JVA

J Vasc Access 2016; 17 (6): 527-534

DOI: 10.5301/jva.5000609

ISSN 1129-7298 ORIGINAL RESEARCH ARTICLE

Quality-of-life assessment: arm TIVAD versus

chest TIVAD
Brent Burbridge1, Kunal Goyal2

 Medical Imaging, Royal University Hospital, Saskatoon, Saskatchewan - Canada

1

 Department of Diagnostic Radiology, Regina General Hospital, Regina, Saskatchewan - Canada

2

Abstract
Introduction: Venous access devices are essential for the provision of care for patients requiring chemotherapy.
Totally implanted venous access devices (TIVADs), also known as ports, are an option for infusion care. Medical
devices have an impact upon patient quality of life. We assessed the impact on quality of life and satisfaction with
their venous device, for patients with a chest TIVAD versus an upper arm TIVAD.
Materials and methods: Sequential subjects were administered a questionnaire, “Quality of Life Assessment,
Venous Device - Port (QLAVD-P)” at the time of their TIVAD removal. All subjects consented to complete the
questionnaire and volunteered for this assessment. The TIVADs were all implanted and removed in the medical
imaging department.
Results: Between March 1, 2014 and August 30, 2015, 127 subjects completed the QLAVD-P. At the time of their
port removal, 51 had chest ports while 76 had arm ports. There were some negative features of the chest ports
that were statistically significant in comparison to the arm ports. Most of the subjects felt that their port had a
positive impact upon their treatment and they would have another port inserted if required for future treatment.
Discussion: Quality of life for those requiring intravenous chemotherapy is very important. This should be consid-
ered when selecting an infusion device. Venous ports were positively received by the subjects in our study and
there were fewer negative impacts upon subject satisfaction and quality of life for those with upper-arm devices.
Keywords: Arm implantation, Chest implantation, Quality of life, TIVADs

Introduction no standardized, validated, tools that have been deployed in

Implanted medical devices have an impact upon patient
quality of life (1). There are a wide variety of possible venous
access devices available to facilitate infusion therapy. Some of
these devices are external while others are implanted subcu-
taneously. Two different anatomic sites for totally implanted
venous access devices (TIVADs), or port devices, were investi-
gated to determine if there was any discernible differential in
quality of life. The anatomic sites investigated were the chest
and the upper arm.
Venous access device-specific assessment tools that eval-
uate the impact of TIVADS upon patient quality of life and
satisfaction with their infusion device are lacking. There are
Accepted: July 22, 2016
Published online: October 15, 2016
Corresponding author:
Dr. Brent Burbridge
Medical Imaging
Royal University Hospital
103 Hospital Drive
Saskatoon, SK
S7N 0W8, Canada
Brent.burbridge@usask.ca
a clinical setting. Marcy et al (2), have recently published find-
ings about their development, and validation, of a quality-
of-life survey for patients with venous access devices. Their
project began with a large number of patient questions that
they tested, revised and shortened to 27 questions in to-
tal. They called this assessment tool the Questionnaire for
­Acceptance of and Satisfaction with Implanted Central Ve-
nous Catheter (QASICC). They felt that this survey tool re-
quired further testing and utilization for more specific patient
groups in order to assess the utility and value of their work.
Also, the majority of their work was done in French and then
translated into English, which also will require further testing
and analysis (2).
In order to perform an assessment of the effects of im-
planted chest and arm ports in our jurisdiction, we created
a locally designed, paper-based, questionnaire to evalu-
ate patient satisfaction with their venous device and the
impact of their TIVAD upon their quality of life. This ques-
tionnaire was entitled, Quality of Life Assessment, Venous
Device - Port (QLAVD-P). This questionnaire was created by
a group of interventional radiologists in consultation with a
medical oncologist by incorporating some of the questions
used by Marcy et al (2), and by developing unique local con-
tent to result in the QLAVD-P. The QLAVD-P comprised 32
questions.

