Implantable vascular access devices are frequently used in patients who have poor peripheral venous access. These devices can be partially implanted as tunneled and nontunneled central catheters, or they can be fully implanted as ports. Compared with long-term catheters, implanted ports have lower infection rates and improved perceptions of quality of life, but complications still occur in 2% to 18% of patients, frequently requiring removal of the device. Since the conception of implantable vascular access device ports, numerous advances in port design, materials, and techniques for implantation and care have been developed with the goal of overcoming frequent complications. We review the evidence related to these advances and their effect on the safety profile and complications of implantable vascular access device ports. Since the first report of a fully implantable vascular access device (IVAD) in 1982, 1 the use of these devices has grown exponentially. They consist of a reservoir cradled in the subcutaneous tissue that is connected to a catheter, with its tip terminating into a major vein. IVADs are frequently used in patients who have poor peripheral venous access and are in need of long-term administration of vesicant drugs, antimicrobials, blood products, or parenteral nutrition.2,3 They also are used as access for long-term therapeutic apheresis procedures. 4 Although nonimplanted, long-term catheters can be used for all of these purposes as well, the lack of an external component in IVAD ports provides multiple advantages; patients have improved perceptions of quality of life and body image and less limitation in their mobility. 5 These ports also minimize the need for maintenance care and risk of infectious complications when the IVAD is not in use. 6 These benefits of IVAD port use have also been demonstrated in pediatric cancer patients, with the added advantage of allowing the child to participate in normal activities and preserving body image. 7Despite the vast experience accrued over the years and the large volume of literature studying factors associated with IVAD port outcomes, early perioperative and late postoperative complications still occur (see Table 1). 8,9 Overall complication rates for IVAD ports reportedly occur in the range from 2% to 18% of all implanted devices. 10-12Port-related infections and venous thrombosis are particularly important, because they are associated with additional morbidity and costs and require removal of the IVAD as part of their treatment in as many as 6.5% of patients. 10 An additional complication specific to the use of IVAD ports during therapeutic apheresis is the occurrence of frequent pressure-related alarms, 13-15 which do not always result in a need to abort the procedure but can delay the duration of the treatments and require additional interventions. 13Here, we present a review focused on techniques, materials, and long-term management options of ports as IVAD options that have an impact on the relevant complications and overall safety profile of th...
Background Infection is a major complication during circulatory support with a left ventricular assist device (VAD). Changes in device characteristics and treatment practices in the last decade can affect the epidemiology of infection. The International Society for Heart and Lung Transplantation (ISHLT) has published recommendations on the prevention and management of VAD infections, but data to support these recommendations remain sparse. Methods We performed a retrospective review of 455 patients who underwent VAD placement from 2009 to 2015. Infection episodes were defined using ISHLT criteria and were also grouped as endovascular or local. Analysis included descriptive statistics. Results There were 174 patients (38.6%) with a VAD infection. Infection incidence was 36.9 cases per 100 person-years of VAD support. The driveline was the most common infection site (67.2%). Systemic inflammatory response syndrome (SIRS) criteria were not satisfied in 29.2% of patients with endovascular infections, and computed tomography (CT) examinations were normal in 37.7% of cases. Gram-positive bacteria caused 65.6% of infections in patients with an available culture. Antimicrobial suppression was used in 72.3% of patients who survived treatment. Median survival after infection was 35 months for patients with VAD-related infections versus 14 months for patients with VAD-specific infections. Conclusions VAD infections continue to be a major complication after implantation. Clinical criteria alone were not predictive of serious infections, and many patients with confirmed infection had normal CTs. Patients with VAD-specific infections had lower median survival than patients with VAD-related infections.
High-throughput metagenomic shotgun sequencing revealed P. acnes as the cause of chronic meningitis that had eluded conventional attempts at diagnosis. Treatment directed at this organism resulted in cure of the infection and clinical improvement.
Introduction: Drive line infections (DLIs) are common complications of left ventricular assist devices (LVADs). Data on use of suppression antibiotic therapy are limited. Methods:We performed a retrospective review of 451 patients who underwent LVAD placement from January 2009 to May 2015. First superficial DLIs were included for analysis. We examined factors associated with the use of chronic suppressive antibiotics (CSAs) therapy. Cox proportional hazards models were performed to identify factors associated with DLI relapse with the same organism as the initial DLI.Results: A total of 69 patients developed a superficial DLI within a median of 195 (interquartile range [IQR] 98-348) days of LVAD insertion. The median age was 57 years, 87% were males, and 74% were White. Gram positive bacteria caused 61% of infections, with Staphylococcus aureus being the most common (35%). Forty-three (62%) patients received suppressive antibiotic therapy. Relapse DLI occurred in 29 (42%) patients. Independent risk factors for relapse infection in multivariable analysis were sepsis (aHR 5.94 ), and MRSA DLI (aHR 4.19 ).There was no difference in the proportion of patients with relapse among those who were treated with antibiotic suppression therapy versus not (44% vs. 38%, p = 0.64), although relapse occurred at a later time in those who received suppression (185 vs. 69 days, p < 0.01). Conclusion:CSA therapy was associated with delayed time to DLI relapse but no significant difference in the proportion of patients with relapse. A prospective study is needed to examine the effect of suppression on relapse rates.
statement. Results: Of the 516 patients studied, 37% had HFrEF. Seven patients in the HFpEF group died within 24-hours compared to 2 patients in the HFrEF group (1.9% vs 1.4%, P = .47). Patients with HFrEF had higher mortality at 1 year (19.6% vs 10.9%, P = .009, Fig. 1). Patients with HFpEF had fewer readmissions due to cardiac causes at 1 month (6% vs 11%, P = .05), but not all-cause readmissions (11% vs 15%, P = .24). Patients with HFpEF had lower mortality at 1 month, but this difference was not statistically significant (4.8% vs 8.4%, P = .12). Conclusion: The use of EF may be useful as an early predictor of HF exacerbations and mortality immediately after TAVR when using an MIS. These findings may have implications in the treatment and management of individuals after TAVR.
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