•
• Bard:Congress,Research,Consultant,Education
Disclosure
– Goodimagingmodalities
– Goodbiologyandgood(molecularandgenomic)anatomopathology
– Goodchemiotherapy
– Goodsurgeryandinterventionalradiology
– Goodradiationtherapy
WhatareMedicalorsocietalexpectationsinoncology?
Whatdotheywantincancercare…
WhatisqualityforCancertreatment?
Quality
Relevancebasedonrespectofguidelines
Efficacy
Preventionofadverseevents.Thresholdsdefinitionformajor
complications
Security
Optimaluseofavailableresourcestoachievethebestresults.
EfficiencyEquity
sensitivityofthesystemattherequestofthepatient,respect
forpatientdignity,confidentiality,participationin
choices…
Reactivity
Easeofaccesstogoodhealthservicesattherighttime.
Quality
Andalso:‒ Timeliness‒ Patientcenteredness‒ Continuity‒ Satisfaction‒ Technicalcompetence
WithcortesyofPrMRIVOIRE
1. Long-termsurvival
2. Qualityoflife
3. Goodfunctionalstatus
ForthepatientWhatdotheywant?
What is quality for Central Venous access?
Quality
Relevancebasedonrespectofguidelines
Efficacy
Preventionofadverseevents.Thresholdsdefinitionformajor
complications
Security
Optimaluseofavailableresourcestoachievethebestresults.
Efficiency Equity
sensitivityofthesystemattherequestofthepatient,respect
forpatientdignity,confidentiality,participationin
choices…
Reactivity
Easeofaccesstogoodhealthservicesattherighttime.
Quality
Andalso:‒ Timeliness‒ Patientcenteredness‒ Continuity‒ Satisfaction‒ Technicalcompetence
WithcortesyofPrMRIVOIRE
WhatisqualityforCentralVenousaccess?
Quality
DeviceTeamOrganization
Efficacy
Security
EfficiencyEquity
ReactivityQuality
WithcortesyofPrMRIVOIRE
DeviceTeamOrganization
DeviceTeamOrganization
DeviceTeamOrganization
DeviceTeamOrganization
Manyavailabledevices…
Therapy• Typeoftreatment• Durationoftherapy
• characterics
Device• Potentialofcomplications
• Ressourcesavailablefordevicecare
• Technicalstaffexpertise
• Costs
Patient• Hospitalstatus• Preferencesandlifestyle
• Co-morbidity• Vascularintegrity• Selfcareability
FactorsinfluencingVADselection
Therapy
Irritant?Vesicant?
PeripheralcatheterorMidline
Cis-diaminedichloroplatineCDDPGemcitabineCarboplatinePaclitaclelDocetaxelBleomycineMethotrexateTrastuzumabEribulineCetuximabRituximabTopotécanPemetrexed
Regimenschemotherapy
Durationofchemotherapy
Devices
• Portdevice• PICCline• TunneledCVC• Midline• PVC
Background ‒ High frequency of CVA complications
‒ In oncology CVA complications have great impact on cancer treatment
DevicesPotentialofcomplications
Potentialofcomplications
• Infections • Thombosis
13,6%
11,9%
6,7%
InfectiousComplications
ThromboticComplications
Generalpractice:• indications• materials• Maintenance(fixation,dressings,flushing,hygiene)• Experience
OwndatasExceptlargemulticenterstudiesproperlyconducted,thesestudiesrepresentonlythestatesofsingularplace,leadingalocalpracticetoaparticularmoment;theycanonlyshowtheobjectivestowardswhichweshouldaim.
Weneeddatas…
Inourownhospitals…
Ressourcesavailablefordevices’implantationandcare.Technicalstaffexpertise
Costs
PlacementPortacathmoreexpensive
CareLineswithexternalhub:moreexpensive
Patient:Preferenceandwayoflife
All,wearepatient,Doctor!
