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A clinical decision report appraising
Naranjo J, Portner ER, Jakub JW, Cheville AL, Nuttall GA. Ipsilateral Intravenous Catheter Placement in Breast Cancer Surgery Patients. Anesth Analg. 2021 Sep 1;133(3):707-712. https://doi.org/10.1213/ANE.0000000000005597
for a post-lumpectomy patient requiring ipsilateral peripherally inserted central catheter

Piontkowski, Austin J

Bauer, Abbie R

Clinical Research in Practice: The Journal of 
Team Hippocrates 
Volume 10 Issue 1 Article 1 
2024 
Safety of ipsilateral intravenous access in breast cancer surgery 
patients 
Austin J. Piontkowski 
Wayne State University School of Medicine, gb7278@wayne.edu 
Abbie R. Bauer 
Wayne State University, hm5510@wayne.edu 
Follow this and additional works at: https://digitalcommons.wayne.edu/crp 
 Part of the Medical Education Commons, and the Translational Medical Research Commons 
Recommended Citation 
PIONTKOWSKI AJ, BAUER AR. Safety of ipsilateral intravenous access in breast cancer surgery patients. 
Clin Res Prac. Nov 27 2024;10(1):eP3034. https://doi.org/10.22237/crp/1724284800 
This Clinical Decision Report is brought to you for free and open access by the Open Access Journals at 
DigitalCommons@WayneState. It has been accepted for inclusion in Clinical Research in Practice: The Journal of 
Team Hippocrates by an authorized editor of DigitalCommons@WayneState. 
 
VOL 10 ISS 1 / eP3034 / NOVEMBER 27, 2024  
https://doi.org/10.22237/crp/1724284800 
 
AUSTIN J. PIONTKOWSKI is a third-year medical student at Wayne State University School of Medicine. ABBIE BAUER is a second-year 
Master’s student in the Wayne State University Biomedical graduate program and a student editor of the journal. 
 
 
ISSN: 2379-4550 
http://digitalcommons.wayne.edu/crp, © 2024 The Author(s) 
1 Licensed under Creative Commons Attribution 4.0 International (CC-BY-4.0) 
 
Safety of ipsilateral intravenous access in 
breast cancer surgery patients 
AUSTIN J. PIONTKOWSKI, Wayne State University School of Medicine, gb7278@wayne.edu  
ABBIE BAUER [article editor], Wayne State University School of Medicine, hm5510@wayne.edu 
 
ABSTRACT A clinical decision report appraising 
Naranjo J, Portner ER, Jakub JW, Cheville AL, Nuttall GA. Ipsilateral Intravenous Catheter Placement in Breast Cancer Surgery 
Patients. Anesth Analg. 2021 Sep 1;133(3):707-712. https://doi.org/10.1213/ANE.0000000000005597 
for a post-lumpectomy patient requiring ipsilateral peripherally inserted central catheter. 
Keywords:  breast cancer, lumpectomy, IV placement 
 
Clinical-Social Context 
Ronda Thompson [pseudonym] is a 70-year-old woman with a past medical history of breast cancer presenting to 
the hospital with persistent fevers. Ms. Thompson was diagnosed with ER/PR negative, HER-2/neu negative stage 
1B invasive ductal carcinoma in the spring of 2019. Shortly after, she had a lumpectomy of the left breast, and was 
treated with docetaxel and cyclophosphamide for 5 months. In the fall of 2019, she underwent radiotherapy. For 
the next two years, she followed up in the outpatient setting for surveillance, and had no notable complications or 
recurrence. 
In the spring of 2022, she presented to the emergency room with persistent fevers she was having at home. On 
arrival, she was febrile (37.9℃) with a low neutrophil count of 0.23 x 109/L. She was admitted and treated for 
neutropenic fever, though no source of infection could be identified over the next week. Bone marrow biopsy was 
performed, which suggested a diagnosis of acute myeloid leukemia (AML), likely secondary to chemotherapy use in 
2019. Ms. Thompson lives with her husband with stable income and no food insecurity. Her granddaughter was 
recently diagnosed with autism, and she usually takes care of her granddaughter while her daughter works. Ms. 
Thompson is worried that an extended stay in hospital will negatively impact her granddaughter’s care and will 
disrupt her daughter’s work and income. As such, we wanted to do everything possible to minimize complications 
and shorten her hospital stay. 
Ms. Thompson elected to undergo chemotherapy via a peripherally inserted central catheter (PICC). She was 
scheduled to receive the PICC in her right arm, because the left upper limb was automatically marked as 
contraindicated for procedures due to a traditional concern for complications following lumpectomy. However, 
Ms. Thompson developed a deep vein thrombosis in the right arm, leaving clinical uncertainty about where to 
place the PICC. 
PIONTKOWSKI AJ, BAUER AR. Safety of ipsilateral intravenous access in breast cancer surgery patients. 
Clin Res Prac. Nov 27 2024;10(1):eP3034. https://doi.org/10.22237/crp/1724284800 
 
VOL 10 ISS 1 / eP3034 / NOVEMBER 27, 2024  
https://doi.org/10.22237/crp/1724284800 
 
