Port Placement (Implanted Venous Access Port)
[Diagnosis] requiring long-term central venous access
Same
[Right / Left] [internal jugular / subclavian] implanted venous access port placement with ultrasound and fluoroscopic guidance
[***, MD/DO]
[Resident/PA name]
[Monitored anesthesia care / General anesthesia] with local anesthesia
The patient is a [age]-year-old [male / female] with [diagnosis] who requires long-term central venous access for [chemotherapy / parenteral nutrition / long-term infusions]. The risks, including bleeding, infection, pneumothorax, arterial injury, catheter malposition, thrombosis, and the need for removal, as well as the benefits and alternatives, were discussed, and informed consent was obtained.
The [right / left] [internal jugular / subclavian] vein was patent and compressible on ultrasound. Fluoroscopy confirmed the catheter tip at the cavoatrial junction without kinks. The port aspirated and flushed without resistance. There was no pneumothorax on fluoroscopy.
The patient was placed supine [in Trendelenburg] [with a shoulder roll], and the head was turned away from the operative side. The neck and chest were prepped with chlorhexidine and draped. A time-out was completed. [Preoperative antibiotics were given.]
Local anesthetic was infiltrated at the access site, along the planned tunnel, and over the pocket. Under real-time ultrasound guidance, the [right / left] internal jugular vein was accessed with a micropuncture needle, and a permanent image was saved. A guidewire was advanced into the inferior vena cava under fluoroscopy, confirming a venous course.
A [3]-cm transverse incision was made [2 to 3] cm below the clavicle. A subcutaneous pocket was created on the pectoralis fascia. The catheter was tunneled from the pocket to the venotomy site and measured under fluoroscopy, then cut to length for a tip position at the cavoatrial junction. The tract was dilated, and a [valved] peel-away sheath was placed over the wire. The catheter was advanced through the sheath, and the sheath was removed. Fluoroscopy confirmed the tip at the cavoatrial junction without kinks, and a permanent image was saved.
The catheter was connected to a [single / dual]-lumen [power-injectable] port, and the locking collar was secured. The port was placed in the pocket and secured to the pectoralis fascia with [two / three] [2-0 Prolene] sutures. The port was accessed with a non-coring needle, aspirated with brisk blood return, and flushed with [heparinized saline / normal saline].
Hemostasis was confirmed. The pocket was closed with interrupted [3-0 Vicryl] deep dermal sutures and a running [4-0 Monocryl] subcuticular suture. The venotomy site was closed with [a 4-0 Monocryl suture / skin adhesive], and skin adhesive was applied to the incision. [The port was left accessed for use.] Sponge and needle counts were correct.
None
None
Minimal
None
The patient tolerated the procedure well and was taken to the recovery area in stable condition. The port is ready for use.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** requiring long-term central venous access
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Right / Left] [internal jugular / subclavian] implanted venous access port placement with ultrasound and fluoroscopic guidance
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [MAC / General] with local
INDICATIONS: .PTAGE-year-old .PTSEX with *** requiring long-term central venous access for ***. Risks including bleeding, infection, pneumothorax, arterial injury, malposition, thrombosis, and need for removal, along with benefits and alternatives, were discussed. Informed consent obtained.
FINDINGS: Vein patent and compressible on ultrasound. Catheter tip at the cavoatrial junction on fluoroscopy, no kinks. Port aspirated and flushed without resistance. No pneumothorax.
DESCRIPTION OF PROCEDURE:
Supine[, Trendelenburg], head turned away. Prepped with chlorhexidine and draped. Time-out completed. Local infiltrated at the access site, tunnel, and pocket. Ultrasound-guided micropuncture access of the [right / left] internal jugular vein, permanent image saved. Wire to the IVC under fluoroscopy, confirming venous course. *** cm transverse incision below the clavicle, pocket created on the pectoralis fascia. Catheter tunneled to the venotomy, measured under fluoroscopy, and cut to length. Tract dilated, [valved] peel-away sheath placed, catheter advanced, sheath removed. Tip at the cavoatrial junction without kinks, permanent image saved. Catheter connected to a [single / dual]-lumen port and locked. Port secured to the fascia with *** Prolene. Accessed, brisk blood return, flushed with ***. Hemostasis confirmed. Pocket closed with 3-0 Vicryl deep dermal and 4-0 Monocryl subcuticular. Venotomy closed, skin adhesive applied. Counts correct.
COMPLICATIONS: None
SPECIMENS: None
ESTIMATED BLOOD LOSS: Minimal
DRAINS: None
DISPOSITION: Tolerated well, to recovery in stable condition. Port ready for use.
Signed: .ME, .MYDEGREE
.TODAYVariants
Port Removal
The patient was placed supine, the chest was prepped and draped, and a time-out was completed. Local anesthetic was infiltrated, and the prior incision over the port was reopened. The fibrous capsule was opened, the anchoring sutures were divided, and the port was freed from the capsule. The port and catheter were removed intact, and the full length of the catheter, including the tip, was inspected. Pressure was held over the venotomy tract until hemostasis was achieved. [The catheter tip was sent for culture.] The incision was closed with interrupted [3-0 Vicryl] deep dermal sutures and a running [4-0 Monocryl] subcuticular suture, and skin adhesive was applied.
Cephalic Vein Cutdown
Through a [3]-cm incision in the deltopectoral groove, the cephalic vein was identified and isolated with proximal and distal silk ties. A venotomy was made, and the catheter was advanced into the vein and positioned under fluoroscopy with the tip at the cavoatrial junction. The distal vein was ligated, and the proximal tie was secured around the catheter. The port pocket was created on the pectoralis fascia through the same incision.
Subclavian or Axillary Vein Access
Under real-time ultrasound guidance, the [right / left] [axillary / subclavian] vein was accessed lateral to the junction of the clavicle and first rib with a micropuncture needle, and a permanent image was saved. A guidewire was advanced into the inferior vena cava under fluoroscopy.
Charting Tips
- Record the vein, side, and how access was confirmed. Save a permanent ultrasound image of the venous access and a permanent fluoroscopic image of the final tip position.
- Document the tip at the cavoatrial junction or upper right atrium. A tip high in the superior vena cava is associated with catheter thrombosis and malfunction.
- Record the port brand, number of lumens, catheter size, trimmed catheter length, and whether the port is power-injectable. Infusion and radiology staff need this to access the port and to use it for contrast injection.
- Internal jugular access avoids pinch-off syndrome, in which the catheter is compressed between the clavicle and first rib and can fracture. If subclavian access is needed, enter the vein lateral to that junction.
- For removal, state that the catheter was removed intact with its tip. A fractured or retained segment needs imaging and retrieval.
Documentation & Reimbursement Considerations
- Primary service: Report Port Placement (Implanted Venous Access Port) as the primary service when it is the definitive operation performed.
- Port insertion is coded by patient age (younger than 5 years vs. 5 years and older) and by site (chest vs. arm). A chest port in a patient 5 or older carries 5.65 wRVU and a 10-day global period.
- Ultrasound and fluoroscopic guidance are separately reportable only when the note documents evaluation of the access sites, patency of the selected vein, real-time ultrasound-guided needle entry with a saved image, and a permanent fluoroscopic image of the final tip position.
- Port removal has its own code (3.02 wRVU, 10-day global). State that a subcutaneous port was removed, because removal of a tunneled catheter without a port is coded differently.
- Removal or revision for a complication within the placement's 10-day global period requires the related return-to-OR modifier. Document the complication that prompted it.