You and your Totally Implanted Vascular Access Device (TIVAD) - Portacath

What is a TIVAD?

A totally implanted vascular access device (TIVAD), commonly called a Portacath or a Port, is a long hollow tube that is inserted into one of the large veins in your body, usually within your upper arm or within the neck. One end of the tube sits within a vein ending just above the heart, and the other end is attached to an injection port that sits underneath your skin in your upper arm or the chest. 

These are usually recommended for patients who need certain types of medicines that irritate or damage small veins or for patients whose treatments will take place over many months or years. They are also recommended for patients who need intravenous therapy over a long period of time as an alternative to long-term venous devices that are visible to others and that require regular dressings and frequent care.  

Why is a TIVAD necessary?

TIVADs are used in a number of situations including:

• Chemotherapy that requires a portable pump for a couple of days, regularly over a period of several months, or for long term or open-ended management.
• Veins that prove difficult to repeatedly access or to prevent vein damage.
• Patients whose veins have become painful and more difficult to access following intravenous chemotherapy.
• Patients who want a long-term vascular device that is not visible on the skin or require regular dressings with frequent maintenance.

Before the insertion of the TIVAD

When you are referred for or request a TIVAD you will be given an appointment to meet with one of the nurses from the Clinical Interventions Team approximately one week prior to the date the TIVAD will be inserted.  

At this appointment, the nurse will assess your veins and the area of skin where the TIVAD will be inserted.  The nurse will ask you some relevant questions and will take swabs to screen for the bacterium Methicillin-resistant Staphylococcus aureus (MRSA) and possibly other swabs to check for micro-organisms that may increase the risk of an infection. If these swabs are positive you will be given medication to use prior to the insertion of the TIVAD.  

A blood test may also be taken at this appointment if you have not yet commenced your chemotherapy/immunotherapy treatments in order to monitor for bleeding risks during the procedure. If you are currently receiving treatments, you will be asked to have these necessary blood tests the day before the insertion of the device.

Please note: It is important to tell your doctor or nurse before attending for your TIVAD insertion if you are on any medication to prevent or treat blood clots, such as warfarin, heparin and aspirin.  You must not take aspirin (or aspirin-containing products) for one week before the insertion of your TIVAD as this prevents your blood clotting normally.  If you take warfarin or heparin daily, you must discuss this with your nurse, who will advise you when to stop taking these medications and when you can restart them following the procedure.

The TIVAD insertion

You may eat and drink normally the day you are having a TIVAD inserted. However, you should not drive on the day you have your TIVAD inserted and you should arrange for someone to give you a lift to the hospital and to collect you. It is not normally possible for someone to escort you into the procedure room during the insertion.

We will clean your skin and numb it with an injection of local anaesthetic. The procedure is carried out under fully sterile conditions. You will be expected to wear a surgical hat and mask during the procedure, to lie flat and remain still during the procedure. You will be made comfortable and helped to relax. It is necessary to use a specialist ultrasound which will help locate the most suitable vein. Occasionally, it may be necessary to order a chest x-ray, which will confirm the TIVAD is in the correct position before the procedure is completed. 

To implant the TIVAD, it is necessary to create a ‘pocket’ under the skin of your arm or your chest. This will require sutures and will leave you with a small scar about 3-5 cm in length. A catheter is attached to the TIVAD and tunnelled under the skin once inserted into your vein. Once this has been done, you will not have any external parts of the TIVAD visible, but it may be possible to notice a raised area on your body, depending on the location of the device. You will have dressings initially to cover the wound and sutures where the pocket has been formed and it is essential to keep these dressings dry when bathing or showering to prevent an infection.  

If the TIVAD is to be used within a couple of days, a special needle will be inserted to allow for pain free access while the pocket is healing. Once the sutures have healed, you will be allowed to shower and bathe normally without having to keep the site dry. Your blood tests can then be taken from the TIVAD prior to your treatment or for monitoring purposes. If you attend external blood clinics it is common for staff to refuse to use your port for blood sampling due to their lack of experience. Alternatively you can book into one of the chemotherapy clinics for your pre-treatment bloods if required.

Occasionally, it may be difficult to thread the TIVAD along the vein of choice or to place the line into the correct position, making the procedure unsuccessful at this attempt. Other options will be discussed, if this is the case.

After the procedure

After the procedure, you will be asked to sit in a recovery area until you are ready to go home. If you are an inpatient, you will be transferred back to the ward. You will be able to eat and drink as soon as the procedure has been completed.

The procedure is carried out under local anaesthetic and you will be able to leave hospital after a couple of hours. The actual time that you stay in hospital will depend on other appointments after the insertion and how quickly you recover. You should not drive immediately afterwards if your arm is painful or numb following the procedure. 

Most of the sutures at the insertion site are absorbable and do not need to be removed. It is essential that the site is kept dry for approximately 7-10 days following the procedure to allow for satisfactory healing and avoid infection. You will be given an appointment with the interventional team for an appointment to remove sutures and check the healing of the wound.

