Patients
This prospective cohort study was conducted at Breast Disease Center of the Fourth Hospital of Hebei Medical University (Shijiazhuang, China), and 205 adult female patients with breast cancer who underwent of TIVAD removal between June 2019 and November 2019 were enrolled in the current analysis. Eligible patients were females with breast cancer and older than 18 years, who were scheduled for TIVAD removal at more than 3 months after chemotherapy. Exclusion criteria were set as follows: (1) patients who were unable to sign informed consent, (2) inability to stand for a preoperative chest X-ray, (3) history of diabetes or abnormal white blood cell count and clotting tests (international normalized ratio >2, or platelet count <40,000/mm3 or >1,000,000/mm3), (4) patients taking antiangiogenic drugs (such as anti-vascular endothelial growth factor antibody).
The patients were randomly and evenly assigned into two groups following the simple randomization procedures (computerized random numbers). There were 102 cases in group A, in which the port was removed before the catheter. There were 103 cases in group B, in which, in contrast to group A, the catheter was taken out first, and then the port was removed.
This retrospective study was approved by the Hospital Ethics Committee and patients’ informed consent.
Type of port systems
All the TIVADs used consisted of a silastic port with a silicone membrane connected to a silicone rubber catheter (8F, Groshong catheter, BARD X-Port isp™, CR Bard Inc., Murray Hill, NJ, USA). All the TIVADs were inserted in the internal jugular vein, and the ports were embedded in the lowest part of the deltopectoral groove about two fingers under the inferior border of the clavicle with no suture and fixation.
Procedure for TICVAD removal
The removal of TIVADs was performed in the central catheter room by the same surgeon under local anesthesia without the use of electrocautery. The operative procedure was as follows:
(1) The patient was placed in a supine position with his head tilted to the opposite side and arm slightly abducted.
(2) The operation area was disinfected with iodine and ethanol, and sterile sheets were laid. In addition, 1% lidocaine was used for local anesthetic infiltration.
(3) Two different strategies were used to remove TIVADs.
In group A, the port seat was taken out first, and then the catheter was removed (Fig. 1). After administration of local anesthesia with 1% lidocaine on the previously labeled landmarks, the skin was incised along the previous scar, subcutaneous tissue was dissected, and the position of the catheter lock was determined by palpation. The scalpel blade was inserted parallel to the catheter lock toward the port fibrous capsule to prevent cutting the catheter (Fig. A1). After the port was exposed (Fig. A2), hemostatic forceps were used to bluntly enlarge the opening of the fibrous capsule, the port was flipped (Fig. A3), and the TIVADs were removed with careful manual compression on the insertion point of the catheter (Fig. A4). At last, the catheter surrounded by the fibrous capsule was removed from the location within the vein and tunnel through blunt dissection.
In group B, the catheter was removed before the port seat (Figure 2). After the skin and subcutaneous adipose tissue were incised along the original incision, the fibrous capsule was opened with a scalpel blade along the long axis of the catheter lock to expose the catheter lock (Fig. B1). After blunt dissection, the catheter surrounded by the capsule was mobilized, and the deep side of the catheter lock was fixed by mosquito-type vascular forceps to lift the catheter lock and connect the catheter (Fig. B2). Then the catheter was dissected from the enveloping capsule without damaging it (Fig. B3), the opening of the fibrous sinus around the catheter was ligated, and the port was removed in the same way (Fig. B4).
(4) After the port was removed, the fibrous capsule was slightly punctured with the tip of the blade, which facilitated the growth of granulation tissue into the closed residual cavity. The next step was to vigorously irrigate the pocket with 10−20 mL of sterile saline.
(5) For skin closure, a discontinuous suture for deep tissue was performed with 3-0 non-absorbable suture (Johnson & Johnson, SA84G, USA), and then a subcuticular continuous intradermal suture was performed with 4-0 sterile absorbable multistrand suture (Johnson & Johnson, VCP422H USA). A bandage was applied using sterile excipients.
(6) The integrity of the catheter was examined.
Main outcome measurement
After the operation, all patients were given a Visual Analogue Score (VAS) for pain and asked to fill it under the guidance of the assistant doctor. These patients were also instructed to have a wound check within 7 days to ensure proper healing. A team consisting of a physician assistant and an attending physician followed the patients and collected the information.
The operation time and postoperative complications (pain, local skin infection, and hematoma) were measured. The operation time was determined from the time when the patient received local anesthetics to the time when the aseptic dressing was applied after skin closure. Patient pain was evaluated after the surgery using a VAS ruler as follows: 0 point, no pain, 1–3 points, mild pain, and >3 points, moderate-to-severe pain. Local skin infection was defined by the presence of erythema and/or tenderness over the skin sack and along the tunneled catheter to the vein access. All patients consented to complete the questionnaire and volunteered for this assessment.
Statistical analysis
All data were analyzed with SPSS for Windows, Version 21.0 (IBM Corp., Armonk, NY, USA). The data of age, retention time of TIVADs, and operation time were analyzed using an independent sample t-test. The incidence of postoperative pain, hematoma, and wound infection were analyzed using a chi-square test. When the sample size was less than 40 or the theoretical frequency was less than 1, they were analyzed using a Fisher’s exact test. A two-tailed P<0.05 was considered statistically significant.