Efficacy of preoperative venography in patients undergoing placement of totally implantable venous access ports

Introduction

The utilization of totally implantable venous access ports (TIVAPs) has become prevalent in the management of patients requiring prolonged intravenous infusion. Various percutaneous puncture methods have been employed for TIVAP implantation. While historically guided by anatomical landmarks, this approach is no longer recommended in contemporary clinical practice due to higher complication rates and the availability of superior imaging modalities. Current best practice mandates the use of image guidance, primarily ultrasound and/or venography, with ultrasound-guided insertion being the most common approach (1).

Notably, venous abnormalities are frequently encountered in patients scheduled for TIVAP implantation. Although comprehensive epidemiological data on their prevalence in this specific population are limited, the presence of such abnormalities can necessitate intraoperative changes to the planned vascular access route, prolong procedure time, and potentially increase the risk of associated complications, including infection (2). A structured preoperative assessment is therefore critical. Typically, this includes a detailed history (focusing on ipsilateral surgery, trauma, or prior catheterization), routine laboratory tests (complete blood count, coagulation profile), and electrocardiography to evaluate general fitness for the procedure. While essential for screening, these conventional assessments offer limited direct visualization of venous anatomy.

Duplex ultrasound, when available, provides valuable real-time information on vein diameter, patency, and flow, and is instrumental in ruling out thrombosis. However, it can be operator-dependent and may not fully delineate central venous stenoses or complex collateral pathways (3,4). Consequently, digital subtraction angiography (DSA) is recognized as the gold standard for detecting vascular abnormalities, encompassing both arterial and venous systems. Its diagnostic utility extends beyond specific regions such as the cervico-upper limb or axillo-femoral areas to the entire vascular system. For patients at risk of vascular anomalies—such as those with a history of ipsilateral surgery, trauma, or prior peripherally inserted central catheter (PICC) implantation—DSA holds significant diagnostic value (5). Nevertheless, this method has certain limitations, including the need for specialized equipment, radiation exposure, associated economic considerations, and the inherent risks of iodinated contrast agents, such as allergic reactions and potential nephrotoxicity in patients with renal impairment.

In contrast to Doppler ultrasonography and computed tomography, venography demonstrates superior accuracy in delineating a comprehensive range of venous parameters, including vessel trajectory, transverse diameter, patency, vascular anomalies, and venous malformations (6). Consequently, preoperative venography provides healthcare practitioners with crucial insights into the characteristics of target veins for puncture, thereby mitigating the risk of unforeseen procedural modifications and surgical complications during the operative intervention.

Pinch-off syndrome is an uncommon postoperative complication associated with TIVAP via the axillary vein (AV) and subclavian vein (SCV). Severe cases of pinch-off syndrome can lead to catheter rupture, a critical complication that requires immediate intervention. Although Hinke et al. (7) initially reported and classified pinch-off syndrome, the current literature lacks comprehensive methods for assessing its risk prior to TIVAP implantation.

Venography serves as a valuable tool for predicting the likelihood of pinch-off syndrome by visualizing the venous trajectory and blood flow before the procedure. It is proposed that preoperative venography may help prevent unforeseen procedural alterations during TIVAP implantation. In our medical center, the AV is preferentially used for TIVAP implantation due to several key advantages. The core value of preoperative venography lies in its ability to identify venous abnormalities and high-risk anatomy, thereby guiding the selection of a contralateral healthy AV approach. This strategy avoids the need for intraoperative conversion to an internal jugular vein (IJV) approach and the associated creation of a subcutaneous tunnel. Additionally, the AV route is particularly beneficial for patients with a history of neck surgery or abnormal neck anatomy. In our experience, the AV provides a safe and effective alternative with fewer complications and better long-term outcomes.

In this study, we investigated the efficacy of preoperative venography in two specific contexts: first, as an alternative vascular mapping tool in settings where ultrasound guidance is unavailable, aiming to replace blind puncture and improve procedural planning; and second, to assess the risk of pinch-off syndrome associated with the AV approach—a concern that remains relevant due to patient-specific anatomical variations independent of the puncture technique. It should be emphasized that ultrasound remains the first-line and recommended modality for preoperative assessment; venography is considered only in selected scenarios where ultrasound may be insufficient for comprehensive decision-making. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-aw-2290/rc).

