case: Port A (subcutaneous implanted injection port)

left subclavian vein and innominate vein occlusion

occlusion in SVC

Lesion was crossed by guidewire first, followed by the insertion of Port A catheter
History:
A case of breast cancer with lung metastasis. She had received left side MRM for her breast cancer several years ago. She had alse received a left side Port A insertion in the past for chemotherapy ( which was removed later ). This time she was arrange for a new Port A in order to receive further chemotherapy to cope with the metastatic cancer.
Operative finding and stragegy:
I had attempt to insert the central line via the left side cephalic vein, but failed for some how. On table angiography then showed the left side subclavian vein and innominate vein total occlusion! Thus I have to give up the left side approach. I have tried the right side internal jugular vein for another access to insert the Port A cather. However, the guide wire cannot be put through to the right atrium under the fluroscopic guide. An on table venography was then perform to demostrate any obstruction of the vessel. a filling defect over the SVC was discovered. I have managed to use the Terumo wire to cross the lesion cautiously and then insert the Port A catheter through a peel-away sheath following the guidewire. The injection Port had been placed in the usual site (infraclavicular area).
This was a good example of using on table venography to aid the insertion of a Port A catheter on a difficult case which had a central vein problem.