Informed Consent for Implantable Venous Access Port (Port-a-Cath) Placement

Procedure Name

Form Sections

Section 1info grid

Surgical Facility Name

Performing Surgeon / Radiologist

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Date of Procedure

Port Device Brand and Type

Target Access Vein

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Section 3list block

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Section 13signature block

Patient Signature

Surgeon Signature

Witness Signature

Date and Time of Consent

Informed Consent for Implantable Venous Access Port (Port-a-Cath) Placement

Patient and Surgical Information

Surgical Facility Name

Performing Surgeon / Radiologist

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Date of Procedure

Port Device Brand and Type

Target Access Vein

Nature and Purpose of the Procedure

An implantable venous access port, commonly called a Port-a-Cath, is a small medical device placed under the skin, usually on the upper chest. It is connected to a thin, flexible tube (catheter) that is threaded into a large vein leading directly to the heart. The port is used in oncology patients to deliver chemotherapy, fluids, blood products, and supportive medications, and to draw blood samples, without having to insert needles into arm veins repeatedly. Under local anesthesia and conscious sedation, the surgeon makes two small incisions: one in the neck to access the vein, and a larger one in the upper chest to create a small pocket under the skin for the port reservoir. The catheter is threaded through the vein, connected to the port, and the incisions are closed with stitches or surgical glue. An X-ray is taken at the end of the procedure to confirm the correct position of the catheter tip.

Vein Access and Catheter Placement Verification

I understand that ultrasound imaging will be used to safely locate the target vein in the neck and guide the initial needle access.

I understand that fluoroscopy (live X-ray) will be used during the procedure to track the catheter as it is threaded toward my heart.

I authorize the team to take a chest X-ray immediately after the procedure to verify the catheter position and check for any lung complications.

Material Risks and Potential Complications

Pneumothorax: a collapsed lung caused by the needle accidentally puncturing the lung lining during vein access (less than 1 percent). Symptoms include chest pain and shortness of breath. A chest tube may need to be inserted to re-expand the lung.

Infection: bacteria can enter the port pocket or the catheter. If a port becomes infected, it often cannot be cured with antibiotics alone and must be surgically removed.

Thrombosis (blood clot): a clot can form in the vein around the catheter, causing swelling and pain in the neck, arm, or face. Blood thinners may be required.

Bleeding and hematoma: bleeding at the incision sites or a pocket of blood forming under the skin around the port.

Catheter malposition or migration: the catheter tip can shift out of place over time, requiring a minor procedure to reposition it.

Port damage or leakage: rare failure of the port membrane or catheter connection.

Sedation risks: breathing slowing, drop in blood pressure, or medication reactions.

Alternatives to Port Placement

PICC Line (Peripherally Inserted Central Catheter): a catheter inserted into an arm vein that extends to the heart. It is not fully implanted; the tube exits the skin of the arm. Easier to place but requires weekly dressing changes and cannot be gotten wet.

Repeated peripheral IV access: using standard IV needles in arm veins for each chemotherapy session. This carries a high risk of vein damage (sclerosis) and chemical burns if chemotherapy leaks into the surrounding tissue.

No central line: choosing not to place a port, accepting that delivering chemotherapy through arm veins will be more difficult and carry higher local tissue risks.

Post-Operative Care and Port Maintenance

You will have a sore chest and neck for a few days. You must keep the incisions clean and dry for at least 3 to 5 days. Stitches may need to be removed in 7 to 10 days, or they may dissolve. Once healed, the port requires no daily care. It must be flushed with heparin solution by a nurse every 4 to 6 weeks when not in active use to prevent clots. You can swim, shower, and exercise normally once the incisions have fully healed.

Post-Op Warning Signs

Contact your surgeon or go to the nearest emergency department immediately if you experience: (1) Shortness of breath or difficulty breathing, (2) Sharp chest pain, (3) Fever or chills, (4) Swelling of your neck, face, or arm on the side of the port, (5) Spreading redness, warmth, or pus at the incision sites, (6) Bleeding that does not stop with pressure.

Right to Refuse

You have the right to refuse the port placement. The physician will discuss the impact on your chemotherapy schedule, which may include delays or increased difficulty in completing infusions.

Patient Understanding and Questions

I confirm that I have read this document and understand the port placement procedure, its risks (including pneumothorax and infection), the maintenance requirements, and the alternative options. All my questions have been answered.

Language Access

If English is not your primary language, a qualified interpreter is available at no cost. Please inform staff before signing.

Copy of Consent Acknowledgment

I acknowledge that I have been offered a copy of this signed consent form.

Patient Authorization

I voluntarily consent to the surgical placement of an implantable venous access port (Port-a-Cath). I authorize ultrasound and fluoroscopic guidance, postoperative X-rays, and the administration of local anesthesia and sedation as described.

Signatures and Verification

Patient Signature

Surgeon Signature

Witness Signature

Date and Time of Consent

Document ID: CC-PENDING

CONSENTCOLLECT