Since April 2005 the senior author, (Erwin B. Brown) has placed more than 1600 ports at the University of Texas MD Anderson Cancer Center for breast cancer patients, using ultrasound guidance. Although the routine use of ultrasound guidance is not required, the National Institute of Clinical Excellence advocates the use of 2-dimensional ultrasound when obtaining venous access in elective cases.1
Central venous access can be divided into 2 types of access: (1) implanted central venous catheters, including chest ports (using jugular or subclavian vein) and arm ports (eg, Passport), and (2) nonimplanted central venous access, including peripherally inserted central catheter (PICC) lines, subclavian catheters, and tunneled catheters without implanted subcutaneous ports. Currently, arm ports are not being inserted at MD Anderson Cancer Center. Central venous access can be achieved using various puncture sites, but the most common are the internal jugular veins, the subclavian veins, and the upper limb veins for PICCs. Femoral veins are seldom used, but may be necessary in selective situations. The choice of access route depends on multiple factors, including the reason for central venous catheter insertion, the anticipated duration of access, the intact venous sites available, and the skills of the operator. The internal jugular vein is preferred over the subclavian vein for implanted ports at our institution, compared with the cannulation of the subclavian vein.
A dedicated central venous access team is essential for central venous access in breast oncology patients. Adequate sedation facilitates safe and efficient central venous access in this patient population. This can be achieved by using conscious or unconscious sedation. Our institution's preferred method of sedation is unconscious sedation or general anesthesia. A basic preoperative health evaluation should be performed, including history, current medications (including herbals), allergies, and physical exam. Cardiac and respiratory evaluations should also be conducted. At the start of the procedure, all essential staff and equipment should be in place. Control of personnel traffic is vital.
A knowledge of the surface anatomical landmarks is essential (Fig. 71-1A). The patient should be prepared and draped in the standard sterile fashion for surgical vascular access and then placed in Trendelenburg position. Using a sterile marker, the proposed infraclavicular skin incision should be outlined parallel to the clavicle. The subcutaneous tunnel should be outlined from the wire entrance site to the proposed infraclavicular incision (Fig. 71-1B). The ideal location for the reservoir is thought to be along the anteromedial aspect of the second rib. This high medial position keeps the port away from the breast tissue and reduces the risk of inadvertent retraction of the catheter.
A. Anatomical landmarks. Surface anatomy of the internal jugular vein: a, intertragic notch; b, internal jugular vein; c, ...