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CJON BOOK EXCERPT SERIES
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III. Arterial Access Devices
Mary E. Hagle, PhD, RN, AOCN  
A. Description and types of de-
when the entire tumor is per-
This chapter excerpt from the book Access Device Guide-
vices (Martin, 2002)
fused and infusate can be con-
lines: Recommendations for Nursing Practice and Edu-
1. Arterial therapy delivers
fined to a specific area (Wein-
medication directly into
stein, 2001). Efforts are being
cation, edited by Dawn Camp-Sorrell, MSN, FNP, AOCN,
an organ or tumor via the
made to further restrict systemic
is part of a series of clinically relevant reprints that will
main supply artery, or in
circulation of infusate using
appear periodically in the Clinical Journal of Oncology
the case of metastatic he-
techniques such as arterial, me-
patic tumors, through the
chanical, or chemical emboliza-
Nursing.
common hepatic gastro-
tion (Alsowmely & Hodgson,
duodenal arteries.
2002).
2. Three types of access are used (Mar-
6. Catheters are available with one-way
b) Only in the case of hepatic perfu-
tin, 2002).
valves to prevent retrograde blood
sion may access be achieved
a) Short-term percutaneous cath-
flow.
through the hepatic artery, as well
eters inserted via the femoral or
7. Procedural and overall costs vary.
as through the portal vein, and
brachial artery
a) Costs for placement: Surgical
consideration is being given to use
b) Long-term catheters placed dur-
placement of catheter with direct
both accesses for drug delivery to
ing surgery and either used as an
access to artery, with or without a
the tumor (Paku, Bodoky, Kup-
external catheter or attached to an
port, is initially more costly than
csulik, & Timar, 1998).
implanted port or pump
percutaneous insertion of catheter
c) Increased exposure of tumor to
c) Implanted ports for long-term
(Zanon et al., 1998). However, de-
drug increases tumor response,
therapy
pending on the number of percuta-
whereas less systemic circulation
3. Catheters and ports: Catheters com-
neous reinsertions of catheter, this
and exposure to infusate de-
posed of polyethylene, Pebax nylon
procedure may become more ex-
creases risk of systemic side ef-
(a nylon derivative) (ATOFINA
pensive than surgical placement.
fects (Dizon & Kemeny, 2002;
Chemicals, Philadelphia, PA), or
b) Discussion continues on the clini-
Goodman, 2000; Haller, 2000;
Silastic (Dow Corning, Midland,
cal and economic benefits of arte-
Kemeny, 2000).
MI) materials with internal diameters
rial therapy versus systemic ther-
2. Disadvantages
ranging from 0.51.5 mm and outer
apy (Cole, 1996; Haller, 2000;
a) Less systemic circulation and ex-
diameters ranging from 2.79.6
Kemeny & Fata, 2001). An initial
posure to infusate increases the
French are used. Catheter openings
comparison of costs for hepatic
risk for distant metastasis.
may be at the end or have a closed
arterial therapy, systemic therapy,
b) Positive outcomes from arterial
end with a side hole (Seki et al.,
and symptom control for colo-
therapy, such as improved sur-
1999). Portal bodies are described in
rectal liver metastases revealed
vival and quality of life, remain
Section II-H.
hepatic arterial therapy to be the
under continued investigation
4. Silastic beaded catheter has raised
most costly. The cost-effective-
(Haller, 2000; Kemeny, 2000).
circular rings placed approximately 1
ness of hepatic arterial chemoem-  C. Patient selection criteria
to 2 cm apart. For surgical placement
bolization for the treatment of
of catheter, sutures are positioned
colorectal liver metastases varies
considerably according to the an-  From Access Device Guidelines: Recommen-
around the catheter and between the
ticipated survival benefit (Abram-  dations for Nursing Practice and Education
beads to secure the catheter in place
(2nd ed., pp. 4954) by D. Camp-Sorrell
and prevent it from migrating out of
son et al., 2000).