Methods

Study design and population

The retrospective study analyzed clinical data from 479 patients with cancer who underwent TIVAP implantation at Shanghai Public Health Clinical Center between January 2019 and December 2021. Patients were divided into two groups based on the guidance method for port implantation: one group received venography guidance, while the other received conventional ultrasound guidance. The main purpose was to observe and compare the surgical success and complication rates between the two guidance methods. All TIVAP implantation procedures were performed by experienced interventional specialists at our institution, and postoperative follow-up and maintenance were conducted by trained nursing specialists.

The indications for the implantation of TIVAP include the extended administration of corrosive and/or irritating pharmaceutical agents, the need for prolonged parenteral nutritional support, and difficulties in establishing peripheral venous access. Conversely, contraindications include an inability to endure and/or cooperate with the surgical procedure, uncontrolled bacteremia or localized infection at the operative site, identification of thrombosis or anomalous venous structure at the surgical site, significant coagulation dysfunction, confirmed or suspected allergic reactions to TIVAP materials, and inadequate organ function for venography (8).

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Shanghai Public Health Clinical Center (No. 2024-S037-01). Prior to the surgical intervention, explicit written informed consent was procured from each patient.

Procedure of venography

Venous system assessment was performed using a DSA system, specifically the Siemens Artis ZIII Ceiling model from Germany. This evaluation aimed to examine the conditions of the AV, cephalic vein (CV), SCV, and innominate (or brachiocephalic trunk) vein. Patients were positioned supine, with imaging performed in the anteroposterior projection. A continuous infusion of a non-ionic iodinated contrast medium, specifically Iodixanol injection [50 mL:16 g(I)] obtained from Beilu Pharmaceuticals in China, was administered through the ipsilateral dorsal hand vein. This administration was facilitated by an injection pump at a fixed volume of 10 mL and maintaining a controlled infusion speed of 2 mL/s at a pressure of 200 psi.

Venous abnormalities were defined according to the following criteria: (I) The absence of typical anatomical features, (II) Anomalies in the vein’s structure, and (III) Stenosis (Φ<8 mm) or complete occlusion of the AV. The operator systematically evaluated both the diameter and patency of the AV to determine its accessibility. Concurrently, all assessments were independently reviewed by two interventionists (Figure 1). The inter-rater agreement for the identification of venous abnormalities was perfect, with a Cohen’s kappa coefficient of 1.00 (100% agreement), as the criteria for obstruction, collateral circulation, and vein diameter (objectively measured by the DSA workstation) were unequivocal.

Figure 1 Venography images and adjacent anatomical structures of the axillary vein.

Pinch-off syndrome simulation tests

Venography was performed if provocative maneuvers elicited positive signs (1, weakened or absent radial pulse; 2, upper limb pain, numbness, or paresthesia). Two examinations were employed to replicate the pinch-off syndrome and evaluate its potential risk subsequent to the implantation of a TIVAP. During the costoclavicular test, the patient’s shoulder was retracted backward while the patient was instructed to hyperextend their neck. In the Wright test, the patient’s arm underwent passive elevation to an angle of 90° in abduction and external rotation, without tilting the head, while ensuring that the elbow did not exceed a flexion of 45°. Subsequently, the arm was maintained in this position for 1 min.

Interventionists carefully observed the potential compression of the SCV and assessed the extent of compression. Impeded reflux of contrast medium served as an indicator for mechanical compression of the vein, thereby suggesting a potential manifestation of mild pinch-off syndrome. If patients experienced sensory numbness and pain in the ipsilateral upper limb, coupled with concurrent cessation of blood flow in both the arterial and venous pathways, the likelihood of severe pinch-off syndrome was considered significantly increased. The assessment of blood flow within the vessel was conducted through intraoperative ultrasound examination. In instances where such complications arose, the IJV was recommended as a prudent alternative access site.

Decision making of the surgical procedure

The favored vascular site for the placement of TIVAPs within our medical facilities was the AV. In instances where the successful puncture of the AV was not achievable, the IJV was selected as a viable alternative. To gauge the efficacy of the selected surgical approach, the concordance rate was determined through the application of the following formula: (performed surgical strategies/planned surgical strategies) ×100%.

In the venography-guided group, the surgical intervention was predicated upon the findings derived from preoperative venography. Venography was selectively utilized under the following circumstances: (I) unavailability of ultrasound equipment in the clinical setting; (II) patients with a history of ipsilateral surgery, trauma, or prior PICC placement, given their higher likelihood of venous abnormalities; and (III) patients who exhibited positive provocative tests (e.g., costoclavicular maneuver) suggesting anatomical narrowing of the costoclavicular space. The decision-making process was depicted in Figure 1. Preceding the surgical procedure, careful consideration was given to four pivotal factors: identification of venous abnormalities and variations in the AV and SCV, assessment of stenosis (diameter <8 mm) or occlusion of the AV, evaluation of the feasibility of accessing the SVC through unconventional methodologies, and examination of the accessibility of the SVC via the ipsilateral IJV.

