Reviews of the Bard PowerPort | Which Medical Device

Features

The Bard PowerPort implantable port is a new addition to the Bard range of implantable ports, and is the first Bard port indicated for power injection. The combination of the Powerport and the PowerLoc needle makes the system safe for power injection through a power injector. This new port does continue the Bard port product theme. The Powerport has a small footprint, low profile, is relatively lightweight allowing for easy placement and patient comfort, and has reduced artefact on CT imaging. It has a unique triangular shape, colour and palpation points on the injectable septum for identification. The needle access site is easy to identify and requires little force for penetration giving tactile feedback as to when the needle is correctly sited.

Design/construction

The Powerport is a very well designed port made of lightweight titanium. It has a patented triangular shape and is bright purple in colour.? It is able to be injected at 300psi with a 19G or 20G needle up to a maximum flow rate of 5mls/s (or 2mls/s with a 22G needle). The PowerPort also has three soft palpation points on the septum designed to provide additional identification of the Powerport device for high pressure injections and also to aid the placement of the PowerLoc infusion needle. The PowerLoc infusion set has been designed to be used in conjunction with the Powerport to allow the safe administration of contrast under pressure. The Powerport is attached to an 8F chronoflex catheter which has been developed to be Taxol resistant. The Powerport comes as a complete percutaneous insertion kit (figure 1) and includes an identification card, patient discharge packet, as well as a purple Powerport bracelet.

In use

I use a standard pacemaker insertion sterile pack for the insertion of the Ports (Kimel UK). This contains all the necessary drapes, swabs and dissection tools needed to easily and rapidly form the port pocket and deal with any potential bleeding that can arise during pocket formation. The 8F catheter is stiffer than other lines and for internal jugular insertions the angle of insertion is critical. This helps to prevent a prominent bulge over the clavicle resulting in a poor cosmetic appearance for the patient. Although typically, I place central venous lines or ports with ultrasound guidance through an anterior approach to the vein, I have found a lateral approach with the Powerport allows for a better angle for the stiffer 8F catheter. This then allows easy tunnelling over the anterior chest wall laterally to a Port pocket placed over the second or third anterior ribs just lateral to the mid clavicular line. This, I think, gives a better overall cosmetic appearance to the Powerport when insertion is completed.

The port hub is a little larger than the Bard Slimport, however, the subcutaneous port pocket is easy to form with blunt dissection through a 4cm incision (figure 2). Because the port has a greater depth than the Slimport, it is important to slightly oversize the longitudinal length of the port pocket, so as not to put undue tension on the closing sutures. I ensure that I do not place the port in breast tissue as patients find this particularly uncomfortable.

There are many ways to size the catheter when insertion Ports, but with a stiffer catheter the subcutaneous portion must be exact to prevent pressure on the port hub. With this in mind I have found the ?old fashioned? sizing method used with Hickman* type lines works extremely well. This not only prevents excess catheter lying in the subcutaneous track but allows for much easier placement of the connected port into the port pocket. Once access to the vein is obtained and the port pocket fashioned the catheter is tunnelled (figure 3 & 4). The catheter can then be laid on the anterior chest wall along its planned insertion curve and sized with fluoroscopy to lie at the atriocaval junction (figure 5). The markers on the catheter make it easy to exactly decide the point to divide the catheter at the port pocket site. I generally allow 2cm for the change in the position of the atriocaval junction for supine to erect positions. Once sized the port can be connected, checked and inserted into the port pocket (figure 6, 7 & 8). The tip of the catheter can then be inserted through the peelaway sheath provided to lie at the atriocaval junction (figure 9). Once placement is completed I tend to test the port again with a non-coring needle provided in the insertion kit, puncturing the septum percutaneously through the skin (figure 10). If the port functions normally I then suture the port pocket incision with absorbable subcutaneous or interrupted sutures (figure 11). Although the port does have three silicone filled suture holes to secure the device, they are fiddly to use and often result in the need to increase the size of the incision for the port pocket. I have stopped using them and have not had any problems so far.