8. Table 7 lists the advantages and dis-  (Ed.), 2004, Pittsburgh, PA: Oncology Nurs-
the artery (Martin, 2002).
advantages of an arterial catheter  ing Society. Reprinted with permission. (Men-
5. Arterial catheter gauge has a smaller
(long-term and short-term) versus an  tion of specific products and opinions related
internal diameter and thicker catheter
to those products do not indicate or imply en-
wall compared to a venous catheter
arterial port for arterial infusions.
because of slower arterial administra-  B. Advantages and disadvantages of arterial  dorsement by the Clinical Journal of Oncol-
ogy Nursing or the Oncology Nursing Soci-
tion times, higher vascular arterial
therapy
ety.)
pressures, plus it acts as a safety mea-
1. Advantages
sure to reduce blood backflow.
a) Regional perfusion is useful only   Digital Object Identifier: 10.1188/03.CJON.669-674
669
CLINICAL JOURNAL OF ONCOLOGY NURSING VOLUME 7, NUMBER 6 ARTERIAL ACCESS DEVICES
TABLE 7. ADVANTAGES AND DISADVANTAGES OF ARTERIAL CATHETERS AND PORTS
ADVANTAGES
DISADVANTAGES
DEVICE
Arterial catheter
Long-term catheter
Long-term catheter
Easily accessed
Regular care for patency
One incision for care
Need for patient or other to perform site care
Long- or short-term use
Cost of supplies
Lower incidence of device-related complications com-
pared to short-term catheter (Arru et al., 2000)
Percutaneous short-term catheter
Percutaneous short-term catheter
Quick access to ascertain if treatment effective prior
Frequent insertions cause complications and complete
tumor or regional perfusion is not always obtained.
to long-term catheter placement
No device in place after each drug treatment
Costly because of repeated hospitalization for infusion
Indicated for palliative or neoadjuvant therapy (Arru et
and catheter reinsertion
al., 2000)
Higher risk of complications, such as catheter tip dis-
lodgment, compared to surgical placement, although
results vary among studies
Arterial port
Totally implanted under skin
Potential discomfort with needle sticks
Less effect on body image than percutaneous external
Higher initial cost with insertion
catheter
Special noncoring, single-use needle required
Minimal self-care unless continuous infusion
With continuous infusions: site care, dressing, and
Long-term use
needle changes required
Cost effective
1. Devices are available for children and
including the home, if nursing sup-
5. Check for sites of organ or regional
adults.
port is provided.
perfusion for malignant disease with
2. Assess patient condition, venous and
3. Homecare and visiting nurses must be
arterial access (see Table 8).
arterial infusion device history, and
knowledgeable about the following.
6. Consider contraindications for arte-
type and duration of all antitumor
a) Arterial infusions and administra-
rial access.
therapy (Intravenous Nurses Society
tion techniques
a) Acute infection, prolonged fever,
[INS], 2000).
b) Chemotherapy and side effects
and absolute neutrophil count <
1,500 mm3
3. Consider any age-related factors and
c) Safe handling of cytotoxic drugs
b) Severe coagulopathy
comorbidities for the procedure, sur-
by family and healthcare profes-
D. Patient setting
gery, or drug administration.
sionals
1. Percutaneous placements and infu-
4. Indications for arterial access device
d) Twenty-four-hour on-call assis-
sions usually are performed as an in-
placement are as follows.
tance for pump failure or compli-
patient procedure, but they may be
a) Regional perfusions for adjuvant,
cations
performed as an outpatient proce-
cure, control, and palliative thera-
E. Insertion procedures and perfusion
dure.
pies
checks (Arru et al., 2000)
2. Bolus injections/infusions through a
b) Accessible artery supplying entire
1. Direct arterial access can be performed
long-term catheter or port may be
tumor
at the time of initial tumor resection or
performed in an ambulatory setting,
c) Indications for long-term catheter
during a second surgical procedure.
placement
(1) Disease is confined to area of
perfusion.
TABLE 8. PERFUSION SITES (LISTED IN DECREASING FREQUENCY OF USE) AND ARTERIAL ACCESS
(2) Patient has adequate perfor-
mance status and ability to tol-
PERFUSION SITE
ARTERIAL ACCESS
erate surgical procedure.
d) Percutaneous hepatic artery tem-
Brain
Cerebral, internal carotid, or vertebral artery via femoral artery
porary catheter placement (Habbe
Head and neck region
External carotid artery via femoral artery
et al., 1998)
(1) The liver is the focal point of
Liver
Hepatic artery via brachial, femoral, axillary, or subclavian ar-
disease, although extrahepatic
Used mainly for metastatic dis-
teries
metastatic disease may be
ease
Portal vein (currently minimally used)
present (Bergsland & Venook,
Primary hepatocellular carci-
noma less responsive to re-
2000).
gional therapy
(2) Patient's clinical status pre-
cludes undergoing surgery.
