Original Article | Intervention

http://dx.doi.org/10.3348/kjr.2014.15.4.494
pISSN 1229-6929 · eISSN 2005-8330
Korean J Radiol 2014;15(4):494-500

Incidence and Risk Factors of Infectious Complications

Related to Implantable Venous-Access Ports
Jisue Shim, MD1, Tae-Seok Seo, MD1, Myung Gyu Song, MD1, In-Ho Cha, MD1, Jun Suk Kim, MD2,
Chul Won Choi, MD2, Jae Hong Seo, MD2, Sang Cheul Oh, MD2
Departments of 1Radiology and 2Oncology and Hematology, Korea University Guro Hospital, Korea University College of Medicine, Seoul 152-703,
Korea

Objective: The purpose of this study was to determine the incidence and risk factors of infections associated with
implantable venous access ports (IVAPs).
Materials and Methods: From August 2003 through November 2011, 1747 IVAPs were placed in our interventional
radiology suite. One hundred forty four IVAPs were inserted in patients with hematologic malignancy and 1603 IVAPs in
patients with solid tumors. Among them, 40 ports (23 women and 17 men; mean age, 57.1 years; range, 13–83) were
removed to treat port-related infections. We evaluated the incidence of port-related infection, patient characteristics,
bacteriologic data, and patient progress. Univariable analyses (t test, chi-square test, and Fisher’s exact test) and multiple
logistic regression analyses were used to determine the risk factors for IVAP related infection.
Results: Overall, 40 (2.3%) of 1747 ports were removed for symptoms of infection with an incidence rate of 0.067
events/1000 catheter-days. According to the univariable study, the incidences of infection were seemingly higher in the
patients who received the procedure during inpatient treatment (p = 0.016), the patients with hematologic malignancy (p =
0.041), and the patients receiving palliative chemotherapy (p = 0.022). From the multiple binary logistic regression, the
adjusted odds ratios of infection in patients with hematologic malignancies and those receiving palliative chemotherapy
were 7.769 (p = 0.001) and 4.863 (p = 0.003), respectively. Microorganisms were isolated from 26 (65%) blood samples,
and two of the most causative organisms were found to be Staphylococcus (n = 10) and Candida species (n = 7).
Conclusion: The underlying hematologic malignancy and the state of receiving palliative chemotherapy were the
independent risk factors of IVAP-related infection.
Index terms: Intravenous access; Cancer patient; Subcutaneous port; Infection; Complication

INTRODUCTION ports (IVAPs) placement include infection, thrombosis,

catheter obstruction, extravasation, and catheter migration
The major complications of implantable venous access (1). Among these, IVAP-related infection is the most
common complication that results in device removal (1,
Received August 16, 2013; accepted after revision May 7, 2014. 2). Fischer et al. (2) reported that 46.2% of IVAP removal
Corresponding author: Tae-Seok Seo, MD, Department of was for managing infectious complication, which was much
Radiology, Korea University Guro Hospital, Korea University College higher than the rates for thrombosis or dysfunction. Biffi et
of Medicine, 148 Gurodong-ro, Guro-gu, Seoul 152-703, Korea.
al. (3) analyzed the costs of IVAP-related complications and
• Tel: (822) 2626-1355 • Fax: (822) 863-9282
• E-mail: [email protected] found that the treatment of IVAP-related bacteremia had
This is an Open Access article distributed under the terms of the highest cost.
the Creative Commons Attribution Non-Commercial License Several authors studied the factors that increase the
(http://creativecommons.org/licenses/by-nc/3.0) which permits
unrestricted non-commercial use, distribution, and reproduction in infectious port complications, and one of the most
any medium, provided the original work is properly cited. significant factors was the hematologic malignancy. Samaras