For patients deemed to be susceptible to severe pinch-off syndrome based on simulation tests, the IJV was designated as the preferred target vein for the implantation of TIVAPs.

Surgical procedure and follow-up

The surgical procedures adhered meticulously to established guidelines and referenced prior literature (8-10). Implantations were conducted by interventional specialists. In the venography-guided group, the trajectory of the AV system was visualized through DSA and delineated on the patient’s body surface. Conversely, in the ultrasound-guided group, an Esaote MyLabClassC ultrasound device equipped with a LA523/LA332E probe (frequency 4–13 MHz, Italy) was utilized to assess the condition of the target vein and provide guidance for the puncture needle. Puncture of the AV was achieved using an 18-gauge needle and the Seldinger technique under continuous monitoring. Fluoroscopy was employed throughout the procedure to visualize the position of the guide wire and catheter tip (Figure 2).

Figure 2 Surgical strategy decision-making flowchart. AV, axillary vein; IJV, internal jugular vein; SVC, subclavian vein.

The catheter, with an outer diameter of 1.9 mm and an inner diameter of 1.0 mm, was utilized, and the success rate of puncture and surgical intervention was meticulously recorded. Any intraoperative complications were comprehensively documented. Subsequent to surgery, clinical nurse specialists undertook TIVAP maintenance and diligently monitored postoperative complications at 4-week intervals. Their responsibilities included assessing the port site for signs of infection (e.g., redness, swelling, pain), evaluating catheter patency during routine flushing, and providing patient education. It is important to note that, in accordance with prevailing clinical practice in our setting, these nursing specialists did not perform ultrasonographic assessments of the venous or arterial structures; such imaging evaluations were conducted by radiologists or sonographers when clinically indicated. The follow-up period commenced at the time of surgery and persisted until catheter removal, patient demise, or the last hospital visit, with the conclusive follow-up conducted on December 1, 2022.

Statistical analysis

The statistical analyses were conducted utilizing SPSS version 23.0 (IBM Inc., Chicago, IL, USA). The normality of the data was assessed using the Shapiro-Wilk test and P-P plots. Normally distributed measurement data were presented as mean ± standard deviations, and subsequent analysis was undertaken employing the Student’s t-test. Mann-Whitney U tests are used for non-normally distributed data. The P-P plots of the normality test for the two groups are shown in Figure S1. Concurrently, categorical variables are presented as frequencies and percentages, and their evaluation was conducted using the Chi-squared test. When the sample size was sufficient, Pearson’s Chi-squared test was chosen, and when the sample size was insufficient, Fisher’s exact test was used. P<0.05 served as the criterion for establishing statistical significance. Although this was a retrospective study, an a priori sample size estimation was performed during the planning phase to inform data collection. Based on an assumed success rate of approximately 80% for ultrasound-guided port placement at our institution and a predefined minimum clinically important difference of 5–10% in absolute success rate for venography to be considered valuable, a simulation was conducted. With an alpha level of 0.05 and a power of 0.8, the estimated total sample size required ranged between 400 and 500 patients. The final cohort of 479 patients included in this analysis therefore meets this estimated requirement.

Results

Clinical characteristics of patients

A total of 479 patients underwent TIVAP implantation, including the venography-guided group (252 patients) and the ultrasound-guided group (227 patients). Among these patients, 108 were male. Notably, the mean age was significantly higher in the venography-guided group compared to the ultrasound-guided group (54.4±11.4 years compared to 51.8±13.4 years, P=0.026). Furthermore, the proportion of patients with a history of ipsilateral surgery (including radical mastectomy and axillary lymph node dissection) or prior PICC insertion was significantly higher in the venography-guided group than in the ultrasound-guided group (19 cases vs. 4 cases, P=0.003). Other clinical characteristics were comparable between the two groups (Table 1).

Venous abnormalities were more common in patients with a history of ipsilateral operation or PICC implantation

In the venography-guided group, 18% (46 out of 252) of patients exhibited venous abnormalities. The characteristic visual representations of these abnormalities are delineated in Figures 3,4. Notably, patients with identified venous abnormalities demonstrated a markedly elevated incidence of previous ipsilateral surgical interventions or a history of PICC implantation compared to those without such abnormalities (39.1% vs. 0.5%, P<0.001, Table 2).