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528 Quality of life TIVADs

Materials and methods
This project was reviewed, and approved, by the imaging
departments of the health regions involved, and the project
received ethics approval from the University of Saskatchewan
Research Ethics Committee. All subjects in the project pro-
vided written consent for participation. There were no incen-
tives offered to subjects of this study.
Sequential subjects were prospectively administered a
paper-based quality-of-life assessment tool to evaluate the
impact of the port they had implanted for chemotherapy to
treat a malignancy. The QLAVD-P was used as the question-
naire document. The content of the questionnaire utilized is
provided for review in Table I.
The questionnaire was completed by the subject when
they attended to have their vein port removed at completion
of their treatment or for a port-related complication. Data
collection took place between March 1, 2014 and August 30,
2015.
The two ports compared were the Bard PowerPort®
MRI (Bard Access Systems Inc., Salt Lake City, UT, USA) chest
port and the Cook Vital Petite Mini Titanium arm port (Cook
­Medical, Bloomington, IN, USA). Both of the devices evalu-
ated were implanted by vascular interventional radiologists
utilizing ultrasound, venography, and fluoroscopy for imag-
ing guidance. The arm ports were implanted proximal to the
antecubital fossa. The port implantation procedures were
­facilitated by local anesthetic. Conscious sedation was ad-
ministered at the discretion of the responsible radiologist.
Implantation techniques for these devices have been exten-
sively discussed by previous authors (3, 4).
The chest vein ports were implanted in the Regina
Qu’Appelle Health Region and the arm ports were implanted
in the Saskatoon Health Region. Subjects were not given the
choice to receive an arm or chest port. The health regions
in question were separated by 250 kilometers geographically,
and patient care was planned and administered by two totally
different healthcare teams. There was no cross-over of sub-
jects from one health region to the other. The catheter size
for the Bard port was 8F while the Cook port had a 5F cath-
eter. Technical specifications of the devices used are provided
in Table II. The ports are demonstrated in Figure 1.

TABLE I - The QLAVD-P questionnaire

Appendix 1. Subject satisfaction and quality-of-life questionnaire

1 Are you right or left handed? Right Left
2 Arm used for port implantation? Right Left
3 Did you choose which arm you wanted the port implanted in? Yes No
If No, please explain why, if possible.
4 Do you find it easy to present your port for treatment or blood sampling? Yes No
If No, what issues do you encounter?
5 Please tell us how painful it was for you to have your port implanted. (Circle a number)
1   2   3   4   5   6   7   8   9   10
Minimal Moderate Severe
Discomfort Discomfort Discomfort
6 Do you feel that your port is too visible? Yes No
7 Do you feel that your port is unsightly or ugly? Yes No
8 Do you feel that you have changed the way you dress due to your port? Yes No
9 Have people commented on your port when they see it? Yes No
10 Do you try and cover your port with clothing? Yes No
11 Does your port make you feel anxious (worried)? Yes No
12 Does your port make you feel angry? Yes No
13 Does your port make you feel self-conscious? Yes No
14 Does your port remind you of your illness? Yes No
15 Does your port make you feel embarrassed? Yes No
16 Are you worried that your port might become damaged? Yes No
17 Are you worried that your port might become blocked? Yes No
18 Are you worried that your port might become infected? Yes No
To be continued