494 Korean J Radiol 15(4), Jul/Aug 2014 kjronline.org

Infectious Complications Related to IVAPs

et al. (4) reported that the port-associated infections are punctured in 304 patients, who had any of the following
mostly observed in younger patients with hematologic conditions: right breast cancer, sonographically proven
malignancy, and assumed that intensive chemotherapy and RIJV thrombosis, or any skin lesion around the procedure
prolonged neutropenia might be responsible for the results. site interfering with puncture and port placement. In the
Another recent study showed that outpatient placement remaining two patients, the left and the right axillary
of the IVAPs reduced the infection rate (5). To the best of veins were selected. After making a 0.5-cm stab incision
our knowledge, there are only a few studies systematically at the venipuncture site, a 0.018-inch microwire was
analyzing the risk factors of IVAP related infection, with a fluoroscopically advanced to the cavoatrial junction using
large number of patients. The purposes of this study were a micropuncture set (Micronitinol rapid access kit, Access
to determine the incidence of the infectious complications Point Technologies, Rogers, MN, USA).
in IVAPs placed under sonographic and fluoroscopic Under local anesthesia, horizontal incision of 2–3 cm was
guidance, and to investigate the statistically significant made below the clavicle, following the direction of skin fold,
risk factors of infectious complications. We also determined and a blunt dissection of subcutaneous layer was performed
the microorganisms that commonly cause IVAP-related to create a pocket. After controlling the bleeding, the port
infections. catheter was tunneled from the pocket to the puncture
site using a tunneling device. We measured the length of
MATERIALS AND METHODS a 0.018-inch microwire under fluoroscopy to ensure the
accurate placement of the catheter tip. The microwire was
This retrospective study was approved by the Institutional exchanged to a 0.035-inch guidewire, over which, the serial
Review Board of our hospital, and the requirement for dilation of the venipuncture tract was performed which was
patient informed consent was waived. From August 2003 followed by the placement of a peel-away sheath. Through
through November 2011, we placed 1747 ports under the sheath, the catheter was introduced into the accessed
sonographic and fluoroscopic guidance in our interventional vein and the catheter tip was placed just distal to the
radiology suites. Among 1747 patients of 1042 women cavoatrial junction under fluoroscopic guidance. The port
and 705 men (mean age ± 1 standard deviation, 57.2 ± chamber was fixed to the pectoral fascia with absorbable
13 years; range, 13–90 years), 1603 had solid organ 144 suture (3-0, Surgifit, Ailee Co., Ltd., Busan, Korea). The
had hematologic malignancies, and all of the patients port patency was ascertained by aspirating a small amount
required IVAP placement for long-term administration of blood. Then, 300 units of heparin–saline solution was
of chemotherapy. Of those, 1203 patients received the instilled into the port chamber and the catheter lumen.
procedure while undergoing inpatient management, whereas After flushing the port pocket with a Cefamezine (cefazolin
544 received the procedure as an outpatient procedure. sodium, Dong-A Pharmaceutical Co., Seoul, Korea) 1 g
All IVAPs were placed by one of the two interventional mixture, subcutaneous layer was sutured with absorbable
radiologists over the study period. The procedures were suture material and skin layers of pocket and venous access
carried out under aseptic conditions and the prophylactic site were sutured with non-absorbable material (4-0, Blue
antibiotics were not used. The following equipment were nylon, Ailee Co., Ltd., Busan, Korea) materials. A final
used: Healthport (8-Fr, Baxter Healthcare SA, Zurich, fluoroscopic image documented the correct positioning
Switzerland), Celsite (6.5-Fr or 8.5-Fr, B. Braun Medical, of the catheter tip and the satisfactory catheter course
Boulogne Cedex, France), Vaxel port (8-Fr, Navylist Medical without acute angulation. The needle access of IVAPs was
Inc., Marlborough, MA, USA), X-port (8-Fr, Bard Access permitted from the day of the port placement, according to
Systems Inc., Salt Lake City, UT, USA), and Vital port (6.5-Fr, the patient’s chemotherapy schedule. The wound dressing
Cook Inc., Bloomington, IN, USA). was done on the third or fourth day, and suture removal
Before skin disinfection and sterile draping, we performed was done on the seventh or eighth day after the procedure.
neck ultrasound to select the venous access site and to None of the patients received systemic antibiotics after the
confirm the patency and size of the targeted vein. In 1441 procedure.
cases, the right internal jugular vein (RIJV) was punctured We retrospectively evaluated the incidence of port-related
under sonographic guidance, after subcutaneous injection infections, patient demographic factors, bacteriologic data,
of local anesthesia. The left internal jugular vein was and patient progress by reviewing the medical records.

