Learning Curve of Landmark-Based TIVAP Placements and Revisions in a Low-Resource Setting

Area of Science:

• Vascular Surgery
• Interventional Radiology
• Medical Education

Background:

• Ultrasound guidance is standard for totally implantable venous access port (TIVAP) placement to minimize complications.
• The anatomical landmark technique is prevalent in low-resource settings due to limited ultrasound availability.
• Formal statistical evaluation of the learning curve for landmark-based TIVAP placement is scarce.

Purpose of the Study:

• To evaluate the learning curve and procedural performance stabilization for anatomical landmark-based TIVAP placement.
• To identify the case volume required for consistent technical success and reduced failure rates.
• To assess the safety profile of the landmark technique in a single-operator series.

Main Methods:

• Retrospective analysis of 1285 consecutive TIVAP procedures (placement, revision, removal) by a single surgeon using the landmark technique.
• Cumulative sum (CUSUM) analysis of technical failures (inability to achieve venous cannulation or catheter advancement) in 1160 venous access procedures.
• Stratification of procedures into learning (Phase 1) and stabilization (Phase 2) phases based on the CUSUM inflection point.

Main Results:

• Overall technical success rate was 97.9% (1258/1285 procedures).
• A total of 27 technical failures (2.1%) occurred, with a significantly higher rate in Phase 1 (5.2%) compared to Phase 2 (0.7%) (p < 0.001).
• CUSUM analysis identified an inflection point at the 422nd case, indicating performance stabilization; no failures occurred in the final 252 procedures. Pneumothorax rate was 0.39%.

Conclusions:

• Landmark-based TIVAP placement requires a substantial case volume (approx. 422 procedures) for performance stabilization and reduced technical failure rates.
• The landmark technique demonstrates an acceptable safety profile in low-resource settings when performed with standardized workflows and adequate experience.
• Findings suggest that the learning curve for landmark-based TIVAP placement may be steeper than for ultrasound-guided methods.