Systematic review and meta-analysis of percutaneous subclavian vein puncture versus surgical venous cutdown for the insertion of a totally implantable venous access device.

BACKGROUND: Totally implantable venous access devices (TIVADs) are commonly used in patients with cancer. Although several methods of implantation have been described, there is not enough evidence to support the use of a specific technique on a daily basis. The objective of this study was systematically to assess the literature comparing percutaneous subclavian vein puncture with surgical venous cutdown.

METHODS: MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were searched by two independent authors. No time limits were applied. A systematic review and meta-analysis was carried out according to the recommendations of the Cochrane Collaboration, including randomized clinical trials comparing primary percutaneous subclavian vein puncture with surgical venous cutdown.

RESULTS: Six trials were included, with 772 patients overall. The primary implantation failure rate was significantly lower for the percutaneous approach compared with surgical cutdown (odds ratio (OR) 0.26, 95 per cent confidence interval (c.i.) 0.07 to 0.94; P = 0.039). There was no evidence supporting a significant difference in terms of risk of pneumothorax, haematoma, venous thrombosis, infectious events or catheter migration. After taking between-study heterogeneity into account by using a random-effects model, procedure duration was not significantly longer for surgical cutdown: weighted mean difference +4 (95 per cent c.i. -12 to 20) min (P = 0.625).

CONCLUSION: Percutaneous subclavian vein puncture is associated with a higher TIVAD implantation success rate and a procedure duration similar to that of surgical cutdown. Pneumothorax develops exclusively after percutaneous puncture and requires special attention from clinicians dealing with TIVAD insertion.