Central Venous Catheters

What is a portacath?

A portacath is a tube (catheter) with a small reservoir (port) attached to it. It can be used to give chemotherapy or medicine into your vein, or to take blood sample for blood tests.

Portacaths are also simply called ports and are sometimes called implantable ports or subcutaneous ports.

The catheter is a thin, soft, flexible tube made of silicone. It is usually put in (tunnelled) under the skin of your chest or sometimes in your arm. One end of the tube goes into a large vein just above your heart. The other end connects to the port. The port is a disc that’s about 2.5–4cm (1–1.5in) in diameter. It goes under the skin on your upper chest or arm. You will be able to see and feel a small bump on your skin where the port is.

What is a portacath used for?

A port can be used to give you treatments such as:

• chemotherapy
• blood transfusions
• antibiotics
• intravenous (IV) fluids.

Ports can also be used when you need to have blood tests. This means you won’t need to have needles put into your arms every time you have treatment.

You can go home with the port in. It can be left in for weeks, months or sometimes years.

A port may also be useful if doctors or nurses find it difficult to get needles into your veins.

How is a portacath inserted?

Portacath is usually inserted by a specially trained intervention radiologist in a special X-ray room in a hospital. You will usually have a local anaesthetic to numb the area. You will usually be able to go home on the same day. Feel free to discuss the position of your port with Dr Goyal before it is put in.

A small needle will be put into a vein in your arm or hand and you will have medicine to help you relax. You will receive a local anaesthetic into your skin to numb a few small areas on your chest and neck. You might feel some pressure on your chest or arm during the procedure, but you shouldn’t feel any pain.

Two small cuts (incisions) will be made in your skin. The first is made to create a pocket under the skin for the port. It will be about 3–4cm long. If the port is being put into a vein in your chest, the incisions are made on your upper chest. If the port is being put into a vein in your arm, they will be on the inner side of your arm. There will be a smaller cut in the neck region where the catheter is put into the vein. This incision is usually less than half a cm long.

The port will be inserted under the skin. The tube attached to the port will be tunnelled under your skin to the smaller incision, where it will be put into a vein in your chest. The incisions are then stitched.

You may have a small dressing to cover the wounds for a few days  after the procedure. The nursing team will teach you how to look after this.

You may feel a bit sore and bruised for a few days after the port is put in. Simple painkillers such as paracetamol may help with this.

Straight after the port has been put in, and for a few days after, check for any redness, swelling, bleeding, bruising, pain or heat around the wounds. Let your hospital doctor, your own doctor or Dr Goyal know straight away if you have any of these. You could have an infection, which may need to be treated.

The incisions are closed with dissolvable stitches under the skin which will get dissolved on their own in a few weeks.

How do I prepare for the procedure?

Portacath is usually inserted as a day case procedure which means that you can come in, get the portacath inserted and go home the same day.

Blood tests: Before the procedure, you will need to have a blood test to measure full blood count (FBC) and clotting. This will usually be arranged by your doctor or clinic nurse specialist. Dr Goyal’s team can also arrange for these to be done prior to the procedure.

 If you are currently receiving chemotherapy, a blood test is needed within one week of the procedure. If you are not currently on chemotherapy a blood test within 8 weeks of the procedure is fine. If you have had a blood test for any other reason within this time we can use the results.

Medications: If you are taking any medicines that thin your blood, such as antiplatelet medicines (for example aspirin or clopidogrel) or anticoagulant medicines (for examples warfarin or rivaroxaban), please Dr Goyal or a team member as you may need to stop them temporarily before your procedure. If you have coronary stents or metal heart valves in place then you should not stop these drugs.

You must not eat or drink for six hours before the procedure. We may need to give you a sedative medicine, which may make you feel sick if you have just eaten.

You must not eat or drink for six hours before the procedure. We may need to give you a sedative medicine, which may make you feel sick if you have just eaten.

You will also need somebody to stay with you overnight.

How is the portacath used?

The port can be used soon after it has been put in. About half an hour before it is used, the skin over the port can be numbed with an anaesthetic cream (Emla cream).

Just before you have your treatment or blood test, the skin will be cleaned. The nurse will then push a special needle, called a Huber needle, through the skin and into the port. This shouldn’t be painful, but you may feel a pushing sensation. It is very important that the port is only used this special needle as normal needles will damage the port.

