How has this type of catheter evolved over time and why is it a revolution in terms of cost-effectiveness today?

Positioning of the port

TIVADs [1] (Totally implanted vascular access devices) are central venous catheters whose reservoir is placed under the skin. A catheter is inserted into the vein and then connected to the port reservoir, which will be placed under the patient’s skin. This method provides great advantages, such as the possibility of leading a normal life since it does not require special external care.

The most popular TIVADs are chest ports, placed in veins in the chest or neck with a pocket for the port at chest level. They are the catheters of choice for long term but discontinuous treatments such as chemotherapy treatments.

In addition to being placed in chest or neck veins, for a period of time and before the introduction of ultrasound in the puncture and insertion of the vascular access, some of these devices were placed in the patient’s forearm, inserted in visible and palpable veins, normally in the elbow flexure, with a pocket creation for the port at forearm level on its internal face. These catheters were known as arm port or brachial port, i.e., reservoirs placed in the arm.

The incorporation of ultrasound has allowed an evolution in the area of placement of these catheters and the reduction of potential complications. Thanks to ultrasound, we can approach deep veins in the middle of the arm which can be measured and adapted to the caliber (Fr) of catheter needed. Thus, the placement of the port can be done on the inside of the arm, in its upper area. These catheters placed with ultrasound in the arm are known today as PICC- port.

Accessories for catheter insertion

Beyond the materials that the market offers for access, we should always be particularly interested in knowing the accessories that accompany the catheter, that is to say, the insertion kit. In this case, to be able to talk about PICC-port we have to associate the concept of the mid-arm ultrasound-guided catheter with the concept of micro-puncture and micro-introduction.

The modified Seldinger technique (recommended by international guidelines and accepted worldwide as the standard for PICC placement in general) has reduced endothelial damage when puncturing veins, especially those of limited size such as peripheral veins.

We can say that we have a PICC-port when its insertion set has these fundamental characteristics to perform the modified Seldinger technique safely.

Cost effectiveness

As we have said, brachial ports are nothing new: they have been known and used for years in several countries in the context of the oncology patient.
However, when we talk about cost-effectiveness, it is necessary to point out certain aspects of the PICC-Port compared to the brachial PICC that make it different and, in theory, more effective, i.e., able to achieve the goal desired : achieve a uncomplicated long-term treatment at a reduced cost.

Above all, to be cost-effective, the insertion of the PICC-Port must be performed by properly trained nursing staff. Over the years, nurses around the world have acquired the skills, competencies and abilities to perform ultrasound-guided PICC placement as recommended by international guidelines and studies.

It has been widely demonstrated that this model of vascular equipment with trained nursing staff reduces costs, increases the efficiency of the entire procedure and brings benefits to the patient and the institution in its complexity.

The insertion technique of the PICC-port catheter is similar to the one defined by the SIP-2 [2] protocol internationally recognized by the scientific community and developed by the Italian group GAVeCeLT (Italian group for long-term vascular access). This protocol is fundamentally based on the use of ultrasound for catheter evaluation and insertion and intracavitary ecg for tip location.

In addition, PICC-port insertion can be performed in a clean and controlled environment without having to go to an operating room or having to use x-rays to find the right position. These factors, combined with insertion by nursing staff, allow significant savings in terms of patient safety (no exposure to radiation, avoidance of insertion problems such as pneumothorax, etc.) and in terms of costs (no special room is needed for catheter insertion).

Healthcare professionals have undergone theoretical and practical training processes that include aspects as relevant as a comprehensive understanding of the catheter insertion process and not just puncture. It also includes criteria for choice, selection of appropriate materials, techniques and technologies for each case, their correct use, patient safety, patient follow-up, management of immediate and late complications, monitoring and care of the patient during the process, withdrawal at the end of the treatment, etc.

If they chose to participate, the participants were directed to a link which took them to a patient information sheet. Members were advised that there was no obligation to complete the survey. Those who decided to continue where firstly directed to a consent form. To reassure participants, a link to a privacy notice was provided. Once participants had agreed to the consent statements, they began the survey by clicking a link to the survey data base. Both the system and the virtual private network were password protected. No personal data was collected and therefore it was unlikely that anyone could have been identified by their responses to the questionnaires. The questionnaire was devised using the themes that had been elicited from the PhD study. The first questions collected demographical information, then asked about the device the respondent was living with. The remaining questions related to the objectives of the initial study.

Another concept in the SIP-2 protocol that affects the cost-effectiveness of PICC ports is the use of cyanoacrylate for the superficial closure of the pocket: it makes it possible not to remove stitches, thus avoiding an additional patient visit to the hospital.

The PICC-port is a safe and effective option for patients undergoing prolonged and intermittent treatment. They are not intended to be a replacement for the thoracic port, as each device has a specific field of action and indications. These devices have evolved to adapt to the need to eliminate/reduce complications, to the new technologies available and to the evolution of the figure of the expert nurse, to the benefit of the patient and the health organization.
[1] Totally Inserted vascular Access Device
[2] Inserción Segura de PICC, versión 2

Bibliography:

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– Burbridge, B.; Chan, I. Y.M.; Bryce, R.; Lim, H. J., Stoneham, G.; Haggag, H.; Roh, C. Satisfaction and Quality of Life Related to Chemotherapy With an Arm Port: A Pilot Study Can Assoc Radiol J. 2016, 67 (3), 290-7

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– Manual GAVeCeLT sobre PICC y Midline. Mauro Pittiruti, Giancarlo Scoppetuolo. 2017. Edizioni Edra.