Port-a-Cath (Implantable Venous Port) Insertion

Procedure Snapshot

• Indication: Long-term central venous access for chemotherapy, antibiotics, or parenteral nutrition.
• Expected duration: ~30–60 min.
• Special instruments: Port insertion kit (tunneled catheter, port reservoir, introducer needle, dilator, peel-away sheath), fluoroscopy or C-arm, ultrasound.

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Step Workflow — Right Internal Jugular (Preferred)

1. Supine, Trendelenburg 10°, head turned slightly left.
2. Prep chest, neck, and shoulder; sterile draping.
3. Ultrasound-guided venipuncture of right internal jugular vein; confirm flashback.
4. Advance guidewire under fluoro into SVC-RA junction.
5. Make 3–4 cm chest wall pocket over pectoralis major (2–3 cm below clavicle).
6. Tunnel catheter from pocket to venipuncture site using tunneler.
7. Measure and trim catheter so tip lies at cavoatrial junction.
8. Dilate and insert peel-away sheath; advance catheter; remove sheath.
9. Connect catheter to port reservoir and secure port to pectoralis fascia with 2-0 Ethibond.
10. Confirm flow and aspiration; flush with heparinized saline.
11. Close subcutaneous and skin layers; apply sterile dressing.
12. Confirm placement by CXR or fluoro.

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Alternate Access Sites

• Left internal jugular: if right side contraindicated.
• Subclavian vein: less preferred (risk of pinch-off).
• Femoral vein: for temporary use in infection or occlusion cases.

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Key Pimp Questions

• Q: Ideal catheter tip location?
  A: At the cavoatrial junction (T6–T7 vertebral level; carina).
• Q: Why avoid subclavian entry?
  A: Risk of pneumothorax and pinch-off between clavicle and 1st rib.
• Q: What is the most common complication?
  A: Catheter occlusion or infection (PMID 33223445).
• Q: How is patency maintained?
  A: Heparin lock (100 U/mL) every 4–6 weeks if unused.

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Critical Anatomy

• Landmarks: Sternocleidomastoid heads, clavicle, IJ–subclavian confluence, SVC.
• Danger zones: Carotid artery puncture, pleura (apex of lung), thoracic duct (on left).

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Informed Consent Highlights

• Benefits: Reliable long-term central access, fewer peripheral sticks.
• Alternatives: PICC line, tunneled catheter.
• Risks:
  • Pneumothorax ___ (PMID 31495123)
  • Hemothorax ___
  • Arterial puncture ___
  • Catheter infection ___ (PMID 33223445)
  • Thrombosis or malfunction ___

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Post-op Considerations

• CXR to rule out pneumothorax and verify tip.
• Port ready for use after skin heals (~7 days).
• Routine flush with saline followed by heparin.
• If malfunction → obtain contrast study for fibrin sheath or kinking.

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References

• Chassin’s Operative Strategy, Vascular Access chapter.
• Clinical Scenarios in Surgery, Lines & Tubes section.
• Bodenham A. Br J Anaesth. 2018 (PMID 31495123).
• Teichgräber UKM et al. Eur Radiol 2020 (PMID 33223445).