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Burbridge and Goyal 529

TABLE I - Continued

19 Does your port bother you when performing your work related activities? Yes No
If Yes, please explain how.
20 Does your port bother you when you shower, bath, or perform personal hygiene? Yes No
If Yes, please explain how.
21 Does your port bother you when you engage in sports or exercise? Yes No
If Yes, please explain how.
22 Does your port bother you during social activities? Yes No
If Yes, please explain how.
23 Does your port bother you when you are lying down in bed? Yes No
If Yes, please explain how.
24 Does your port hurt? Yes No
If Yes, please explain how.
25 Rate the degree of discomfort you experience during needle insertion into the port. (Circle a number)
1   2   3   4   5   6   7   8   9   10
Minimal Moderate Severe
Discomfort Discomfort Discomfort
26 Rate the degree of discomfort you experience during treatment infusion. (Circle a number)
1   2   3   4   5   6   7   8   9   10
Minimal Moderate Severe
Discomfort Discomfort Discomfort
27 Rate the degree of discomfort you experience during needle removal after treatment. (Circle a number)
1   2   3   4   5   6   7   8   9   10
Minimal Moderate Severe
Discomfort Discomfort Discomfort
28 Do you believe that insertion of your port was a good thing to have done? (Circle a number)
1   2   3   4   5   6   7   8   9   10
No Probably Definitely
29 Assess your degree of satisfaction with your port. (Circle a number)
1   2   3   4   5   6   7   8   9   10
Not Moderately Very
Satisfied Satisfied Satisfied
30 If you had to have a port implanted for another session of treatment during your life, would you have another
one inserted? (Circle a number)
1   2   3   4   5   6   7   8   9   10
No Probably Definitely
31 Why are you having your ports removed? (Please check one answer below)
– My treatment is complete my port is no longer needed.
– I am having a problem with the port that requires it to be removed.
– If you are having a problem with your port that requires it to be removed, please provide an explanation
of the problem.
32 Please feel free to provide any other comments that you feel are relevant.

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530 Quality of life TIVADs

TABLE II - Technical specifications of the Bard chest port versus the The port was usually removed at completion of chemo-
Cook arm port therapy treatment (88% chest, 88% arm), but some were
removed for management of a device complication (12%
Feature Cook, Vital, Bard, chest, 12% arm). For the chest port, complications were:
Petite, Mini Port PowerPort MRI three total occlusions; two tip displacements (irremedi-
able); and one possible infection (not culture proven).
Height 7.2 mm 14.5 mm
For the arm ports, complications were: two deep venous
Width of the port base 19 mm 29.9 mm thromboses; two culture positive infections (one Candida
Septum diameter 6.6 mm 12 mm albicans); one catheter fracture with embolization; one port
site pain; one total occlusion; one wound dehiscence; and
Septum surface area 35 mm 2
113 mm2 one catheter tip displacement (irremediable). There were
Volume of the port chamber 0.15 mL 0.6 mL no statistically significant differences between the two ana-
tomic sites for those subjects having their port removed for
Outer diameter of the port 5 French 8 French
catheter a complication.
There was a statistical difference in the sidedness of port
Catheter material Silicone Polyurethane insertion. A greater number of subjects had their arm port
implanted on their non-dominant side, and they were able to
opt to have the port implanted on this side more frequently,
than for the chest port cohort. The chest ports were predom-
inantly implanted on the right side (68.6%, p = 0.005). The
vein used for catheter insertion was itemized and data for
these parameters are summarized in Table III.
With regards to pain associated with the two different
anatomic port locations, there were no statistically signifi-
cant differences for pain at implantation, pain at needle
­insertion, or a sense of constant port-site pain. However,
subjects did find pain at infusion and pain at needle removal
to be slightly more frequent with the arm implantation site,
although the frequency of pain with these activities was
very low.
There were perceptions that the devices did create a
negative impact upon the quality of life for the subjects in
this trial. Most of the negative perceptions were low in fre-
Fig. 1 - (A) The Cook Vital Petite Mini Titanium Port, anteroposte- quency. However, some of them were more frequent, e.g.,
rior view; (B) Cook Vital Petite Mini ­Titanium, lateral view; (C) Bard
PowerPort® MRI port, anteroposterior view; (D) Bard PowerPort®
roughly 20% of respondents worried about port damage,
MRI, lateral view. or infection, while 39%-47% felt that the device reminded
them of their disease. A summary of whether the patient felt
that their device had negative impact upon them is provided
TIVAD removal was performed by the same vascular/­ in Table IV.
interventional radiologists, at the same hospital that the It is apparent from the data in Table V that for eight of the
device had been implanted. Local anesthetic was utilized. features assessed there was a statistically significantly great-
Conscious sedation was administered at the discretion of the er degree of negative impact for the chest implantation site.
radiologist. Port removal consisted of the administration of The statistically significant differential negative features for
local anesthetic at the port housing implantation site, an inci- the chest ports were: too visible, felt to be ugly, commented
sion was made in the skin at the location of the incision for upon by others, changed manner of dressing, attempted to
port implantation, blunt dissection liberated the port hous- cover the port with clothing, worried about blockage, nega-
ing and the attached catheter for extraction. Fluoroscopy was tively affected social events and bothered them when lying
used at the discretion of the radiologist. The skin incision was in bed.
sutured closed, using standard techniques, and a pressure Despite the negative perceptions of these devices, it is
dressing was applied. generally apparent that there was a general positive recep-
tion for both of the TIVADs, despite anatomic location, and
Results there was no anatomic location that diminished the general
positive perception of both devices. These positive percep-
A total of 127 subjects completed the questionnaire be- tions are summarized in Table V. Most subjects felt that TIVAD
tween March 1, 2014 and August 30, 2015. At the time of implantation had been convenient for laboratory work and
their port removal, 51 of the respondents had chest ports infusions and that the decision to have a TIVAD implanted
while 76 had arm ports. The study group was matched for had a positive impact upon their care. The majority felt that
age, gender, port days in situ, and tumor type and stage at the they were, for the most part, satisfied with their device and
time of port implantation, with none of these variables being would have another port implanted if further treatment was
statistically different. required in the future.

