 Last updated: 2019-08-01Bibliographically approved
List of papers
1. A prospective observational study on 249 subcutaneous central vein access ports in a Swedish county hospital
Open this publication in new window or tab >>A prospective observational study on 249 subcutaneous central vein access ports in a Swedish county hospital
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2013 (English)In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 52, no 5, p. 893-901Article in journal (Refereed) Published
Abstract [en]

Background. Reliable central vein access is a fundamental issue in modern advanced oncological care. The aim of this study was to determine the incidence of complications and patient perception regarding central vein access ports. Methods. We prospectively studied 249 single lumen access ports implanted between 1 July 2008 and 15 March 2010 in a mixed patient population at a 500-bed secondary level hospital in Sweden. We determined the number of catheter days, infection rate and mechanical complications, as well as patient satisfaction regarding the access port, over a six-month follow-up period. Results. Two hundred and forty-four different patients received 249 ports yielding a total of 37 763 catheter days. Ultrasound and fluoroscopic guidance was used in 98% of procedures. Vein access was obtained percutanously by an anaesthesiologist in all cases. There was no case of pneumo- or haemothorax. The incidence of catheter-related bloodstream infection, was 0.05/1000 catheter days and the incidence of pocket/tunnel infection was 0.39/1000 catheter days. Clinically apparent deep vein thrombosis occurred in four patients (1.6%). Patient satisfaction was overall high. Conclusion. These results confirm that our team-based approach with written easily accessible evidence-based guidelines and a structured education programme leads to a very low complication rate and a high degree of patient satisfaction.

Place, publisher, year, edition, pages
Informa Healthcare, 2013
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-93959 (URN)10.3109/0284186X.2013.770601 (DOI)000318655300003 ()
Note

Funding Agencies|Futurum - the Academy for Healthcare, Jonkoping County Council, Jonkoping, Sweden||

Available from: 2013-06-13 Created: 2013-06-13 Last updated: 2019-07-23
2. Clinical impact of peripherally inserted central catheters vs implanted port catheters in patients with cancer: an open-label, randomised, two-centre trial
Open this publication in new window or tab >>Clinical impact of peripherally inserted central catheters vs implanted port catheters in patients with cancer: an open-label, randomised, two-centre trial
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2019 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 122, no 6, p. 734-741Article in journal (Refereed) Published
Abstract [en]

Background

Centrally inserted totally implanted vascular access ports (PORTs) and peripherally inserted central catheters (PICCs) are widely used for the administration of chemotherapy. Our aim was to study the incidence of catheter-related deep venous thrombosis in patients with cancer receiving chemotherapy through either a PICC or a PORT.

Methods

Adults with non-haematological cancer (mainly breast and colorectal) from two Swedish oncology centres were included and followed for up to 1 yr. Patients were randomly assigned to receive a single-lumen PICC or PORT. The primary end point was the occurrence of a clinically significant catheter-related deep venous thrombosis, and the secondary end point was a composite of adverse events related to the catheter: insertion complication, thrombosis, occlusion, infection, and mechanical problems.

Results

The trial recruited 399 participants (PICC, n=201; PORT, n=198) between March 2013 and February 2017. The PICCs were associated with 16 (8%) deep venous thromboses compared with two (1%) in the PORT group (HR=10.2; 95% confidence interval, 2.3–44.6; P=0.002). The overall incidence of composite adverse events was higher for patients with a PICC compared with those with a PORT (HR=2.7; 95% confidence interval, 1.6–4.6; P<0.001).

Conclusions

PICCs are associated with higher risk for catheter-related deep venous thrombosis and other adverse events when compared with PORTs. This increased risk should be considered when choosing a vascular access device for chemotherapy, especially in patients with solid malignancy.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
central venous catheter; central venous catheter thrombosis; peripherally inserted central catheter line insertion; vascular access devices
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-158319 (URN)10.1016/j.bja.2019.01.038 (DOI)000467806400034 ()31005243 (PubMedID)2-s2.0-85064326103 (Scopus ID)
Note

Funding Agencies|Futurum (Academy for Healthcare, Jonkoping County Council, Sweden) [767451]; FORSS (Research Council in South East Sweden) [295881]

Available from: 2019-07-02 Created: 2019-07-02 Last updated: 2019-10-15Bibliographically approved

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Taxbro, Knut

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