What is the procedure for surgically placing a port (peripherally inserted central catheter)?

Surgical Placement of a Port (Implantable Venous Access Device)

The surgical placement of a port involves creating a subcutaneous pocket and accessing a central vein (typically the internal jugular vein) under ultrasound guidance, followed by tunneling and connecting the catheter to the port reservoir. 1

Patient Preparation and Positioning

• Position the patient in a supine position with slight Trendelenburg positioning when clinically appropriate to reduce the risk of air embolism and increase venous distention 1
• Apply appropriate antiseptic preparation to the insertion site and surrounding area 1
• Use local anesthesia at the insertion site; superficial cervical plexus block may provide better pain control than local infiltration for patients with high anxiety 2

Vein Selection

• The right internal jugular vein (IJV) is the preferred access site for port placement due to:
  • Lower risk of thrombotic complications compared to femoral sites 1
  • Lower infection rates compared to other sites 1
  • More direct path to the superior vena cava 1
• Alternative sites include:
  • Left internal jugular vein (if right IJV is unavailable) 3
  • Subclavian vein (higher risk of mechanical complications) 1
  • External jugular vein (less commonly used) 3

Port Insertion Procedure

Step 1: Venous Access

• Use real-time ultrasound guidance for vessel localization and venipuncture of the internal jugular vein 1
• Select the smallest appropriate catheter size based on clinical needs 1
• Use a thin-wall needle (Seldinger) technique or catheter-over-needle (modified Seldinger) technique based on operator experience 1
• Confirm venous placement (not arterial) using ultrasound, pressure waveform, or manometry 1

Step 2: Pocket Creation

• Create a 2-4 cm incision below the clavicle on the anterior chest wall 3, 4
• Dissect a subcutaneous pocket large enough to accommodate the port 4
• Some surgeons use a single-incision technique where the port pocket and venous access are achieved through the same incision, which may reduce complications 3

Step 3: Catheter Tunneling and Placement

• Create a subcutaneous tunnel from the venous puncture site to the port pocket 4
• Pass the catheter through the tunnel from the pocket to the venous access site 4
• Advance the catheter through the needle/introducer into the central venous system 1
• Position the catheter tip at the junction of the superior vena cava and right atrium 1
• Verify correct catheter tip position using fluoroscopy 1

Step 4: Port Connection and Fixation

• Connect the catheter to the port reservoir, ensuring a secure connection 4
• Place the port in the subcutaneous pocket 4
• Port fixation to the underlying fascia with sutures is not routinely necessary, as studies show very low rates (0.2%) of port inversion without fixation 5

Step 5: Closure and Verification

• Close the incision in layers using absorbable sutures 4
• Verify port function by aspirating blood and flushing with heparinized saline 4
• Obtain a post-procedure chest X-ray to confirm proper catheter tip position and rule out pneumothorax 1

Complications and Their Management

• Immediate complications:

  • Pneumothorax (rare with ultrasound guidance) 4
  • Arterial puncture or hematoma 1
  • Arrhythmias during catheter advancement 5

• Delayed complications:

  • Infection (pocket infection or catheter-related bloodstream infection) - occurs in approximately 5% of cases 5
  • Venous thrombosis - occurs in less than 1% of cases 5
  • Catheter malposition - occurs in approximately 1.5% of cases 6
  • Port inversion - very rare (0.2%) even without suture fixation 5

Special Considerations

• For patients with difficult venous access (previous multiple attempts, scarring), consider:

  • Using high-resolution ultrasound with color Doppler 1
  • Consulting interventional radiology for fluoroscopic guidance 1
  • Using micro-puncture needles (20-21G) with compatible guidewires 1

• For patients with coagulopathy:

  • More experienced operators should perform the procedure 1
  • Choose insertion sites that allow easy compression of vessels 1
  • Routine reversal of coagulopathy is only necessary if platelet count < 50×10⁹/L, aPTT > 1.3 times normal, or INR > 1.8 1