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 Shim et al.

The local infections include phlebitis, tunnel infection, exact test) and multiple logistic regression analyses were
and exit site infection. The patients with erythema, used. The age, gender, patient location (i.e., inpatient
warmth, induration, and pain along the catheterized vein vs. outpatient), puncture site, performance status, types
or around the catheter exit site were enrolled in the local of malignancy, and the nature of chemotherapy (i.e.,
infection group. The wound dehiscence, pus discharge, skin palliative vs. curative-intent) were analyzed. Variables were
discoloration with fistula formation, and skin ulceration included in the multivariable analysis if the p value at the
were also assumed as the clinical signs of IVAP-related univariable analysis was less than 0.1, with the exception of
local infection. The systemic infection, which is a synonym the patients’ location. The patients’ location was considered
for bloodstream infection, was defined by the following only for the univariable analysis, because it is likely to
conditions: bacteremia or fungemia in a patient with represent multiple individual factors collectively (Table
intravascular device, where more than one positive blood 2) and would hinder the analysis of individual factors due
culture results were obtained from the peripheral vein; to multicollinearity. We used backward method of binary
and clinical manifestations of infection (e.g., fever, chills) logistic regression analysis. P values < 0.05 were considered
with no apparent source for bloodstream infection (6). statistically significant.
The patients with suspected catheter-related infection
were also included in systemic infection group; these RESULTS
patients had microbiological results that are insufficient
to diagnose catheter-related bloodstream infection, but In 345 cases of IVAP removal, the most common
the demonstrated apparent symptoms of infections. The indication for removal was termination of chemotherapy and
immediate infections were defined as the infections the second most common was to treat suspected infection.
occurring within 30 days of IVAP placement (4, 7). Other Overall, 45 (2.58%) of 1747 IVAPs were explanted to treat
infections were classified as the delayed infections. suspected infection. Five patients were proven to have
For all patients with signs and symptoms of catheter- incidental infections unrelated to IVAP (i.e., pneumonia
related infections, we performed aerobic and anaerobic or urinary tract infection). The calculated incidence rate
microorganism culture with whole blood samples before of IVAP-related infection was 0.067 events/1000 catheter-
explantating the port device. The catheter tips of the days. For the infection group (n = 40; 23 women and 17
removed IVAPs were placed on agar plates and delivered to men; mean age, 57.1 years; range, 13–83), the median
the laboratory for microbiology study. When local infection patency of inserted IVAPs was 143 days (range 18–827
was suspected, we obtained a wound swab culture.
Table 1. Duration of IVAP Use and Cause of IVAP Removal
For calculating the incidence rate (events per 1000
n Duration*
catheter days), the duration of IVAP catheter use was
Removal for all cause 345 249 ± 210
incorporated (Table 1). A total of 345 patients had their
Termination of chemotherapy 267
IVAPs removed during the study period. The reasons for Symptom and signs of infection 45
IVAP removal were chemotherapy termination in 270 Superior vena cava thrombosis 15
patients and development of complications in 75 patients; Migration 4
the complications included thrombosis, skin necrosis due Occlusion 3
to catheter leakage, migration, occlusion, and intractable Pain 3
pain. In 566 patients who still had devices in place, we Refusal of further treatment 3
calculated the duration of IVAP use from the cutoff day of Catheter leakage due to needling 2
February 11, 2012. For the patients who died or those who Superior vena cava syndrome
1
(caused by lung cancer)
were lost to follow-up before the cutoff day (n = 836), we
Innominate vein stenosis 1
used the last day of their medical records instead of the day
Unknown 1
of IVAP removal.
Termination of using before cutoff day 836 231 ± 268
Statistical analysis was performed with IBM SPSS IVAP in use 566 566 ± 434
Statistics 20.0 (SPSS IBM, New York, NY, USA). To determine Total 1747 343 ± 357
risk factors for infectious complications, univariable Note.— *Mean value with standard deviation. IVAP = implantable
analyses (using the t test, chi-square test, and Fisher’s venous access port

