Hepatic artery infusion pumps: cannulation techniques and other surgical considerations

Long term hepatic artery chemotherapy for metastatic disease to the liver has been made practical by technologic advances in pumps and catheters. The surgical placement of these pumps and catheters can be associated with a significant morbidity unless careful attention is given to variations in hepatic arterial anatomy and to eliminating collateral arterial supply to the distal stomach and duodenum. Gastroduodenal devascularization should be performed in all patients and should be confirmed both with intra-operative fluorescein injection and postoperative scintigraphy scanning. Routine cholecystectomy avoids the complication of chemical cholecystitis. Exact placement of the catheter tip at the junction of the gastroduodenal artery and the hepatic artery with fixation of the catheter in this position by placement of bidirectional ligatures around the catheter bead will reduce the incidence of hepatic artery thrombosis and catheter migration. Intrahepatic arterial collateralization in most patients allows for ligation of variant lobar vessels with total liver perfusion through the remaining lobar arterial supply. This again can be confirmed intra-operatively with fluorescein injection and postoperatively with scintigraphy scanning. Strict attention to these technical details will allow continued use of this important therapeutic modality in the treatment of hepatic metastases and by minimizing surgical complications will encourage continued trials to improve the efficacy of long term hepatic arterial chemotherapy.

[Systemically administered regional tumor therapy. Regional hemi-body chemotherapy of metastatic malignant melanoma--an experimental therapy concept]

Since systemic application of a high-dose chemotherapy is limited by the extent of intolerable toxicity and overall response rates so far are rather poor, the systemic mode of chemotherapy for metastatic melanoma appears to be of only limited benefit. On the other hand, results from isolated limb perfusion for satellitosis and in-transit metastasis suggest distinct dose-response correlations with tumoricidal properties of appropriate antineoplastic agents. This experience prompted the idea to pilot the anti-tumor action of a high-dose regimen confined to one hemibody compartment for targeted tumor therapy. After having standardized the surgical procedure this goal appeared to be achievable by expanding the perfused area and by simultaneously detoxifying toxic drug levels within the non-perfused compartment by venous filtration. Two initial causal experiences revealed impressive tumor regressions and are therefore reported on preceding subsequent evaluation within a controlled clinical trial being designed at different solid tumors.

[Current results and prospects of intra-arterial chemotherapy in hepatic metastases of carcinoma of the colorectum]

The development of safe arterial access devices and totally implantable or portable infusion pumps for intrahepatic chemotherapy has generated a renewed interest in regional treatment of liver metastases from colo-rectal primaries. Several phase II trials have been carried out, mostly using prolonged infusion of fluorinated pyrimidines showing very high activity for this method of treatment with response rates up to 80%. Randomized trials between systemic and regional therapy have confirmed the higher efficacy of arterial treatment in inducing objective responses but neither of the two studies with a follow-up long enough to assess survival data showed a clear advantage for the patients receiving intraarterial chemotherapy. Gastroduodenitis, ulcers and chemical hepatitis are frequently observed in patients treated with intrahepatic arterial chemotherapy but their incidence can be substantially reduced by a careful surgical procedure during the implant of the arterial catheter and by a close follow-up during chemotherapy. Since toxicity can be serious and no definitive improvement of survival has been shown, this modality of treatment is still applicable only in an investigational setting.

[Intra-arterial infusion port system for intermittent degradable starch microsphere chemoembolization and implantation method]

On the basis of our experience of 182 cases of port implantation in 165 patients (May, 1985-April, 1989), we clarify problems of each system and discuss the usefulness of our present "port-and-catheter connecting system, PCCS," which facilitated repeated infusion of the angiographic medium and embolization materials such as Degradable Starch Microspheres (DSM) and Lipiodol. The effectiveness, especially, of the intermittent DSM chemoembolization therapy is reported.

