Superselective angio-CT of brain tumors

PURPOSE

To determine the efficacy of superselective angio-CT in the diagnosis of astrocytoma.

METHODS

Nineteen patients with astrocytoma had superselective angio-CT before chemotherapeutic agents were administered via superselective intraarterial infusion. CT was performed after contrast material was delivered through a microcatheter, which had been advanced into the feeding arteries of the tumor. Superselective angio-CT scans were compared with digital subtraction angiograms, conventional contrast-enhanced CT scans, and contrast-enhanced T1-weighted MR images.

RESULTS

Superselective angio-CT scans depicted contrast enhancement of the tumor in all of the patients and the medullary veins of the tumors in 32% of the patients. Digital subtraction angiograms showed tumor stains in 68% of the patients and the medullary veins in only 5%. Conventional CT scans and MR images showed contrast enhancement of the tumor in 89% of the patients. Superselective angio-CT scans confirmed the proper position of the catheter tip for the infusion of a chemotherapeutic agent.

CONCLUSIONS

Superselective angio-CT can be used to depict contrast enhancement of tumors and the vascular structures that are characteristic of astrocytomas.

A prospective evaluation of the treatment of primary or metastatic liver carcinoma with hepatic arterial infusion chemotherapy

The efficacy of hepatic arterial infusion chemotherapy (HAICT) in the treatment of primary or metastatic liver carcinoma was evaluated in 37 patients. The infusions were administered through a catheter that was placed in the hepatic artery, either surgically or by percutaneous puncture of the femoral artery. A complete response was observed in four patients. A partial response was observed in six patients and a minor response in another six. In nine patients the disease had stabilized, while a progression of the disease had developed in 12 patients. After a mean of 4.7 cycles per patient, the response rate (complete, partial and minor responses) was 43.2% and median survival 12.0 months. Seventeen Grade III toxicities were observed in a total of 174 cycles, but none of them were fatal. HAICT has demonstrated a successful palliation with minimal toxicity in patients with unresectable liver carcinoma.

[A modified technic for local rt-PA catheter-mediated lysis]

PURPOSE

To develop an economic and efficient concept for more time-saving local rt-PA thrombolysis therapy.

METHOD

40 patients with peripheral vascular occlusive disease stage IIb-III according to the Fontaine classification and with angiographically proven occluded segments of pelvic and lower limb arteries were treated by a modified concept of local rt-PA catheter thrombolysis. Via a thin guide wire the catheter for thrombolysis is slowly advanced through the thrombus without fluoroscopic control, outside the room in which angiography is performed. In 24 cases a short-term lysis and in 16 cases a long-term lysis was carried out.

RESULTS

The initial success rate was 75%, the patency rate in six months' follow-up was 66.7%. The ankle-brachial index decreased from 0.4 +/- 0.3 to 0.8 +/- 0.2 on the average. There were no relevant clinical complications. The average occupancy time of the angiography room or table was 60 +/- 52 min, the average time of fluoroscopy was 17 +/- 13 min.

CONCLUSION

In modified local rt-PA thrombolysis, short-term lysis and long-term lysis were mostly performed outside the angiography room, so that the exposure to radiation and there fore the radiation dose were reduced for both the patient and the attending staff. The angiography room is thus available for other patients and can therefore be used more efficiently.

Technical determinants of success in catheter-directed thrombolysis for peripheral arterial occlusions

Local intraarterial thrombolytic therapy restores blood flow to the ischemic limb by dissolving the occlusive thrombus and identifies culprit lesions for treatment by means of surgical and/or percutaneous procedures. The techniques used for administration of the thrombolytic agent, the drug used, and the criteria for termination of the therapy are all factors that can influence both technical success and speed of lysis. This article discusses these factors and their influence on thrombolytic success.

Arterial, peritoneal, and intraventricular access devices

OBJECTIVE

To provide an overview of access devices used to treat cancers through the arterial, peritoneal, and intraventricular body systems.

CONCLUSIONS

Short-term and long-term devices have been developed over the last 35 years for cancer treatment. Although less amenable to standard methods of therapy, the various access devices available to access the arterial, peritoneal, and intraventricular systems have provided a safe and reliable means for drug therapy. Access devices assist in delivering high concentrations of drugs directly to the center of the tumor. Complications and toxicities are inherent with these devices from the drug therapy as well as the device. Nursing assessment can provide early identification of potential problems and implementation of appropriate interventions.

IMPLICATIONS FOR NURSING PRACTICE

As the availability of these devices increases, so must the nurse's knowledge base to provide optimal safe care. Oncology nurses are challenged to know the differences between the devices, the device of choice for the individual patient, insertion procedures, and maintenance protocols.

Effect of balloon occluded arterial infusion of anticancer drugs on the prognosis of cervical cancer treated with radiation therapy

PURPOSE

The effect of local injection of anticancer drugs by balloon catheter, i.e., balloon occluded arterial infusion (BOAI), on the prognosis of cervical cancer treated with radiotherapy were retrospectively estimated.