Figure 3 Preoperative venography findings revealing various venous abnormalities. (A) Preoperative venography revealed an enlarged vena suprascapular, suggesting that a conventional J-type guide wire could easily enter the unintended veins. The guide wire was replaced during the surgery. (B) A patient with a history of ipsilateral PICC implantation. Preoperative venography revealed venous thrombosis and collateral circulation. PICC, peripherally inserted central catheter.

Figure 4 Venous anatomical variations detected by preoperative venography in patients with prior ipsilateral interventions. (A) A patient with a history of ipsilateral radical mastectomy. Preoperative venography revealed the absence of the cephalic vein. (B) A patient with absence of the axillary vein shown by venography. (C) A patient with a history of ipsilateral PICC implantation. Venography identified vein stenosis and collateral circulation. PICC, peripherally inserted central catheter.

Preoperative venography prevented an unexpected change of surgical procedure

In the venography-guided group, a total of 230 patients were designated for the implantation of TIVAP through the AV, with an additional 22 patients scheduled for the IJV approach, in accordance with a predetermined decision-making flowchart. Notably, there were no documented alterations in the planned surgical procedures. Conversely, in the ultrasound-guided group, 211 patients were earmarked for TIVAP insertion through the AV, while 16 patients were slated for the IJV route. Noteworthy during the surgical procedure was the conversion of access for six patients initially intended for AV access to IJV access, and one patient experienced an aborted implantation. The rate of concordance in the venography-guided group was markedly superior to that in the ultrasound-guided group (100% vs. 96.9%, P=0.005, Table 3). While the difference in concordance rates between the venography-guided and ultrasound-guided groups was statistically significant, the absolute risk difference was 3.1% (95% confidence interval: 0.7–6.7%). The lower limit of this confidence interval approaches zero, and the upper limit does not exceed the conventional threshold for a minimum clinically important difference (typically considered 5–10% for procedural success). This suggests that, although statistically detectable, the magnitude of the observed difference may not translate into a decisive change in clinical practice regarding the primary outcome of procedural concordance.

The frequency of intraoperative complications within the venography-guided group was 2.8% (7 out of 252 cases), comprising instances of arterial penetration (5 cases) and pneumothorax (2 cases). Conversely, in the ultrasound-guided group, the occurrence of intraoperative complications was 2.6% (6 out of 227 cases), encompassing arterial penetration (3 cases), pneumothorax (1 case), and arrhythmia (2 cases). Notably, no complications attributable to venography were discerned.

Pinch-off syndrome after TIVAP implantation

In the venography-guided group, the simulation tests revealed severe pinch-off syndrome in five patients (Figure 5). Surgical interventions were subsequently tailored based on these findings. Remarkably, none of the patients in the venography-guided group developed signs of pinch-off syndrome during postoperative follow-up. In contrast, three patients in the ultrasound-guided group experienced pinch-off syndrome during follow-up, requiring removal of the port systems and catheters following diagnosis.

Figure 5 Positive provocative tests indicating risk of pinch-off syndrome. (A) A patient with a positive costoclavicular test. (B) A patient with a positive Wright test and collateral circulation.

Discussion

In the present study, we observed a relatively high incidence of venous abnormalities among cancer patients, particularly those with a history of PICC implantation or prior surgical interventions such as radical mastectomy and axillary lymph node dissection. For patients with bilateral breast cancer, we typically recommend port placement through the IJV. However, patients often request implantation through the AV for comfort and cosmetic reasons, especially right-handed patients who tend to prefer left-sided placement. We select the side that does not require postoperative adjuvant radiotherapy and minimizes trauma during port implantation. Preoperative venography proved to be an effective method for identifying venous irregularities, providing physicians with a valuable tool to optimize surgical planning, including the evaluation of potential risks for severe pinch-off syndrome.

Venous irregularities frequently present without noticeable symptoms and are difficult to detect during standard pre-TIVAP assessments. Despite their asymptomatic nature, these anomalies carry the potential for consequential complications, both during the intraoperative and postoperative phases. Unexpected modifications to the surgical plan may prolong the procedure, thereby increasing the risk of intraoperative complications and subsequent implant-related infections (11). Our study revealed an 18% prevalence of venous abnormalities, with 19 participants exhibiting AV stenosis or occlusion. This finding underscores a significant correlation between such irregularities and preceding ipsilateral surgical interventions or PICC insertions, implying that these procedures may induce structural alterations in the normal anatomy of the AV. The ability of venography to identify these abnormalities enables tailored surgical planning, thereby reducing the likelihood of intraoperative complications and procedural modifications.