 
 
ISSN: 2379-4550 
http://digitalcommons.wayne.edu/crp, © 2024 The Author(s) 
2 Licensed under Creative Commons Attribution 4.0 International (CC-BY-4.0) 
 
Clinical Question 
Do intravenous access procedures performed on the ipsilateral limb to lumpectomy increase risk of complications? 
Research Article 
Naranjo J, Portner ER, Jakub JW, Cheville AL, Nuttall GA. Ipsilateral Intravenous Catheter Placement in Breast Cancer Surgery 
Patients. Anesth Analg. 2021 Sep 1;133(3):707-712. https://doi.org/10.1213/ANE.0000000000005597 1 
Description of Related Literature 
Advanced PubMed and Google Scholar searches were conducted using the key terms “neoplasm,” “procedure,” “operative,” 
“ipsilateral,” and “same side.”. This yielded 223 results. Titles and abstracts were manually screened for relevance and impact. 
Related articles were also screened for relevance. There is seemingly a lack of research on ipsilateral venous access in breast cancer 
surgery patients, with virtually no randomized controlled trials. All relevant studies were retrospective institutional studies, or self-
reported questionnaires.  
First, a retrospective study by Naranjo et al. looked at the risk of breast-cancer related lymphedema following intravenous line 
placement. They identified 3724 patients undergoing 7896 intravenous lines and compared complications from ipsilateral and 
contralateral IV placements in patients with previous breast cancer surgery.1 Given the comparatively large sample size and direct 
relevance to our question, we selected this study as our primary source.  
Another similar retrospective study by Isom et al. found that in their single-institution study of 581 women, central venous port 
placed ipsilaterally to breast surgical site was not associated with increased risk of lymphedema compared to contralaterally placed 
port sites (p=0.64).2 Likewise, Nas et al. found no difference in complications between ipsilateral and contralateral subcutaneous 
port placement in breast cancer surgery patients.3 However, these studies looked at central venous catheters, and we were primarily 
interested in peripherally inserted catheters.  
Other relevant studies included Ferguson et al.’s single-institution study that looked at 3041 measurements taken from the 
ipsilateral arm of breast cancer surgery patients. They found no association between blood draws (p=0.62) and injections (p=0.77) 
with increased arm volume.4 While this supported our hypothesis that procedures do not increase risk of complications in breast 
cancer surgery patients, this study failed to address the use of intravenous catheters, which was our primary variable of interest. 
Lastly, Winge et al. looked at the complications of intravenous infusions after axillary surgery in breast cancer patients. They found 
that ipsilateral infusions were associated with only minor complications, such as itching and bruising. However, our patient 
underwent lumpectomy and not axillary surgery, making the applicability difficult to assess. In addition, study design also used a 
self-reported questionnaire, introducing the possibility of recall bias.5 
Critical Appraisal 
Our study of interest was a single-institutional, retrospective study. According to SORT criteria, this is a level 2 evidence study and 
the Strength of Recommendation is C.6 
The authors identified 3724 patients with a history of breast cancer surgery who underwent 7896 IV placements. The authors then 
compared complications occurring in the ipsilateral versus contralateral arm. Complications were screened using ICD-9 codes, 
including compartment syndrome, cellulitis, and lymphedema related to breast cancer. Rates of complications were used for 
analysis, defined as the number of complications per 10,000 IV placements. The rate of complications was then compared in the 
ipsilateral vs. contralateral arm using a continuity-adjusted chi-square test. 
The authors first reported that patients who received IV placements in the contralateral limb were older and had higher Charlson 
comorbidity scores (p-values <0.001). Of the 2743 contralaterally placed IVs, there were only 2 complications, compared to 2 
PIONTKOWSKI AJ, BAUER AR. Safety of ipsilateral intravenous access in breast cancer surgery patients. 
Clin Res Prac. Nov 27 2024;10(1):eP3034. https://doi.org/10.22237/crp/1724284800 
 
VOL 10 ISS 1 / eP3034 / NOVEMBER 27, 2024  
https://doi.org/10.22237/crp/1724284800 
 
 
 
ISSN: 2379-4550 
http://digitalcommons.wayne.edu/crp, © 2024 The Author(s) 
3 Licensed under Creative Commons Attribution 4.0 International (CC-BY-4.0) 
 