METHODS AND MATERIALS

Sixty-five patients with cervical cancer (Stage I-IV) treated by irradiation were included in the study. Among the 65 cases, 2 were in Stage I, 13 in Stage II, 40 in Stage III, and 10 in Stage IV. Patients who received surgical resection were excluded. Thirty-nine patients received BOAI and 44 received brachytherapy. Twenty-six patients were not indicated for BOAI because of insufficient renal function, hepatic complications, hematological complications, and refusal from the patients. Cisplatin (0.9-1.7 mg/kg), Adriamycin (0.7-0.9 mg/kg), and Pepleomycin (0.4-0.6 mg/kg) were administered simultaneously into the bilateral internal iliac arteries by BOAI. External irradiation was given by 10 MV x-ray. Total dose administered to the regional lymph nodes by the external irradiation was 48.3 +/- 8.7 Gy. Radium was used at brachytherapy. The dose delivered by the brachytherapy at point A was 45.3 +/- 14.9 Gy. Patients without brachytherapy received 26.1 +/- 19.1 Gy of boost irradiation by the external photon beam. The survival probabilities of the patients were calculated by Kaplan-Meier method.

RESULTS

The 5-year survival rates of the Stage III patients with and without BOAI were 53 +/- 13% and 24 +/- 18%, respectively (p = 0.036). By multivariate analyses using Cox's proportional hazard model, stage and BOAI were selected as significant predictors of the prognosis. Transient bone marrow suppression was observed in about half of the patients with BOAI. No significant increase of the incidence of the late radiation damage by BOAI in rectum or in urinary bladder was observed.

CONCLUSION

Balloon occluded arterial infusion of anticancer drugs may improve the prognosis of the patients with cervical cancer without increasing the incidence of the late radiation damage. A larger scale prospective randomized study is desired.

[Tactics in choosing a vascular collector and drug administration method in intra-arterial infusion therapy of organs of vision]

Anatomical variants of the direction and diameter of the supraorbital artery revealed by the authors and the clinical variants of the intensity and direction of periorbital bloodstream shown by doppler studies helped optimize the selection of a facial artery for inserting an infusion system for drug delivery to the vascular system of the eye. The advantages of intraarterial infusion of drugs in the system of ocular blood supply using an automated thermo-infusion dispenser vs. the traditional methods are demonstrated: no side effects on the intraocular and regional hemodynamics, purposeful delivery of drugs to the site of ocular blood supply with a simple and convenient device. This method for the choice of a collector for intraarterial infusions and the method of drug infusion were clinically tried in 2 groups of patients: with retrobulbar intoxication neuritis and partial atrophy of the optic nerve (a total of 21 patients, 23 operations for implantation of infusion system; control group consisted of 11 patients). 120-Hour infusion therapy with, alternately, trental and actovegin resulted in improvement of the vision acuity from 0.03-0.06 to 0.3-0.8 in virtually all group 1 patients. Moreover, central scotomas disappeared and the conductivity of the axial bundle of the optic nerve recovered from 28-32 to 38-40 Hz. In group 2 defects in the visual field disappeared and its peripheral borders widened. In controls no improvement of the visual function was observed.

A comparison of the priming properties of two central venous catheters and one pulmonary artery catheter

The time taken to prime the individual lumina of two multilumen central venous catheters (Viggo-Spectramed 14G 20 cm Hydrocath and Vialon 14G 20 cm Deltacath) and one pulmonary artery catheter (Viggo-Spectramed 110 cm 7.5F Pentacath) at flows between 5 ml.h-1 and 99 ml.h-1 is reported. The catheters supplied by different manufacturers but of identical length and gauge have significantly different priming times (p < 0.001). A protocol which may be used to prime the individual lumina of the three catheters studied is described. By means of an in vitro test the accuracy of this protocol is validated.

Dye-injection method for placement of an infusion catheter in regional hepatic chemotherapy

PURPOSE

To evaluate the usefulness of a dye-injection method in the placement of an infusion catheter and port via proximal branches of the axillary artery for hepatic infusion chemotherapy.

MATERIALS AND METHODS

Sixteen patients with surgically unresectable hepatic cancer underwent transfemoral hepatic arteriography. Then a 3-F coaxial catheter was inserted into a proximal branch of the left axillary artery. Dye injected through the coaxial catheter during the surgical procedure improved the visualization of the target branch. The coaxial catheter was also used as a guide for retrograde insertion through the target branch of an infusion catheter into the descending aorta.

RESULTS

In 13 of 16 patients (81%), catheterization was successful without exposure of the axillary artery. In these patients, the acromial-deltoid branch of the thoracoacromial artery was chosen as the target.

CONCLUSION

Injection of dye simplifies the surgical procedure for placement of a hepatic infusion catheter via proximal branches of the axillary artery. The depth and extent of incisions, as well as the risk of nerve injury, are reduced.

Palliative, intraarterial chemotherapy for advanced head and neck cancer using an implantable port system

PURPOSE

Intraarterial drug therapy for head and neck cancer has been used for more than 30 years. However, because of catheter-related complications occurring quite frequently, this method was abandoned in many institutions. The development of subcutaneously implantable injection ports has renewed interest in regional drug delivery.

PATIENTS AND METHODS

This study reports the authors' experience with 11 injection ports implanted in 10 patients suffering from advanced or recurrent head and neck cancer.

RESULTS

The regional chemotherapy was well tolerated; the predominant side effects were hemialopecia and mild unilateral mucositis.

