• Medications

  • Anesthesia

    • Local anesthetic: 1% lidocaine

    • Conscious sedation: Fentanyl, midazolam

    • General anesthesia (if needed)

  • Heparin

  • Heparinized saline

  • Prophylactic antibiotics

    • Based to local protocol

  • Management of co-morbidities  (allergy, blood glucose, blood pressure, nausea, etc)

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• Trolley/Equipment​

  • Micropuncture access kit

  • Portacath kit:

    • Portacath

    • Peel-away sheath

    • Dilators

    • Microwire (0.018”)

  • Sheaths

  • Wires 

    • 0.018”

    • 0.0035” (standard, hydrophilic, Amplatz superstiff)

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• Checklist

  • CIRSE (IR Patient Safety Checklist)

  • LocSSIPs (Local Safety Standards for Invasive Procedures)

  • NatSSIPs (National Safety Standards for Invasive Procedures)

  • WHO (World Health Organization Surgical Safety Checklist)

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• Access

  • Supine position with rotation of the neck at the contralateral side

  • Ultrasound guided is recommended

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• Technique

  • Cleanse the access sites of the neck and upper chest wall 

  • Cover with sterile drapes

  • Venous access:

    • Administer local anesthetic at the skin and subcutaneous tissues, up to the IJV

    • Perform a skin nick that will fit the peel-away sheath and the tunneling device

    • Use the micropuncture kit to access the IJV under ultrasound guidance

    • Use the microwire (0.018”) to measure the length from the access to the SVC/RA level, under fluoroscopy

    • Exchange the microwire with an 0.0035” wire

    • Dilate the track and insert the peel-away sheath

  • Pocket creation:

    • Choose the implantation site based to:

      • The BMI of the patient

      • Create a smooth tunnel towards the IJV 

    • Administer local anesthetic at the skin and subcutaneous tissues

    • Perform skin incision 

    • At the upper or lower level of the pocket

    • To fit the port’s width

    • Use blunt dissection to create the pocket

    • Pocket’s size should not be larger from the port

    • Frequently test the port into the pocket

  • Tunnel preparation:

    • Administer local anesthetic subcutaneously from the pocket to the neck access

  • Portacath insertion:

    • Use the microwire that was used to measure the venous length, to size the total length of the line from the port to the SVC/RA level

    • Connect and secure the line to the port

    • Flush the port to ensure no leakage

    • Attach the tip of the line to the tunneler

    • Advance the tunneler from the pocket to the exit site on the neck, parallel to the peel-away sheath

    • Detach the tunneler

    • Fit the port into the pocket

      • If needed secure the port with non-absorbable sutures

      • If the pocket is tight, the sutures are not needed usually

    • Remove the wire and the dilator from the peel-away sheath

    • Advance the line into the peel-away sheath

    • Peel and remove the sheath

    • Confirm fluoroscopically that the tip of the line is at the SVC/RA level

    • Flush/aspirate the port with the indicated needle (comes with the kit)

    • Completion chest image

  • Close incisions:

    • Pocket

      • Subcutaneous: 2-0 or 3-0 absorbable sutures (Vicryl)

      • Subcuticular: 3-0 absorbable sutures (Monocryl)

      • Steri-Strips over incision

      • Dressing

    • Neck:

      • Stitches (if needed)

      • Steri-Strips over incision

      • Dressing

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• Tips​

  • Portacath can be used immediately

  • Avoid a large subcutaneous pocket as the Port can migrate or flip

  • In obese patients, create a superficial pocket closer to the clavicle and always secure the port with stiches

  • Keep in mind that the tip of the line will rise as the patient stands

 

• Report

  • Describe the technique

  • Mention venous patency

  • Post-procedure instructions if needed