Treatment can then be given directly into the bloodstream, or blood samples can be taken. Dr Goyal inserts ‘Power’ ports, which may also be used to administer radiology contrast if you need scan.

If you are having a short treatment, the needle will then be removed. For longer treatments, you will have a dressing placed over the needle to hold it in place until your treatment is finished. The needle is then removed.

Caring for your portacath

After each treatment, a small amount of fluid is flushed into the catheter so it doesn’t get blocked. The port will need to be flushed every four to six weeks if it is not being used regularly.

If you feel able to, the nurses at the hospital will teach you how to do this. They can also teach a partner, relative or friend. A district nurse can also do it for you at home.

Your port will not need any other care.

Possible problems with portacath

The likelihood of problems with port is low. Most of the problems can be sorted with medication or simple interventions. However, they may require removal and replacement of the port.

Infection: It is possible for an infection to develop inside the catheter or around the port. You should tell your hospital if you have redness, swelling or pain around the port, develop a high temperature (fever), feel faint, shivery, breathless or dizzy.

If an infection develops, you will be given antibiotics. If the infection doesn’t get better, the port may need to be removed.

Blood clots: It is possible for a blood to clot in the vein where the catheter sits. You should contact your hospital doctor or nurse if you notice any swelling, tenderness or redness in the neck or arm on the same side of the body as the port.

If a clot does form, you will be given medication to dissolve it. Your port may have to be removed.

Blocked port: The inside of the catheter can sometimes become partly or completely blocked.

If this happens, it can be difficult to give treatment or to take blood tests through it. The catheter may be flushed with a solution to try to clear the blockage, or the port may need to be removed.

How is the portacath removed?

When you don’t need the port any more, it will be taken out. This is usually a much simpler procedure than insertion. A local anaesthetic is used to numb the area.

A small incision is made over the site of the port and the port removed. The catheter is gently pulled out of the vein. The wound is then stitched and covered with a small dressing.

You may feel a bit sore and bruised after your port is removed. Simple painkillers such as paracetamol may help with this.

Some special precautions

The port shouldn’t interfere with your daily activities. It is best to avoid strenuous exercise for a few weeks after insertion, so your body can heal.

Only the Huber needles should be used on your port. Don’t let anyone use any other type of needle.

If the port is in your arm, don’t let anyone take your blood pressure or take blood from a vein in that arm. Don’t lift anything heavier than 15lb (7kg).

You may want to wear a medical ID bracelet saying you have an implanted port.

If you need more information, please feel free to contact Dr Goyal.

What is a Hickman line?

Hickman line is a long, hollow tube made from silicone rubber.

The Hickman line is put in (tunnelled) under the skin of your chest and into a nearby vein. One end of the line goes into a large vein just above your heart. The other end comes out from under the skin on your chest.

The line is usually sealed with a special cap or bung. This can be attached to a drip or syringe containing your chemotherapy or medication. Sometimes it divides into two or three lines which allow you to have different treatments and medications at the same time.

What is Hickman line used for?

A Hickman line can be used for various purposes:

• Chemotherapy
• Blood transfusions
• Antibiotics
• Intravenous (IV) fluids
• Liquid food (TPN) if you’re not able to eat
• To take samples of your blood for testing

How is a Hickman Line inserted?

Hickman lines are inserted in the X-ray department using ultrasound and x-ray. The line is put in through the vein at the bottom of the neck, or the vein below the collar-bone.

You will be asked to lie on your back on the X-ray table. You will be connected to monitoring equipment to check your heart tracing, blood pressure and blood oxygen levels. It is very important to insert Hickman lines under sterile conditions to avoid infection. Hair on the skin at the entrance or exit sites may be removed. The radiologist will put on a sterile gown, theatre cap and mask, and you may need to wear a theatre cap also.

The skin on your chest and neck is cleaned with antiseptic and you will then be covered in sterile towels. Local anaesthetic is used to numb the skin over the vein (the ‘entrance site’) and a point lower down the front chest wall (the ‘exit site’), as well as the skin in between (which will form the tunnel). A small incision is made at the entrance and exit sites. The tube is then tunnelled under the skin from the exit site to the entrance site. The tip of the line is gently threaded into a large vein, towards the heart. The position of line is adjusted until it is satisfactory. The line is secured at the exit site with a stitch. Another stitch is used to close the small incision at the entry site. A dressing is placed over these. The Hickman line is flushed to ensure that there is no clotted blood with in it and it is then clamped off. The line is taped to the chest in a loop.

