Vol.2, No.

2, 15-18 (2013) Modern Chemotherapy

http://dx.doi.org/10.4236/mc.2013.22003

Extending the interval for port-a-cath maintenance

Eugenia Girda, Rebecca Phaeton, Gary L. Goldberg, Dennis Kuo*
Department of Obstetrics & Gynecology and Women’s Health, Division of Gynecologic Oncology, Albert Einstein College of Medi-
cine and Montefiore Medical Center, New York City, USA; *Corresponding Author: [email protected]

Received 18 February 2013; revised 20 March 2013; accepted 28 March 2013

Copyright © 2013 Eugenia Girda et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT venient in the patient population with gyneco-

logic malignancies.
Objective: The objective of this study is to as-
sess the outcome of port-a-cath (PAC) mainte- Keywords: Indwelling Port-A-Cath; Flushing;
nance every three months in patients with gy- Complication; Prevention
necologic malignancies with the goal of stan-
dardizing a safe and appropriate interval that
would maintain patency and minimize side ef- 1. INTRODUCTION
fects. Methods: We performed a retrospective The safe and timely administration of chemotherapy in
medical record review and evaluation of all pa- part relies on consistent access to the venous system. In
©
tients with a Bard PAC who were noted to have many patients with advanced malignancies and other
no evidence of disease (NED) during the years medical co-morbidities, such as peripheral vascular dis-
2003 to 2010. The interval between accessions ease, a more reliable form of access is mediated by
and any complications related to the presence of semi-permanent or permanent devices such as a periph-
the PAC were recorded. Relevant complications erally inserted central catheter (PICC), Hickman catheter,
included skin infections, bacteremia, thrombo- or port-a-cath (PAC). Implantable venous access devices
sis, and occlusions. Statistical analysis was provide repeated access to the vascular system and have
done using the Fisher’s exact test. Results: A been widely used in patients with malignancies receiving
total of 201 patients had PAC placed and 43 pa- long-term treatments such as chemotherapy and total
tients underwent PAC accessions to maintain parenteral nutrition (TPN).
patency. The total number of accessions was Port-A-Cath consists of a port and an intravascular de-
150 with a median number per patient of 2.0 vice. The intravascular device is inserted into a sub-
(range 1 - 10). The mean time between flushes clavian or jugular vein and tunneled under the skin of the
was 112 days (SD = 57). When comparing wo- chest wall. The procedure is usually performed under
men in maintenance who had flushes within sedation or general anesthetic. As the breach of skin in-
90 days versus those who had flushes over 90 tegrity does not exceed the caliber of the needle, the risk
days apart, there was no difference in infection of infection and thrombosis is lower compared to in-
or occlusion rates between these groups (p = dwelling catheters such as Hickman catheters [1]. Many
0.515). In the <90-day group, one patient was studies have analyzed the complications associated with
noted to have resistance during the flush. In the implantable catheters, however very few have com-
≥90-day group, one patient had an occlusion mented on the ideal or recommended length of the main-
that did not resolve with Alteplase. Another pa- tenance period between flushing the port with heparin
tient had skin erythema with spontaneous reso- [2-5].
lution. Conclusion: Infections and occlusions At our institution, several patients, at the completion
are rare in women with gynecologic malignan- of the chemotherapy course, retain their PAC due to the
cies undergoing maintenance of their PAC. Lon- high recurrence rate of some of these malignancies and
ger intervals between PAC flushes do not appear therefore a possible need for subsequent use of PAC for
to affect the outcome in our patients. Our ongo- additional chemotherapy cycles after advisement by their
ing data and follow-up confirm that extending provider. During this maintenance period, many of our
the interval of PAC accession to every 3 months, patients are no longer receiving chemotherapy or having
rather than monthly, is safe, effective and con- regular blood tests performed and have relatively poor

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16 E. Girda et al. / Modern Chemotherapy 2 (2013) 15-18