CONCLUSIONS

These results suggest that regional, intra-arterial chemotherapy using implantable injection ports should be considered for palliative treatment of advanced head and neck cancer.

Percutaneous hepatic vein isolation and high-dose hepatic arterial infusion chemotherapy for unresectable liver tumors

PURPOSE

This prospective, nonrandomized trial evaluated a percutaneous isolated chemotherapy perfusion approach for treating advanced primary and metastatic liver tumors. Chemotherapy was administered via hepatic artery catheter and hepatic venous blood isolated by a novel percutaneous double-balloon inferior vena cava (IVC) catheter was passed through a detoxification/filtration cartridge in a venovenous bypass circuit.

PATIENTS AND METHODS

Among 23 patients enrolled onto the study, 58 procedures were performed on 21 patients. Twelve patients received dose escalations of fluorouracil (5-FU) (1,000 mg/m2 to 5,000 mg/m2), and nine received dose escalations of doxorubicin (50 mg/m2 to 120 mg/m2). Pharmacokinetic studies included drug accumulation in the liver, extraction by detoxification filters, systemic exposure, and alterations of half-life. Each patient received two treatments at 3-week intervals. Those showing stabilization or response received additional treatments.

RESULTS

There was a direct relationship between dose and peak concentration of drug entering the hepatic veins. The system functioned efficiently throughout the dose range, with extraction efficiencies ranging from 64% to 91% (P < .001). The hepatic vein drug levels showed a sixfold increase in 5-FU with dose escalation from 1,000 to 5,000 mg/m2, and a twofold increase in dox with dose escalation from 50 to 120 mg/m2 (P < .001, filter-mediated drug extraction). The treatments were accomplished with only an overnight hospital stay and no mortality. The common procedure-related toxicity was transient hypotension (grade I to II), due to catecholamine depletion by the filter. Dose-limiting toxicity (leukopenia) was observed in patients receiving 5-FU at a dose of 5,000 mg/m2 and doxorubicin at a dose of 120 mg/m2. Significant tumor response (> 95% reduction) was obtained in two patients receiving doxorubicin at 90 mg/m2 and 120 mg/m2.

CONCLUSION

The use of a double-balloon catheter to isolate and detoxify hepatic venous blood during intraarterial therapy is technically feasible, safe, and allows administration of large doses of intrahepatic chemotherapy at short intervals. This approach should allow new dose-intensification strategies to increase tumor responses in primary and metastatic liver tumors.

Pharmacomechanical thrombolysis of experimental pulmonary emboli. Rapid low-dose intraembolic therapy

We utilized low-dose intraembolic urokinase (UK) infusions in a canine model of experimental pulmonary embolism (PE) and compared the arteriographic extent of thrombolysis with three other treatment regimens. Group 1 animals (n = 16) received the intraembolic UK infused directly into the PE offering the mechanical effect of the infusion combined with pharmacologic thrombolysis. In the group 2 animals (n = 5), UK was delivered via a guide catheter placed proximal to the clot. Group 3 animals (n = 6) were treated with a direct intraembolic saline solution infusion. Group 4 (n = 7) received only intravenous heparin. The arteriographic extent of thrombolysis was graded 1+ to 3+. The extent of thrombolysis was 2.88+ in the group 1 animals and was significantly greater than in groups 2, 3, or 4 (p = 0.003, 0.0005, and 0.0001, respectively). Fibrinogen levels did not significantly decrease with intraembolic treatment (p = 0.07). Delivery of UK directly into emboli in an experimental canine PE model appears to elicit a combined mechanical and pharmacologic effect resulting in extensive thrombolysis.

[Device for intraarterial access for locoregional chemotherapy in hepatic metastasis from colorectal neoplasms (technical note)]

Metastasis are the most common malignant lesions of the liver. Liver is the most common site of visceral metastasis from colo-rectal carcinoma. Only in few patients are the lesions surgically resectable for cure and standard intravenous chemotherapy produces a low response rate. An intrahepatic arterial device for regional chemotherapy is an effective and safe alternative for unresectable liver metastasis from colorectal carcinoma, with a significant improvement on response rates compared with conventional i.v. chemotherapy; a longer survival is also reported in patients receiving intrahepatic therapy, even if the difference is not statistically significant. The catheter is inserted through the gastro-duodenal artery and the reservoir is placed in a subcutaneous pocket on the anterior thoracic wall. The Authors discuss indications, implantation technique and complications. Intra-arterial chemotherapy is administered in ambulatorial regimen and scintigraphic scanning and/or epatic ultrasonography are performed every three months to evaluate response rate. Median survival is variable from 12 to 17 months in the different series with response rates (disappeared metastases or tumor-mass reduction over 50%) of 48%-62%. The increased tumor responses reported together with a lower systemic toxicity (compared with systemic therapy) suggest that intra-arterial chemotherapy is a reliable and well tolerated treatment.