The procedure takes 30-45 minutes.

What stops the Hickman line from falling out?

There is a small cuff around the Hickman line. It can be felt under the skin, just above the exit site. The tissue under the skin grows around this cuff in about three weeks and holds the line safely in place.

Until this happens, you will have a stitch holding the line in place. This stitch usually stays in place for about three weeks.

How to care for my Hickman line?

When the line is not being used, there is a small risk of it becoming blocked. A small amount of fluid is flushed into the line using a syringe, once a week, to stop this from happening. The caps or bungs at the end of each line should also be changed every week.

The exit site needs to be cleaned once a week to reduce the risk of infection. If you have a dressing on the site, it will also need to be changed once a week.

Sometimes a special dressing, such as an antibiotic disc, may be put over the exit site. The dressing helps to reduce the risk of infection.

If you feel able, the nurses at the hospital will teach you how to flush the line and change the dressings. They can also show a relative, partner or friend how to do this.

When you are at home, it is safe for you to have a shower or bath with your central line in. You can place your line in a plastic bag and tape it to your skin so that the line does not get wet. If having a bath, you should keep the exit site out of the water in a bath.

Swimming should usually be avoided because there is a risk of infection. It is best to avoid other sports such as golf, tennis or strenuous gym exercises. This is because there is a risk that your central line could become dislodged.

Can I exercise with a Hickman Line?

Strenuous exercise or heavy lifting should be avoided for three weeks after insertion till the cuff is secure in place by growth of tissue. After that you may exercise and do most of your normal daily activities. However you should avoid:

Swimming as it is difficult to prevent the line and dressing from becoming wet.

Activities involving big arm movements such as golf, tennis and skiing because there is a risk that line may become displaced.

If exercise is really important to you then please discuss the option of Portacath with Dr Goyal.

Can there be problems with Hickman lines?

The chances of problems are low with Hickman lines. However, unfortunately as the Hickman lines are external tubes, there are some potential problems.

Infection: Infection may develop inside the line or in the area under the skin where it is tunnelled. Contact your hospital doctor or nurse if you have:

• redness, swelling or pain in the area
• discoloured fluid coming from the area
• a high temperature (fever)

If you get an infection, you will be given antibiotics. If the infection doesn’t get better, the line will need to be removed.

Blood clots: A blood clot may form in your vein at the tip of the line or around the line within the vein. This usually causes difficulty in aspirating blood from the line or injecting fluids into the line. Regular flushing of the line especially when it is not being used helps prevent this. If a clot does form, you will be given some medication to dissolve it. Your line may have to be removed.

Air in the Hickman line: It is important not to get any air into your Hickman line. A cap (or bung) should always be placed at the end of the line (or each lumen if more than one lumen).

Line displacement:  To stop the line coming out by accident, it should always be well secured with tape or covered with a dressing especially in the first three weeks until the tissue around cuff has grown. If the dressing holding the Hickman line in place becomes loose, please have it replaced as soon as possible.

How is the Hickman line removed?

When you do not need the central line anymore, it will be taken out. It is usually done in the outpatient department and takes about 30 minutes.

Once you are lying down comfortably, the skin over your chest will be cleaned with antiseptic. The doctor or nurse will then numb the area around the cuff with local anaesthetic. They will make a small cut to release the cuff, and then slowly remove the line. You might find this uncomfortable, but it should not be painful.

Once the line is out, a dressing will be placed over the exit site. You may be asked to stay in the hospital for a couple of hours to ensure that bleeding from the line site has fully stopped before discharge.

What is a PICC line?

A PICC line is a long, thin, flexible tube called a catheter. It’s put into one of the large veins of the arm, above elbow joint. It is then threaded into the vein until the tip is in a large vein just above the heart.

The line is usually sealed with a special cap or bung. This can be attached to a drip or syringe containing your chemotherapy or medication. Sometimes it divides into two or three lines which allow you to have different treatments and medications at the same time.

What is a PICC line used for?