[Distribution of pulsed intra arterial infusion chemotherapy in hepatic carcinomas]

Evaluation of "Gianturco-Wallace chemotherapy pulser," which was developed to produce a more homogeneous drug distribution of the tumors in intra-arterial infusion chemotherapy, was assessed by comparative study of pulsed and nonpulsed arterial radionuclide infusion using Tc-99m pertechnetate for 18 cases of hepatic carcinomas (11 cases of hepatocellular carcinomas and 7 cases of metastatic hepatic carcinomas). Tc-99m pertechnetate, 740 MBq (20 mCi) diluted with saline (30 mL) was infused with or without pulse through the catheter into the hepatic artery at a rate of 1mL per minute. The intrahepatic dynamic radionuclide distribution was analyzed by the time activity curves of ROIs in the tumor and nontumor areas. Pulsed infusion interrupted laminar flow and produced more homogeneous radionuclide distribution in the liver, and combination of pulsed and nonpulsed infusion also produced better radionuclide distribution in the areas of the tumors. This method using Tc-99m pertechnetate was very useful as a simulation to determine the dynamic drug distribution of the tumor and non-tumor region in intraarterial infusion methods.

Tourniquet infusion chemotherapy of the lower extremities--clinical and pharmacokinetic results

A prospective analysis of tourniquet infusion chemotherapy is reported. Twelve patients with recurrent malignant melanoma and one patient with Kaposi's sarcoma on the lower extremities were treated. An objective tumor response (CR + PR) was noted in 4/8 patients with DTIC and in 1/5 with Adriamycin. Stable disease was registered in 2/8 and 2/5 when respective drugs were used. No major side effects were observed. Pharmacolkinetical analysis of Adriamycin were performed in five patients after two to three treatments. The plasma concentration time-curves of Adriamycin were in most cases described by an open three-compartment model. The AUC (area under the curve) values for Adriamycin were 3.4 (median value 95% CI 2.9-5.1) times higher than for Adriamycinol. The reproducibility of the intra-arterial techniques was established by the repeated pharmacokinetic analysis. This technique seems to give lower AUC (mg/m2) when compared with earlier published intravenous data. The results indicate that tourniquet infusion chemotherapy produces a reasonable response, and that further evaluation with other drugs and comparison with isolation hyperthermic drug perfusion will be of interest.

Balloon-occluded arterial infusion therapy in the treatment of primary and recurrent gynecologic malignancies

Balloon-occluded arterial infusion (BOAI) of bilateral internal iliac arteries produces high drug concentration as well as increased arterial flow of pelvic organs. Twenty-seven patients with primary and locally recurrent gynecologic malignancies were treated with BOAI of cisplatinum. Six of 10 patients with primary advanced uterine cancer and 5 of 11 patients with recurrent cancer showed clinical response. In 6 patients, BOAI was performed as an adjuvant therapy to radiation or other chemotherapy. Toxicity was similar to that seen with systemic treatment using cisplatinum, but its frequency and degree were less severe.

[Catheter implantation for intra-arterial chemotherapy of malignant tumors of the head and neck]

Tumors of the head and neck are mainly squamous cell carcinomas of varying differentiation. If the tumor is advanced (T3-T4) or distant metastases are present, the tumor is often to be regarded as inoperable. If cure is unlikely or substantial functional impairment is to be expected, surgery may no longer seem reasonable, even for tumors limited to one side. Since either radiotherapy or chemotherapy alone or in combination are often disappointing or have considerable side-effects, it seems reasonable to try to inhibit malignant cell growth by administering a cytostatic agent by intra-arterial "superselective" chemotherapy using an implantable catheter. The method is simple, and the patients may also receive combined radiotherapy if necessary. Furthermore, ambulant treatment is possible, with a substantially reduced risk of infection. This is an advantage compared with other catheter techniques, particularly in view of the restricted expectation of life of patients with advanced tumor. The disadvantage of "A-port implantation" is that chemotherapy can only start after complete wound healing.