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Infectious Complications Related to IVAPs

days). Of 40 patients who had symptoms and signs of infection group and the control group, and the results are
infection, 31 had systemic illness and 8 had local infection. shown in Table 5. Multivariable binary logistic regression
A patient with breast cancer had signs of both systemic analysis revealed that hematologic malignancy and
and local infection. Six patients had immediate infections palliative chemotherapy were independent risk factors of
(median patency, 24; range, 18–25 days), and 34 had IVAP-related infection (Table 6). The adjusted odds ratio
delayed infection (median patency, 158; range, 31–827 (OR) of infectious complication for hematologic malignancy
days) (Table 3). versus solid organ malignancy was 7.769 (95% confidence
We removed 7 devices from patients with hematologic interval, 2.356 to 25.615). The adjusted OR for palliative
malignancy and 33 from patients with solid organ chemotherapy versus adjuvant, neoadjuvant, and curative
malignancy. The infection incidence rate per 1000 catheter chemotherapy was 4.863 (95% confidence interval, 1.726
days was 0.116 for hematologic malignancy and 0.061 for
solid organ malignancy. The proportion of port-related
Table 4. Characteristics of IVAP-Related Infection
infection was higher in the patients with hematologic
Diagnosis n Incidence
disease than in the patients with solid organ tumors (4.9%
Stomach cancer 10
and 2.1%, respectively, p = 0.041) (Table 4). However, the Lung cancer 7
incidence did not correlate with white blood cell counts at Colon cancer 6
the time of IVAP placement. Breast cancer 3
We performed the univariable comparison between the Solid organ Ovarian cancer 2 2.1%*
malignancy Bladder cancer 1 (33/1603)
Table 2. Characteristics Analysis of Inpatients and Outpatients Gallbladder cancer 1
Osteosarcoma 1
Inpatient Outpatient
Esophageal cancer 1
n = 1203 n = 544
Pancreatic cancer 1
Age (yrs)* 54 (16–83) 60 (13–90)
Lymphoma 5
Sex Hematologic 4.9%*
Myelodysplastic syndrome 1
Male 515 (42.8) 190 (34.9) malignancy (7/144)
Multiple myeloma 1
Female 688 (57.2) 354 (65.1)
Cancer types Note.— *P values = 0.041. IVAP = implantable venous access port
Hematologic 125 (10.4) 19 (3.5)
Table 5. Univariable Comparison between Infection Group and
Solid 1078 (89.6) 525 (96.5) Control Group
Performance states
Infection Group Control Group
0 327 (27.2) 223 (41.0) P
(n = 40) (n = 1707)
1 614 (51.1) 272 (50.0)
Age (yrs)* 57.9 ± 15.2 57.2 ± 12.7 0.936
2 154 (12.8) 33 (6.1)
Gender (male)‡ 18 (45.0) 687 (40.2) 0.326
3 104 (8.6) 15 (2.8)
Patient category‡ 0.016
4 4 (0.3) 1 (0.2)
Outpatient 6 (15.0) 538 (31.5)
Nature of chemotherapy
Inpatient 34 (85.0) 1169 (68.5)
Curative-intent 405 (33.7) 320 (58.8) †
Puncture sites 0.107
Palliative 798 (66.3) 224 (41.2)
RIJV 38 (95.0) 1402 (82.1)
Note.— *Median age with range. Otherwise, all values in
LIJV 2 (5.0) 302 (17.7)
parentheses are in percentile.
Others 0 (0) 3 (0.2)
ECOG performance status* 1.08 ± 0.797 0.93 ± 0.849 0.297
Table 3. Types of Infection
Malignancy type‡
Solid Organ Hematologic
Hematologic (%) 7 (17.5) 137 (8.0) 0.041
Malignancy Malignancy
Nature of chemotherapy‡
Early infection 6 0
Palliative (%) 30 (58.5) 992 (58.1) 0.022
Delayed infection 27 7
Note.— All values in parentheses are in percentile. ECOG
Systemic infection 26* 7
performance status is written in average ± standard deviation.
Localized infection 8* 0 Statistical tests were performed with *t test, †Chi-square test, and
Note.— *One patient had symptoms of both local and systemic ‡
Fisher’s exact test. ECOG = Eastern cooperative oncology group,
infection. LIJV = left internal jugular vein, RIJV = right internal jugular vein