Vascular access device for treatment of cancer patients

Vascular access devices that are completely implanted have been used for treatment of cancer patients. Vascular access devices are useful for transarterial infusion of anticancer drugs, intravenous hyperalimentation, and drainage of bile juice in obstructive jaundice. These systems have several advantages in the care of patients: they are sealed, they have no external tubes, and they may be useful for blood or biliary sample and intravenous hyperalimentation or chemotherapy. There are only minimal discomforts related to the implantation procedure and no need for routine external catheter care. Most importantly, the quality of the patient's life is dramatically improved without external tubes. For these reasons, we believe that vascular access devices should be indicated for patients with malignant tumors as much as placement of these devices is technically feasible.

Pressure and volume control for local drug-delivery catheters: development of a new microprocessor-controlled system

BACKGROUND

Local drug delivery is a potential solution to postintervention restenosis. Most catheters developed for local delivery depend upon control of pressure and of delivered volume for optimal performance. The present study was designed to assess the accuracy of current methods for inflation of local delivery catheters compared with a new microprocessor-controlled system specifically designed for this application.

METHODS

An in vitro gravimetric testing system was constructed to record developed pressure and delivered volume using a variety of inflation devices and a microporous infusion catheter. Experienced catheterization laboratory personnel were given commercial angioplasty indeflators and a pressure-driven syringe and asked to quickly apply 5 atm and deliver 2.0 ml. A new microprocessor-controlled system was then tested using the same protocol.

RESULTS

The time required to reach a plateau pressure was lowest with the pressure-driven syringe (0.164 +/- 0.017 s) and much higher with standard indeflators (2.94 +/- 2.54, 4.64 +/- 2.98, 7.69 +/- 4.89, 8.28 +/- 6.31 s). The corresponding microprocessor-controlled value was much lower than that of the manual systems (0.84 +/- 0.37 s). The variability of plateau pressure, as measured by the standard deviation, was lowest with the pressure-driven syringe (0.029 +/- 0.014 atm) and highest with the manual systems (0.37 +/- 0.26, 0.40 +/- 0.18, 0.44 +/- 0.31, 0.32 +/- 0.10 atm). The microprocessor-controlled system also produced very little variability in pressure (0.08 +/- 0.004 atm). The volume delivered varied significantly with all manual devices (1.77 +/- 0.64, 1.74 +/- 0.66, 1.36 +/- 0.45, 1.80 +/- 0.33 ml) as well as with the pressure-driven syringe (1.86 +/- 0.32 ml), but the volume delivered by the microprocessor-controlled system was highly accurate (1.99 +/- 0.06 ml).

CONCLUSIONS

Manual inflation devices do not allow precise control of pressure or volume when used with local delivery catheters. Use of a pressure-driven syringe minimizes pressure error, but does not deliver an accurate volume. The microprocessor-controlled system minimizes pressure and volume error and should maximize transfer efficiency for local delivery catheter systems.

Use of a remotely controlled mechanical pump for coronary arteriography: a study of radiation exposure and quality implications

BACKGROUND

Exposure to radiation is a hazard of invasive cardiology. To minimise the risk it is essential to keep the doses received as low as possible.

AIM

To assess the effect on cardiologist radiation exposure and the quality of coronary artery opacification of the use of a remotely controlled mechanical pump for coronary arteriography. A secondary aim was to assess any disadvantages and safety.

METHODS

319 patients were randomised to have coronary arteriography carried out with contrast injected either by hand or by a remotely controlled mechanical pump. Six cardiologists participated: two catheter laboratories were used and both brachial and femoral approaches were included. The exposure of the cardiologists to radiation was assessed by film badge dosimetry. The badges were worn on the hat. The total time for the procedure, screening time, the dose-area product meter reading, and any complications were recorded for each examination. The quality of arterial opacification was reported on a scale of 0-5.

RESULTS

The mean radiation dose per procedure was 0.011 mSv for hand injection of contrast and 0.005 mSv for mechanical injection (p < 0.01). There were no differences in procedure times or screening times. There were no complications attributable to mechanical injection. Arterial opacification was not significantly different in the two groups (4.01 v 4.03 for the left coronary artery, 4.68 v 4.78 for the right coronary artery). The right coronary artery was consistently better opacified than the left by both techniques (4.59 v 3.89, p < 0.001).

CONCLUSIONS

Use of a remotely controlled mechanical pump for coronary arteriography reduced cardiologist radiation exposure by half. It was not associated with any inconvenience, expense, or complications and produced arterial opacification at least as good as injection by hand.

Reduction of systemic drug exposure after hepatic arterial infusion of doxorubicin with complete hepatic venous isolation and extracorporeal chemofiltration

BACKGROUND

Hepatic arterial infusion of doxorubicin has produced tumor response in hepatic malignancies; however, the limited success of these treatments is related in part to dose-limiting systemic toxicities. The purpose of this study was to determine whether a novel venous isolation-chemofiltration system could limit systemic exposure to doxorubicin after hepatic arterial infusion.

METHODS

Doxorubicin (1 or 3 mg/kg) was infused in the hepatic arteries of domestic pigs after complete hepatic venous isolation was achieved with a dual-balloon vena cava catheter. The hepatic vein effluent was pumped through an extracorporeal carbon chemofiltration circuit. Doxorubicin levels were measured in prefilter (hepatic vein), postfilter, and systemic serum at intervals up to 1 hour after drug infusion.