[Superselective bronchial arterial catheterization via a sheath catheter (SS-BAC)]

Bronchial artery infusion therapy including embolization of the artery has been widely used in the treatment of lung cancer and also for the treatment of hemoptysis due to various lung diseases. However, some serious complications such as spinal cord lesion, tracheobronchial fistula formation and so on have been documented in the literature and these complications are attributed to anatomical characteristics of the bronchial artery having a common trunk with feeding arteries to the spinal cord, esophagus and trachea. To prevent these hazardous events we attempted to infuse and embolize the proper bronchial artery with high selectivity by using catheter-in-catheter technique. A Cook green catheter, 7.2 Fr. size, was wedged in the intercostobronchial trunk artery by a Seldinger technique and then a small catheter, 3.0 Fr. size, was passes through the former catheter to the proper bronchial artery beyond the orifices of other feeding arteries. In 26 out of 30 patients who underwent this procedure we successfully performed this superselective bronchial artery catheterization and the 26 patients consisted of 15 patients with lung cancer and one with metastatic lung tumor who were treated with bronchial artery infusion therapy and ten with various lung diseases who were treated with bronchial artery embolization because of hemoptysis. Bronchial artery infusion therapy including embolization has gained higher safety and effectiveness by means of this superselective catheterization.

Early detection and simplified management of obstructed Hickman and Broviac catheters

Thrombotic occlusion of Hickman and Broviac central venous catheters is a serious obstacle to their long-term use. Because resistance to flow (R) through a catheter of lumen radius, r, is proportional to 1/r4, we hypothesized that measurement of R would provide an objective and sensitive monitor for partial occlusions. Our measurements showed that median R at a flow of 17 mL/min was 0.7 cmH2O/mL/min in normally functioning Hickman catheters, and 4.1 cmH2O/mL/min in Broviac catheters. In obstructed catheters, which by subjective standards resisted flushing or blood withdrawal, median R was 3.0 cmH2O/mL/min for Hickman and 5.6 cmH2O/mL/min for Broviac catheters, representing significant increases. In a series of obstructed lines in which urokinase was administered, R decreased from 7.7 to 4.5 in Hickman catheters and from 5.6 to 4.2 in obstructed Broviac catheters. The elevated resistance in Hickman catheters after urokinase suggested that residual catheter obstruction was present even though catheter function returned to normal. Elevated R was seen with abnormal venograms in seven of 13 patients. Four patients had normal R values and abnormal venograms, and two patients had elevated R values with normal venograms. Measurement of resistance in Hickman and Broviac catheters provides a simple technique that can supplement or replace venography in the serial assessment and treatment of partial obstruction.

[Intra-arterial chemotherapy. Presentation of a method to insure patency of the catheter]

Following some brief remarks on the main techniques of antineoplastic chemotherapy, a simple technique for guaranteeing patency of the endarterial catheter is presented. Using a special microchannel infusor, it was possible to prevent catheter obstruction in 100% of the cases treated.

Floxuridine-associated sclerosing cholangitis. A dog model

The authors developed a dog model for the biliary sclerosis that occurs as a severe complication of protracted hepatic arterial floxuridine (FUDR) infusions (using implanted drug delivery systems) in patients with hepatic cancers. Infusaid pumps attached to hepatic arterial catheters were used for protracted infusions in ten mixed breed hounds. To allow repeated cholangiograms, the animals' gallbladders were removed and catheters connected to subcutaneous infusion ports were positioned in the cystic ducts. Five treated dogs received FUDR 0.3 mg/kg/day through the pump for a total of 30 days. Five control dogs received only saline through the pump. Cholangiograms were obtained before and after treatment in all animals. In the control group, serum liver function test results and the cholangiographic appearance of the biliary tree remained within normal limits. By contrast, in the FUDR-treated group, serum glutamic-pyruvic transaminase and alkaline phosphatase progressively rose above normal, starting 2-3 weeks into FUDR infusion, followed by hyperbilirubinemia (7-28 mg/dl peak levels) beginning 4 to 6 weeks after initiation of the drug infusion. Cholangiograms revealed focal strictures involving the central bile ducts (five dogs) and diffuse attenuation of the intrahepatic ducts (four dogs). Thus, the liver function abnormalities and the cholangiographic findings in this dog model mimic the hepatobiliary toxicity in sensitive patients receiving similar treatment.