The selection of target veins for TIVAP implantation varies among medical institutions, influenced by clinical protocols and the expertise of operators. Each access route presents distinct merits and carries potential complications (10). The right IJV is frequently favored due to its large diameter, superficial location, and direct pathway to the right atrium. Nevertheless, this approach has certain drawbacks, including the need for two separate incisions, potential cosmetic concerns, and challenges associated with establishing a subcutaneous tunnel in certain patient cases (12).

Conversely, the SCV and AV stand are common alternatives, offering the benefits of concealed incisions and avoidance of a subcutaneous tunnel. Despite these advantages, these routes are linked to a relatively higher incidence of complications, which may lead to severe adverse events and compromise the patients’ overall quality of life (13).

Hence, a thorough evaluation of the patient’s status is essential before selecting the SCV/AV approach, taking into account factors such as anatomical variations and the potential for surgical complications. Preoperative venography, which provides a comprehensive visual representation of the SCV/AV, offers indispensable insights. This information is critical in aiding clinicians to make informed decisions and determine the optimal access route, especially in patients with a history of ipsilateral PICC insertion or prior surgical interventions.

Our study demonstrated a 100% concordance rate between planned and executed surgical strategies among patients who underwent preoperative venography, guided by a decision-making flowchart. Notably, this high level of agreement was maintained within the subset of patients in the venography-guided group who had a higher incidence of prior PICC placements or operations compared to those in the ultrasound-guided group.

Conversely, although the concordance rate in the ultrasound-guided group remained above 90%, instances of surgical plan modifications were identified, including one case that required abortion of the surgery. Such deviations from the initial plan have the potential to introduce unwarranted risks and financial repercussions. These findings underscore the significance of incorporating preoperative venography in the management of selected patients. This significant difference highlights the value of venography in ensuring that the surgical plan proceeds without unexpected changes, thereby reducing surgical risks and improving patient outcomes. The ability to visualize the venous anatomy preoperatively allows for more precise planning and the selection of the optimal access route, minimizing the need for intraoperative adjustments.

An infrequent yet consequential postoperative complication linked to the AV and SCV approach is the pinch-off syndrome, as documented in literature (14). It is crucial to distinguish between two potential contributors to this complication: iatrogenic technical risk and patient-specific anatomical risk. The former, primarily related to suboptimal needle entry points and trajectories during infraclavicular puncture, has been drastically reduced with the advent of real-time ultrasound guidance. However, the latter stems from an inherently narrow costoclavicular space, which can lead to catheter compression regardless of puncture accuracy. This syndrome is contingent upon the patient’s body position and manifests when the catheter becomes compressed between the first rib and the clavicle. Therefore, while ultrasound minimizes the technical risk, it does not fully eliminate the anatomical predisposition. In our recent investigation, we incorporated two simulation tests within the venography process to systematically evaluate this anatomical risk of severe pinch-off syndrome (15). Our aim was to preoperatively identify patients with a predisposing narrow space, for whom an alternative access route (e.g., IJV) might be advisable even if the AV appears patent on static imaging.

Based on our study results, we identified five patients deemed at a heightened risk for pinch-off syndrome, prompting adjustments to their surgical procedures. While definitive cases of pinch-off syndrome did not manifest during the extended follow-up period for these five patients, it is noteworthy that three patients in the ultrasound-guided group did develop pinch-off syndrome. This underscores the significance of preoperative venography as a preemptive measure against severe intraoperative and postoperative complications associated with TIVAP implantation.

In our study, the definitions of venous abnormalities were derived from existing literature and original research. These definitions comprehensively considered criteria such as the absence of normal venous structures, anatomical irregularities, and AV stenosis characterized by a diameter of less than 8 mm. Regarding venous stenosis, our definition was established through empirical reference to patients undergoing chronic hemodialysis, where venograms were considered abnormal when unequivocal strictures, representing more than 30% narrowing, were evident, regardless of the presence or absence of collateral circulation (16).

Prior studies have suggested that the typical diameter of the AV falls from 11 to 12 mm (17). Consequently, we identified a diameter of less than 8 mm as indicative of AV stenosis. In terms of the catheter-to-vein ratio, Sharp et al. determined that a 45% ratio was the optimal cutoff value for mitigating the risk of venous thromboembolism (18). A more recent study in patients with solid tumors proposed that a catheter-to-vein ratio exceeding 33% was associated with an elevated risk of thrombosis (19). Considering the outer diameter of the catheter, which ranged from 1.9 to 2.6 mm, it follows that the veins should exhibit a diameter greater than 8 mm.

