PICC, Port, PIV in oncology...• characterics Device • Potential of complications • Ressources available for device care • Technical staff expertise • Costs Patient • Hospital

PICC,Port,PIVinoncology

DrROSAYHervéDARCLB

VascularAccessUnitLYON-France

[email protected]

• 

• Bard:Congress,Research,Consultant,Education

Disclosure

– Goodimagingmodalities

– Goodbiologyandgood(molecularandgenomic)anatomopathology

– Goodchemiotherapy

– Goodsurgeryandinterventionalradiology

– Goodradiationtherapy

WhatareMedicalorsocietalexpectationsinoncology?

Whatdotheywantincancercare…

WhatisqualityforCancertreatment?

Quality

Relevancebasedonrespectofguidelines

Efficacy

Preventionofadverseevents.Thresholdsdefinitionformajor

complications

Security

Optimaluseofavailableresourcestoachievethebestresults.

EfficiencyEquity

sensitivityofthesystemattherequestofthepatient,respect

forpatientdignity,confidentiality,participationin

choices…

Reactivity

Easeofaccesstogoodhealthservicesattherighttime.

Quality

Andalso:‒  Timeliness‒  Patientcenteredness‒  Continuity‒  Satisfaction‒  Technicalcompetence

WithcortesyofPrMRIVOIRE

1.  Long-termsurvival

2.  Qualityoflife

3.  Goodfunctionalstatus

ForthepatientWhatdotheywant?

What is quality for Central Venous access?

Quality

Relevancebasedonrespectofguidelines

Efficacy

Preventionofadverseevents.Thresholdsdefinitionformajor

complications

Security

Optimaluseofavailableresourcestoachievethebestresults.

Efficiency Equity

sensitivityofthesystemattherequestofthepatient,respect

forpatientdignity,confidentiality,participationin

choices…

Reactivity

Easeofaccesstogoodhealthservicesattherighttime.

Quality

Andalso:‒  Timeliness‒  Patientcenteredness‒  Continuity‒  Satisfaction‒  Technicalcompetence

WithcortesyofPrMRIVOIRE

WhatisqualityforCentralVenousaccess?

Quality

DeviceTeamOrganization

Efficacy

Security

EfficiencyEquity

ReactivityQuality

WithcortesyofPrMRIVOIRE

DeviceTeamOrganization

DeviceTeamOrganization

DeviceTeamOrganization

DeviceTeamOrganization

Manyavailabledevices…

Therapy• Typeoftreatment• Durationoftherapy

• characterics

Device• Potentialofcomplications

• Ressourcesavailablefordevicecare

• Technicalstaffexpertise

• Costs

Patient• Hospitalstatus• Preferencesandlifestyle

• Co-morbidity• Vascularintegrity• Selfcareability

FactorsinfluencingVADselection

Therapy

Irritant?Vesicant?

PeripheralcatheterorMidline

Cis-diaminedichloroplatineCDDPGemcitabineCarboplatinePaclitaclelDocetaxelBleomycineMethotrexateTrastuzumabEribulineCetuximabRituximabTopotécanPemetrexed

Regimenschemotherapy

Durationofchemotherapy

Devices

•  Portdevice•  PICCline•  TunneledCVC•  Midline•  PVC

Background ‒  High frequency of CVA complications

‒  In oncology CVA complications have great impact on cancer treatment

DevicesPotentialofcomplications

Potentialofcomplications

•  Infections •  Thombosis

13,6%

11,9%

6,7%

InfectiousComplications

ThromboticComplications

Generalpractice:•  indications•  materials•  Maintenance(fixation,dressings,flushing,hygiene)•  Experience

OwndatasExceptlargemulticenterstudiesproperlyconducted,thesestudiesrepresentonlythestatesofsingularplace,leadingalocalpracticetoaparticularmoment;theycanonlyshowtheobjectivestowardswhichweshouldaim.

Weneeddatas…

Inourownhospitals…

Ressourcesavailablefordevices’implantationandcare.Technicalstaffexpertise

Costs

PlacementPortacathmoreexpensive

CareLineswithexternalhub:moreexpensive

Patient:Preferenceandwayoflife

All,wearepatient,Doctor!

Undissociatedwiththeco-morbidity

undissociateditspathology…

Hospitalstatus

Inthereallife…

•  Patientsandphysicianswant:

Whatweknow?•  TIVAD

•  Goodperformingdevice•  Totallyimplantable •  Invasive/Expensiveinsertion•  Invasivewithdrawal•  Residualskinscar•  NoMaintenance•  FewPhysicallimitations

–  Swimandbath

•  Lowinfectionrates•  LowDVTrates•  FewMechanicalcomplications

•  Lowratesbutserious/extravasation

•  PICC

InspiredfromPrSBERTOGLIO

Whatweknow?•  TIVAD

•  Goodperformingdevice•  Totallyimplantable •  Invasive/Expensiveinsertion•  Invasivewithdrawal•  Residualskinscar•  NoMaintenance•  FewPhysicallimitations

