Chinese-German Journal of Clinical Oncology December 2011, Vol. 10, No.

12, P695–P698
DOI 10.1007/s10330-011-0842-3

Central venous port placement in advanced breast

cancer patients: comparison of the anatomic-
landmark and ultrasound-guided techniques
Nanyan Rao, Jiannan Wu, Shunrong Li, Liang Jin, Weijuan Jia, Heran Deng, Fengxi Su

Department of breast Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guanzhou 510260, China

Received: 4 May 2011 / Revised: 20 August 2011 / Accepted: 10 October 2011

© Huazhong University of Science and Technology and Springer-Verlag Berlin Heidelberg 2011

Abstract Objective: The aim of this study was to compare the anatomic-landmark and ultrasound-guided techniques in
the placement of an internal jugular vein port in patients with advanced breast cancer. Methods: Between March 2010 and
October 2010, 60 patients with advanced breast cancer underwent central venous port placement for the delivery of chemo-
therapy, preferably through the internal jugular vein. Patients were randomly assigned to either the anatomic-landmark or
the ultrasound-guided group. Failure on first attempt, number of attempts until successful catheterization, time to successful
placement, the accordance of the two placement approaches, and the demographics of each patient were recorded. Results:
The consistency of the direction of two lines drawn using the anatomic-landmark and ultrasound-guided techniques or of the
diameter of the internal jugular vein as determined by the two approaches was 85% (51/60). The rate of successful place-
ment at first attempt was higher in the ultrasound group than in the anatomic-landmark group (P < 0.05). A greater number
of attempts and longer time to successful port placement were needed in the latter (P < 0.05). Conclusion: The findings of
this study indicate that, in the placement of an internal jugular vein port, the ultrasound (US)-guided technique has several
advantages over the anatomic-landmark technique.

Key words central venous port; breast cancer; catheterization

Reliable central venous access is necessary for the
treatment of patients who require chemotherapy, pro-
longed antibiotic therapy, parental nutrition, and/or fre-
quent blood draws [1]. In our department, peripherally
inserted central catheter lines were once routinely used
in advanced breast cancer patients to administer chemo-
therapy. Beginning in January 2010, however, we chose
the subcutaneous BardPort system to obtain central ve-
nous access because this venous port is more comfort-
able and there is less risk of infection. The right internal
jugular vein is usually preferred for cannulation prior to
port placement because its diameter is much wider than
that of the left jugular vein [2] and there is a lower risk of
pinch-off compared to the subclavian vein [3].
Internal jugular vein cannulation is the most impor-
tant step in port placement. Two randomized clinical tri-
als carried out in emergency departments demonstrated
that ultrasound (US) guidance decreases the mean num-
ber of needle sticks required to successfully cannulate the
internal jugular vein and modestly reduces associated ad-
verse events [4, 5]. A meta-analysis also supported the use
Correspondence to: Nanyan Rao. Email: raonany@126.com
of two dimensional US for central venous cannulation,
especially of the internal jugular vein. Although the US
method has been favorably compared to the anatomic
landmark technique, its widespread use has been ham-
pered in many institutions by the lack of equipment, in
particular the specially designed ultrasound device, and
the need for trained personnel. US-guided port place-
ment is also associated with higher costs. In a search for
alternatives that avoid these limitations, we designed a
randomized trial to assess the value of common ultraso-
nography in US-guided internal jugular vein cannulation
and port placement.
Materials and Methods
Patients
From March 2010 to October 2010, 60 patients with
advanced breast cancer who required long-term venous
access for chemotherapy were recruited into the trial.
Patients were assigned to undergo implantation of a 7.0
Fr. single-lumen BardPort (Bard Access Systems, USA) in
the jugular vein. The right internal jugular vein was the
preferred cannulation site for central venous port place-
696
Fig. 1 (a) Transverse section of the internal jugular vein; (b) vertical section of the internal jugular vein; (c) the A-A line, drawn using anatomic land-
marks, and the ultrasonographically determined B-B line
Fig. 2 (a) The A-A line was consistent with the B-B line; (b and c) the A-A line was not consistent with the B-B line
ment, unless radiotherapy or metastasis in the right su-
praclavicular site indicated otherwise. A computer gener-
ated randomization table was used to assign patients into
group A (cannulation using the anatomic-landmark tech-
nique) or group B (cannulation using the US-guided tech-
nique). This prospective randomized trial was conducted
with the approval of the institutional review board at Sun
Yat-Sen Memorial Hospital of Zhongshan University. In-
formed consent was obtained from each patient enrolled
in the study. Demographic characteristics, i.e., age and
gender, along with the physiological score, coagulation
parameters (such as platelet number), and clinical param-
eters were recorded for all patients.
Anatomic-landmark vs US-guided placement
The patient’s neck was slightly extended by placing a
rolled up sheet transversely under her shoulders, with the
head turned slightly (about 20°) to the left. The triangle
formed by the clavicle and the clavicular and sternal
heads of the sternocleidomastoid was identified by care-
ful palpation. The carotid artery at the medial end of this
triangle was also identified. By drawing a line from the
apex of this triangle to the ipsilateral nipple, we were able
to demarcate the direction of cannulation (A-A line).
The position of the internal jugular vein was deter-
mined using a 7.5-MHz linear US probe (GE LOGIQ
BOOK XP). From the middle of the neck to the clavicle,
the trans-sectional position of the internal jugular vein
was ultrasonographically identified and marked by dots
placed every 0.5 cm. The diameter and depth of the tar-
geted internal jugular vein were measured preoperatively.
www.springerlink.com/content/1613-9089
By connecting all the dots, a B-B line was drawn. The B
line was ultrasonographically confirmed to be accordant
with the longitudinal section of the internal jugular vein
(Fig. 1).
Internal jugular vein port placement
After infiltration with 1% lidocaine, the internal jugu-
lar vein was located with a ‘finder’ needle connected to
a 5-mL syringe. The needle was advanced through the
skin at a 45° angle in the direction of either the A-A or
the B-B line.
The port was surgically placed into the internal jugu-
lar vein using standard technique, with the patient un-
der general anesthesia, after successful cannulation of the
internal jugular vein. Appropriate placement was con-
firmed intra-operatively by chest radiograph. The port
reservoir was implanted in a subcutaneous infraclavicular
pocket and fixed to the fascia of the pectoralis muscle.
Initial port function was insured by intra-operative access
prior to skin closure.
Statistical analysis
Demographic characteristics were obtained for all pa-
tients and were analyzed using descriptive statistics. The
measured outcomes were the access time, the number of
attempts required for successful catheter placement, and
catheter complications, such as carotid artery puncture,
skin hematoma, pneumothorax, and hemothorax. Base-
line incidence of demographic variables and access time
for port placement were compared between the anatomi-
cally guided and US-guided groups using 2-sample asymp-
Chinese-German J Clin Oncol, December 2011, Vol. 10, No. 12 697

