Arm port vs chest port: a systematic review and meta-analysis

Figures & data

Figure 1 Flow diagram of study selection process.

Table 1 Characteristics of included studies

Study	Year	Country	Design	Patients					Approach for CP	Approach for AP	Antibiotic	Coagulation	Matching
Age, years (mean/median)	Range	CP	AP	TIVAP	Prophylaxis	Prophylaxis
Alahyane et al^Citation32	2010	Morroco	RC	43	16–76	340	240	NR	NR	NR	NR	Yes	NR
Akahane et al^Citation33	2011	Japan	RC	64	20–91	47	115	P-U Celsite	Puncture/ultrasound	Puncture/radiological	None	NR	1,2,4,5,7,8,9
Biffi et al^Citation29	2009	Italy	RCT	52	18–75	270	133	Bard port	Puncture/ultrasound	Surgical cut-down	NR	None	1,2,4,5,6,7
D'Angelo et al^Citation30	2002	Italy	RCT	61.5	17–75	25	25	NR	Puncture/ultrasound	Surgical cut-down	NR	NR	1,2,4,7
Goltz et al^Citation34	2012	Germany	RC	58.8	18–88	52	152	PowerPort	Puncture/radiological	Puncture/radiological	Yes	NR	1,2,4,5,7,8
Goltz et al^Citation10	2013	Germany	PC	55.8	19–84	25	25	PowerPort/P.A.S Port	Puncture/radiological	Puncture/radiological	NR	NR	1,2,4,5,7
Kuriakose et al^Citation35	2002	USA	RC	58	14–88	273	149	BardPort/Meditec-R-Port	Puncture/NR	Puncture/radiological	NR	Yes	1,2,4,5,6,7,9
Li et al^Citation36	2016	People's Republic of China	RC	53.6	NR	237	107	Bard port	Puncture/direct	Puncture/ultrasound	NR	NR	1,2,4,5,7
Marcy et al^Citation37	2005	France	RC	55.7	NR	100	100	Bard/BraunMedical	Surgical cut-down	Puncture/radiological	None	NR	1,2,4,5,7,8
Marcy et al^Citation38	2008	France	RC	59	20–83	112	113	Bard/BraunMedical	Surgical cut-down	Puncture/radiological	None	None	1,2,4,5,7,8,9
Matiotti-Neto et al^Citation39	2017	USA	RC	NR	NR	247	195	NR	Puncture/fluoroscopy	Surgical cut-down	NR	NR	1,2,3,4,5,6,7
Iorio et al^Citation31	2018	Italy	PC	59.5	NR	106	109	NR	Surgical cut-down	Surgical cut-down	Yes	NR	1,2,4,5,6,7,8
Shiono et al^Citation40	2014	Japan	RC	62.9	NR	342	257	Bard X-Port/SlimPort	Puncture/fluoroscopy	Puncture/fluoroscopy	Yes	NR	1,2,4,5,7,8

Notes: Matching criteria: 1= age; 2= sex; 3= body mass index; 4= TIVAP procedure; 5= primary malignancy; 6= side of placement; 7= single surgical or radiologist team; 8= antibiotics description; 9= coagulation description.

Abbreviations: RC, retrospective cohort; PC, prospective cohort; RCT, randomized controlled trial; CP, chest port; AP, arm port; NR, not reported; TIVAP, totally implantable venous access port.

Table 2 Risk of bias of included randomized controlled trials based on Cochrane Handbook for Systematic Reviews of Interventions

Study	Sequence generation	Allocation concealment	Blinding	Incomplete outcome data	Selective outcome reporting	Other sources of bias	Risk of bias
D'Angelo et al, 2002^Citation30	Yes	Uncertain	Uncertain	Yes	Yes	Yes	Moderate
Biffi et al, 2009^Citation29	Yes	Yes	Uncertain	Yes	Yes	Yes	Low

Notes: Low risk: 5–6 sections with “yes”; moderate risk: 3–4 sections with “yes”; high risk: ≤2 sections with “yes”.

