Editorial Regarding Use of Modified Femoral Vein Approach as Method for Implanting a Totally Implantable Access Port in Patients With Synchrounous Bilateral Mastectomes (Chen et al.)

摘要

(1) The authors have described the use of a totally implantable access port (TIAP) using the femoral vein approach, which may be of value in patients with bilateral breast cancers who require bilateral mastectomies and postoperative chemotherapy or who have clinical surgical limitation to placement of conventional ports in subclavicular jugular vein. In this retrospective study of 86 patients receiving the TIAP using the modified femoral vein approach, the major 30-day complication was 2.3% primarily involving groin hematoma caused by mispuncture of the femoral artery. The postoperative complication rate included local port infection (2.3%), groin infection (1.2%), and catheter occlusion (3.5%). There were no complications associated with disconnection or systemic infection. The modified femoral vein approach may be workable and should certainly be a consideration in patients who otherwise would not be good candidates for subclavian or jugular vein placement, or who have had bilateral reconstructions and who are probably not good candidates for cephalic vein cut-down. The bilateral cephalic veins may be ether damaged or could have been affected by the mastectomy, and a cut-down in this area might enhance the hazard of arm swelling or lymphedema as a consequence. The use of the femoral vein would obviate this problem. The authors describe the technique well and it appears that this may definitely have value in selected patients. It may be useful value in patients whose breast cancer management requires bilateral mastectomies, unilateral mastectomy with reconstruction, or bilateral mastectomies with immediate reconstruction in which complications could be totally avoided by implant in the femoral vein. The authors short term complications were minimal (groin hematoma) and the long term complications port infection (2-3%), groin infection (1.2%) and catheterocclusion (2.3%) are fewer and less ominous than commonly reported complications for brachial vein and chest wall implantable ports, that in the latter case is thrombogenic complications and catheter related infections and sepsis are major concerns (as summarized in review by Vescia et al., Ann Oncol 19:9-15, 2008). (2) The femoral vein approach could be considered an alternative method for TIAP implantation. With the vascular catheter being implanted in the anterior thigh or abdominal wall or near the anterior superior crest, the port can be positioned even at a higher position on the abdominal wall to make it easily accessible (just above the patient's waist). This placement may preserve the patient's privacy and allow easy access in an office setting. The left femoral vein is the site of choice (avoiding the hazard of surgery necessitated by acute appendicitis). The catheter itself is implanted in the left lower abdomen to minimize the complications, for which surgical intervention would be required for an acute abdomen. The placement of the port in the mid-upper abdomen also minimizes the punctures near the groin and reduces the risk of infection.The port can also be placed in the lateral thigh, but this may cause some added problems in a physically active patient.