Pelvic
Internal iliac or hypogastric arteries
(3) Evaluate tumor response be-
fore placing a permanent de-
Note. Infusates for all regions are continually being tested and updated; these include cytotoxic agents,
vice.
immunotherapy, and others. Consult a drug or chemotherapy handbook for specific infusates.
670
NOVEMBER/DECEMBER 2003 VOLUME 7, NUMBER 6 CLINICAL JOURNAL OF ONCOLOGY NURSING
Although commonly viewed as a per-
tions for subsequent treat-
tion, such as the leg if the femoral
manent catheter, it may be removed
ment.
artery is used.
if a specific surgical technique is used
(3) It possibly precludes ability to
(1) The involved limb is assessed
(Maruyama, Takamatsu, Nagahama,
ligate other vessels.
for pulse, color, temperature,
& Ebuchi, 1999).
3. Port placement (see Section II-H)
capillary refill, numbness or
a) Advantages of catheter placement
a) Port is attached or preconnected
tingling, edema, or hema-
during the initial surgery include
to a long-term catheter.
toma. The specific insertion
the following.
b) Port is placed in SC pocket and
site determines any additional
(1) Catheter can be sutured in
sutured to underlying fascia.
observations (i.e., a carotid ar-
place, reducing the risk of
c) The port pocket usually is placed
tery insertion indicates the
catheter migration and dis-
over a bony prominence in the
patient's neurologic signs are
placement.
upper chest wall area or in the
monitored for potential sei-
(2) Vessels can be viewed di-
lower abdomen, but it can be
zures) (West, 1998).
rectly.
placed anywhere on the trunk.
(2) Assess the catheter and exit
(3) Accessory vessels can be li-
d) Pocket incision should not trans-
site for catheter kinking, leak-
gated (i.e., during hepatic per-
verse the septum.
ing, or migration; site bleed-
fusion, the right gastric artery
4. Perfusion check
ing; or hematoma.
is ligated to prevent perfusion
a) Intraoperatively, adequacy of he-
(3) Frequency of assessment var-
of cytotoxic drugs to the stom-
patic perfusion is checked to en-
ies, and further research is
ach with resultant erosion).
sure absence of extrahepatic or ac-
warranted. Assessment fre-
(4) Gallbladder can be removed
cessory organ perfusion using
quency ranges from every
before hepatic arterial perfu-
intra-arterial injection of fluores-
four hours to every 15 minutes
sion to prevent biliary sclero-
cein dye and Woods lamp (Cur-
for one hour, every 30 min-
sis and cholangitis.
ley, Chase, Roh, & Hohn, 1993).
utes for three hours, every one
b) Disadvantages of surgical catheter
b) Perfusion checks confirm perma-
hour for four hours, and then
placement involve the stress and
nent catheter patency and extent
every four hours (Alma-
recovery period because of surgery.
of perfusion. Checks are per-
drones, Campana, & Dantis,
2. Percutaneous access with a local an-
formed postoperatively, before
1995; Lynes, 1993).
esthetic is accomplished in the radi-
cytotoxic therapy, and every three
4. Dressing: If oozing, use gauze and
ology department.
months (Martin, 2002).
change every 24 hours or more fre-
a) Percutaneous access provides the
F. Postoperative care
quently. If dry, use transparent semi-
advantage of excluding a surgical
1. Surgically placed external catheter
permeable dressing. No ointments are
procedure and its cost and poten-
a) Assess exit site for drainage,
applied to the site (Centers for Dis-
tial postoperative complications.
edema, erythema, and catheter
ease Control and Prevention, 2002).
b) Accessory vessels also can be li-
connections. Assess patient for
5. Brachial access--arm is secured in
gated successfully (Habbe et al.,
pain.
sling
1998).
b) Measure external catheter length
6. Femoral artery access
c) A newer technique uses a fixed-
to obtain baseline measurement.