RESULTS

Complete hepatic venous isolation with extracorporeal chemofiltration significantly reduced (> 90%) the postfilter and systemic levels of doxorubicin compared with prefilter levels (p < 0.01). At the time animals were killed 7 days after infusion of doxorubicin (3 mg/kg), tissue levels of doxorubicin in the liver showed a 16-fold increase compared with levels in the heart (p < 0.01).

CONCLUSIONS

For chemotherapeutic drugs like doxorubicin with a low first-pass extraction by the liver, the novel system described herein achieved significant reduction in systemic drug exposure. This system will allow dose intensification of doxorubicin administered by hepatic arterial infusion to treat hepatic malignancies.

Intraarterial infusion of high-dose adriamycin for unresectable hepatocellular carcinoma using direct hemoperfusion under hepatic venous isolation

A 67-year-old man with an extensive hepatocellular carcinoma (HCC) was treated successfully with intraarterial infusion of high-dose adriamycin (ADR), 150 mg/m2, five minutes continuous infusion using an extra-corporeal system consisting of direct hemoperfusion (DHP) under hepatic venous isolation (HVI). During drug infusion, hepatic effluent was isolated and adsorbed by the DHP for 30 mins. Plasma ADR levels in the radial artery reached a peak of 2.00 micrograms/ml at five mins after the initiation of drug infusion. Peak values at the inlet and outlet of the DHP were 19.71 micrograms/ml and 1.75 micrograms/ml, respectively, indicating substantial drug adsorption by the DHP. The estimated drug removal rate was 31.1%. This treatment led to a marked regression of tumors with tolerable systemic toxicities. Although the patient subsequently died 9 months after treatment of progression of disease, this treatment resulted in a remission of significant duration.

Repositioning of a displaced catheter for percutaneous hepatic arterial infusion chemotherapy

This is a report of a patient with hepatocellular carcinoma whose hepatic arterial catheter, which was introduced via a subclavian arterial branch, migrated into his right gastric artery. The catheter was successfully maneuvered to a suitable position without any further invasive procedure. The importance of preparatory embolization of the right gastric artery is underscored.

Efficacy of digital subtraction angiography for confirmation of position of the infusion tube for delivery of intra-arterial chemotherapy as treatment of the head and neck cancer

This study was conducted in 47 patients with biopsy-proven cancer of the head or neck. These patients each had an intra-arterial infusion tube inserted retrogradely. Positioning in the infusion tubes had been determined by staining of the mucocutaneous area of the malignant lesion under observation with injection of blue dye. Digital subtraction angiography (DSA) was performed from the infusion tube. DSA demonstrated that infusion tubes were in the correct position in 26 patients (55%), and in an incorrect position in 21 patients (45%). The infusion tubes of all patients with cancer of the maxillary sinus were in the correct position. However, the majority (54%) of infusion tubes in patients with cancer of the tongue were in an incorrect position. Observation of arterial flow from the infusion tube using DSA should be made in all patients with head or neck cancer in order to avoid the potential complications of intra-arterial chemotherapy.

Comparison of intra-arterial and intravenous infusion of cisplatin for head and neck squamous cell carcinoma in a modified rat model

To study intra-arterial infusion of chemotherapeutic agents, human squamous carcinoma cells were obtained from the FaDu cell line and were implanted in athymic rats (rnu/rnu). The xenografts were grown and then were reimplanted on a vascular pedicle and were completely isolated from the surrounding tissue. The vascular isolation of these pedicles was confirmed radiographically and histologically. After 26 days of growth, an osmotic pump was implanted to deliver either saline, intra-arterial cisplatin, or intravenous cisplatin to the vascular pedicle. Platinum levels were identified in the tumors following intra-arterial and intravenous infusions, demonstrating the usefulness of this model for delivery of antineoplastic agents. We were unable to detect differences between tumor groups for final tumor volume, tumor platinum levels, and tumor histology with the one-dose schedule used. We were able to show a remarkable uniformity of the tumor platinum levels with varying serum platinum levels with intra-arterial and intravenous infusion of cisplatin. The toxicity of each drug administration method was assessed by levels of renal platinum and rat serum creatinine and blood urea nitrogen. No differences in toxicity with the dose administrated. We believe the immunodeficient rat with a xenografted isolated vascular pedicle is an excellent model to study the effect of intra-arterial therapeutic modalities on head and neck squamous cell carcinoma.

Local drug delivery catheters: functional comparison of porous and microporous designs

BACKGROUND

The porous (Wolinski) balloon was designed to allow local delivery of compounds targeted to inhibit postintervention restenosis; however, successful use of the device has been hampered by arterial trauma caused by the balloon itself. This study utilized several experimental systems to assess the functional characteristics of the porous balloon catheter. This information was utilized to design and test a new microporous infusion catheter for local intra-arterial drug delivery.

METHODS

Flow characteristics in fluid and semisolid media as well as arterial trauma by light and electron microscopy were documented for the porous and microporous balloons. In addition, the efficacy of methylene blue delivery in situ and in vitro was documented and quantified for the microporous design.

RESULTS

The porous balloon exhibits flow characteristics consistent with orifice-related streaming that produces arterial trauma. By maximizing external balloon-pore density and minimizing pore size, the microporous design minimizes streaming in test systems. This is manifested by minimal arterial trauma when applied to intact arteries. The microporous catheter is effective for dye delivery both in situ and in vivo.