Table 3 Risk of bias for included non-randomized studies based on Newcastle-Ottawa scale

Study	Representativeness of the exposed cohort	Selection of the non-exposed cohort	Ascertainment of exposure	Demonstration that outcome of interest was not present at start of study	Comparability of cohorts on the basis of the design or analysis	Assessment of outcome	Was follow-up long enough for outcomes to occur	Adequacy of follow-up of cohorts	Quality score
Alahyane et al, 2010^Citation32	1	1	0	1	2	1	0	0	6
Akahane et al, 2011^Citation33	1	1	1	1	2	1	1	1	9
Goltz et al, 2012^Citation34	1	1	1	1	2	1	0	0	7
Goltz et al, 2013^Citation10	1	1	1	1	2	1	1	1	9
Kuriakose et al, 2002^Citation35	1	1	1	1	2	1	1	0	8
Li et al, 2016^Citation36	1	1	1	1	2	1	1	1	9
Marcy et al, 2005^Citation37	1	1	1	1	2	1	1	1	9
Marcy et al, 2008^Citation38	1	1	1	1	2	1	1	0	8
Matiotti-Neto et al, 2017^Citation39	1	1	1	1	1	1	0	0	6
Iorio et al, 2018^Citation31	1	1	1	1	2	1	0	0	7
Shiono et al, 2014^Citation40	1	1	1	1	2	1	0	0	7

Notes: Quality of observational study is assessed according to Newcastle-Ottawa scale (NOS), consisting of three components: patient selection (4 points), comparability of the study groups (2 points) and assessment of outcome (3 points).

Figure 2 Forest plot and meta-analysis of total complication events.

Abbreviation: M-H, Mantel-Haenszel method.

Figure 3 Forest plot and meta-analysis of primary outcomes.

Abbreviation: M-H, Mantel-Haenszel method.

Figure 4 Forest plot and meta-analysis of secondary outcomes. (A) Comparison of procedure conversion rate and early port removal. (B) Comparison of operating time between groups.

Abbreviations: M-H, Mantel-Haenszel method; IV, inverse variance method.

Table 4 Subgroup analysis comparing chest ports and arm ports

Group	Procedure-related infections				Procedure-related thrombotic complications				Intra-operative events				Mechanical complications
	n	OR(95%CI)	I^Citation2(%)	Heterogeneity	n	OR(95%CI)	I^Citation2(%)	Heterogeneity	n	OR(95%CI)	I^Citation2(%)	Heterogeneity	n	OR(95%CI)	I^Citation2(%)	Heterogeneity
Overall	11	1.11(0.74–1.66)	0	0.59	11	0.75(0.49–1.13)	28	0.19	11	2.38(1.07–5.29)	36	0.17	11	1.34(0.92–1.95)	25	0.21
Antibiotic prophylaxis
Yes	3	1.12(0.56–2.24)	0	0.74	N/A				N/A				N/A
No	3	1.24(0.55–2.76)	0	0.52	N/A				N/A				N/A
Anti-coagulant prophylaxis
Yes	N/A				1	0.91(0.21–3.85)	N/A	N/A	N/A				N/A
No	N/A				2	0.54(0.12–2.32)	74	0.05	N/A				N/A
Method of insertion
Surgical cut-down	1	0.51(0.05–5.70)	N/A	N/A	1	3.11(0.13–77.29)	N/A	N/A	1	0	N/A	N/A	1	0	N/A	N/A
Puncture	6	1.03(0.63–1.68)	0	0.51	6	0.81(0.42–1.56)	19	0.29	6	7.87(1.82–34.13)	0	0.93	6	1.55(0.98–2.47)	38	0.15
Age
<60 years old	8	0.90(0.54–1.52)	0	0.6	8	0.78(0.50–1.23)	35	0.15	8	2.59(0.74–9.08)	44	0.17	8	1.14(0.75–1.74)	0	0.51
>60 years old	2	1.25(0.61–2.54)	0	0.8	2	1.00(0.22–4.52)	N/A	N/A	2	9.81(1.13–85.37)	0	0.84	2	1.47(0.03–71.26)	79	0.03

Abbreviations: n, number of studies; N/A, not applicable.

Table 5 Sensitivity analysis comparing chest ports and arm ports

Outcome of interest	Number of studies	Number of chest port patients	Number of arm port patients	OR (95%CI)	p-value	I^2 (%)	Heterogeneity
Total complication events	7	1,064	742	0.88 (0.67–1.17)	0.38	41	0.12
Procedure-related infections	7	1,064	742	0.95 (0.56–1.62)	0.86	0	0.49
Procedure-related thrombotic complications	7	1,064	742	0.92 (0.56–1.51)	0.74	34	0.18
Intra-operative events	7	1,064	742	3.28 (1.03–10.40)	0.04	33	0.21
Mechanical complications	7	1,064	742	1.06 (0.71–1.58)	0.79	0	0.52
Conversion rate	3	619	353	0.33 (0.19–0.57)	<0.001	0	0.44

Figure 5 Funnel plot demonstrating meta-analysis of primary outcomes of interest.