Undissociatedwiththeco-morbidity
undissociateditspathology…
Hospitalstatus
Inthereallife…
• Patientsandphysicianswant:
Whatweknow?• TIVAD
• Goodperformingdevice• Totallyimplantable • Invasive/Expensiveinsertion• Invasivewithdrawal• Residualskinscar• NoMaintenance• FewPhysicallimitations
– Swimandbath
• Lowinfectionrates• LowDVTrates• FewMechanicalcomplications
• Lowratesbutserious/extravasation
• PICC
InspiredfromPrSBERTOGLIO
Whatweknow?• TIVAD
• Goodperformingdevice• Totallyimplantable • Invasive/Expensiveinsertion• Invasivewithdrawal• Residualskinscar• NoMaintenance• FewPhysicallimitations
– Swimandbath
• Lowinfectionrates• LowDVTrates• FewMechanicalcomplications
• Lowratesbutserious/
extravasation
• PICC
InspiredfromPrSBERTOGLIO
Whatweknow?TIVAD
• Goodperformingdevice• Totallyimplantable • Invasive/Expensiveinsertion• Invasivewithdrawal• Residualskinscar• NoMaintenance• FewPhysicallimitations
– Swimandbath
• Lowinfectionrates• LowDVTrates• FewMechanicalcomplications• Lowratesbutserious/
extravasation
PICC• Goodperformingdevice• Partiallyimplantable• Easyandlowcostinsertion• Easywithdrawal• Noskinscar• Weeklymaintenance• MorePhysicallimitations
– Noswim,Nobathexceptspecialequipments
• Lowinfectionrates• SomehowhigherDVTrates• Somehowhighermechanicalcomplications• Noextravasation
InspiredfromPrSBERTOGLIO
Whatweknow?TIVAD
• Goodperformingdevice• Totallyimplantable • Invasive/Expensiveinsertion• Invasivewithdrawal• Residualskinscar• NoMaintenance• FewPhysicallimitations
– Swimandbath
• Lowinfectionrates• LowDVTrates• FewMechanicalcomplications• Lowratesbutserious/
extravasation
PICC• Goodperformingdevice• Partiallyimplantable• Easyandlowcostinsertion• Easywithdrawal• Noskinscar• Weeklymaintenance• MorePhysicallimitations
– Noswim,Nobathexceptspecialequipments
• Lowinfectionrates• SomehowhigherDVTrates• Somehowhighermechanicalcomplications• Noextravasation
InspiredfromPrSBERTOGLIO
Difficultanddailyquestions
• WhichperformingandsafecentralvasculardeviceforprimaryoradjuvantCTofsolidtumours?
Forbreastcancer?Fortesticlecancer?...
Primaryandoradjuvant
chemotherapyPICCShortterm
<4months
PalliativeChemotherapyfor
advancedorpalliativepatients
TIVADLonglifeexpectancy
Chemotherapyandsupportivecare PICCMorecomfort
Whichvascularaccessforcancerpatients?
Primaryandoradjuvant
chemotherapy
PalliativeChemotherapyfor
advancedorpalliative,metastaticpatients
Chemotherapyandsupportive
care
Dependofthestep,theevolutivity,theexpectedduration,theregimen…
algorithm
Decisionnaltreeforcentralvenousaccess
DurationofTTT>4monthsDurationofTTT#4months
PICC
KT
USaspec
Sizeofthevein
NecksurgeryThrombosis
…
TIVADKT
Hemostasisdisorderslowplateletss<80000,PT<50%,AVK,Clopidogel,NACO,DIVC,Emmergency,nonplanned
CICC
PICCPICC
CICC
or
or
Patient’schoice
DiscontinuousTTTContinuousTTT
Hydratation,Nutrition,Analgésia,Mannitol
Chemotherapy
Patient’schoice
DecisionnalAlgorithmforthechoiceinhematologywithacutemyloidleukemiapatientseligibletoaintensivetreatment
INDUCTION
CONSOLIDATION
DLnontunneledCVC PICCLINE
GROSHUNGDL
TIVAD
CIVDorthrombopeniaNohaemostasistrouble
Bonetransplant ExclusiveChemotherapy
UnitdischargeCVCremoved
4to6weeks
Manymon
ths
CLBMiseàjournovembre2015,L.GILIS
WithcourtesyofAlessioPireddaGavecelt2015
WithcourtesyofAlessioPireddaGavecelt2015
CancerTreatments’evolutions
BREASTCANCERADJUVANTTREATMENT
SubcutaneousTRANSTUZUMABreduceslenghtI.V.adjuventCT
LUNGCANCER
IncreasedefficacyoforalTherapyForNSCLC-MolecularTargetTherapy-EGFR/ALKinihibitors
LARGEBOWELCANCER-Increaseduseoforal5FU-Ostomyincreaseriskforinfection
Takehomemessage
VADPlanning(DeviceChoice)“TheappropriatetypeofVADisselectedtoaccommodatethepatient’svascularaccessneedsbasedon:• theprescribedtherapyortreatmentregimen;• anticipateddurationoftherapy;• vascularcharacteristics;• andpatient’sage,comorbidities,historyofinfusiontherapy,preferenceforVADlocation,• andabilityandresourcesavailabletocareforthedevice”
INS(2016)StandardsforInfusionTherapy
Patientcent
ered
• Devicechoiceshouldbepatientcentered
• Requirestheinputofamultidisciplinaryteam
• Shouldensurethepreventionofdammage
Lifehangsbyathread
http://tamarafowler.blogspot.fr/
Inoncology,thisthreadisfrequentlyaCVA