Long term central venous access in oncology: Who, why, when?

Long Term Central Venous Catheters (LTCVC) are widely used for administration of chemotherapy, blood products, parenteral nutrition, analgesics, antibiotics. Nevertheless, indications for the placement of LTCVC are not well defined in cancer patients and specific guidelines are still missing, so that the need for placement of an LTCVC is often based on the lack of alternative routes for intravenous treatments secondary to the severe loss of peripheral veins by recurrent and/or prolonged infusion of toxic drugs, such as chemotherapy and parenteral nutrition. This approach is the main factor behind several local complications (phlebitis, extravasation of drugs with ulcers or necrosis, pain) as well as an unacceptable delay in the chemotherapy schedule. The need for an LTCVC has to be considered during the first patient assessment while defining the plan of therapy and placement has to be planned prior to therapy administration. The pre-therapy placement of LTCVC is mandatory if one of the following criteria is present: low availability of peripheral venous accesses, schedules of chemotherapy by continuous infusion or by bolus with vesicant drugs with possible local toxicity with or without extravasation, high-dose chemotherapy, multiple infusion requirements (i.e. chemotherapy plus high volumes of intravenous fluids plus blood products), total parenteral nutrition. Pre-therapy placement of LTCVC is suggested for adjuvant chemotherapy in patients at high risk for early tumour recurrence, low patient compliance to multiple venipunctures, domiciliary treatment. In all other conditions, pre-therapy placement of LTCVC is not indicated but infusion routes should be carefully evaluated during the course of therapy so that the need for an LTCVC may be detected before treatment has to be interrupted for lack of vascular access.