Sensitivity of graft rejection in rats to local immunosuppressive therapy

In this study we investigated whether allograft rejection is sensitive to local immunosuppressive therapy. In rats, cardiac transplantations (BN----Lewis) were performed with venous return on the portal vein of the recipient. For local treatment the topical steroid budesonide was infused with an osmotic minipump directly into the carotid artery of the transplant. Budesonide is rapidly cleared by the liver, and cardiac tissue binding of the drug is high. Hence, local budesonide administration, 120 micrograms/kg/day, resulted in high drug levels within the graft (29.6 ng/mg) and low systemic drug levels (0.34 ng/ml). Systemic drug levels were so low that systemic biological effects of the drug during local administration were not measurable. In contrast systemic drug delivery, via the jugular vein of recipient, resulted in similar drug levels within the graft (31.0 ng/mg), but with high systemic drug levels within the graft (31.0 ng/mg), but with high systemic drug levels (1.65 ng/ml) and important systemic side effects. Both local and systemic administration of budesonide, 120 micrograms/kg/day for 13 days, resulted in significant prolongation of graft survival; median graft survival time was respectively 19.5 days and 20.0 days, compared with 7 days in controls. These results demonstrate that allograft rejection can be treated locally without significant systemic immunosuppression.

[Fabrication and clinical application of intrahepatic arterial catheter facilitating repeated infusion therapy and experience]

Balloon occluded arterial infusion (BOAI) is an ideal and widely accepted method for augmentation of the intrahepatic tissue level of anticancer drugs. But this method nakes repeated infusion very difficult because the Seldinger method is needed to cannulate into the hepatic artery. Recently, we made an intrahepatic artery catheter attached with an implantable reservoir, consisting of an intra-arterial catheter, reservoir and cylinder-like device which has a small balloon on its inner part. The cannulation is done at laparotomy. With this method, five cases of nonresectable hepatocellular carcinoma, one metastatic liver cancer and one noncurative hepatocellular carcinoma were treated. Intrahepatic vessels were quite visible by DSA using CO2 gas. Serum concentration level of adriamycin was lower and undetectable at 120 minutes after infusion. No side effects nor catheter complications were observed. Intra-arterial infusion therapy using this device will be a most useful routine method for cancer control in the outpatient clinic.

[New type pump for continuous arterial infusion]

We have been attempting to improve the arterial infusion pump, and two new type instruments have been completed. One is the normopressure type and another is the high pressure type. The normopressure type pump is similar to the usual infusion pump but it is much more compact and light. The size is 12.5 x 12.5 x 5 cm, and the weight is 250 grams when the bag is full of drug. Therefore, it is more comfortable and enables patients to continue the infusion longer than usual. An alarm mechanism to indicate a low power of battery and a changeable function for infusing speed (2.5-20 ml/day) are equipped. The energy source is obtained from an alkaline battery (6-P type) which is easily bought on the market. The maximum volume of the bag for drug is 50 ml. The purpose of the high-pressure pump is the infusion of fluids of higher viscosity (e.g., adriamycin) or a drug requiring a large volume over a short time. The maximum pressure at the tip of the catheter is 4 kg/cm2. If the pressure is beyond this level, the pump stops and the alarm sounds. The size is 30 x 5 x 5 cm and weight is 650 grams. The patient can easily move during infusion with the pump. These two new pumps for arterial infusion promise a greater choice of drugs and free combination of therapy in the future.

[New infusion port for intermittent infusion chemotherapy]

We devised a new infusion port for the intermittent infusion chemotherapy to the hepatic artery. This device has the following advantages: 1. A large needle (18 G) may be used to infuse the medicine because of the special urethane gum parts of the port. 2. One need only exchange the port for a new one or to the tube for continuous infusion chemotherapy under local anesthesia. 3. This port can be employed for arterial embolization because of its large inner diameter. In this report we introduce the structure and advantages of this new port device.

