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Luc Rotenberg, Gregory Lenczner ULTRASOUND GUIDED VENOUS ACCESS CHEST PORT IMPLANTATION

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Luc Rotenberg, Gregory Lenczner ULTRASOUND GUIDED VENOUS ACCESS CHEST PORT IMPLANTATION

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LUC ROTENBERG, GREGORY LENCZNER, ULTRASOUND GUIDED VENOUS ACCESS CHEST PORT IMPLANTATION, SUBCLAVIAN ACCESS, NO TUNELISATION, DELTOPECTORAL GROOVE INCISION AND ACCESS , TIP POSITION XRAY CONTROL

LUC ROTENBERG, GREGORY LENCZNER, ULTRASOUND GUIDED VENOUS ACCESS CHEST PORT IMPLANTATION, SUBCLAVIAN ACCESS, NO TUNELISATION, DELTOPECTORAL GROOVE INCISION AND ACCESS , TIP POSITION XRAY CONTROL

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Luc Rotenberg, Gregory Lenczner ULTRASOUND GUIDED VENOUS ACCESS CHEST PORT IMPLANTATION

  1. 1. ! Chest port implantation by venous access with US Guidance Luc Rotenberg, Gregory Lenczner Clinique Hartmann – Ambroise Paré 26-27 bd Victor Hugo, 92200 Neuilly Sur Seine – France www.radiologieparisouest.com dr.rotenberg@radiologieparisouest.com Nanjing-China June 24th 2017
  2. 2. ! S  358 000 cancers cases/year S  145 000 ports S  50 000 PICC Lines Ports implantation in France private/public Potential ports APHP 10 000 CHU 26 000 Public 35 000 CRLCC 17 000 Private 57 000 Total 145 000
  3. 3. ! !
  4. 4. ! Hartmann Clinic Built in 1904 Prof Henri Hartmann
  5. 5. ! In the 1920’s… Radioherapy in Hartmann Clinic
  6. 6. ! First Cobalt bomb HARTMANN 1955
  7. 7. ! S  ISHH = 700 ports / year S  Radiologists S  Surgeon S  Non dedicated or dedicated operating session S  Mean of 5 implants/session S  300 ablations !
  8. 8. ! Clinical Pathway Balistic preoperative consultation §  Report Study §  Interrogatory (risk factors…) §  Balistic approch §  Targeted §  Device and guidance technique choice §  Patient explanation of : §  Intervention §  complications §  Possible results and implications §  Pricing §  Written informed consent is required before all interventions +++
  9. 9. ! Clinical Pathway S  Ambulatory S  Short delay : 0 to10 days S  Mean delay : 5 days S  No delay in case of emmergency
  10. 10. ! Quality of life S  Before intervention S  Ports implantation S  During chimotherapy S  After treatment
  11. 11. ! US guidance S  Venous direct puncture US guided S  100 % access SCV S  Difficult cases S  Asepsia +++ S  Steril pouch S  protection for patient S  protection for probe S  Steril gel
  12. 12. ! § non ionizing radiation § multiples access § real time control US Guidance
  13. 13. ! ULTRASOUNDS REVIEWS S  Skolnick ML : The role of sonography in the placement and management of jugular and subclavian central venous catheters. Am J Roentgenol. 1994; 163:291-5 « US improve safety, speed, comfort » S  Randolph AG, Cook DJ, Gonzales CA, Pribble CG : Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996; 24:2053-8 « US increase probability of successful placement, reduce complications, decrease multiple attempts » S  Hind D, Calvert N, McWilliams R et all : Ultrasonic locating devices for central venous cannulation: meta-analysis. . BMJ. 2003, 16; 327(7411):361 « US decrease failures, reduce complications, decrease failure at 1rst attempt, decrease Nb of attempts, decrease Nb of seconds for successful catheterization  » S  Cavanna, Luigi, et al. "Ultrasound-guided central venous catheterization in cancer patients improves the success rate of cannulation and reduces mechanical complications: a prospective observational study of 1,978 consecutive catheterizations." World journal of surgical oncology 8.1 (2010): 1. « US-improves the success rate of cannulation and reduces mechanical complications »
  14. 14. ! n Before intervention n End point venous access n Local structures: §  pleura § sub clavian artery §  clavicle n feasability US checking venous access
  15. 15. ! Compression of the Vein
  16. 16. !
  17. 17. ! S  Installation +++ S  Fast intervention S  Start with easy access S  Phantom training Key point
  18. 18. ! Puncture technique Access/ / long probe axis S  Out plane : Perpendicular to the major axis of the probe S  In plane : In the longitudinal axis of the probe
  19. 19. ! Out Plane Access orthogonal
  20. 20. ! Out Plane Access orthogonal
  21. 21. ! In Plane Access Longitudinal
  22. 22. ! Sterile pouch
  23. 23. ! INTERNAL JUGULAR VEIN
 direct puncture
  24. 24. ! Landmarks
  25. 25. ! HOW ? JUGULAR VEIN APPROACH: UltraSounds locating is more reliable than anatomical landmarks HIND Br Med J 2003:361 MAC GEEN N Eng J Med 2003:1123
  26. 26. ! In plane approach Courtesy of Dr Eric Desruennes
  27. 27. ! In plane approach Courtesy of Dr Eric Desruennes
  28. 28. ! INTERNAL JUGULAR 
 « in short »
 
 tunneling the catheter
  29. 29. !
  30. 30. !
  31. 31. !
  32. 32. ! INTERNAL JUGULAR 
 
