Difficult re-cannulation of the ipsilateral internal jugular vein 3 years after port-a-cath totally implantable venous access ports (TIVAP) removal: a case report

Totally implantable venous access ports (TIVAPs) are the cornerstone of long-term intravenous access for chemotherapy in cancer patients. A history of ipsilateral central venous catheterization is a well-established risk factor for difficult re-puncture; however, the persistence of this risk after device removal has not been well characterized. This report describes a case of difficult re-cannulation of the ipsilateral internal jugular vein (IJV) three years after TIVAP removal, highlighting the potential for long-lasting venous changes after explantation, the difficulties of re-puncture, and the necessity of routine ultrasound examination. Importantly, the patient was completely asymptomatic during the entire indwelling period and at removal. A 50-year-old female patient from China was referred for right IJV re-cannulation to receive parenteral nutrition following gynecological surgery. She had a history of breast cancer and had undergone removal of a right IJV port after 13 uneventful months. Three years later, she required parenteral nutrition because protective bowel rest was needed after sigmoid colon repair and oral/enteral feeding was expected to be impossible for 7 days. Ultrasound revealed the right IJV tapered from approximately 13 mm at the submandibular level to a narrowest measured diameter of 3.16 mm (reported as approximately 3.2 mm) proximally, with segmental stenosis, irregular contour, and adhesions—a gradient pattern opposite to the normal cephalad-to-caudal widening. The gradient was determined by the narrowest measured diameter at each plane (12.67 mm → 7.55 mm → 3.16 mm), not by a single representative value. Puncture yielded blood return, but guidewire advancement was impeded. The operator stopped immediately after this single blind attempt, without repeated puncture, dilation, or catheter placement. The procedure was switched to the left IJV, with successful first-attempt cannulation. This case demonstrates that venous injury after TIVAP removal may be irreversible. Preoperative ultrasound and alternative access planning should be mandatory before ipsilateral re-cannulation, regardless of the time elapsed, as prior TIVAP placement is a lasting risk factor for difficult venous access. The absence of symptoms during indwelling and at removal does not exclude severe residual stenosis.