A GAVeCeLT bundle for chest-port insertion: The SIC-Port protocol

The insertion of totally implantable venous access devices (ports) is a procedure widely used in clinical practice. Ports are generally used in cancer patients undergoing chemotherapy and in patients who require long-term, infrequent access (less than once a week). Over the past four decades, ports have been inserted primarily by direct cannulation of the deep veins of the supra/infra-clavicular area, with subcutaneous placement of the reservoir over the pectoralis major muscle (so-called "thoracic port" or "chest-port"). This paper describes an insertion bundle-developed by GAVeCeLT, the Italian Group of Long-Term Venous Access Devices, and nicknamed "SIC-Port" (Safe Insertion of Chest-Port)-which consists of few evidence-based strategies aiming to further minimize all immediate, early, or late complications potentially associated with chest-port insertion. The SIC-Port bundle is currently adopted by all training courses on chest-port insertion held by GAVeCeLT. It includes eight steps: (1) systematic ultrasound evaluation of the supra/infra-clavicular veins according to the Rapid Central Venous Assessment (RaCeVA) protocol, thus choosing the most appropriate vein, in terms of caliber, site, depth, safety of venipuncture, and ease of tunneling; (2) appropriate hand hygiene, proper skin antisepsis, and maximal barrier precautions; (3) ultrasound-guided cannulation of the best available vein, with preference for the axillary vein (if adequate), so to avoid tunneling above the clavicle; (4) ultrasound control of the pleura, to exclude pneumothorax; (5) ultrasound-guided tip navigation; (6) intra-procedural assessment of tip location by intracavitary ECG and/or trans-thoracic echocardiography with bubble test; (7) appropriate creation of the subcutaneous pocket over the muscle; (8) appropriate closure of the subcutaneous pocket.