Right Arm DVT and Port-a-Cath Placement
A right arm DVT is a relative contraindication, not an absolute contraindication, to placing a port-a-cath on the right side, but you should strongly consider alternative sites or wait until the thrombosis is treated and resolved before proceeding with right-sided placement.
Primary Recommendation
Avoid placing the port on the same side as an active DVT because introducing a catheter into a thrombosed venous system significantly increases the risk of catheter malfunction, propagation of thrombus, pulmonary embolism (5-14% incidence), and post-thrombotic syndrome (10-28% incidence) 1.
The preferred approach is to place the port on the contralateral (left) side if the right arm has active DVT, though this comes with its own considerations 1.
Site Selection When Right Side is Unavailable
Left-Sided Placement Considerations
Left-sided catheter insertion carries a higher thrombosis risk than right-sided placement (left > right for DVT risk), with studies showing 25.6% vs 6.8% DVT rates respectively 2.
The increased risk is due to the longer catheter path and greater vessel length exposed when accessing from the left side 1, 2.
Despite the higher risk, left-sided placement is acceptable when right-sided access is contraindicated by existing thrombosis 1.
Optimal Technique for Left-Sided Placement
Use the left internal jugular vein as the access site rather than subclavian, as jugular access has lower thrombosis risk than subclavian 1.
Position the catheter tip at the junction of the superior vena cava and right atrium or in the lower third of the SVC, as this location significantly reduces thrombosis risk (0-2.6% vs 41.7% in upper SVC) 3, 2, 4.
Verify tip position with intraoperative fluoroscopy or post-procedure chest radiograph to ensure proper placement 3.
Alternative Strategy: Treat DVT First
Consider treating the right arm DVT with anticoagulation first, then reassessing for right-sided port placement once the thrombus has resolved or stabilized 5, 6.
Catheter-directed thrombolysis may be an option for acute DVT to expedite resolution if urgent port access is needed 5, 6.
This approach allows you to use the preferred right-sided placement with its inherently lower thrombosis risk once the venous system is clear 1.
Critical Technical Points
Use ultrasound guidance for venous access to increase first-attempt success and reduce complications 3.
Choose an implanted port over external catheters when possible, as ports carry lower thrombosis risk 1.
Use the minimum number of lumens required, as thrombosis risk increases with more lumens 1.
Ensure strict sterile technique with chlorhexidine-alcohol skin preparation 3.
Common Pitfalls to Avoid
Do not use the subclavian vein as it has higher stenosis and thrombosis rates compared to jugular access 1, 7.
Do not place the catheter tip above the mid-SVC, as this dramatically increases thrombosis risk (41.7% in upper third SVC vs 2.6% in lower third) 2, 4.
Do not assume anticoagulation prophylaxis will prevent catheter-related thrombosis - routine prophylaxis is not recommended and has not been shown to be effective 1.
Monitoring After Placement
Monitor for signs of thrombosis: arm swelling, pain, erythema, venous distention, or catheter malfunction 1, 2.
Watch for catheter dysfunction: inability to aspirate blood or resistance during infusion may indicate thrombotic complications 1, 2.
Maintain catheter patency with regular flushing protocols per institutional guidelines 2.