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 Shim et al.

to 13.700). samples, and the common causative microorganisms were

We also compared the systemic infection and local found to be Staphylococcus species (n = 10), Candida
infection groups, and there were no statistically significant species (n = 7), and non-tuberculosis Mycobacterium (n = 2).
differences in all variables (p values = 0.102 to 0.703). Other microorganisms such as Escherichia coli, Acinetobacter
The microorganisms were isolated from 26 (65%) blood baumannii, Klebsiella pneumonia, etc. were isolated from
the rest of the 6 blood samples (Table 7). In addition,
Table 6. Logistic Regression Analysis for Predicting IVAP- a microbiological study of catheter tip was shown to be
Related Infection positive in 9 cases, with microorganisms that were the
OR 95% CI P same as the blood culture studies. The wound culture was
Gender performed in the patients with clinically suspected localized
Male 1 infection without any detection of microorganisms (Table 7).
Female 1.225 0.637–2.356 0.542 After IVAP removal, antibiotics were administered according
Age
to the results of microbiology and antibiotic sensitivity
21–64 1 0.545
tests.
≤ 20 1.781 0.215–14.746 0.593
≥ 65 0.729 0.366–1.453 0.369
Puncture site DISCUSSION
RIJV 1 0.567
LIJV 0.447 0.102–1.965 0.287 The total incidence of IVAP-related infection was 0.067
Others 0.000 0.000 0.999 events/1000 catheter days. The previously reported IVAP-
Malignancy types related infection rates were considerably higher (0.16 to
Solid organ malignancy 1 0.35 events/1000 port days) (4, 8-13). However, the lower
Hematologic malignancy 7.769 2.356–25.615 0.001 incidence has been reported on recent studies, indicating
Performance status
that a large number of cases, well-experienced procedures,
0–1 1
and management had lowered the infection. Ahn et al. (14)
2–4 0.937 0.421–2.090 0.875
reported a lower infectious complication rates (0.64%, 0.018
Nature of chemotherapy
Curative-intent per 1000 catheter days) and they emphasized the clinical
Palliative 4.863 1.726–13.700 0.003 importance of the infectious complication as a major cause
Note.— Regressions include adjustments for age, gender, puncture of prolongation of hospitalization. They strictly defined the
site, and ECOG performance state. CI = confidence interval, ECOG catheter-related bloodstream infection as when a blood
= Eastern cooperative oncology group, IVAP = implantable venous culture is positive without other identifiable sources of
access port, LIJV = left internal jugular vein, OR = odds ratio, RIJV
= right internal jugular vein infection, and if the clinical signs resolve within 48 hours
after port explantation.
Table 7. Bacteriologic Data of IVAP-Related Infection Demographic factors, such as the relatively small number
Micro-Organism Whole Blood Tip of hematologic malignancy patients, might contribute
Staphylococcus species 10 2 to lower infection rates. The proportion of hematologic
Candida species 7 4
malignancy patients was relatively small in our study (8.2%,
Non-tuberculosis Mycobacterium 2
144/1747) compared to other studies (27–36%) (4, 8-13).
Staphylococcus/candida 1
Since hematologic malignancy is highly associated with
Escherichia coli 1
Acinetobacter baumannii 1 catheter-related bloodstream infection, this difference
Klebsiella pneumonia/ could have led to selection bias in our study (4). However,
Staphylococcus epidermidis/ 1 the incidence rate of infection in hematologic malignancy
Streptococcus salivarius patients (0.116 events/1000 catheter-days) was not higher
Klebsiella pneumonia/
Acinetobacter baumannii
1 1 than other studies. A larger proportion of outpatients might
Rhodotorula mucilaginosa 1 1 be related to the low infection rate.
Enterococcus faecium 1 1 The incidence of infection was significantly higher in
Total 26 9 hematologic malignancy patients. Hematologic malignancy
Note.— IVAP = implantable venous access port was more strongly related to the delayed bloodstream