Results so far

I have been placing implantable Ports for over 7 years and initially found most devices on the market were designed for placement to be performed by surgeons. This meant that the devices available were bulky, heavy, uncomfortable with patients and often led to surgeons finding innovative sites to place them. I have seen numerous ports placed from an axilla approach, and placed under the pectoral muscles for this very reason. Whilst making these devices more comfortable they are a nightmare to cannulate rather detracting from the purpose of the device! With the rise of interventional radiology companies are now manufacturing low profile devices for us. There are now many sizes, shapes and designs on the open market, some of which have shapes that make forming the port pocket seamless. However, having used a few of these devices I have discovered that whilst I like them very much, the chemotherapy nurses often do not! This is because they require absolute reassurance that they are placing the needles in the correct position, the fact that they can firmly grip a port prior to insertion is very important to them. The ?self? forming pocket ports do not allow this. I have therefore been led by the chemotherapy nurses in the choice of port I routinely place. For sometime now this has been the Bard Slimport*. They are fast, simple and easy to place and patients like them. They, however, cannot be used for the injection of intravenous contrast at virtually any level of pressure above manual ? and this is their major limitation.

In part due to the cost, a business case needs to be put forward for PCT funding on an individual basis for everyone placed in the NHS. This means that patients do not have free access to this type of venous access and often end up with tunnelled lines where a Port would make more sense. For this reason the number of Powerport?s placed at my institution is smaller than it should be. I have placed around 20 Powerports to date and over 50 Slimport?s previously.

The insertion of a Powerport takes exactly the same time as for the Slimport, and due to the subcutaneous position I favour, is easy to identify for needle cannulation. Patients are very satisfied with the port and grateful for the reduced numbers of IV cannulae needed for intravenous contrast injections. Although this may not seem much, we often forget that these patients have very poor venous access or lymphoedema, and an IV cannula can take four to five attempts for successful placement. The Powerport is heavier than the Bard Slimport and this needs to be taken into consideration. I have had one elderly lady who was very thin with very little subcutaneous fat who initially found the Powerport to be very heavy on her chest, especially at night. However, with reassurance and following two visits to the CT scanning department, at which she did not require an IV line, the symptoms of her heavy Powerport abated!

When deciding what type of Port to place in patients, one often needs to decide on the frequency of IV contrast injections. Although some Oncologists, will say that they need very little CT imaging, I have yet to meet an Oncologist who does not image their patient?s at very regular intervals. I have, therefore, changed my practice to favouring the Powerport as my chosen port for the majority of my patients. The exception is those patients who need Herceptin for the treatment of their breast cancer. The Powerport is, at the end of the day, the ?Ronseal? of ports ? it does exactly what it says on the tin!

I have not seen any infections in these ports to date ? maximum insertion time is 1 year. They are well tolerated by patients and removal of the ports is a very simple procedure. There appears to be no more reaction around the port than any other port device.

Comparison

There are very few implantable port devices that allow power injections on the market. There is a titanium device which is low profile and is available in single or dual chamber ports that allows injection of upto 125psi at an injection rate of 5mls/s maximum (Smiths medical). The main competitor I believe, however, is the ProFuse CT power injectable infusion Port+ (Medcomp International). This device also claims to be the first power injectable port and is well co-ordinated with its competitor sharing the purple colouration! It also comes with a patient bracelet in bright purple with the words ?Pro Fuse? written on it. It allows the same pressure and injection rate as the Powerport has several unique identification markers, and comes with a patient information guide. The main difference appears to be the shape of the device, the Profuse CT is round, and the compound the devide is constructed of - molded high quality plastic.

I have not used the ProFuse CT+ implantable port device and therefore cannot make any direct comparisons. However, I believe that there is a review of this device on this website.

Conclusion

Given the ease at which the port is identified under the skin with it very palpable, patented, triangular shape, I am yet to be convinced of the necessity of the soft palpation points on the septum for further identification. I had always thought that they were there to help identify the port septum and aid needle insertion. Given the triangular shape one needs to be completely devoid of any skill not to be able to find the middle! My experience of chemotherapy nurses is that they are highly trained competent individuals who do not need these palpation points!