CONCLUSIONS

The microporous catheter design offers improved functional characteristics when compared with the porous balloon for local intra-arterial drug delivery.

Intra-arterial infusion chemotherapy on unresectable hepatocellular carcinoma under occlusion of hepatic arterial flow

Intra-arterial infusion chemotherapy (IAIC) by occluding hepatic arterial flow augments intrahepatic drug concentrations, resulting in response rates higher than those with conventional infusion methods. We recently developed an intra-hepatic artery catheter and device attached with an implantable double-lumen reservoir that can be used for repeated IAIC in outpatient clinics. Eight patients with unresectable hepatocellular carcinoma were treated by infusion of anticancer drugs using this method. The catheter was inserted into the hepatic artery under laparotomy. The occlusion balloon was attached to the common hepatic artery, and catheters were connected to the subcutaneous double-lumen reservoir. Approximately 0.5 ml of distilled water was injected through the one port of the double-lumen reservoir to inflate the balloon, which compressed the artery within the cylinder-like occluder. 4'-O-tetrahydropyranyladriamycin (THP-ADM) was used as the anticancer agent, and two patients received combined administration with carboplatin. Three to seven repeated infusions were possible without any severe side effects. This treatment was also easy to perform in the outpatient clinic. Six of the eight patients survived for more than 2 years, an improvement over the survival rates obtained in a previous conventional IAIC group. We conclude that IAIC with THP-ADM for unresectable hepatocellular carcinoma under occluding blood flow using our device is more convenient and more effective than other available methods.

Selective and superselective infusion of urokinase for embolic stroke

Intraarterial administration of urokinase using Tracker microcatheter was performed in 11 patients with acute cerebral infarction caused by embolic occlusion of the internal carotid or the middle cerebral artery. Recanalization was observed in seven cases (64%) following the fibrinolytic therapy, and the time until recanalization from the start of the treatment was on the average 2.8 hours. Recanalization was seen in five out of six cases that received superselective infusion of urokinase, while it was seen in two out of five cases that received selective infusion. This study suggests that superselective infusion of urokinase is an excellent therapeutic method for embolic occlusion of the cerebral artery.

[A case report of metastatic colonic carcinoma in the liver effectively treated by long-term, ambulatory and continuous, intra-hepatic-arterial infusion of 5-fluorouracil using disposable multi-day-type infusor]

A 42-year-old female was diagnosed as having sigmoid colonic carcinoma with multiple metastases in the liver. Following sigmoid colectomy and descending colostomy, a catheter was inserted from the right gastroepiploic artery to the proper hepatic artery. From the day of surgery 5-Fluorouracil was administered in doses of 250 mg/day continuously through a catheter over the 2-month period of hospitalization. After the patient was discharged, 250 mg/day of 5-Fluorouracil was administered at home using Vaxter Infusor according to a regimen of 10-day continuous infusion and subsequent 4-day rest. Five months after the initial operation, the serum CEA level decreased dramatically, and CT scan of the liver revealed the complete disappearance of the metastases. The patient underwent a second operation in which the colostomy was closed, and she is doing well at this writing. This case suggests that long-term, ambulatory, continuous and intra-hepatic-arterial infusion of 5-Fluorouracil can be a very effective treatment not only in reducing the hepatic metastases but also in improving the quality of life of patients with colonic carcinoma.

[Complications and their management in intraarterial infusion chemotherapy]

Complications and its management were evaluated in intraarterial infusion chemotherapy for 188 patients with advanced carcinoma of the digestive organs from 1975 to Sept. 1991. Subjects were divided into four groups: Group I was 62 patients in whom the tip of the catheter without knots was established in the abdominal aorta via celiac axis, Group II consisted of 72 patients with the tip of the catheter without knots in the common hepatic artery. Group III had 35 patients with the tip of the catheter with knots (Anthron catheter) in the common hepatic artery. Group IV was 19 patients with the tip of the anthron catheter connected to the Infuse A-Port in the common hepatic artery. The most frequent complications seen among Group I, II and III were caused by catheter thrombosis (11.3%) in Group I, spontaneous dislodgement of catheter (26.4%) in Group II and extravasation (20%) in Group III. By using 16 gauge Toray Anthron catheter with Heparin coating on its inner and outer surfaces, the number of complications in Group I and II was kept smaller. Extravasation, on the other hand, has been less frequently seen in Group III by establishing the tip of the catheter at the branching site of the gastroduodenal artery from the common hepatic artery. Complications in Group IV (19 patients) were noted only in 3 patients, i.e., extravasation, subcutaneous necrosis and subcutaneous abscess, respectively. Therefore, we concluded that Group IV showed the most favorable intraarterial infusion chemotherapy with the most infrequent complications.

[Locoregional chemotherapy in neoplasms]

Intra-arterial chemotherapy of carcinoma increases drug concentration at the level of the tumour and reduces systemic toxicity. It is being used in the treatment of solid tumours in various parts of the body with increasingly encouraging results. It can also be carried out in an outpatient setting owing to the use of particularly advanced techniques.