Table 1 Patients characteristics Table 3 Consistency between the A-A’ line and the B-B line
Group A Group B Consistent Not consistent
Characteristics P value
(n = 30) (n = 30)
Number 51 (85%) 9 (15%)
Age (years) 49.8 ± 11.1 48.2 ± 10.9 0.219 BMI (mean ± SD)* 22.4 ± 2.32 28.8 ± 1.94
Height (cm) 158.5 ± 5.9 159.7 ± 5.2 0.406
* P < 0.01
Weight (kg) 57.9 ± 8.2 60.4 ± 8.4 0.254
BMI (kg.m-2) 23.1 ± 3.4 23.7 ± 3.1 0.489
Neck length (cm)* 16.0 ± 0.9 16.1 ± 0.7 0.702 Consistency of the anatomically determined
Right-side port placement (%) 83.3 93.3 0.187 and US-guided cannulation lines
Percentage of MBC (%) 16.7 20 0.739 The diameter of the internal jugular vein at the level of
* Length of the neck was the length from the mastoid to the sternal heads the lower one-third of the neck was measured in group B
of the sternocleidomastoid. MBC: metastatic breast cancer breast cancer patients and in 30 healthy volunteers. The
mean internal diameter of the jugular vein was 1.14 cm.
Table 2 Comparison of anatomic-landmark and US-guided techniques If the direction of the A-A line was totally different from
for port placement in the internal jugular vein that of the B-B line or the distance between the two lines
Group A Group B was wider than one half of the diameter of the internal
P
(n = 30) (n = 30) jugular vein, then the two lines were defined as being
Success at the first attempt 22 (73.3%) 28 (93.3%) 0.038 inconsistent. Otherwise the two lines were considered
Number of attempts 1.87 ± 1.78 1.07± 0.25 0.021 as consistent with each other. Accordingly, in the 60 pa-
Number of successful cannulations 29 30 0.313 tients, the lines were inconsistent in nine patients (15%)
Mean time to cannulation (min) 13.0 ± 10.8 5.6 ± 1.5 0.033 and consistent in 51 patients (85%). BMI was significant-
Mean time to port placement (min) 54.5 ± 19.2 41.8 ± 9.9 0.002 ly different between the nine patients in the inconsistent
Carotid artery puncture 2 (6.7%) 0 (0.0%) 0.246
Skin hematoma 1 (3.3%) 0 (0.0%) 0.500 group and the 51 patients in the consistent group, being
Hemothorax 0 (0.0%) 0 (0.0%) higher in the latter (Fig. 2 and Table 3).
Pneumothorax 0 (0.0%) 0 (0.0%)
Access time and the average number of attempts are shown as mean ± Discussion
SD. Successful first attempt, carotid puncture, hematoma, hemothorax,
and pneumothorax are shown as the absolute number of patients and as Most patients with advanced breast cancer require
a percentage of the respective group long-term central venous access for the administration of
chemotherapy, nutritional therapy, and blood products as
well as for blood withdrawal. Central venous catheters
totic t tests. The rate of success at the first attempt was
have evolved considerably since they were first described
compared for the two techniques using the chi-square
by Dudric, more than 30 years ago [6]. Subcutaneous chest
test. Statistical significance was defined as P < 0.05. All
ports are advantageous for long-term central venous ac-
statistical calculations were performed using SPSS 11.5.
cess as they are generally associated with fewer infectious
complications compared to external catheters [7]. In addi-
Results tion, they allow patients unrestricted mobility and great-
er freedom in their activities [8, 9]. Venous cannulation is
Patients characteristics the most important step in subcutaneous ports placement.
The characteristics of the 60 patients who participated The right side is preferred because it is more accessible for
in the study were summarized in Table 1. There were no right-handed practitioners. Moreover, it offers the most
significant differences between the two groups for age, direct route to the superior vena cava and hence to the
height, weight, body mass index (BMI), neck length, side right atrium, right ventricle, and pulmonary artery. The
of port placement, and percentage of patients with breast right internal jugular vein also has a much wider diameter
cancer metastases (Table 1). and runs more superficially than the left jugular vein [2].
Cannulation of the vein is most often achieved using the
Comparison of the two placement techniques anatomic-landmark technique, with the main advantage