compliance with their regular port accession appoint- 2003 and 2010 at Montefiore Medical Center. Twenty-
ments. At present, the ideal interval of accession to main- one percent (43) of patients retained their port at the
tain patency is unknown. Therefore, it is important to de- completion of chemotherapy and had continued PAC
velop a safe, cost effective and convenient catheter main- accessions to maintain patency. Of the patients who were
tenance protocol. excluded (158), one hundred and six (106) patients did
Although the manufacturer’s guidelines usually re- not have adequate maintenance period due to either hos-
commend monthly accession in order to maintain port pitalization or continued chemotherapy, thirty nine (39)
patency, based on our previous data and safety profile we patients died following PAC placement, eight (8) patients
currently access the PAC every three months to maintain had PAC removed following chemotherapy and five (5)
port patency [6]. The purpose of this study is to assess patients transferred care or were lost to follow-up.
the follow up and outcome of PAC maintenance every 3 Forty-three patients who were included in the study
months in patients with gynecologic cancers and provide had been scheduled for PAC maintenance every 3 mon-
a more comprehensive analysis of longer-term data. ths. The primary malignancies for these patients were as
follows: 25 patients with uterine cancers, 15 patients
2. METHODS with ovarian cancers, and 3 patients with cervical cancer
All patients who underwent care in the Gynecologic (Table 1).
Oncology Division of the Department of Obstetrics and Compliance with visits for PAC maintenance varied
Gynecology and Women’s Health at the Albert Einstein significantly with the individual mean accession times
College of Medicine and Montefiore Medical Center varying between 30 days and 210 days. The total number
were considered for entry into the study. The placement of accessions was 150 with a median number per patient
of PAC and subsequent follow-up was derived from both of 2.0 (range 1 - 10). The mean time between flushes was
a computer database and complementary medical records 112 days (SD = 57). Figure 1 shows the distribution of
at the divisions’ administrative offices. The computer mean accession intervals for all of the patients.
database and the medical records were accessed to obtain Since our initial pilot study analyzed a 90-day main-
a listing of all patients who had a procedure of PAC in- tenance follow-up, we aimed to determine if extending
sertion. Review and screening of all the charts was per- maintenance beyond 90 days was associated with any
formed to include eligible patients. difference in side effects. Therefore, the accession inter-
Inclusion criteria were: confirmed placement of PAC vals were divided into two groups: greater than 90 days
on imaging, subsequent treatment with the practice as and fewer than 90 days. The interval of accessions, right
well as follow up during the maintenance period. The before each of the complications, was recorded. In the
exclusion criteria were: patients who were receiving anti- group with less than 90-day intervals, 30 accessions were
coagulation with Lovenox, Fragmin, or Coumadin for noted and 1 complication was observed. In the second
other medical issues or those who had PAC device re- group with flush intervals more than 90 days apart, 111
moved immediately after first-line chemotherapy. accessions and 2 complications were noted.
Maintenance period was defined as a minimum of six There was no statistical difference in infection or oc-
months without chemotherapy, intravenous hydration or clusion rates between these groups (p = 0.515). Table 2
other infusion. The protocol for PAC access used stan- notes the complications associated with PAC accessions.
dard sterile precautions using 10 cc of normal saline fol- In the <90-day group, one patient had resistance with
lowed by 5 cc of heparin flush (100 units heparin/cc). If slow return of blood during flushing. This patient had
there was no blood return, Alteplase was administered two port accessions with the interval of 30 days, and the
and results noted. complication was noted at the time of second port acces-
Chart review included collection of data such as age, sion. In the ≥90-day group, one patient had an occlusion
date of PAC insertion, location of PAC and dates of PAC that did not respond to Alteplase. This patient had two
accessions. Complications associated with PAC flushing, PAC accessions, which were 92 days apart. Another pa-
including catheter tip thrombus and infections, were re- tient in the ≥90-day group had skin erythema around the
corded as well as results of managing these complica- PAC flush site. This patient has 11 port accessions for
tions. The data was subsequently entered into an Excel
spreadsheet. From the collected data, the total number of Table 1. Types of malignancies.
port access flushes and the interval in days between each
Type of Tumor No. of patients
flush was calculated. Statistical analysis was performed
using the student t test. Uterine 25

Ovarian 15
3. RESULTS
Cervical 3
A total of 201 patients had a PAC placed between

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 E. Girda et al. / Modern Chemotherapy 2 (2013) 15-18 17

Maintenance PAC Flush previous pilot study demonstrating that longer intervals
between PAC flushes do not increase the catheter com-
90
plication rate.
80
This retrospective analysis of a relatively small popu-
70
lation limited to one geographic location has certain
60
limitations. In our initial pilot study, 7 out of 73 patients
50
had no blood return during PAC accession. When ana-
40
lyzing average interval between accessions, no statistical
30
significant was noted between these patients compared to
20
those patients without any difficulty with port accessions
10
[6]. Our initial and now follow-up data suggest that ex-
0
tending the interval of PAC accession to every 3 months,
<90 days 90-119 days 120-150 days 150-180 days >180 days rather than monthly, is safe, effective and convenient in
Interval (Days) maintaining PAC patency in this patient population. Fur-
thermore, more frequent flushing can reach the limit of
Figure 1. Distribution of mean accession intervals.
maximum accessions of a PAC device if the maintenance
Table 2. Complications associated with PAC accessions. period is prolonged in cases where malignancy does not
recur. Accessing the device too frequently can potentially
Patient Date of Last Date of No. of Days cause more residual blood in the catheter and further
Complication
No. Accession Complication between
limit the successful blood return during the flushing.
1 4/16/2010 7/30/2010 105 Erythema Furthermore, catheter maintenance is associated with
2 5/1/2008 5/31/2008 30 Resistance significant costs, which primarily affect the patients and
the healthcare system. Although cost was not considered
3 8/20/2010 11/20/2010 92 Occlusion in this analysis, it can be assumed that more frequent
flushing is more costly and burdensome not only to the
patency with intervals ranging between 91 and 338 days. medical system, but for patient transportation and com-
The complication occurred at the eleventh PAC flush pliance. Indeed, for women who have completed their
with preceding interval of 105 days. There were no other therapy, monthly visits to the doctor’s office for PAC
complications, such as fever, DVT, or infection noted flush have resulted in poor patient compliance, as it is
during the time of remaining maintenance accessions. It invasive, inconvenient and expensive. Thus, extending
is important to note that 10 patients had greater than 5 the interval for PAC maintenance period is feasible, safe,
maintenance periods in the ≥90-day group without any convenient and cost effective. It will facilitate patient’s
complications, which may suggest that prolonged main- follow up and compliance. A three-month catheter main-
tenance periods of PAC is not a factor in causing com- tenance schedule would also coincide with patient’s re-
plications, such as thrombosis of the catheter. quired clinical cancer follow up office visits and may
improve their compliance and satisfaction, while de-
4. DISCUSSION creasing healthcare costs.

To date, there has been no standardized assessment of

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