a) To decrease the chance of dislodg-
tip catheter, reducing migration
This measurement is used to de-
ment, patient may be required to lie
(Irie, 2001; Seki et al., 1999). In
termine if the catheter is becom-
flat with a pressure dressing over
the fixed-tip catheter placement,
ing dislodged.
insertion site. Use a loose restraint
the open end of the catheter is at-
c) Ensure catheter connections or
around ankle to remind patient not
tached to the gastroduodenal ar-
cap are Luer-locked and firmly
to move leg, and provide appropri-
tery with microcoils that also dis-
connected.
ate care for immobilization. Care-
continue blood flow to this artery
2. Surgically placed internal catheter
ful ambulation may be permitted in
and occlude the open end of the
connected to port or implanted pump
some settings (Habbe et al., 1998).
catheter. A side hole in this cath-
a) Assess port or pump site for drain-
b) Antiembolic stockings are recom-
eter is located in the hepatic ar-
age, edema, and erythema. Assess
mended to decrease risk of throm-
tery, which is the desired location
patient for pain.
bus (West, 1998).
for drug administration.
b) Antibiotics are given intrave-
c) Hemodynamic monitoring and
d) Catheter may be inserted percuta-
nously, prophylactically before
venipuncture should not be per-
neously and connected to a sub-
and after surgery.
formed on the involved extremity
cutaneous (SC) port (Seki et al.,
3. Percutaneous arterial catheter insertion
except with physician order (INS,
1999).
a) Heparin may be continuously in-
2000).
e) Disadvantages to percutaneous
fused to maintain artery patency.
d) Ensure catheter connections or
access include the following.
Blood coagulation values, such as
cap are Luer-locked and firmly
(1) An inability to suture the cath-
partial thromboplastin time, should
connected.
eter to the vessel exists, in-
be monitored closely.
G. Removal
creasing the potential for cath-
b) Catheter migration or dislodg-
1. Long-term external catheter: May be
eter migration.
ment may impede blood supply to
in place indefinitely. The catheter
(2) Catheter is not long-term, so
the limb. Assessment is made of
may be removed by a surgeon. The
percutaneous access may re-
the limb, which is supplied by the
catheter is tied off and buried SC by
quire repeated catheter inser-
artery used for the catheter inser-
surgeon (Maruyama et al., 1999).
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CLINICAL JOURNAL OF ONCOLOGY NURSING VOLUME 7, NUMBER 6 ARTERIAL ACCESS DEVICES
2. Port: May be in place indefinitely.
exist, suggesting catheter migra-
5. A pump is required for arterial infu-
The port may be removed using a lo-
tion.
sions; this may be an implantable
cal anesthetic, and the catheter is tied
2. Laboratory studies are conducted to
pump or an external pump (see Sec-
off and buried subcutaneously by a
monitor regional and systemic side
tion VII).
surgeon.
effects of the infused drug.
6. Arterial access devices are not to be
3. Percutaneous catheter: The catheter is
a) Area of perfusion and drugs used
used for other therapies (e.g., total
removed in radiology or at the bed-
dictate type of studies that need to
parenteral nutrition, lipid administra-
side with close observation by a sur-
be conducted to monitor regional
tion).
geon. It is usually removed after four
side effects (e.g., liver function
I. Access, flushing, and dressing (see Table
days or, at the maximum, seven days.
tests for hepatic artery infusion).
9)
a) Apply pressure for 10 minutes
b) Monitoring for systemic side ef-
1. For proper use of these devices, the
over exit site or until bleeding
fects follows a similar pattern as
nurse should be familiar with the de-
stops.
if the drug was given systemi-
vice, its features, patient- and drug-
b) Apply povidone-iodine ointment
cally; thus assessment depends on
related considerations, and precau-
or a triple-antibiotic ointment to
the drug given.
tions provided by the manufacturer.
the site, cover with gauze, and ap-
3. Infusates used in regional therapy in-
2. Use aseptic technique for all care pro-
ply an adhesive, occlusive pres-
clude cytotoxic agents, lymphocytes,
vided.
sure dressing.
and tumor necrosis factor. Any drug
3. Catheter access is at the hub.
c) Place a small sandbag over the site
can be delivered through an implanted
a) Clean catheter connection with
for eight hours.
port without concerns about drug-de-
70% alcohol or povidone-iodine.
d) Monitor for bleeding or edema at
vice biocompatibility because of the
b) Clamp catheter during tubing or
site, and check extremity pulse,
limited time of contact with the drug
cap changes.
skin color, and temperature
and port (Graham & Holohan, 1994).