[Regional therapy of isolated liver metastases from breast cancer]

Because of the high rate of response in colorectal liver metastases, intra-arterial chemotherapy was studied in 14 patients with isolated breast cancer liver metastases. After extrahepatic metastasization had been ruled out, a catheter was placed surgically and connected to a cytostatic pump (in two cases) or to a subcutaneous infusion chamber (in 12 cases). Every four to six weeks, the patients with an infusion chamber received a modified FAM treatment (fluorouracil, doxorubicin, mitomycin C) for three days continuously. In 11 out of 14 patients (79%) a clear tumor reduction was observed (duration of remission 11 months). In an average of six cycles of chemotherapy administered, a total of 50% of the patients manifested local side effects (including two cases of toxic hepatitis, one case of biliary sclerosis). Systemic side effects were negligible. Termination of therapy was necessitated by three catheter tip migrations and two thromboses of the hepatic artery. Extrahepatic metastases occurred in six patients. Here, the average latency period between diagnosis of the primary tumor and that of liver metastasis was significantly shorter (x = 9 months) than in the other patients (x = 39 months). Intra-arterial chemotherapy thus represents a therapeutic method which, although complicated, is extremely effective in selected patients with isolated breast cancer liver metastases. A final evaluation must be subject to a randomized comparison with a systemic therapy.

Intra-arterial infusion catheters with implantable injection chambers in maxillo-facial oncology

An intra-arterial chemotherapy procedure in patients with malignant tumours in the oral and maxillo-facial region which, from the vascular point of view, can be dependent on the external carotid artery and/or its branches is presented. Particularly for the prevention of catheter infection, obstruction, etc., a subcutaneous pouch, connected to the infusion catheter, is implanted subcutaneously in the submastoid region.

Selective delivery of chemotherapeutic agents with a new catheter system

A new catheter system was used in ten patients (16 infusions) for infusion of chemotherapeutic agents to the sites of malignant gliomas. Thirteen infusions to the supraophthalmic region were successful, as were three infusions to the posterior cerebral region. There were no complications after the infusions. A neurologic complication occurred in one patient in whom two successful supraophthalmic infusions were previously carried out. In this patient the guide wire separated during catheter placement into the posterior cerebral artery.

Normothermic rapid volume replacement in vascular catastrophes using the Infuser 37

Twenty patients (Group 1) with a mean age of 38.5 +/- 16 years and an admission Trauma Score of 7.26 +/- 5.9, suffered 27 vascular injuries and were resuscitated with the Infuser 37 (IN-37) with an integral heat exchanger. Admission systolic BP averaged 46.47 mmHg (seven with absent vital signs). A mean of 7,030 ml of blood, 3,313 ml of colloid and 13,630 ml of crystalloid per patient was given in less than 24 hours, mostly through the IN-37. Twelve thoracotomies, nine laparotomies, and one extremity exploration were performed. Twelve patients, seven with a Trauma Score less than 3, died in less than 24 hours of exsanguination. The survival rate was 40% at 24 hours and 25% at 30 days. Six patients (Group 2) with a mean age of 70.33 +/- 8.3 years underwent operation for ruptured aortic aneurysm (5 pts), and elective aortic aneurysm (1 pt) with a 66% survival at 24 hours. Admission systolic blood pressure averaged 84 mmHg. A mean of 3,895 ml of blood, 1,900 ml of colloid and 7,733 ml of crystalloid per patient was administered in less than 24 hours, mostly through the IN-37. The IN-37 provides a safe and simple means of normothermic, rapid volume replacement in hemorrhagic shock. Its use in critically ill but potentially salvageable patients with vascular injuries and aortic aneurysm may avoid the consequences of prolonged hypoperfusion and hypothermia.

