Prolonged venous access is a part of the management of conditions such as malignancy and thalassemia. Multiple venous punctures in these patients for delivering chemotherapeutic agents, parenteral nutrition, and blood products cause thrombophlebitis, rupture of veins, venous extravasation, cellulitis, and so on. This leads to physical and psychological trauma to the patient with primary illness. The problem worsens if the patient is a child. The less cooperative nature of children, thinner caliber veins, and easy compromise of venous integrity in children are major concerns for the treating physician. Broviac et al.  and Hickman et al.  introduced indwelling tunneled exteriorized catheters. However, these exteriorized catheters were found to confer an increased risk of bloodstream infection and increased discomfort to patients . Hence, in 1982, Niederhuber et al. devised a totally implantable venous access port (TIVAP) . The use of TIVAP was found to have increased owing to its better comfort and lower prevalence of infective complications. The chemoport can be used to draw blood for investigations, administer hyperosmolar solutions, extreme-pH drugs, chemotherapeutic agents, blood and blood products, and nutrients. Owing to its increased use in oncology, TIVAP is also called chemoport .
Several studies reported in the literature have used chemoports in adults. However, studies in children are rare. Hence, a retrospective study was conducted to evaluate the indication, efficacy, and safety of chemoport in children.
Acute leukemias combined with lymphomas constituted 69% of our study group (Table 1), which is similar to the incidence reported in most of the studies published [7–9]. This is because leukemia is the most common pediatric malignancy, constituting 25% of cases .
The IJV was the preferred vein in most of the studies including ours [1,3,7,9,11]. The advantages of the IJV over the SCV are that it is associated with lower incidence rates of pneumothorax, upper extremity deep vein thrombosis, chylothorax, catheter pinch-off, and no brachial plexus injury . Of our study population, 29% underwent port insertion via the SCV. None of the patients had a pneumothorax, chylothorax, brachial plexus injury, or upper extremity deep vein thrombosis.
The mean chemoport days in our study was 832±666 days, which is significantly higher than those in other studies such as Charvát et al.  (407 days), Kim et al.  (262 days), Teichgräber et al.  (292 days), Ng et al.  (158 days), Aparna et al.  (270 days), Chandrasekaran and Somasundaram  (216 days), and Seok et al.  (307 days). The proper care of the chemoports helped us achieve the longer chemoport indwelling days.
Port-related bloodstream infection is the most common complication of chemoport use and is the most common indication for premature chemoport removal. The other indications for premature removal are thrombosis of the chemoport or catheter, which causes blockage, thrombosis of the superior vena cava, kinking, decubitus-over-port, exposed chemoport due to the erosion of the overlying skin, and spontaneous disunion of the port and the catheter [1–4,7–9,11,12].
To the best of our knowledge, we had the lowest (0.15 per 1,000 chemoport days) complication rate ever published in the literature [1–4,7,8,11]. Early complications are defined as those that occur within 30 days and include vein avulsion, bleeding, hematoma, arterial puncture, air embolism, pneumothorax, hemothorax, chylothorax, arrhythmia, brachial plexus injury, early bloodstream infection, surgical site infection, thoracic duct injury, and arteriovenous fistula.
We had an avulsion of the SCV by the peel-away sheath. The child with avulsion had to undergo thoracotomy and repair of the SCV. She underwent chemoport insertion a week later (in the IJV), and the follow-up was uneventful. The friable nature of veins in the pediatric age predisposes patients to the risk of vein avulsion by the stiff peel-away sheath. Hence, we had to stop using the peel-away sheath and start using an open technique to insert the chemoport catheter. However, the recent change in the quality of the peel-away sheath made us use the percutaneous technique again. In addition, we use the C-arm to identify and place the catheter tip.