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Burbridge and Goyal 531

TABLE III - Demographics and port placement factors/characteristics, stratified by port type (n = 127)*

Feature Anatomic site p value*

Chest, n = 51 Arm, n = 76

Age, mean (SD) 55.9 (16.4) 54.2 (14.2) 0.48

Age, median (IQR) 58.0 (48.7) 56.0 (45.3, 64.8) 0.67
Sex, n (%)
 Male 10 (19.6) 11 (14.5) 0.45
 Female 41 (86.4) 65 (85.5)
Stage, n (%)‡
  In situ/1 11 (22.4) 15 (21.1) 0.56
 2 13 (26.5) 27 (38.0)
 3 13 (26.5) 17 (23.9)
 4 12 (24.5) 12 (16.9)
Diagnosis categories, n (%)
 Breast 35 (68.6) 54 (71.1) 0.71
 Colon 10 (19.6) 11 (14.5)
 Other 6 (11.8) 11 (14.5)
Port placement factors/characteristics
Handedness, n (%)
 Right 47 (92.2) 70 (92.1) >0.999†
  Left 4 (7.8) 6 (7.9)
Port location, n (%)
 Right 35 (68.6) 33 (43.4) 0.005
  Left 16 (31.4) 43 (56.6)
Vein used for catheter insertion Right Left Right Left
  Internal jugular 30 17 0 0
 Subclavian 3 1 0 0
 Basilic 0 0 25 24
 Brachial 0 0 3 6
 Cephalic 0 0 1 1
 Unknown 0 16
Subject chose location (right or left), n (%)
  Yes 9 (17.6) 26 (34.2) 0.04
  No 42 (82.4) 50 (65.8)
Placed in dominant arm, n (%)
  Yes 31 (60.8) 31 (40.8) 0.03
  No 20 (39.2) 45 (59.2)
Reason for port removal, n (%)
  Treatment completed 45 (88.2) 67 (88.1) 0.82
  Port complication 6 (11.8) 9 (11.8)
Days in situ, mean (SD) 427.8 (272.4) 517.6 (591.7) 0.31
Days in situ, median (IQR) 383.0 (219, 513) 386.5 (214, 498.5) 0.96
* Means compared by t-test; Medians compared by Mann-Whitney U-test; proportions compared by chi-square test unless indicated.
†
 Fisher’s exact test used due to small expected cell sizes.
‡
 Stage at diagnosis was unavailable for two chest port subjects and five arm port subjects, data otherwise complete.
SD = standard deviation; IQR = interquartile range.

