When the FICC-PORT is (maybe) the first option: A case report

Abstract

Ports are totally implanted intravenous devices used to administer intravenous therapies that require the central venous pathway. Traditionally, ports are implanted mostly on the chest wall or on the arms (PICC PORTs). In some patients, CHEST PORTs and PICC PORTs are contraindicated, and ports are implanted by inserting the catheter into the femoral vein (FEMORAL PORT or FICC PORT). In this report, we want to describe an unusual case of placement of a FICC-PORT using the most recent techniques of implantation and tip location.

Introduction

Ports are totally implanted intravenous devices used to administer intravenous therapies that require the central venous pathway, such as antiblastic chemotherapy.

Traditionally, ports are implanted mostly on the chest wall (chest-port), after cannulation of the axillary/subclavian or internal jugular vein, but recently, PICC-PORTs (whose reservoir is implanted on the arms) are also becoming increasingly popular because of their advantages over chest ports.[1]

In some patients, however, CHEST-PORTs and PICC-PORTs cannot be implanted because of superior vena cava obstruction due to tumor masses or venous thrombosis.

In these patients, ports can be implanted by inserting the catheter into the femoral vein and placing the reservoir on the thigh: these devices are called FEMORAL-PORTs[2,3] or “FICC-PORTs”.

In most studies concerning FICC PORTs, central venous access has been achieved by cannulation of the common femoral vein (CFV), but recent work has described a new approach to the inferior vena cava (IVC) through ultrasound-guided puncture of the superficial femoral vein (SFV)[4] combined with intraprocedural catheter tip localization (“tip location”) also using ultrasound.[5]

In this report, we want to describe a peculiar case of placement of a FICC-PORT using the most recent techniques of implantation and tip location.

Case

A 42-year-old woman with left breast cancer without other systemic disease needs the implantation of a PORT to receive chemotherapy.

However, the patient presents a very extensive scar extending from the anterior region of the chest to the arms bilaterally, due to a severe burn in childhood [Figure 1].

Figure 1.

Extensive scar extending from the anterior region of the chest to the arms bilaterally: This results in the impracticality of reservoir placement due to increased risk of infection and skin dehiscence

In this case, placement of a CHEST PORT or PICC PORT had a high risk of infection and wound dehiscence, so we decided for a FICC-PORT right and the patient signs informed consent for this procedure.

After performing a preprocedural evaluation of the deep veins of the groin and thigh according to the RaFeVA protocol (Rapid Femoral Vein Assessment),[6] skin antisepsis was performed, and maximal barrier precautions were used.

After infiltration with local anesthesia, the SFV right is cannulated by real-time ultrasound guidance using a micro-introducer kit. Venipuncture was performed with an off-plane approach.

A polyurethane catheter was introduced into the venous system through the introducer to the subdiaphragmatic IVC (below the hepatic veins and above the renal veins), and the correct tip position was detected by ultrasound using a convex probe with transhepatic view and performing the “bubble test” (rapid injection of 10 cc of saline resulting in fast flow seen in real time from the catheter tip) [Figure 2].

Figure 2.

Tip location procedure ultrasound-guided with trans-hepatic view. a) catheter to the subdiaphragmatic IVC below the hepatic veins and above the renal veins. b) Bubble test: Rapid injection of 10 cc of saline resulting in fast flow seen in real time from the catheter tip

The reservoir was connected to the catheter and placed in a subcutaneous pocket above the quadriceps muscle, at mid-thigh.

After ensuring proper function of the device for both infusion and blood aspiration, the pocket is closed with absorbable sutures and cyanoacrylate glue. There were no immediate or early complications such as arterial puncture, nerve injury, or hematoma.

Discussion and Conclusion

FICC-PORTs are an excellent alternative for patients with contraindications to thoracic PORTs and PICC-PORTs implantation (due to nonaccessibility to the subclavian or jugular vein).

However, in many works, the implantation procedure described appeared to be somewhat invasive: percutaneous puncture of the common femoral vein, reservoir located on the abdomen, and tip position assessed by abdominal radiography at the end of the procedure.[2]

This report focuses on new innovations adopted for FICC-PORT implantation based on the latest evidence in the literature: ultrasound-guided SFV venipuncture, tip placement in the subdiaphragmatic IVC (between the hepatic and renal veins) with intraprocedural tip localization by ultrasound and bubble test, reservoir placed in the mid-thigh.

In conclusion, we can confirm that this new approach is minimally invasive, minimizes the risk of immediate complications, and ensures absolute patient satisfaction.

Consent for publication

The authors certify that they have obtained all appropriate patient consent forms.

In the form, the patient has given her consent for her clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.