complications in the 5153 ipsilaterally placed IVs. There was no significant difference in the frequency of complications between the 
two groups (p-value=0.91).  
These findings suggest complications from IVs are generally rare, and that IV placements are safe in the arm ipsilateral to breast 
surgery site. However, there are some limitations. First, the study is a single-center retrospective study, and the authors did not 
report demographics such as race. This makes the results less generalizable to Ms. Thompson. Although randomized control trials 
(RCT) are the gold standard for evidence-based medicine, they are infeasible in this instance given the impossibility to predict if 
breast cancer patients will need IVs in the future. Additionally, RCTs with the primary goal of risk assessment may not be ethical. It 
would also be impossible to blind the patients and medical team. Unfortunately, retrospective studies such as the one selected run 
the risk of missing important data points and recall bias. It is also difficult to determine the external validity of single-center studies.  
Nonetheless, this study is one of the first to provide data on IV placement in breast cancer surgery patients. Given the large sample 
size, they provide strong evidence that IV placement is not associated with an increased risk of complications when placed in the 
ipsilateral arm to breast cancer surgery site. 
Clinical Application 
Ms. Thompson needed a PICC line for initiation of chemotherapy for her newly diagnosed AML. Due to her history 
of lumpectomy on the left side and a current DVT in the right arm, there was uncertainty on where to place the 
PICC. 
Based on the study by Naranjo et al., ipsilaterally placed IVs were not associated with increased risk in patients 
with a history of breast cancer surgery. As a result, we reasoned that placing the PICC in the ipsilateral arm was 
safer than placing the PICC in the other limb with an acute DVT. Ms. Thompson, however, identified as an African 
American woman. This study failed to provide racial demographics, which somewhat limited our application. 
Nonetheless, there were only 2 complications of 5153 ipsilaterally placed IVs, making racial bias unlikely. As a 
result, we went ahead and placed the PICC in Ms. Thompson’s left arm, where she also had a lumpectomy several 
years prior. 
In the future, we suggest modifying hospital protocol to incorporate the current research. Limb contraindications 
in breast cancer surgery patients are outdated. Even in an abundance of caution, we suggest modifying the 
language to indicate a preferred arm, rather than a complete contraindication. 
New Knowledge Related to Clinical Decision Science 
Many institutions automatically flag patients with limb precautions who have a history of breast cancer or axillary surgery. In the 
case of Ms. Thompson, a sign was placed on her door as soon as she was admitted that read “No procedures in left arm.” However, 
there is a scarcity of research that supports this. Naranjo et al., for example, showed that IV placement is not associated with 
increased risk, such as lymphedema or cellulitis, in breast cancer surgery patients. 
So, why the need for limb precautions for breast cancer surgery patients in hospitals? Studies show this is an outdated practice. In 
the case of Ms. Thompson, we wanted to initiate chemotherapy as soon as possible, so that she could go home to her 
granddaughter. This limb precaution created confusion and could have delayed the start of her treatment. Thankfully, we received a 
phone call from the nursing staff to confirm the arm placement. If the PICC was inserted in the right arm as indicated by the sign on 
her door, we could have created an embolus. Unfortunately, current rules are not always backed by evidence. In this example, the 
door sign could be seen and thought to be backed by evidence, but it is not. More research is needed to validate the use of the door 
sign in similar cases. 
Using this clinical social context as vignette, the clinical question for clinicians could be randomized to the two suggested hospital 
policies: “contraindicated” versus “preferred arm”. This would test the hypothesis of changing policy to actual clinical decisions. 
PIONTKOWSKI AJ, BAUER AR. Safety of ipsilateral intravenous access in breast cancer surgery patients. 
Clin Res Prac. Nov 27 2024;10(1):eP3034. https://doi.org/10.22237/crp/1724284800 
 
VOL 10 ISS 1 / eP3034 / NOVEMBER 27, 2024  
https://doi.org/10.22237/crp/1724284800 
 
 
 
ISSN: 2379-4550 
http://digitalcommons.wayne.edu/crp, © 2024 The Author(s) 
4 Licensed under Creative Commons Attribution 4.0 International (CC-BY-4.0) 
 
Conflict Of Interest Statement 
The authors declare no conflicts of interest. 
References 
1. Naranjo J, Portner ER, Jakub JW, Cheville AL, Nuttall GA. Ipsilateral Intravenous Catheter Placement in Breast Cancer Surgery 
Patients. Anesth Analg. 2021 Sep 1;133(3):707-712. https://doi.org/10.1213/ANE.0000000000005597  
2. Isom C, Bream P Jr, Gallagher K, Walia S, Ahmed R, Kauffmann R. Placement of Subcutaneous Central Venous Ports in Breast 
Cancer Patients: Does Side Matter? J Surg Res. 2019 Dec;244:296-301. https://doi.org/10.1016/j.jss.2019.06.028  
3. Nas OF, Hacikurt K, Kaya A, Dogan N, Sanal B, Ozkaya G, et al. Choosing the appropriate side for subcutaneous port catheter 
placement in patients with mastectomy: ipsilateral or contralateral? Radiol Med. 2017 Jun;122(6):472-478. 
https://doi.org/10.1007/s11547-017-0736-8  
4. Ferguson CM, Swaroop MN, Horick N, Skolny MN, Miller CL, Jammallo LS, et al. Impact of Ipsilateral Blood Draws, Injections, 
Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer. J Clin Oncol. 
2016 Mar 1;34(7):691-8. https://doi.org/10.1200/JCO.2015.61.5948  
5. Winge C, Mattiasson AC, Schultz I. After axillary surgery for breast cancer--is it safe to take blood samples or give intravenous 
infusions? J Clin Nurs. 2010 May;19(9-10):1270-4. https://doi.org/10.1111/j.1365-2702.2009.03153.x  
6. Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading 
evidence in the medical literature. J Am Board Fam Med. 2004;17(1):59-67. https://doi.org/10.3122/jabfm.17.1.59  


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