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Infectious Complications Related to IVAPs

infections rather than immediate local infections. This (comorbidities and performance status) and elevated
observation was similar to the previous studies (2, 4, C-reactive protein levels were associated with unfavorable
13). Impaired immunity caused by both the disease itself clinical outcomes after an IVAP-related infection. In our
and the use of immunosuppressants after bone marrow study, the performance status did not significantly correlate
transplantation would result in the difference of outbreak with the incidence of IVAP-related infection. But, we found
of infection. More intensive chemotherapy schedule for that the patients receiving palliative chemotherapy were
hematologic malignancies compared to that of solid tumors more susceptible to infection than others, probably related
can contribute to increased infection (15). to the prolonged use of IVAP due to frequent chemotherapy
The IVAP-related infection rate was significantly higher schedules.
when ports were placed in the inpatients (p = 0.016), The use of antibacterial-impregnated catheters was
although it may not be a true risk factor for infection. limited to catheter-related bloodstream infections,
Pandey et al. (5) argued that the outpatient port placement but further studies may be needed to clarify the cost
is associated with a decreased risk of infection, and it is effectiveness of those devices. The periprocedural antibiotic
possibly owing to the frequent needle access and exposure prophylaxis is controversial; some randomized prospective
to nosocomial infection of the inpatients. Further studies studies from surgical teams suggested that IVAPs may
with strictly controlling intervariable collinearity and be implanted without any antibiotic prophylaxis when
confounding factors should be followed to clarify the cause- following strict methods of pre- and postoperative care,
and-effect relationship of the outpatient port placement especially in patients with solid organ malignancy (22,
and the infection. 23). The education and training programs for the patients
Staphylococcus and Candida species were the two most and healthcare providers involved in the insertion and
commonly isolated organisms from the patients with IVAP- maintenance of catheters will be helpful for reducing the
related infections. For these infections, removal is always infection rate (24).
necessary, while the system can be successfully maintained The limitations of our study were as follows. First,
for infections with coagulase-negative Staphylococcus, it was a retrospective, single-centered study, and the
Corynebacterium jeikeium, or Pseudomonas aeruginosa (16). retrospective collection of periprocedural clinical data was
If a patient presents with fever and a negative culture frequently impossible due to lack of documents. Second,
study, the decision for removing the port device is difficult. a considerable number of follow-up loss of patients was
However, in our study, 14 patients had fever with negative not excluded from our study, which possibly could have
results of microbiologic studies, and they experienced resulted in over- or undercalculation of incidence. Third,
symptom relief after IVAP removal and antibiotic the incidence of infection could have been underestimated,
administration. if the clinically undetected catheter-related bloodstream
Some authors previously analyzed the risk factors infection, the rapidly progressing catheter-related fatal
affecting catheter-related infection and suggested some bloodstream infection, or the medically treated infections
strategies for reducing the infection rate. The young age and were not notified to the intervention radiologists. Fourth,
hematologic malignancy are known to be highly associated some of the infections that we have reported may have
with catheter-related bloodstream infections (4, 17, 18). resulted from other sites of unrecognized infections. Fifth,
However, patient age was not associated with infection further retrospective analyses of periprocedural laboratory
in our study. The catheter-related thrombosis was also data were impossible due to the heterogeneity of the
known to increase the risk of systemic catheter-associated time intervals between the procedures and the laboratory
infections, although no thrombotic complications occurred examinations; the data including the periprocedural
in our infection group (19, 20). Fischer et al. (2) reported data after chemotherapy were not obtained, which may
that the patients with ongoing chemotherapy and those considerably have affected the results.
with recurrent IVAP placement experienced infections far In conclusion, the underlying hematologic malignancy
more frequently than the others. They also reported that the and the state of receiving palliative chemotherapy were the
breast cancer patients are less likely to experience catheter- independent risk factors of IVAP-related infection.
related infection than the patients with other malignancies.
Lebeaux et al. (21) reported patients’ overall conditions

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