–  Swimandbath

•  Lowinfectionrates•  LowDVTrates•  FewMechanicalcomplications

•  Lowratesbutserious/

extravasation

•  PICC

InspiredfromPrSBERTOGLIO

Whatweknow?TIVAD

•  Goodperformingdevice•  Totallyimplantable •  Invasive/Expensiveinsertion•  Invasivewithdrawal•  Residualskinscar•  NoMaintenance•  FewPhysicallimitations

–  Swimandbath

•  Lowinfectionrates•  LowDVTrates•  FewMechanicalcomplications•  Lowratesbutserious/

extravasation

PICC•  Goodperformingdevice•  Partiallyimplantable•  Easyandlowcostinsertion•  Easywithdrawal•  Noskinscar•  Weeklymaintenance•  MorePhysicallimitations

–  Noswim,Nobathexceptspecialequipments

•  Lowinfectionrates•  SomehowhigherDVTrates•  Somehowhighermechanicalcomplications•  Noextravasation

InspiredfromPrSBERTOGLIO

Whatweknow?TIVAD

•  Goodperformingdevice•  Totallyimplantable •  Invasive/Expensiveinsertion•  Invasivewithdrawal•  Residualskinscar•  NoMaintenance•  FewPhysicallimitations

–  Swimandbath

•  Lowinfectionrates•  LowDVTrates•  FewMechanicalcomplications•  Lowratesbutserious/

extravasation

PICC•  Goodperformingdevice•  Partiallyimplantable•  Easyandlowcostinsertion•  Easywithdrawal•  Noskinscar•  Weeklymaintenance•  MorePhysicallimitations

–  Noswim,Nobathexceptspecialequipments

•  Lowinfectionrates•  SomehowhigherDVTrates•  Somehowhighermechanicalcomplications•  Noextravasation

InspiredfromPrSBERTOGLIO

Difficultanddailyquestions

•  WhichperformingandsafecentralvasculardeviceforprimaryoradjuvantCTofsolidtumours?

Forbreastcancer?Fortesticlecancer?...

Primaryandoradjuvant

chemotherapyPICCShortterm

<4months

PalliativeChemotherapyfor

advancedorpalliativepatients

TIVADLonglifeexpectancy

Chemotherapyandsupportivecare PICCMorecomfort

Whichvascularaccessforcancerpatients?

Primaryandoradjuvant

chemotherapy

PalliativeChemotherapyfor

advancedorpalliative,metastaticpatients

Chemotherapyandsupportive

care

Dependofthestep,theevolutivity,theexpectedduration,theregimen…

algorithm

Decisionnaltreeforcentralvenousaccess

DurationofTTT>4monthsDurationofTTT#4months

PICC

KT

USaspec

Sizeofthevein

NecksurgeryThrombosis

…

TIVADKT

Hemostasisdisorderslowplateletss<80000,PT<50%,AVK,Clopidogel,NACO,DIVC,Emmergency,nonplanned

CICC

PICCPICC

CICC

or

or

Patient’schoice

DiscontinuousTTTContinuousTTT

Hydratation,Nutrition,Analgésia,Mannitol

Chemotherapy

Patient’schoice

DecisionnalAlgorithmforthechoiceinhematologywithacutemyloidleukemiapatientseligibletoaintensivetreatment

INDUCTION

CONSOLIDATION

DLnontunneledCVC PICCLINE

GROSHUNGDL

TIVAD

CIVDorthrombopeniaNohaemostasistrouble

Bonetransplant ExclusiveChemotherapy

UnitdischargeCVCremoved

4to6weeks

Manymon

ths

CLBMiseàjournovembre2015,L.GILIS

WithcourtesyofAlessioPireddaGavecelt2015

WithcourtesyofAlessioPireddaGavecelt2015

CancerTreatments’evolutions

BREASTCANCERADJUVANTTREATMENT

SubcutaneousTRANSTUZUMABreduceslenghtI.V.adjuventCT

LUNGCANCER

IncreasedefficacyoforalTherapyForNSCLC-MolecularTargetTherapy-EGFR/ALKinihibitors

LARGEBOWELCANCER-Increaseduseoforal5FU-Ostomyincreaseriskforinfection

Takehomemessage

VADPlanning(DeviceChoice)“TheappropriatetypeofVADisselectedtoaccommodatethepatient’svascularaccessneedsbasedon:• theprescribedtherapyortreatmentregimen;• anticipateddurationoftherapy;• vascularcharacteristics;• andpatient’sage,comorbidities,historyofinfusiontherapy,preferenceforVADlocation,• andabilityandresourcesavailabletocareforthedevice”

INS(2016)StandardsforInfusionTherapy

Patientcent

ered

•  Devicechoiceshouldbepatientcentered

•  Requirestheinputofamultidisciplinaryteam

•  Shouldensurethepreventionofdammage

Lifehangsbyathread

http://tamarafowler.blogspot.fr/

Inoncology,thisthreadisfrequentlyaCVA