 in PAEDIATRICS
  33. 33. !
  34. 34. ! Sub Clavian chest port S  In recent years, the surgical approach to the subclavian vein by sub clavicular "classic" was partially abandoned in favor of the internal jugular, supposedly safer. S  The addition of ultrasound guidance helps restore its credentials in this way, more functional and aesthetic avoiding many of the previous complications of « blind » puncture. S  Surroundings 5000 procedures were performed in our institute since 2007, with this technique and this way without first pneumothorax, arterial puncture or pinch off syndrome.
  35. 35. ! US and SUBCLAV.VEIN S  Laméris JS, Post PJ, Zonderland HM et all : Percutaneous placement of Hickman catheters: comparison of sonographically guided and blind techniques. AJR Am J Roentgenol. 1990; 155(5):1097-9 radiologist vs surgeon pneumo/hemothorax: US 0% vs Landmarks 10% S  Gualtieri E, Deppe SA, Sipperly ME, Thompson DR :Subclavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance. Crit Care Med. 1995; 23(4):692-7 less experienced Drs success rate: US 92% vs Landmarks 44% S  Pirotte T, Veyckemans F : Ultrasound-guided subclavian vein cannulation in infants and children: a novel approach. Br J Anaesth. 2007; 98(4):509-14 (successive/children < 10kg): exp Dr success rate: 1rst attempt 84%, 2nd attempt 100%
  36. 36. Target to follow
  37. 37. !
  38. 38. ! Longitudinale approach In plane way Courtesy of Dr Eric Desruennes
  39. 39. ! Subclavian Port
  40. 40. !
  41. 41. ! Subclavian Port
  42. 42. ! US guidance ultrasound guidance with sterile pouch allows direct puncture of the subclavian vein and avoids the tunneling
  43. 43. !
  44. 44. !
  45. 45. ! US guidance
  46. 46. ! Puncture of the subclavian vein is always distant from the clavicle : 2-4 cm up of the costovertebral joint), and not crossing over. Compression and ponction scv Orthogonal approach Out plane way
  47. 47. !
  48. 48. ! Subclavian Port
  49. 49. ! Subclavian Port
  50. 50. !
  51. 51. !
  52. 52. !
  53. 53. !
  54. 54. !
  55. 55. !
  56. 56. !
  57. 57. ! CEPHALIC VEIN
 surgical procedure
 at chest level
  58. 58. ! CEPHALIC VEIN « in short »
  59. 59. !
  60. 60. !
  61. 61. ! BRACHIAL VEIN
 by BASILIC approach
  62. 62. ! BASILIC VEIN « in short »
  63. 63. !
  64. 64. !
  65. 65. !
  66. 66. !
  67. 67. !
  68. 68. !
  69. 69. ! AXILLARY VEIN
  70. 70. ! AXILLARY VEIN « in short »
  71. 71. !
  72. 72. !
  73. 73. ! EXTERNAL JUGULAR VEIN
 
 …exceptionnal
  74. 74. ! FEMORAL VEIN …exceptionnal
  75. 75. ! In all cases Plain Chest XRAY control •  Ports position •  Reference imaging
  76. 76. ! Profile if necessary
  77. 77. !
  78. 78. ! « the Chest Port horror show » What not suppose to do
  79. 79. ! Never in the decollete « the Chest Port horror show »
  80. 80. ! « the Chest Port horror show »
  81. 81. !
  82. 82. !
  83. 83. !
  84. 84. !
  85. 85. !
  86. 86. !
  87. 87. ! Surgical approach §  surgical approach by the healthy side §  prevent disease areas §  radiotherapy
  88. 88. !
  89. 89. !
  90. 90. ! Esthetic respect neckline and decollete (BUNODIERE 2001) Criteria for selection of surgical approach
  91. 91. !
  92. 92. ! Good result •  Small scar (1 to 2 cm) •  Oblique or vertical scar by deltopectoral groove approach •  invisible suture by a buried overlock and/or biological glue
  93. 93. ! Discreet or invisible scare in deltopectoral groove
  94. 94. !
  95. 95. ! Almost invisible scar in deltopectoral groove
  96. 96. !
  97. 97. ! For male to
  98. 98. ! Preventing complications of central venous catheterization
 McGee N Engl J Med 2003; 348:1123-33
  99. 99. ! Injuries and liability related to central vascular catheters: 
 a closed claims analysis 
 Domino Anesthesiology 2004; 100:1411-8
  100. 100. ! conclusion : patient opinion 0 10 20 30 40 50 60 70 80 90 100 Before After Favorable Not Favorable Retrospective study 100 consecutive women Hartmann 2005 n  Satisfaction 97 % n  Gratefull for preserving the cleavage 64 %
  101. 101. ! WHAT IS GOOD FOR THE PATIENT …IS GOOD FOR THE DOCTOR THE REVERSE MAY BE WRONG ! Dr Michel BUNODIERE, 2001
  102. 102. ! Take home : US guidance ports access 1.  Technique 1.  US guidance scv ponction 2.  Verticale or oblique scare in deltopectoral groove, 1 to 2 cm 3.  Direct SCV ponction through the ports hole : no tunelisation 4.  Xray intervention guidance 5.  Deep point with vicryl 3.0 and intradermal surjet monocryl 4.0 and/or biological glue 2.  Advantages / misadvantages 1.  Esthetic 2.  Fonctionnal 3.  Fast 4.  Few complication since 10 years: pneumothorax = 0, pinch-off = 0 5.  Operating dependant

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