The introduction of totally implantable devices started in the 1980s. Since none of their parts are outside the body, port catheters allow freedom of movement during daily activities in the children, and therefore they are more convenient and the infection incidence is lower as compared to non-totally implantable devices [1] . The port catheters are used to give long-term total parenteral nutrition, intravenous fluids, blood and blood products, or to be preferred for oncology and hematological diseases [2] . However, several complications may occur during their use and insertion [3] [4] . Infection and thrombosis are the most common complications [5] [6] . The complications increase the hospitalization period, hospital costs, morbidity and mortality. In this study, we sought to review our results concerning the subcutaneous port catheter appliance in childhood malignancies.

In cardiovascular surgery clinic, total of 210 subcutaneous port catheters were inserted to 192 patients between November 2010 and October 2015. The average age of the patients was 6.4 ± 4.9 year (1 month - 17 years) and 77 (40.1%) of them were female and 115 (59.9%) of them were male. The demographical data, types and characteristics of the port catheters were summarized in Table 1 & Table 2. The distribution of cases by diagnosis according to International Pediatric Cancer Classification (ICCC, 1996) was presented in Table 3 [8] . Two hundred ten cases, the following veins were used for port catheter insertion: 129 (61.4%) to right internal jugular, 59 (28.1%) to right subclavian, 14 (6.7%) to left subclavian and 8 (3.8%) to left internal jugular. Three cases had 3 times port catheter insertions (1.4%), 12 cases (5.7%) had twice. Total port day was 55,492 days and mean port day was 289 days. The early complications were as follows: 1 (0.5%) hemothorax, 1 (0.5%) pneumothorax, 1 (0.5%) carotid artery injury, 1 (0.5%) arrhythmia, and 2 (1%) malposition. The late complications as follows: 9 (4.3%) infections, 7 (3.3%) port thromboses and 1 (0.5%) port fracture. No significant difference was found

when jugular and subclavian vein implantation was compared in terms of all complications, especially infection and thrombosis.

Cephalic, internal jugular, subclavian or lower extremity veins may be used for catheterization. Subclavian vein is preferred due to the short distance to the vena cava superior. However, a puncture in this vein has higher risk of pneumothorax [9] [10] . In a meta-analyze, compared the complication incidence of jugular and subclavian catheter insertion, infection and artery injury complications were higher in the internal jugular insertions, and hemo-pneumothorax and malposition complications were higher in the subclavian insertions. In our study, internal jugular vein was chosen in 65.2% (n = 137) cases, subclavian vein was chosen in 34.8% (n = 73) cases and 23 cases (10.9%) had complications (Table 4). Four (6.6%) of them were to jugular, and 9 (4.3%) of them to subclavian insertion. Pneumothorax (n = 1), hemothorax (n = 1), carotid artery injury (n = 1) and malposition (n = 2) were observed following jugular port implantation; arrhythmia (n = 1) was observed following subclavian port implantation. Infection (P = 0.722) and thrombosis (P = 0.24) No statistical significant differences were found between jugular and subclavian insertions in terms of development.

Right atrium and superior vena cava junction is the best site for the port tip. If port catheter tip is not localized close to here, it is defined as a catheter malposition [11] - [13] . We detected in our 2 patients (1%) after the port insertion to right internal jugular vein showed that the tip of port catheter is inserted right subclavian vein instead of cava-atrial junction. A guide wire was pushed forward on port by scope in these patients. The port catheter was drawn back and was directed to superior vena cava. Besides, if the catheter tip is moved into right ventricle or inferior vena cava, arrhythmia may occur [14] . The arrhythmia was observed during follow-up in a patient whom had been inserted from right internal jugular vein. The echocardiography showed the port tip was in the right ventricle wall. The port was drawn back by scope and turned down and pushed forward to the cava-atrial junction. We don’t use scope for port catheter insertion routinely in our clinic.

We detected the incidence of infection induced by port insertion ranges between 0.8 - 7.5 percent [15] [16] . In oncology patients, the infection incidence of port catheters is lower than tunneled catheters [17] . The infection is commonly caused by Staphylococcus epidermidis or aureus and Candida albicans [18] [19] . However port systems must be removed in case of persistent sepsis/bacteremia or relapse of infection after antibiotic treatment, signs of port or catheter tunnel infection, unstable patients (port infection and hypotension), systemic complications (e.g. septic thrombosis/embolism, osteomyelitis, abscess formation or endocarditis) or detection of certain microorganisms such as S. aureus or Candida species [20] - [22] . Port catheter was removed from total of 18 (8.6%) patients (Table 5). Nine patients (4.3%) whose port was removed due to infection had the local signs of inflammation and 4 of them (1.9%) had positive blood culture for Candida albicans proliferation. In these cases, a new port catheter was placed to the contralateral side after removing port removal immediately. Another major long-term complication is port thrombosis [23] . In the cancer patients, the incidence of catheter-induced thrombosis was 3% - 4% in several studies [24] . Avoiding from this complication, port care is important. Cancer Care Ontario guideline is accepted as a care guide [25] . Compatible with the literature, the incidence of port catheter thrombosis was 3.3% (n = 7) in our study. “Pinch off” syndrome is defined as a port catheter fracture due to compression between the clavicle and first costae, leading to pain under clavicle, paresthaesia in arm, subdermal fluid extravasations, pain in arm, and ubdermal necrosis [26] [27] . In our case, subdermal fluid collection and fluid extravasations during infusion was identified 148 days after the port catheter insertion. Catheter fracture was identified and then port catheter was removed, a new port catheter was implanted to the contralateral side. Carotid artery injury during central venous catheterization could lead to catastrophic serious complications. In some studies, the incidence of carotid artery injury was especially higher in the infants younger than 6 months [28] - [30] . In a patient who had been inserted to right subclavian vein, the port catheter was in the right subclavian artery. Right subclavian artery and catheter were explored, and then catheter was drawn back and the vessel was repaired primarily.

Our study, as with all cross-sectional studies, was limited by follow-up data quality, availability and interpretation. Non-homogenous patient population led to another difficulty of statistical analysis. Therefore, we tried to

reflect the real-life data all we had.

In conclusion, despite the higher risk of complications, subcutaneous port catheter implantation was the gold standard for the treatment of pediatric malignancies. The increased use of subcutaneous port catheters increased the incidence of catheter-induced complications. The experience was very important to prevent these complications. We believed that the incidence of the complications related with subcutaneous port catheter would decrease if the doctor, nurse and patient’s family got more knowledge.

We wish to thank Assoc. Prof. Murat Muhtar Yilmazer, M.D. in Department of Pediatric Cardiology, Dr. Behçet Uz Children’s Hospital, for help on statistical analysis. The authors received no financial support for the research and/or authorship of this article. The authors declare that they have no conflict of interests.

Onur Doyurgan,Uğur Karagöz,Bengü Demirağ,Mustafa Karaçelik,Yılmaz Ay,Raziye Canan Vergin,Osman Nejat Sarıosmanoğlu, (2016) Use of Subcutaneous Port Catheter in Childhood Malignancies. World Journal of Cardiovascular Diseases,06,126-132. doi: 10.4236/wjcd.2016.65013