Port-a-Cath

A Port-a-Cath® is a type of device for intravenous access in patients who require frequent or continuous administration of intravenous substances. The major users of Port-a-Caths are hematology oncology patients but recently, they have been adapted for treating hemodialysis patients as well. The Port-a-Cath® is produced by Smiths Medical MD, Inc. However, the term is used generically for similar devices by other manufacturers (usually as portacath). Other synonymous brand names include Bardport, Passport, Infuse-a-Port, Medi-Port, and Lifesite (for hemodialysis patients). The term totally implantable venous access system (TIVAS) is also used.

Portacaths are most commonly inserted as day surgery procedures in a hospital or clinic by a surgeon or an interventional radiologist using local anaesthetic. They can be removed more simply in a clinic or doctor's office when treatment is complete.

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Principles

The name "portacath" is a portmanteau of "portal" and "catheter". It consists of a reservoir compartment (the portal) that has a silicone bubble for needle insertion (the septum), with an attached plastic tube (the catheter). The device is surgically inserted under the skin in the upper chest or in the arm and appears as a bump under the skin. It requires no special maintenance and is completely internal so swimming and bathing are not a problem. The catheter runs from the portal and is surgically inserted into a vein (usually the jugular vein, subclavian vein, or superior vena cava.) The surgery itself is considered minor, and is typically performed under both local anaesthesia and conscious sedation. Patients sometimes have a little discomfort with breathing after the procedure, and can be managed with over the counter anti-inflammatories & tylenol.

The septum is made of a special self-sealing silicone rubber; it can be punctured up to one thousand times before it needs to be replaced. To administer treatment or to withdraw blood, a health professional will first locate the portal and sterilize the area. Then he or she will access the port by puncturing the overlying skin with a Huber point needle. (Due to its design, there is a very low infection risk, as the breach of skin integrity is never larger than the caliber of the needle. This gives it an advantage over indwelling lines such as the Hickman line.) Negative pressure is created to withdraw blood into the vacuumized needle, to check for blood return and see if the port is functioning normally. Next, the portacath will be flushed with a saline solution. Then, treatment will begin. Also, after each use, a heparin lock is made by injecting a small amount of heparin (an anticoagulant) into the catheter. This prevents development of clots in the system.

Uses

Port-a-Caths have many uses:

• To deliver total parenteral nutrition in those unable to take (adequate) food orally for a long period of time.
• To deliver chemotherapy to cancer patients who must undergo treatment frequently. Chemotherapy is often toxic, and can damage skin and muscle tissue, and therefore should not be delivered through these tissues. Portacaths provide a solution, delivering drugs quickly and efficiently through the entire body via the circulatory system.
• To deliver coagulation factors in patients with severe hemophilia.
• To withdraw (and/or return) blood to the body in patients who require frequent blood tests, and in hemodialysis patients.
• To deliver antibiotics to patients requiring them for a long time or frequently, such as those with cystic fibrosis and bronchiectasis.
• Delivering medications to patients with immune disorders.
• For treating alpha 1-antitrypsin deficiency with replacement therapy

Alternatives to portacaths include the Hickman line and the PICC line.

Variability

There are many different types of portacaths. The particular type selected is based on the patient's specific medical conditions.

Portals:

• can be made of plastic, stainless steel, or titanium
• can be single chamber or dual chamber
• vary in height (although the base is about the size of a quarter)

Catheters:

• can be made of polyurethane (like grocery bags) or silicone (like breast implants)
• can vary in length (cm)
• can vary in diameter (mm)

Portacaths can be put in the upper chest or arm. The exact positioning itself is variable as it can be inserted to avoid visibility when wearing low cut shirts, and to avoid excess contact due to a backpack or bra strap. The most common placement is on the upper right portion of the chest, with the catheter itself looping through the jugular vein down near the patient's heart.

Risks

1. Infection - a severe bacterial infection can compromise the device, require its surgical removal, and seriously jeopardize the health of the already weak patient.
2. Thrombosis - formation of a blood clot in the catheter may block the device irrevocably. To prevent clotting the portacath is flushed with saline and heparin, usually by a nurse or other medical professional, at least once every four weeks, or more often in conjunction with administering medication.
3. Mechanical failure - is extremely unlikely. It is possible in a rare event that part of the system could break and become lodged in the circulatory system. In such case it is unlikely to cause any serious harm.
4. Age - If the device is put into a child, the child's growth means that the catheter becomes relatively shorter and will move away from the inferior part of the superior vena cava - it might be necessary to remove or replace it.
5. Pneumothorax - Attempts to gain access to the subclavian vein or jugular vein can injure the lung, possibly leading to this complication. If the pneumothorax is large enough, a chest tube might need to be placed. In experienced hands, the incidence of this complication is about 1%.
6. Arterial injury - The subclavian artery can be inadvertently punctured. This usually leads to a subcutaneous hematoma and occasionally a pseudoaneurysm. An alternative site may need to be used for port placement. Puncture of the carotid artery is more rare, since attempts to access the nearby jugular vein and increasingly done with ultrasound guidance.

Production

The major manufacturers of portacaths are Smiths Medical, Bard Access Systems, and Rita Medical Systems. In the United States, insertion of a TIVAS costs about $5,000 (material and staff costs). Medical insurance will usually cover part or all of the cost.