Totally implantable vascular access devices 30 years after the first procedure. What has changed and what is still unsolved?

The first placement of a totally implantable central venous access device (TIVAD) was performed in 1982 at the MD Anderson Cancer Center in Houston by John Niederhuber, using the cephalic vein - exposed by surgical cut-down - as route of access to central veins. After that, TIVADs proved to be safe and effective for repeated administration of drugs, blood, nutrients, and blood drawing for testing in many clinical settings, especially in the oncologic applications. They allow for administration of hyperosmolar solutions, extreme pH drugs, and vescicant chemotherapeutic agents, thus improving venous access reliability and overall patients' quality of life. Despite the availability of a variety of devices, each showing different features and performances, many issues are still unsolved. The aim of this review article is to point out what has changed since the first implant of a TIVAD, and what it is still matter of debate, thus needing more investigation. Topics analyzed here include materials, choice of the veins and techniques of implantation, role of ultrasound (US) guidance in central venous access, position of catheter tip assessment, TIVAD-related infection and thrombosis, and quality of life issues