The rate of success at the first attempt was higher in being its simplicity. However, since the needle is inserted
the group B than in the group A (P < 0.05). In the latter, a blindly this method may be associated with increased
greater number of attempts and a longer time to success- morbidity and high failure rates. Since the first report of
ful port placement were needed (P < 0.05). Two patients combined real-time visual ultrasonographic imaging for
in group A had a carotid puncture and one developed a internal jugular catheter placement, by Yonei in 1986
skin hematoma. Hemothorax or pneumothorax did not [10]
, there has been mounting evidence demonstrating the
occur in any of the patients (Table 2). benefits of US for central venous catheter placement, in-
698
cluding rapid vein localization, a reduction in needle at-
tempts, and fewer complications [4, 11]. Consequently, the
US-guided technique has been proposed as an alternative
method for central vein cannulation and port placement,
with the aim of improving success rates and minimizing
morbidity [12, 13]. US-guided access also has been found to
be safer and more effective than the traditional anatomic-
landmark approach for accessing the right internal jugu-
lar vein, with results compelling enough to conclude that
“Image-guided insertion of chest ports should replace
rather than supplement unguided placement”[14]. Fur-
thermore, ultrasonography has a significant clinical role
in allowing visualization of the vessels of interest. This is
especially valuable given the variability of the anatomic
position and diameter of the internal jugular vein rela-
tive to the carotid artery [15]. However, the real-time US-
guided procedure requires a specifically designed device
for needle puncture and the vein is at risk of collapse if
pressure from the probe is too strong. Moreover, use of
the US device may be problematic and of considerable
inconvenience for the clinician. Another drawback is
that extensive use of ultrasonographically guided central
vein cannulation may prevent trainees from acquiring
the skills needed for the anatomic-landmark method. In
the present study, we designed a randomized prospective
trial to determine the value of US-guided port placement
in breast cancer patients. The skill with which the central
vein is cannulated plays an important role in port place-
ment. According to previous reports, the US-guided tech-
nique results in a marked reduction of access time [16]. In
our study, the access time required for both cannulation
and port placement were statistically different between
the US-guided group and the anatomic-landmark group,
in agreement with previous studies. We found that the
consistency rate between the A-A line (group A) and the
B-B line (group B) was about 85%. Patients in whom the
two lines were inconsistent were found to have a higher
BMI and accounted for a success rate at first attempt of
only 73.3% in the anatomic-landmark group. Nonethe-
less, even in the US-guided group failure at first attempt
occurred in 6.7% of the patients, most likely due to the
inadequate skills of the personnel. Puncture of the ca-
rotid artery is the most frequent complication of internal
jugular vein cannulation because of the artery’s close ana-
tomical proximity to the vein. Using ultrasonographically
determined landmarks, we were able to accurately deter-
mine the location and the direction of the internal jugular
vein, which dramatically decreased the arterial puncture
rate to zero.
In conclusion, the US-guided technique is a safer and
more effective method than the classical anatomic-land-
mark technique to achieve central venous access and
subcutaneous port placement in patients with advanced
breast cancer. Especially in those patients with a higher
www.springerlink.com/content/1613-9089
BMI, it provides a satisfactory alternative for internal jug-
ular vein cannulation and subcutaneous port placement
when a real-time US-guided procedure is not feasible.
Acknowledgment
I would like to thank International Science Editing for
giving me kind advice and great editing of the paper.
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