Abbreviation: SE, standard error.

Alahyane A, Bounaim A, El Fahssi M. Complications of implanted venous sites for chemotherapy. J Afr Du Cancer. 2010;2(4):240–244. doi:10.1007/s12558-010-0115-z

 Google Scholar

Akahane A, Sone M, Ehara S, Kato K, Tanaka R, Nakasato T. Subclavian vein versus arm vein for totally implantable central venous port for patients with head and neck cancer a retrospective comparative analysis. Cardiovasc Intervent Radiol. 2011;34(6):1222–1229. doi:10.1007/s00270-010-0051-421127864

 PubMed Web of Science ®Google Scholar

Biffi R, Orsi F, Pozzi S, et al. Best choice of central venous insertion site for the prevention of catheter-related complications in adult patients who need cancer therapy a randomized trial. Ann Oncol. 2009;20(5):935–940. doi:10.1093/annonc/mdn70119179550

 PubMed Web of Science ®Google Scholar

D’Angelo FA, Ramacciato G, Aurello P, et al. Prospective randomised study of cephalic vein cut-down versus subclavian vein puncture technique in the implantation of subcutaneous venous access devices. Chir Ital. 2002;54(4):495–500.12239758

 PubMedGoogle Scholar

Goltz JP, Noack C, Petritsch B, Kirchner J, Hahn D, Kickuth R. Totally implantable venous power ports of the forearm and the chest: initial clinical experiencewith port devices approved for high-pressure injections. Br J Radiol. 2012;85(1019):e966–e972. doi:10.1259/bjr/3322434122674705

 PubMed Web of Science ®Google Scholar

Goltz JP, Petritsch B, Kirchner J, Hahn D, Kickuth R. Percutaneous image guided implantation of totally implantable venous access ports in the forearm or the chest? A patients point of view. Support Care Cancer. 2013;21(2):505–510. doi:10.1007/s00520-012-1544-222829323

 PubMed Web of Science ®Google Scholar

Kuriakose P, Colon-Otero G, Paz-Fumagalli R. Risk of deep venous thrombosis associated with chest versus arm central venous subcutaneous port catheters a 5-year single-institution retrospective study. J Vasc Interv Radiol. 2002;13:179–184.11830624

 PubMed Web of Science ®Google Scholar

Li Y, Cai Y, Gan X, et al. Application and comparison of different implanted ports in malignant tumor patients. World J Surg Oncol. 2016;14(1):251. doi:10.1186/s12957-016-1002-627664131

 PubMedGoogle Scholar

Marcy PY, Magné N, Castadot P, et al. Radiological and surgical placement of port devices a 4-year institutional analysis of procedure performance, quality of life and cost in breast cancer patients. Breast Cancer Res Treat. 2005;92(1):61–67. doi:10.1007/s10549-005-1711-y15980992

 PubMed Web of Science ®Google Scholar

Marcy PY, Chamorey E, Amoretti N, et al. A comparison between distal and proximal port device insertion in head and neck cancer. Eur J Surg Oncol. 2008;34(11):1262–1269. doi:10.1016/j.ejso.2007.09.01117981432

 PubMed Web of Science ®Google Scholar

Matiotti-Neto M, Eskander MF, Tabatabaie O, et al. Percutaneous versus cut-down technique for indwelling port placement. Am Surg. 2017;83(12):1336–1342.29336750

 PubMed Web of Science ®Google Scholar

Iorio O, Gazzanelli S, D’Ermo G, et al. A prospective comparative evaluation on totally implantable venous access devices by external jugular vein versus cephalic vein cutdown. Am Surg. 2018;84(6):841–843.29981612

 PubMed Web of Science ®Google Scholar

Shiono M, Takahashi S, Kakudo Y, et al. Upper arm central venous port implantation A 6-year single institutional retrospective analysis and pictorial essay of procedures for insertion. PLoS One. 2014;9(3):e91335. doi:10.1371/journal.pone.009133524614412

 PubMed Web of Science ®Google Scholar

Bow EJ, Kilpatrick MG, Clinch JJ. Totally implantable venous access ports systems for patients receiving chemotherapy for solid tissue malignancies: a randomized controlled trial examining the safety, efficacy, costs, and impact on quality of life. J Clin Oncol. 1999;17:1267. doi:10.1200/JCO.1999.17.4.126710561188

 PubMed Web of Science ®Google Scholar