Percutaneous transfemoral arterial infusion chemotherapy for metastatic liver tumors--placement of 3 Fr balloon catheters

A 3 Fr single lumen balloon catheter was successfully introduced for arterial infusion chemotherapy by percutaneous transfemoral arterial insertion. This balloon catheter was combined with a 6.3 Fr outer catheter coaxially. After placing the catheter into the target artery, the balloon was ruptured by injecting 1 ml of contrast medium. Alternatively, the balloon was made into a leaky balloon catheter by a small needle puncture before use. In 34 patients with liver tumors, we used this method combined with the continuous infusion of 5-fluorouracil for three to five weeks and once-a-week intra-arterial administration of mitomycin C and adriamycin. The result of this therapy was as follows: CR, 8.8%; PR, 29.4%; NC, 50.0%; and PD, 11.8%. No serious complications were encountered in our series except for some minor arterial problems caused by the catheter tip.

Clinical evaluation of intermittent arterial infusion chemotherapy with an implanted reservoir for hepatocellular carcinoma

A total of 45 patients with advanced hepatocellular carcinoma were treated at Osaka City University Hospital by intermittent arterial infusion chemotherapy with an implanted reservoir. The treatment consisted of intermittent infusion of doxorubicin (5-20 mg/body), mitomycin C (4-10 mg/body) or degradable starch microspheres (600-1200 mg/body) plus doxorubicin (30 mg/body). In all, 26% of the patients received this treatment for disease recurrence following transcatheter arterial embolization (TAE). Among 43 evaluable patients, 4 showed a complete remission (CR) and 16 showed a partial response (PR) on computed tomograms and angiograms. For all 45 patients, the 1-year survival value was 41% and the 2-year value was 14%. Of the 20 patients who showed a CR or PR, 77% survived for 1 year and 29% survived for 2 years. Tumor regression showed a close relationship with the duration of survival. Intermittent arterial infusion with an implanted reservoir caused the least adverse reactions and seems to be appropriate for use in patients with advanced tumor extension or stenosis of the hepatic artery caused by repeated TAE.

[Permanent arterial approach to the lower extremity using a totally implantable reservoir system]

In 10 patients with peripheral arterial occlusive disease intraarterial infusions were performed using a totally implantable port system. The port is fixed to the gluteal fascia on the outside of the iliac wing. The inferior epigastric artery is dissected through an additional incision above the inguinal ligament. A 2 mm catheter is connected to the port and inserted through the epigastric artery into the external iliac artery. Using this new suprainguinal technique the groin remains intact permitting surgical and interventional procedures. In one case a dislocation of the catheter occurred. The reason for this complication was an unsafe surgical fixation. The totally implantable port system is an alternative to conventional intraarterial infusions. There are several advantages using the suprainguinal technique as described above.

[Effects and complications of continuous hepatic arterial infusion chemotherapy using implantable reservoir for liver metastases from colorectal cancer]

Continuous arterial infusion chemotherapy using implantable reservoir was performed for unresectable liver metastases from colorectal cancer and the therapeutic effects, side effects and complications were evaluated. Eleven patients were treated with four kinds of arterial infusion courses that mainly consisted of 5-FU. The arterial infusion courses were discontinued in 2 patients because of nausea and vomiting, and in one patient because of diarrhea. The catheters were dislocated in 2 patients and another 2 developed fistulous between the hepatic artery and bile duct. Three patients developed duodenal ulcer. Serum CEA was reduced in 4 patients (36%). After all, response rate was 9% (1/11). The one-year survival rates of all cases and cases treated with more than 4 courses were 36.3% and 80.0%, respectively.

[Intra-arterial chemotherapy in locally advanced breast carcinomas]

Transcatheter arterial chemotherapy with mitoxantrone was carried out in 9 patients suffering from advanced breast cancer. The anticancer agent was selectively injected in the internal mammary artery. In 2 cases the catheter was super-selectively advanced into a peripheral branch of the internal mammary artery supplying the breast carcinoma. No complication of the transcatheter treatment could be observed. CT examinations for controlling the catheter position showed perfusion of breast cancers between 40 and 90 per cent. Histological examinations of the 7 resected specimens revealed extensive necrosis in all cases. All 7 patients who underwent surgery have been without local recurrence for 3 to 12 months after treatment.

[Port-catheter perforation into the duodenum and other early complications after port implantation before intra-arterial infusion therapy of the liver with chemotherapeutic drugs]

Early complications following implantation of intraarterial hepatic port catheter systems from 1985 to 1988 in 24 patients are reported with special view to the perforation of a port catheter into the duodenum. In this case the primary postoperative angiographic control four weeks after implantation showed correct placement and perfusion of the liver. The perforation occurred before starting any cytostatic regimen. We observed a total of 21% irregularities and complications: dislocation of port membrane (n = 1), incorrect catheter displacement but regular liver perfusion (n = 1), catheter leakage (n = 1), subhepatic abscess (n = 1) and perforation of the catheter in the duodenum. When possible we combine port-implantation with resection of the liver.