A PICC line can be used for various purposes:

• Chemotherapy
• Blood transfusions
• Antibiotics
• Intravenous (IV) fluids
• Liquid food (TPN)  if you’re not able to eat
• To take samples of your blood for testing

How is a PICC line inserted?

A PICC line is inserted as an outpatient or day case procedure. Before the procedure, Dr Nimit Goyal will discuss with you which arm would be better to use.

Dr Goyal will first do an ultrasound scan of your arm veins to assess the best vein for the procedure. The skin over the area is cleaned with antiseptic solution. Then this area is numbed with an anaesthetic injection.

When the skin is completely numb, a needle will be put into the vein using ultrasound to guide the needle. Dr Goyal is an interventional radiologist and is specially trained to use ultrasound to guide interventions. Ultrasound itself is painless and its use ensures that the correct vein is punctured with minimum discomfort.

The PICC line is threaded through the needle into a large vein that leads to your heart. The needle is removed at the same time. This shouldn’t take long and is usually painless. The PICC line will be held in place by a clear dressing.

Dr Goyal will do the procedure with you lying on an X-ray table and confirm the position of the tip of the line. You will therefore not need a separate chest x-ray.

How can I prepare for the PICC insertion?

The line is inserted under a local anaesthetic and you can eat and drink normally beforehand. Keep up your fluid intake as being dehydrated can make it more difficult to access the veins in your arm.

Please take all of your regular medications as usual, unless advised otherwise.

Wear loose fitting clothes particularly around the arms. Choose clothes in such a way so that the top can be removed easily if necessary.

Are there any potential problems when inserting a PICC line?

It can sometimes be difficult to thread the PICC line up the vein towards the heart. If this happens, we will try again using a different vein.

Sometimes, position of the PICC line may not be adequate and it may need to be repositioned. As Dr Goyal does the procedure on an X-ray table, this problem is avoided.

How do I care for the PICC line?

When the PICC line is not being used, there is a small risk of it getting blocked. To stop this from happening, once a week, a small amount of fluid is flushed into the line using a syringe.

The caps at the end of the line need to be changed each week to reduce the risk of infection. The dressing also needs to be changed every week. If it gets wet or starts to peel off, it should be changed sooner. It is difficult to change the dressing with one hand, so the nurses at the hospital may do it for you or arrange for a district nurse to visit you at home. They can also teach a relative, partner or friend how to change the dressing.

When you are at home, it’s safe for you to have a shower or bath with your PICC line in. Your nurse can give you waterproof covers to stop the line getting wet.

Can I exercise with a PICC Line?

Strenuous exercise or heavy lifting should be avoided on the day of insertion or until any oozing of blood around the line has stopped. After that you may exercise and do most of your normal daily activities. However you should avoid:

Swimming as it is difficult to prevent the line and dressing from becoming wet.

Activities involving big arm movements such as golf, tennis and skiing because there is a risk that line may become displaced.

If exercise is really important to you then please discuss the option of Portacath with Dr Goyal.

Can there be problems with PICC lines?

The chances of problems are low with PICC lines. However, unfortunately as the PICC lines are external tubes, there are some potential problems.

Infection: Infection may develop inside the line or in the area under the skin where it goes into the vein. Contact your hospital doctor or nurse if you have:

• redness, swelling or pain in the area
• discoloured fluid coming from the area
• a high temperature (fever)

If you get an infection, you will be given antibiotics. If the infection doesn’t get better, the line will need to be removed.

Blood clots: A blood clot may form in your vein at the tip of the line or around the line within the vein. This usually causes difficulty in aspirating blood from the line or injecting fluids into the line. Regular flushing of the line especially when it is not being used helps prevent this. If a clot does form, you will be given some medication to dissolve it. Your line may have to be removed.

Air in the PICC line: It is important not to get any air into your PICC line. A cap (or bung) should always be placed at the end of the line (or each lumen if more than one lumen).

Line displacement:  To stop the line coming out by accident, it should always be well secured with tape or covered with a dressing. If the dressing holding the PICC line in place becomes loose, please have it replaced as soon as possible.

How is the PICC line removed?

When you don’t need a PICC line any more, it can be taken out by gently pulling it out and the area where the PICC line was put in will be covered with a small dressing. This is a painless procedure and only takes a few minutes. It is done as an outpatient.