Removal of a tunneled subcutaneous port can be challenging. The literature has evolved to better understand characteristics of catheters (silicone vs polyurethane) and patient characteristics that are associated with SSPC [6, 7]. The focus of the current study is to review the management of SSPC using the guidewire extraction technique practiced in a university pediatric surgical group. This cohort includes catheters placed for induction chemotherapy, maintained for an extended duration, and with external compression from neoplastic disease. In all cases of a SSPC, removal using the guidewire extraction technique was successful for complete removal of the device without the need for additional invasive maneuvers.

The characteristics of our pediatric cohort are diverse and reinforce the utilization of this technique in varying circumstances. Sixty percent of patients had acute lymphoblastic leukemia. Induction treatment for this disease has been hypothesized to increase the risk of a stuck catheter by creating an organized and calcified fibrin sheath around the device [8, 9]. The insulation of these solutions may also exacerbate the tenuous nature of certain catheters. In all six cases, a polyurethane catheter was used which has been considered a risk for difficult removal [7, 10, 11]. The use of this technique can overcome SSCP that develops from catheter properties and the purpose of its use.

Duration in situ has been shown as a predictor of difficult port removal with a mean duration of 2 to 3 years [6]. In this cohort, a duration of up to 7 years was noted yet still the guidewire extraction technique was successful. Idowu et al. examined the physics of catheter removal over a guidewire and their results showed that the insertion of a guidewire allowed for greater force to be applied to the catheter prior to fracture. By placing the guidewire through the catheter, the force applied is exerted through the length of the catheter with a uniform decrease in the diameter as opposed to disproportionate stretching of the catheter, leading to narrowing at the site adjacent to the adherence. In doing so, they were able to increase the amount of force applied by 160% prior to fracture. Utilizing this technique, the hypothesized bridging that develops over time between the catheter and the vein wall can be broken, making it the preferred method of removal [12].

All patients in this cohort had their subcutaneous port placed into the subclavian (SC) vein. This location has been associated with difficulty at removal due to a “pinch off” phenomenon between the first rib and the clavicle [13]. Given the subclavian’s trajectory under the clavicle, a venotomy and extensive dissection of the vessel cannot be relied upon like in the case of an internal jugular (IJ) catheter. Although a similar technique has been described for the removal of catheters in the IJ location, this is the largest cohort undergoing SC catheter removal using the guidewire extraction technique. In the current study, this technique was successful in all cases and averted the need for endovascular instrumentation or leaving the catheter in situ permanently. The guidewire extraction technique has been a standard practice of the pediatric surgical group at our institution with optimal results.