Portacath insertion

A Portacath (also referred to as Port, Chemoport or Power Port) is an implanted central venous access device recommended for patients who need chemotherapy over several months. The main advantage the Portacath has over the other devices is that it is completely covered by your skin so you can shower, bathe or even swim with it in place.

It consists of two parts – an injection port (the portal), which is about the size of a ten pence piece, and a long flexible tube (the catheter). The portal is implanted under the skin in the upper chest and the catheter runs under the skin and enters either the large vein in the lower neck (internal jugular vein) or the vein under the collar bone (axillary vein).

The portal has a septum made of a special self-sealing silicone which can be punctured many hundreds of times so the port can be used for years, if necessary.

How is the Portacath used?

The skin over the Portacath is sterilised and the port is accessed by puncturing the overlying skin with a special needle (Huber needle). If necessary, anaesthetic cream can be applied to the skin beforehand to make this more comfortable.

The Huber needle is designed so that it will not damage the silicone septum. Blood is drawn back to check that the port is functioning normally and then it is flushed with saline before treatment can begin. After each use, the Portacath is flushed with saline to prevent any clots from forming. The needle is then removed from the port just leaving a pinprick mark on the skin.

How is the Portacath inserted?

The procedure is performed under local anaesthetic and intravenous sedation in either the Oncology Theatre or Interventional Radiology suite at Maidstone Hospital or the Interventional Radiology suite at Tunbridge Wells Hospital by a highly trained doctor (either a Consultant Anaesthetist or Interventional Radiologist). They will examine the veins using an ultrasound machine to check their position and suitability and then insert a flexible wire into the vein.

X-rays are used to check the final position of the port ensuring that the tip of the catheter lies in the large vein just outside the heart.

The actual procedure takes approximately 30-60 minutes. If the axillary vein is used the procedure can be done through a single 2-3cm incision on the chest wall. If the internal jugular vein is used it is necessary to make a second smaller incision (approximately 3mm) in the lower neck to access the vein. The consultant will discuss this with you when they consent you for the procedure.

At the end of the procedure, absorbable sutures are used to close the wounds so there are no stitches to remove afterwards. These wounds are covered with a water resistant ‘skin glue’ so there are no dressings to change. Typically, most patients go home 30-60 minutes after the procedure. You should arrange for someone to take you home, as you must not drive for 24 hours following sedation.

What preparation is required?

All patients need to have MRSA swabs taken at least 48 hours prior to the procedure. If you are a Haematology patient or have already started chemotherapy you will also need to have some blood tests. If you are taking anticoagulant drugs (blood thinning medication such as Warfarin, Dalteparin (Fragmin), Rivaroxaban etc), these will need to be stopped. You should receive advice on when to stop these but in general:

• Warfarin – stop for 5 days but take Fragmin until 24 hours before the procedure
• Rivaroxaban/ Apixaban – stop 48 hours before the procedure
• Dalteparin/Enoxaparin – stop 24 hours before the procedure
• Clopidogrel/Aspirin – just omit on the day of the procedure

Fasting

On the day of insertion, you need to fast for 6 hours but you may drink water right up until the time of the procedure.

You will need someone with you to drive you home afterwards because the procedure is performed under sedation and you must not drive/operate machinery for 24 hours.

Aftercare

For two weeks, avoid strenuous activities of the upper limb and chest wall (no golf, contact sports or swimming for four weeks) and be careful showering. The skin glue is water-resistant but should not be washed vigorously with soap. The wounds should be dried carefully after showering (do not rub them). It is inadvisable to soak in a bath until the wounds have fully healed (approximately two weeks).

If there are any issues associated with wound healing, persistent redness or soreness please contact your oncologist or chemotherapy nurse.

It is quite usual for your neck and chest to ache for a few days after the procedure. Simple pain killers such as paracetamol will help relieve this or you can take any other pain-relieving medication prescribed for you.

The Portacath needs to be flushed with saline once every 4-8 weeks to keep it working (if your chemotherapy is more frequent than this it will be flushed at the same time). When the Portacath is no longer required, it can be removed. This is normally done under local anaesthetic (and sedation if required) but is a more minor procedure than the insertion.

Complications

With modern imaging techniques (using both ultrasound and x-rays), the risks of the procedure itself are minimal. However, there is still a small risk of blood vessel injury, nerve damage, collapse of the lung and wound infection. There is also the very remote chance of being allergic to the local anaesthetic or the skin glue that is used.

Bruising is relatively common especially in patients taking anticoagulant therapy but is normally confined to a small area and resolves within a couple of weeks.

Thrombosis (blood clots) is a risk for all patients on chemotherapy and having a Portacath may increase this risk slightly. If you do experience any sudden onset of pain and swelling in your arm, neck or face, you should contact your oncologist or chemotherapy nurse.

Rarely the catheter can move within the body and become malpositioned. This is known as migration and occurs more common with PICCs and tunnelled CVCs rather than ports. If a chest x-ray confirms that this has happened, it may be necessary to re-position the catheter.

– Dr Richard Leech

Vascular access service consultants

• Dr David Golden, Consultant Anaesthetist
• Dr Bhavin Kawa, Consultant Interventional Radiologist
• Dr Richard Leech, Consultant Anaesthetist and Lead for the Vascular Access Service
• Dr Aidan Shaw, Consultant Interventional Radiologist
• Dr Roy Wheeler, Consultant Interventional Radiologist
• Dr James Wood, Consultant Anaesthetist