4. Port access
changes every 10 minutes six
4. Administration schedule depends on
a) See Section II-H-5 on accessing a
times, then every 30 minutes two
specific protocol.
port.
times, and then hourly six times.
a) Drugs may be given as a bolus, in-
b) Flush port to verify patency. The
After eight hours, change the pres-
termittent, or continuous long-
port should have a brisk blood re-
sure dressing to an occlusive ban-
term infusion using either exter-
turn, allow easy flow of fluids,
dage (INS, 2000).
nal or implanted pumps. The drug
and cause no edema, pain, or
H. Drug delivery with arterial access
administration may continue for a
erythema.
1. Determine catheter placement and
specified number of cycles or in-
c) Clinicians are divided on the prac-
perfusion area.
definitely until there is response
tice of aspirating blood to verify
a) If sutured, perform perfusion
or disease progression (Lorenz &
needle placement because of the
check every three months or more
Muller, 2000).
risk of occlusion after repeated as-
frequently if regional side effects
b) Hepatic arterial infusions through
pirations. Research is needed in
exist, suggesting catheter migra-
a temporary percutaneous catheter
this area.
tion.
often are for four days, then the
d) Blood cannot be aspirated from
b) If not sutured, perform perfusion
catheter is pulled. The cycle is fre-
catheters with a one-way valve
check every course or every other
quently repeated for several
design.
course unless regional side effects
months (Copur et al., 2001).
e) When administering vesicants
TABLE 9. MAINTENANCE AND USE OF ARTERIAL ACCESS DEVICES
DEVICE
FLUSHING
EXIT SITE CARE AND DRESSINGS
Catheter
Before and after each drug: 510 ml normal saline
Perform usual incisional care post-op.
Final flush (if catheter capped):
Continue exit site care for external catheters or for port with needle access
Amount is at least two times the catheter plus add-on
during continuous infusions.
set volume
Apply sterile, occlusive dressing.
5,000 units heparin/ml, usually 35 ml every day
Change dressing every two days for gauze and at least weekly for trans-
parent semipermeable dressing (Centers for Disease Control and Preven-
tion [CDC], 2002).
Port
Before and after each drug: 20 ml normal saline (West,
Change port needle every seven days.
1998)
Use alcohol, povidone-iodine, or 2% chlorhexidine-based skin prep
(CDC, 2002).
Final flush:
Do not use topical antibiotic ointment or cream on insertion sites; potential
to promote fungal infections and antimicrobial resistance (CDC, 2002).
Amount is 5 ml
1,000 units heparin/ml or 5,000 units heparin/ml*
weekly
Gauze wrap occasionally is used to protect the catheter and keep patient
from bending or pulling catheter within involved extremity.
* If 1,000 units/ml is used, aspirate heparin solution from catheter before infusion and monitor coagulation values.
672
NOVEMBER/DECEMBER 2003 VOLUME 7, NUMBER 6 CLINICAL JOURNAL OF ONCOLOGY NURSING
through a port: If no blood return
(b) Flush with heparin solution
techniques (Schallom & Bisch,
or perfusion, radiographic check
as ordered by physician to
2001).
needs to be obtained to verify
maintain catheter patency
K. Complications
catheter placement.
(Martin, 2002).
1. For more information on major com-
f) Interventions for painful needle
J. General practice issues
plications, see Table 10.
sticks during port access are de-
1. Use pressure tubing, positive pres-
2. Less frequent complications are as
scribed previously (see Section II-
sure pumps, and stopcocks with Luer
follows.
B-4 on peripheral IVs).
locks.
a) Percutaneous arterial catheter leak
5. Flushing to maintain patency
2. Always use positive pressure when
or break.
a) Controversy exists related to the
withdrawing needle or clamp before
b) Hepatic artery injury (dissection)
type, amount, and concentration
withdrawing needle from injection
(Habbe et al., 1998)
of final flush solutions.
cap.
c) Arterial spasm during insertion or
b) For information on port flushing,
3. Never leave open to air; maintain a
infusion of an irritating drug (Cho,
see Table 9.
closed system.