[Catheter-in-catheter replacement technique for bronchial arterial continuous infusion therapy for pulmonary malignancies]

The purpose of this study was to improve tumor effects and to reduce side effects caused by one shot bronchial arterial infusion therapy for pulmonary malignancies. The catheter-in catheter replacement technique in proper bronchial artery was introduced for infusion therapy for several hours for this purpose. Three kinds of combination of catheters were selected and the duration of replacement in bronchial artery was either eight or 24 hours. In eight patients of 12 patients with pulmonary malignancies superselective bronchial arterial infusion was carried out through the inner small catheter. No significant complications developed either at the time of replacement or during continuous infusion.

The open-ended guidewire as superselective catheter for intraarterial chemotherapy: experience in 190 procedures

With intraarterial infusion, high levels of chemotherapeutic agents can be achieved in the tumoral area. We present our experience with open-ended guidewire (OEGW) associated with steerable guidewires (SGW) as superselective catheters for intraarterial chemotherapeutic infusion and embolization. This technique was used successfully in 62 patients (190 procedures) over 15 months.

[Application of an angiographic catheter with side holes to intra-arterial drug infusion--improvement of drug distribution by occlusion of the catheter tip]

To improve distribution of drug by intraarterial infusion a new catheter system with sideholes, tip of which was able to be occluded by an embolus, was developed. Inner diameter of the catheter was 0.038 inch. Tip of the catheter was so smoothly tapered to 0.025 inch in inner diameter that it could be occluded by an embolus of 0.038 inch in diameter. After occlusion of the tip, drug flowed out rectangly to catheter axis from only sideholes, resulting that drug flowed out was mixtured by blood stream to make a uniform distribution of it.

Patency rate of implantable devices during long-term intraarterial chemotherapy

Intraarterial implantable drug delivery systems have been considered as an alternative method for treating patients with unresectable liver malignancies. However, catheter problems with external implanted devices have resulted in limited application of chemotherapy. The introduction of subcutaneous devices offers an opportunity for long-term locoregional chemotherapy. Twelve external intraarterial catheters were implanted into 12 patients and 52 subcutaneously placed devices into 51 patients, all with various hepatic malignancies. Retrospective analyses comparing those two intraarterial systems were conducted taking into account the function and complication rate (hepatic artery thrombosis, infection, leaking, hemorrhage, and dislocation). The follow-up time for the external system was two to eight months (median five weeks), the thrombosis rate 33.3%, and the infection rate 25%. One instance of severe bleeding from the hepatic artery occurred during chemotherapy. One catheter dislocated. For the subcutaneously implanted intraarterial devices the follow-up time was five to forty-one months (median sixteen months), the thrombotic complication rate 17.3%, and the infection rate 7.6% (all patients with simultaneous bowel surgery). Catheter dislocation one year later required reimplantation; in 1 patient therapy had to be discontinued because of a catheter leak. The overall function rate was 71.3% with a median follow-up time of eight months. Anticoagulation therapy for subcutaneously implanted devices starting from the beginning of intraarterial chemotherapy is recommended to achieve long-term patency. No implantation should be preformed simultaneously with bowel surgery. The subcutaneously placed intraarterial devices had a higher function rate and were available for a longer period as compared with external implanted catheters.

[Home administration of anti-cancer drug with Baxter infusor]

Baxter infusor was evaluated for the degree of its safeness, and effectiveness, to use in a chemotherapy. The study covered a total of 36 cases, each receiving an average 11 days of care under this therapy. In seventeen of those cases, the patient had received outpatient care, or had spent day and night at their homes. In nine of the total 36 cases, the infusor had been set for use by the patients or by their family. Results were evaluated with a focus on three factors: the patients' quality of life, the infusor's ease of use and its comparability to conventional systems. As to quality of life, those patients generally appreciated the infusor as an improvement to conventional systems with 10 of them citing "an ability to live with their family", 16 citing "freedom to move around", and 35 citing "satisfying functional performance", as reasons for their favorable acceptance. 97% of the patients had found the infusor easy to use, and all had found it simpler and easier to use than the conventional system. Their overall rating for the infusor was "good" to "excellent" in 97% of the cases. And 33 out of the 36 patients thought the infusor safe and effective if used at the homes.

[Primary and metastatic liver tumors--evaluation of tumor regression and response with regional cytostatic drug therapy by sonography and fine needle puncture histology]

Primary and metastatic hepatic tumours--evaluation of tumour regression or response under regional cytostasis with sonography and fine needle puncture histology. The results obtained through the use of regional liver perfusion with a 5-FU-BCNU application on non-resectable hepatic metastases of colorectal tumours following primary curative removal of the primary tumour and primary hepatocellular carcinomas display comparable results to those specified in the literature after the use of 5-FUDR. The effectivity of the cytostasis regime is checked using histological criteria. The ultrasonically guided fine needle puncture can prove the success of the cytostasis regime on the basis of cytomorphologic criteria more reliably than has been the case up to now. Patients displaying histological signs of tumour regression have a significantly longer survival time than those displaying no signs of regression (12 +/- 9.2 vs 4.5 +/- 2.2 months; p less than 0.05).

Self-contained, coaxial delivery system for intraarterial infusion of thrombolytic agents

To facilitate continued direct intrathrombus infusion of a thrombolytic agent and yet minimize catheter exchanges and manipulations, the authors developed a simple, self-contained delivery system. It involves the use of supplies available in most angiographic suites. The system has been used in 44 patients; there have been no infectious complications, and it has been well tolerated by the patients.