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532 Quality of life TIVADs

TABLE IV - Negative perceptions around port, compared by port type (n = 127)

Negative perception Chest, n = 51 Arm, n = 76 p value*

Too visible - n (%)

  Yes 14 (27.5) 9 (11.8) 0.03
  No 37 (72.5) 67 (88.2)
Ugly - n (%)
  Yes 16 (31.4) 9 (11.8) 0.007
  No 35 (68.6) 67 (88.2)
Commented on by others - n (%)
  Yes 22 (43.1) 16 (21.1) 0.008
  No 29 (56.9) 60 (78.9)
Changed manner of dressing due to port - n (%)
  Yes 18 (35.3) 9 (11.8) 0.002
  No 33 (64.7) 67 (88.2)
Attempted to cover port with clothing, n (%)
  Yes 20 (39.2) 14 (18.4) 0.009
  No 31 (60.8) 62 (81.6)
Creates self-consciousness - n (%)
  Yes 9 (17.6) 7 (9.2) 0.16
  No 42 (82.4) 69 (90.8)
Embarrassing - n (%)
  Yes 2 (3.9) 4 (5.3) 0.41†
  No 49 (96.1) 72 (94.7)
Creates anger - n (%)
  Yes 2 (3.9) 3 (3.9) >0.999†
  No 49 (96.1) 73 (96.1)
Creates anxiety - n (%)
  Yes 5 (9.8) 4 (5.3) 0.48†
  No 46 (90.2) 72 (94.7)
Reminds of illness - n (%)
  Yes 20 (39.2) 36 (47.4) 0.36
  No 31 (60.8) 40 (52.6)
Worry about damage - n (%)
  Yes 16 (31.4) 18 (23.7) 0.34
  No 35 (68.6) 58 (76.3)
Worry about blockage - n (%)
  Yes 23 (45.1) 18 (23.7) 0.01
  No 28 (54.1) 58 (76.3)
Worry about infection - n (%)
  Yes 10 (19.6) 17 (22.4) 0.71
  No 41 (80.4) 59 (77.6)
Bothers activities
Work - n (%)
  Yes 9 (17.6) 11 (14.5) 0.63
  No 42 (82.4) 65 (85.5)
Social events - n (%)
  Yes 5 (9.8) 1 (1.3) 0.04
  No 46 (90.2) 75 (98.7)
Sports/exercise - n (%)
  Yes 5 (9.8) 9 (11.8) 0.72
  No 46 (90.2) 67 (88.2)
Lying in bed - n (%)
  Yes 14 (27.5) 10 (13.2) 0.04
  No 37 (72.5) 66 (86.8)
Personal hygiene - n (%)
  Yes 1 (2.0) 1 (1.3) >0.999†
  No 50 (98.0) 75 (98.7)
* Proportions compared by chi-square testing unless indicated.
† 
Fisher’s exact test used due to small expected cell sizes.