Andrews, Williams, Doenz, &
c) Flushing for external catheters
4. If external catheter is capped, keep
Guy, 1989; Perdue, 1995)
(see Table 9)
clamped to avoid retrograde blood
d) Cerebral vascular accident from a
(1) Post-surgery: Usually in-
flow.
brachial percutaneous catheter
stilled with 1,000 units of he-
5. Make sure dressing is secure. Loop
(Habbe et al., 1998)
parin/ml using 2 ml.
catheter to dressing, and tape securely
e) Migrating embolization coils or
(2) During continuous drug infu-
so catheter loop is not exposed to ac-
microcoils (Habbe et al., 1998)
sions or for "keep open" pur-
cidental pulling.
3. Skin reaction: Redness, rash, or blis-
poses when drug infusion is
6. Arterial access devices for regional
tering of skin around port could be a
completed, the type and
cytotoxic therapy are not used for
reaction to tape or dressing.
amount of solution and rate
blood sampling. Other arterial cath-
L. Education and documentation (see Sec-
may be the following.
eters (pulmonary artery catheter or
tion VIII)
(a) Use continuous normal sa-
radial artery catheter) often are used
M. For a practicum on arterial catheter care,
line.
for blood sampling using specific
see Appendix 7.
TABLE 10. MAJOR COMPLICATIONS ASSOCIATED WITH ARTERIAL ACCESS DEVICES
INTERVENTION
PRESENTATION
SOURCES
COMPLICATIONS/INCIDENCE
PREVENTION
Infection:
Aseptic technique
Tenderness at site
Administer oral or IV antibiot-
Raad, Abi-Said, Car-
(septicema, 1%)
Sterile, occlusive dressings
Drainage
ics.
rasco, Umphrey, &
All type catheters:
Keep duration of percutaneous
Fever
Evaluate need to stop infu-
Hill, 1998
Long-term 25%
arterial catheters less than
Erythema
sion and remove device.
Ports 7.6%
six days
Catheter migration/dislodg-
Surgical placement of catheter,
Epigastric pain
Differentiate between chemo-
Grosso et al., 2000*
ment:
sutured in place
Nausea or vomiting
therapy-related and perfu-
Habbe et al., 1998*
Percutaneous catheters:
Beaded catheter to secure ves-
Diarrhea
sion of ancillary organs.
Irie, 2001***
12% migration rate (36 migra-
sel
Other systemic effects:
Stop infusion, hang saline, or
Kemeny, 2000**
tions per 300 catheters)
Fixed-tip percutaneous cath-
Edema
cap line.
Seki et al., 1999***
Surgically placed catheters:
eter placement***
Weak or absent peripheral
Obtain perfusion study.
Zanon et al., 1998**
6.4% migration rate (10 migra-
Regular check of tip placement
pulse
Evaluate need to remove de-
tions per 157 catheters)
and flow study
Inability to infuse or dis-
vice.
comfort during infusion
Occlusion/thrombosis:
Positive pressure when de-
Unable to flush or withdraw
DO NOT force flush: catheter
Doughty, Keogh, &
Percutaneous catheters: 7%
accessing catheter/port
fluid
will rupture.
McArdle, 1997
rate (21 occlusions per 300
Flushing with saline between
Percutaneous
catheter:
Use tissue plasminogen acti-
catheters)
drugs
change in color, pulse, and
vator according to direc-
Surgically placed catheters:
Use of heparinized solution
temperature of involved ex-
tions.
3.8% rate (6 occlusions per
flushes
tremity
Evaluate need to remove de-
157 catheters)
Use of positive pressure pump
Abdominal pain
vice and replace.
Continuous flushing after che-
motherapy infused
Almadrones et al.,
Bleeding at exit site
Baseline assessment of dress-
Some serous or bloody drain-
Apply pressure dressing.
1995
age after placement ex-
Apply sandbags to site.
ing
pected; excessive drainage
Frequent observation of exit
considered a complication
site
* Percutaneous catheter; ** surgically placed catheter; *** fixed-tip catheter placement
673
CLINICAL JOURNAL OF ONCOLOGY NURSING VOLUME 7, NUMBER 6 ARTERIAL ACCESS DEVICES
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NOVEMBER/DECEMBER 2003 VOLUME 7, NUMBER 6 CLINICAL JOURNAL OF ONCOLOGY NURSING