What is the step‑by‑step protocol for placing a chemotherapy port, including pre‑operative preparation, insertion technique, and post‑operative care?

Chemoport Placement Protocol

Pre-Operative Preparation

Insertion of an implantable venous access device should be carried out under strict sterile conditions in the operating room, with either general or local anesthesia acceptable for most patients. 1

Patient Selection and Timing

• Chemoports are appropriate for chemotherapy administration when treatment duration is projected to be 6 months or longer 1
• For irritant or vesicant chemotherapy, ports are rated as appropriate at all time intervals, though neutral for 3-6 months duration 1
• Assess coagulation status and platelet counts, as coagulopathy may necessitate alternative approaches 1

Sterile Preparation

• Use chlorhexidine solutions with alcohol for skin preparation 1
• Maintain strict sterile technique throughout the procedure 1
• Antimicrobial prophylaxis is NOT recommended 1

Vein Selection

• Avoid femoral vein insertion due to increased risk of infection and thrombosis 1
• Right-sided insertion is preferred and should be performed in a specialized unit when possible 1
• The cephalic vein cut-down approach is successful in approximately 82% of cases and represents the safest technique to avoid immediate complications 1, 2

Insertion Technique

Venous Access Approach

• Initial venous access can be performed using either open (cephalic vein cut-down) or percutaneous approach, with the open technique being the best approach to avoid immediate complications 1
• The cephalic vein cut-down technique avoids risks of pneumothorax and arterial puncture associated with percutaneous subclavian approaches 2
• If percutaneous approach is used, ultrasound guidance improves success rates and reduces complications 3

Critical Procedural Steps

• Create subcutaneous tunnel (8-15 cm) for the catheter 1
• The subcutaneous tunnel induces inflammatory reaction leading to fibrosis and catheter fixation within 3-4 weeks 1
• Position catheter tip at the junction between the superior vena cava and right atrium 1
• Secure the port reservoir in the subcutaneous pocket 4
• An assistant surgeon is necessary for retraction, suctioning, catheter manipulation, and closure of the subcutaneous pocket 4

Intraoperative Confirmation

• Catheter tip position must be verified radiologically with intraoperative fluoroscopy or post-operative chest X-ray 1
• Alternative verification method is intracavitary ECG, where arrhythmia is documented during wire insertion 1
• Fluoroscopy with contrast media can further reduce malposition complications 3

Device Specifications

• Use smallest diameter catheter necessary (typically 9.6F polyurethane catheters for oncology patients) 5
• Polyurethane and silicone materials are associated with fewer infections than older materials 1
• Ports have the lowest reported rates of catheter-related bloodstream infections (0.8-7.5%) compared to other central venous catheters 1, 6

Post-Operative Care

Immediate Post-Procedure Monitoring

• Patients require 4-hourly observations including temperature, pulse, blood pressure, and respiratory rate 1
• Obtain chest X-ray if patient develops dyspnea or chest wall pain 1
• Monitor for immediate complications including pneumothorax (1.4% incidence), hematoma, or arterial puncture 5, 7

Port Maintenance Protocol

• Routine flushing with normal saline after completion of any infusion or blood sampling is recommended 1
• For subcutaneous ports not in active use, perform four-weekly flush with normal saline 1, 6
• Normal saline is equally effective as heparin for routine flushing 6
• Use 10mL or larger syringes with turbulent push-pause technique to avoid excessive pressure 6

Infection Prevention

• Maintain strict aseptic technique during all port manipulations 6
• In neutropenic patients (absolute count <500/mm³), document heightened infection prevention measures 8
• Port-related infection rates range from 0.24-0.66 per 1,000 catheter days with proper multidisciplinary care protocols 1, 9
• Over 60% of catheter-related sepsis occurs during neutropenic periods 1

Functional Assessment

• Verify port function by confirming blood return and ability to flush without resistance 8
• Document port type, specifications (single/double lumen), and power-injectable capability 8
• Absence of blood return can occur with patent catheters due to tip position or fibrin sheath formation 6
• If no blood return, reposition patient (raise arms, turn head, cough) before assuming malfunction 6

Common Complications and Management

Early Complications (Procedure-Related)

• Catheter malposition occurs in approximately 1.5% of cases and may require repositioning under fluoroscopy 3
• Pneumothorax risk is 1.4% with percutaneous approaches but eliminated with cephalic cut-down 7, 2
• Port site infection requiring removal occurs in 0.74-2.8% of cases 3, 7

Late Complications

• Deep vein thrombosis occurs in 1.5% of cases, requiring port removal and anticoagulation 3
• Catheter fracture and port reversal are rare mechanical complications 5
• Routine anticoagulant prophylaxis is NOT recommended despite elevated thrombosis risk in cancer patients 1

Red Flags Requiring Immediate Intervention

• Pain, swelling, or redness at insertion site suggests thrombosis or infection 6
• Resistance during flushing with inability to aspirate indicates occlusion 6
• Systemic symptoms (fever, chills, shortness of breath, chest pain) during flushing require immediate attention 6