I have subsequently found out, whilst writing this review, that these palpation points are to aid identification of the Powerport device and to reassure the individual giving the power injection that it is safe.? However if they can not work this out from the patient, the bracelet and the triangular shape I suspect a few palpation points is not going to tip the scales of confidence to give a power injection. I always find that everyone forgets about the patient in situations like this. I have found that empowering the patient is the best method to reduce infection rates and educate those around them. I give simple advice that the Port inserted can be used for everything; blood tests, chemotherapy, blood and contrast for CT scans and that this negates the need for further identification markers on the Powerport.

Furthermore, with regards the palpation points, I have heard reports of several cases where these have eroded through the skin. Whilst this maybe related to the insertion technique, the fact it has happened at all coupled with their rather tenuous benefit (in my opinion), raises questions as to whether they should be removed from the port design.

The Powerport is purple ? yes purple! It does look very nice but only I get to appreciate the beautiful colour as the sedated patient whilst interested at the time, never remembers.? Once the port is inserted and the patient has recovered from the sedation, there is no evidence of this beautiful coloured port, which now sits under the patient skin. There are other power injectable ports on the market but not one is the device itself such a vivid purple!

In terms of improvement, I would like to see the implantable port become lighter and even more slender, especially in the depth of the device. This would mean a much improved cosmetic result for the patients who at the end of the day do not like to be constantly reminded of their underlying condition. I am sure that in making the port more petit would not detract from the ease of identifying and accessing the septum. It would also be a great improvement if the catheter supplied was a little more compliant, although I completely accept that this is a difficult problem, given that the primary role is to allow power injections and be resistant to Taxol.

Unfortunately one cannot purchase a single Powerport. The company requires a commitment to purchase at least 5 Powerport?s initially before an order can be placed. Whilst the company provides excellent on site support and training for oncology nurses and CT radiographers, I cannot help think that they are reducing their potential market if they insist on this at every individual centre. My understanding is that part of this requirement has been imposed when obtaining CE marking but I think the company needs a more innovative approach to circumvent this.? It is however, important to ensure that the place where patients will be having their CT scanning have a supply of appropriate PowerLoc needles to access the port device.? I have found that it can be impossible to train even the core CT radiographers, especially in some of the Private Hospitals where CT scanning machines are provided on a lorry that attends once a week or even once a fortnight! The best person to train in my opinion is the patient. There is no stronger force than empowering the patient.? Explaining the specific reasons behind the choice of the port and ensuring that the patient knows that there is never a need to place an IV cannula improves the usage of the port. It is not uncommon that a colleague who is unfamiliar with ports or Powerport?s to be reluctant to use it and suggest to the patient it would be better to place an IV cannula. This is then met with the patient?s response ?If they do not know what they are doing then please call someone who does?. Training the patient to place the PowerLoc needle is the final level which would then lead to a 100% usage irrespective of whether the CT radiographer or Radiologist has even seen or heard of a port.

Finally, I have mentioned previously that the colour of the Powerport is vivid purple, and a nice change to the shades of grey that we are usually faced with. What is even better is that in the Powerport kit is a very loud purple bracelet with the words ?Powerport? written on it - clearly for the patient to wear as a fashion statement and as an aide memoir. Obviously having completely forgotten about the lump on their chest ?the Powerport?, the patient, and to some degree an observant CT radiographer, will look at the bracelet and remember in the nick of time that an IV line is not required!? In my experience, offering this very loud fashion accessory to the patient, frequently results in it remaining in the angiography room. Patients do not seem very keen! I do, however, have one patient who worn it religiously for over 6 months.

For me, this is fine. I have an 11 year old daughter who is into her jewellery, shoes and dressing up. These loud purple rubber wrist bracelets make a welcomed addition to her jewellery collection ? a small consolation in the current credit crisis!

*are all trademarks of C R Bard Inc or an affiliate
?+are all trademarks of Medcomp International

Dr Ian McAfferty, Consultant Interventional Radiologist, UK

No conflict declared.