As the most common indication of chemoport insertion in pediatric age is hematological malignancies, children are prone to bleeding and hematoma. This can be managed by optimizing the patient for surgery by transfusing platelets at the time of starting the procedure. Malposition of the catheter leads to arrhythmias. This can be prevented by placing the tip of the catheter at the superior vena cava and right atrium junction under C-arm guidance. We had one child with arrhythmias treated with repositioning of the catheter.
Hemothorax, pneumothorax, chylothorax, arterial puncture, injury to the brachial plexus, and injury to the thoracic duct can all be prevented by using ultrasonography. Image guidance helps in reducing several of these complications. Ultrasonography is a good imaging modality to locate the vein, and C-arm guidance can be used to place the catheter. Studies such as that by Yaacob et al.  found that image-guided chemoport insertion reduces the risk of periprocedural complications. Hemothorax, chylothorax, and pneumothorax will need intercostal drainage. The arterial puncture can be managed by removing the needle and continuous pressure for a few minutes.
Owing to an immunocompromised state, children with hematological malignancy are at risk of surgical site infection and early bloodstream infection. A strict aseptic precaution during surgery and chemoport use will help to prevent these two complications. The surgical site infection is managed by wound care and sensitive systemic antibiotic therapy. Early port-related bloodstream infection is managed in accordance with the Infectious Diseases Society of America guidelines for intravascular catheter infection .
Late complications occur after 30 days and include port-related bloodstream infection, port pocket infection, blocked chemoport chamber or catheter, exposure of the chemoport, leakage of the chemoport, catheter pinch-off, decubitus-over-port, fracture of the chemoport catheter, dislocation of the catheter from the chemoport, and thrombosis of the superior vena cava [1–4,7–12].
The most common organism causing port-related bloodstream infection is staphylococcus, which migrates from the skin surface during needle insertion . The risk factors of bloodstream infection in these patients are the immunocompromised state of the child, poor nutrition, neutropenia, lack of skilled manpower, lack of appropriate medical supplies, lack of resources, and prolonged use of the chemoport. The incidence of port-related bloodstream infection in the developing nation is higher than that in the developed nation . In our developing country, the incidence of port-related infection is lower owing to proper care of the chemoport. Hence, in our study, the most common organism that caused port-related bloodstream infection was Candida rather than skin flora. The immunocompromised status of the children in our study population predisposes them to an increased risk of fungal infection. In all suspected cases of bloodstream infection, we removed the port and treated them with appropriate antibiotics or antifungal agents.
Port pocket infection can occur in the immediate postoperative period or as a delayed complication. This is caused by skin flora, most commonly Staphylococcus. Blocked chemoport due to thrombus formation in the chemoport chamber, chemoport catheter, or superior vena cava is the second most common complication of chemoport insertion [1,2,7]. The risk factors of thrombosis are chemotherapeutic agents, poor hydration, the presence of a foreign body in the vein (chemoport catheter), infection, immobility, age, and hypercoagulable states. Thrombosis is prevented by flushing the catheter with diluted heparin solution after each use and once every month when it is not in use. Overlying skin necrosis exposing the chemoport occurs due to malnutrition, thinning of the skin, and constant pressure by the chemoport. This can be reduced by using low-profile chemoports [7,9].
Decubitus-over-port can occur due to suture cutting through, more space in the chemoport pouch, and the heavy nature of the port. This can be reduced by using low-profile ports or fixing the chemoport at least at three points. Fracture of the chemoport catheter can occur after years of use. As the child grows, the chemoport catheter is stretched, which leads to either fracture of the catheter or disconnection of the catheter from chemoport .
Leakage of chemoport can occur due to disconnection of the chemoport catheter from the chemoport, fracture of the chemoport catheter, penetration of the posterior wall of the chemoport, or damaged septum of the chemoport. Sharp et al. found penetration of the posterior wall in 3.2% of their ports, which were all plastic ports . Using a port with posterior wall metal backing can avoid its penetration. Proper care of the chemoport by using only a Huber needle to penetrate the septum of the chemoport will avoid damage to the septum. We had no case of chemoport leakage in this study.