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Burbridge and Goyal
TABLE V - Positive perceptions around port, compared by port type (n = 127)*
Positive perception
Convenient for lab work/treatment - n (%)
  Yes
  No
Degree to which port has been a positive decision (1-10)
  Mean (SD)
  Median (IQR)
Degree of satisfaction with port
  Mean (SD)
  Median (IQR)
Willingness to repeat placement if required (1-10)
  Mean (SD)
  Median (IQR)
* Mean compared by t-test; medians compared by Mann-Whitney U-test; proportions compared by Fisher’s exact test. Data complete.
SD = standard deviation; IQR = interquartile range.
Discussion
The choice of a type of venous access device for chemo-
therapy infusion is multifactorial. It may be impacted upon
by the duration of expected treatment, the availability of dif-
ferent venous access devices, the relative cost of one device
versus another, the local expertise available to implant the
devices, past successes or failures with different devices, per-
sonal preferences of the clinical team, and possibly the pref-
erence of the patient.
The complications encountered that led to removal of the
ports were not statistically significantly different. However,
the occurrence of deep venous thrombosis and a catheter
fracture that resulted in a catheter pulmonary embolism
were unique to the arm port cohort. Deep venous thrombosis
is a multifactorial condition and may be associated with ma-
lignancy. The frequency of this complication does not exceed
the 6% threshold level for this complication as established
by the Society of Interventional Radiology (5). A discussion
of catheter fracture associated with the Cook Vital Port by
Burbridge et al, identifies this as a potential complication for
which a definitive cause has not been determined (6).
The technical process of chest implantation of venous ac-
cess devices can potentially result in several complications that
are not possible with arm implantation: subclavian artery in-
jury, carotid artery injury, pneumothorax, hemothorax, and air
embolism, to cite some of the possible unique complications
associated with this anatomic location. It has been demon-
strated that the use of ultrasound guidance for central venous
access can substantially reduce insertion site complications
and procedure failure rates. Hence, some of the complications
of chest port implantation can be substantially reduced, or
eliminated, when ultrasound is used for venous access. This
should be taken into consideration based upon the local avail-
ability of ultrasound for venous access guidance (7-9).
A limitation of our current study is that all chest ports
were inserted and removed in the Regina Qu’Appelle Health
© 2016 Wichtig Publishing
533
Chest, n = 51 Arm, n = 76 p value
49 (96.1) 70 (92.1) 0.47
2 (3.9) 6 (7.9)
9.3 (1.6) 9.3 (1.5) 0.88
10 (9, 10) 10 (9, 10) 0.88
8.9 (1.7) 8.8 (1.9) 0.61
10 (8, 10) 9.5 (8.3, 10) 0.41
8.8 (2.0) 9.0 (2.0) 0.77
10 (8, 10) 10 (9, 10) 0.81
Region while all of the arm port were inserted and removed
in the Saskatoon Health Region. It is possible that there was
an uncontrolled for geographic bias that we were unaware
of when analyzing the data. However, the two health regions
were 250 kilometers apart and neither the healthcare teams
nor the project subjects crossed jurisdictional boundaries and
could not discuss the differences in their TIVADs. Addition-
ally, none of the volunteers knew that a questionnaire was to
be administered at the time of device removal and could not
have prepared in advance for this.
Both groups of subjects experienced a similar rate of com-
plications, 12%. However, despite the complications encoun-
tered, there was no statistical difference in quality of life or
satisfaction based upon the types of complications encoun-
tered. A limitation of our statistical analysis was the inability
to assess if the degree of severity of the complications en-
countered varied between devices and if this had an impact
upon subject responses.
There were some negative impressions of the chest de-
vice in that the right-sided implantation site, that was favored
by those inserting the devices, left some subjects feeling that
they had no say in what side the device should be implant-
ed, and if it could be on the non-dominant side of the body.
This, associated with the feelings that the chest device was
too visible, ugly, and led to subjects changing their manner
of dressing in order to cover the device, suggests that there
are concerns about the cosmetic impact of the chest devices.
Additionally, the chest subjects also were statistically found
to be worried about their device blocking and found the chest
port adversely affected their social life and bothered them
while lying in bed.
Due to the anatomic constraints of the arm anatomy, port
infusion devices implanted in the arm have had to be minia-
turized in comparison to chest ports. Lilienberg et al, found
that peripherally inserted vein ports, due to their smaller size,
were prone to difficulties associated with aspiration and rate
of injection versus chest ports (10).
534
However, port manufacturers are now marketing smaller
port designs, with power-injection capabilities, suitable for
arm implantation, e.g., Angiodynamics, Vortex, Smart Port,
CT Mini (Angiodynamics, Latham, NY, USA) and the Bard,
PowerPort® Slim (Bard Access Systems Inc., Salt Lake City, UT,
USA). Other manufacturers will be certain to develop addi-
tional devices that are targeted for arm implantation.
Overall, the majority of individuals who received a port
for chemotherapy felt that it was a good decision to employ
one of these devices for their care and would have another
implanted if required, which speaks highly to the utility and
value these venous access devices have for chemotherapy,
regardless of their anatomic location. Based upon the results
of the QLAVD-P questionnaire completed at the time of port
removal, the arm implantation site lends itself to improve-
ment in subject satisfaction and quality-of-life categories,
during chemotherapy.
Disclosures
Financial support: No grants or funding have been received for this
study.
Conflict of interest: None of the authors has financial interest re-
lated to this study to disclose.
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