In light of our findings and the current clinical consensus, we propose that preoperative venography should not be viewed as a routine alternative to ultrasound, but rather as a complementary tool in carefully selected cases. Ultrasound guidance remains the cornerstone of modern TIVAP implantation due to its real-time, non-invasive, and radiation-free nature. However, venography may offer additional value in the following specific scenarios: (I) resource-constrained settings where ultrasound is unavailable; (II) patients with a history of ipsilateral interventions (surgery, PICC) who are at higher risk of venous abnormalities; and (III) patients with positive preoperative provocative tests indicating potential anatomical susceptibility to pinch-off syndrome, where dynamic assessment of venous compression may inform route selection. This selective approach aligns with the goal of personalized procedural planning while upholding ultrasound as the standard of care.

Our study has several inherent limitations that merit acknowledgment. Primarily, this was a retrospective study, drawing upon clinical data from patients with cancer. Retrospective studies face challenges such as data incompleteness and potential biases, which may impact the validity of the findings. In our study, the reliance on historical data may have introduced selection bias, as patients were not randomly assigned to the venography-guided or ultrasound-guided groups. Furthermore, retrospective data collection may result in missing or incomplete information, thereby affecting the comprehensiveness of our analysis. While similar investigations are uncommon, our study nonetheless furnishes invaluable perspectives regarding the application of preoperative venography in the context of TIVAP implantation.

A secondary consideration pertains to the potential risks associated with employing preoperative venography, notably including susceptibility to contrast medium allergies and radiation exposure. Noteworthy, in our study, we detected no instances of complications attributable to venography, even with extended implantation periods.

Conversely, the notable prevalence of venous abnormalities, especially among patients with a history of ipsilateral PICC lines or prior surgical interventions, underscores the enduring utility of venography in carefully selected cohorts. Importantly, the associated risks appear to be manageable.

Additionally, it is important to contextualize our findings within current clinical guidelines. Modern guidelines universally recommend ultrasound as the primary preoperative vascular assessment tool for TIVAP implantation due to its safety, accessibility, and cost-effectiveness. Our study, which highlights a potential role for preoperative venography, is not intended to challenge this standard of care. Instead, its relevance may be most pronounced in resource-limited settings where portable ultrasound equipment is unavailable, but fixed DSA suites are present. The observed benefits of venography in preventing procedural changes and assessing pinch-off risk should be interpreted with this specific scenario in mind. Furthermore, the risks associated with contrast exposure and radiation, albeit minimal in our cohort, remain inherent drawbacks of venography compared to ultrasound.

Lastly, our study assumes a non-randomized controlled design, as venography was not conducted in the ultrasound-guided cohort. A prospective, meticulously designed controlled study in the future holds the potential to furnish additional insights into the nuanced role of venography in this context. Furthermore, regarding the provocative tests (e.g., Wright test) used to assess the risk of pinch-off syndrome, our study primarily employed them as a screening tool to guide clinical decisions. A formal correlation between a positive physical test and quantifiable venographic evidence of venous compression (such as reduced contrast reflux) under the same maneuver was not systematically established. Future studies designed to validate such tests as imaging-correlated predictive tools would further strengthen their clinical utility.

Conclusions

Venous irregularities are commonly observed in patients with cancer. Ultrasound with Doppler remains the cornerstone of preoperative vascular assessment. The application of preoperative venography should be selective and is found to be advantageous in preventing unforeseen surgical modifications and assessing the potential risk of severe pinch-off syndrome only in specific instances. A decision-making algorithm should prioritize non-invasive methods, considering venography as a last resort when ultrasound evaluation (potentially assisted by provocative tests like the Wright test) is inconclusive or insufficient for planning. Preoperative venography is particularly recommended for patients with a history of ipsilateral surgery, trauma, prior PICC placement, or those with positive provocative tests, rather than for patients without these ipsilateral risk factors.

Acknowledgments

We would like to acknowledge the hard and dedicated work of all the staff that implemented the intervention and evaluation components of the study.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-aw-2290/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-aw-2290/dss

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-aw-2290/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Shanghai Public Health Clinical Center (No. 2024-S037-01). Prior to the surgical intervention, explicit written informed consent was procured from each patient.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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