You should not drive initially afterwards if your arm is painful or numb following the procedure.

Whilst you have a TIVAD, it is vital that anyone who accesses or uses it has a good standard of hand hygiene by washing their hands with antibacterial soap/gel first and by using a sterile method during all actions. It is essential to cover the needle when the port is being used to reduce dislodgement of the needle or infection risks.

When your port is not in use, and you are not receiving regular treatment, it will need flushing every eight to twelve weeks to ensure the line remains open. Routine line care when the port is not being used on a regular basis, or to remove the chemotherapy bottle, or to flush and remove the needle, can be carried out in the chemotherapy clinics. Or it can be done at home by the district nurses or by family members with support, with training and equipment. Please speak to your chemotherapy nurses to arrange this if required.  

Normal activities can be carried out when the sutures have healed, and the TIVAD is not in use. It is possible to swim with a TIVAD, but heavy exercises and some sports may need to be modified. For those patients who regularly propel themselves in a wheelchair it may not be suitable for a port to be placed in the arm. A chest port would be a better option to avoid the adverse effects of regular movement of the arms and the chest muscles.

Please note: Before chemotherapy is administered via the TIVAD, blood should be withdrawn to ensure it is safe to be used. If this is not possible, an infusion of fluid may be administered over a short period to ensure the line is working safely. You will be asked to report any pain or discomfort that you experience during an infusion given via the TIVAD. If this occurs the infusion must be stopped. The staff will then assess the needle position and TIVAD site immediately and, if necessary, perform any required management of the leakage.

When your TIVAD is no longer required it may be removed. Prior to this, you will need to stop any blood thinning medication. This will be explained to you, and you will require blood tests prior to the removal to check for bleeding risks and complications. You will be given an appointment for the removal which is carried out as a sterile procedure with local anaesthetic. You should arrange for someone to bring you and collect you on the day. For patients who face long-term, ongoing intravenous therapies, your TIVAD may remain in place, but it will need to be maintained on a monthly basis.

Infection

Ports can become infected, which can be from a local skin infection at the port site or from a systemic bloodstream infection. Please report any pain, redness or oozing from the site by contacting The Clatterbridge Cancer Centre Hotline. Please also check your temperature if you are feeling unwell, and report any temperatures above 37.5°C promptly. We will provide you with information on how to care for your TIVAD during the initial few weeks post insertion whilst the skin is healing. If necessary, antibiotics to treat infections with be commenced to salvage the line, however in rare cases, it may be necessary to remove the device and wait for all signs of the infections to clear. Portacaths should not be removed if an infection has not been confirmed that the port is the source of the infection.

Blood clots

Blood clots can develop in the vein or along the route where the TIVAD is sitting. Signs include pain, swelling and discomfort in the neck or arm/axillary area on the side where the TIVAD is placed. If this occurs, the clot will be treated with daily blood thinning injections, or oral anticoagulant medications which will continue for as long as the TIVAD remains in place. The TIVAD may be used as planned.

Port erosion

Port erosion is when the TIVAD can wear thin or break the tissue above the port. If this happens (and it rarely will), the port will need removing. It is more likely to occur following an infection at the site of the portacath.

Lung puncture

Lung puncture this may happen when ports are placed in the chest (in less than 1 in every 6000 patients) and may require further treatment to avoid breathing complications. You will usually have to stay in hospital until the lung has healed.

Arterial puncture

Arterial puncture is a puncture of an artery that can cause bleeding which can occur during the insertion of the device. This risk is greatly reduced by the use of ultrasound.

Extravasation

Extravasation is a leakage of medication from the TIVAD into the surrounding tissues. Extravasation of chemotherapy drugs can cause tissue damage which may require surgical intervention and removal. The nurse will check the TIVAD is working properly prior to giving you medications.

Lymph leakage

Lymph leakage can occur rarely when the TIVAD is placed in the arm and the line presses on one of the lymph nodes in the axillary area causing fluid to collect around the port and leak yellow coloured fluid when the port is accessed. This commonly settles over time but can be troublesome when the port is accessed and may require removal of the port.

Occlusion

Occlusion can occur rarely when a line becomes blocked if it has not been flushed correctly. All attempts to keep the line open will be taken, but occasionally the device will need to be removed if the line cannot be fixed.

Reduced blood return

Reduced blood return can occur occasionally when withdrawal of blood from the line becomes difficult or impossible. If this occurs your nurse can instil a special fluid either by a drip or an injection through your TIVAD to help restore this function.

During the first few days, your arm can ache and become bruised after having a TIVAD implanted. Try placing warm compresses on your arm or shoulder to help ease this, particularly within the first 24-72 hours.  Simple analgesia may help, but please check your temperature if you are receiving chemotherapy. It is still necessary to move your arm as normal during this period to avoid the development of a thrombus (blood clot). If worried, please call The Clatterbridge Cancer Centre Hotline for help or advice. Rarely a port may sit on a nerve within your upper arm, which can cause numbness or intermittent pain on movement. If this does not settle the port may need to be removed.