By Steven Deitcher‚ MD‚ and Joseph Kuhn‚ MD

Question:
I am scheduled to start chemotherapy in a few weeks and I want to know if I should get a Port–A–Cath inserted instead of doing treatment through an I.V. in my arm. I know a “port” is surgically implanted to give consistent access‚ but it seems extreme compared to just finding a vein for an intravenous injection. What do you think?

Answer:
Steven R. Deitcher‚ MD
Head‚ Section of Hematology and Coagulation Medicine
The Cleveland Clinic Foundation
Cleveland‚ Ohio

Port–A–Caths and other central venous access devices (CVADs) provide a reliable and semi–permanent means of providing infusional therapy and withdrawal of blood samples.

Infusional therapy provided via a CVAD may consist of chemotherapy‚ blood products‚ antibiotics‚ nutrition‚ and intravenous fluids. Unlike temporary indwelling catheters (I.V.)‚ which are usually inserted into peripheral‚ superficial veins of the arms‚ CVADs do not require frequent placement and replacement–related needle sticks or extensive taping to secure and prevent catheters from falling out. Because CVADs can have more than one catheter opening‚ multiple infusions can take place simultaneously‚ which can translate into shorter clinic and hospital stays.

In many patients‚ veins become thrombosed (full of coagulated blood) or sclerosed (hardened and scarred) as a result of I.V–administered drugs. Some patients choose to have a CVAD for convenience‚ while others must have “a line” to allow their therapy to proceed without interruption.

While at times CVADs seem life saving‚ they are not devoid of risks and complications. CVADs‚ like Port–A–Caths‚ require surgical insertion‚ usually into the internal jugular (neck) vein or subclavian (chest) vein by a surgeon or interventional radiologist. Insertion can be complicated by discomfort‚ bleeding‚ pneumothorax (collapsed lung)‚ and infection. After insertion‚ CVADs may stop functioning‚ become infected‚ or result in blood clots.

These complications may necessitate line removal and replacement at another site‚ as well as the need for additional antibiotics and/or blood thinner therapy.
CVAD dysfunction can result in the inability to infuse fluids‚ the inability to withdraw blood‚ or a combination of both. Luckily‚ clot–busting medications like those used in patients with heart attack and peripheral vascular thrombosis (i.e.‚ t–PA and urokinase) can be administered into a catheter and safely restore function in the great majority of cases.

Which CVAD should be inserted into a particular patient depends on the underlying illness‚ the intended therapy‚ and intended duration of therapy. Consultation with the appropriate surgeon or radiologist is advised.

Answer:
Joseph Kuhn‚ MD
Department of Surgery‚ Baylor University Medical Center
Dallas‚ Texas

Since the catheter from a port lies in the superior vena cava‚ one of the main veins in the body‚ the flow of blood around the catheter is rapid‚ so the risk of clotting in the vein or irritation of the vein is very low. On the other hand‚ delivery of hcgh concentrations of drugs directly into a smaller vein by intravenous catheters in the arm may increase the risk of vein reaction‚ clotting of the vein‚ or leakage of the drug out of the vein.

Many patients dread the prospect of nurses searching for a good vein prior to the next course of therapy. Advantages of a port include lower risk of infection‚ avoidance of a catheter sticking out of the skin‚ and longer durability of the ports‚ which can often function for years.

Disadvantages of a port include greater difficulty in removing the port if there is an infection and the risk of blood clots.

The ideal patient for a port is someone who will be getting intermittent blood work or infusions and who has veins that are difficult to locate.
The patient who is not a good candidate for a port is one who will be suffering from extremely low white blood cell counts due to high dose chemotherapy‚ commonly used for bone marrow transplantation. In these patients‚ the risk of infection is too high.

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