[The availability of digital subtraction angiography using continuous intra-arterial infusion tubes founded various malignancy]

DSA was employed using continuous intraarterial infusion tubes for various malignancies (73 cases) which were examined a total of 135 times. In head and neck malignancy (50 cases), the general position of the infusion tube had been determined beforehand by dye infusion, but DSA from the tube showed that the tubes in 24 cases (48%) were located in the wrong position, especially in tongue cancer (21 cases) where many tubes were discovered to be in an erroneous position (71%) such as the common carotid artery. We were unable to determine the effect of chemotherapy and radiation using DSA only. In 9 cases of breast cancer for which fixation of the tube was not attempted under X-ray fluoroscopy, 7 (78%) showed an unusual tube position such as the intraaortic arch. In 5 cases of abdominal malignancy, only the tube position for sigmoid colon cancer was unusual. We were able to observe the effect of chemotherapy by DSA in 2 cases. For DSA in one out of 3 hepatomas using a Port-A-Cath, we observed that infusion of anticancer drug with degradable starch microspheres caused a reduction in tumor size. However, in the two remaining cases, we were unable to observe any effect of infusion of these drugs by DSA for various mechanical reasons. DSA from an infusion tube revealed not only the location of the tube accurately and promptly, but also the effect of chemotherapy.

[Personal catheter technic for intra-arterial chemotherapy in cancers of the head and neck]

Regional intraarterial chemotherapy can display its advantages as augmented concentrations of effective substances within the tumour tissue and lower systemic side effects, only if tumour perfusion can be carried out superselectively. For different reasons, the present techniques have not been accepted for extensive clinical use. A new catheter technique is, therefore, presented that is appropriate for both clinical routine and superselective tumour perfusion.

[Intra-arterial chemotherapy, using the hepatic artery, in metastases of colorectal carcinoma]

Hepatic metastasis is the major cause of death in advanced cancer of the colon and rectum. Various modes of therapy have been attempted with only partial success. Infusion of cytotoxic agents into the hepatic artery has allowed a higher concentration of drug into the tumor capillary bed than is achievable with intravenous administration. We review the data on therapeutic outcome, administration techniques and toxicity of hepatic arterial chemotherapy for colorectal cancer metastatic to the liver.

[A case of intra-arterial infusion chemotherapy using the vascular-access-port]

For the treatment of progressive bladder tumors, intraarterial infusion chemotherapy has been performed extensively with satisfactory results. However, we have experienced various cases not only in which side effects of the infusion drug appeared, but also in which treatment had to be discontinued because of infections and flexuous caused by the intraarterial infusion catheter. In this study, intraarterial infusion chemotherapy was done using the vascular-access-port (VAP) which is an access implanted in the body devised to improve the fault of the intraarterial catheter exposed outside of the body.

[Regional chemotherapy of liver metastases]

Intraarterial regional chemotherapy of the liver by implantable pumps and port-systems is currently applied predominantly in patients with isolated colorectal metastases. Therapy and evaluation of results must consider the following factors: natural course of the disease; classification of tumor extent in the liver; evidence of isolated liver metastases; vascular anatomy, optimal catheter-implantation technique, complete perfusion; choice of drugs and dosage; technical complications; local toxicity, extra-hepatic recurrence, definition of therapeutic success. Our own experiences with regional chemotherapy in 145 patients with metastases to the liver and in 9 patients with hepatocellular carcinoma are reported. Using different therapeutic modalities we found a significantly enlarged response rate and at this time a true prolongation of life of about 8 months. Further prospective studies are necessary. The use of regional chemotherapy for liver metastases seems to be recommended at this time only under study conditions.

[Infusion systems for intra-arterial chemotherapy]

A short description of the standard devices with extra-corporal or intracorporal pumps is followed by a description of a new extracorporal pump. Since the new pump is independent of electric mains supply, it is more comfortable for the patient, who can walk around even during intraarterial infusion. However, as the flow rate of the pump is low, very thin catheters have to be used to avoid clotting caused by blood reflux within the catheter.

[Clinical experience of a subcutaneously implantable drug delivery catheter (PORT-A-CATH)]

A drug delivery catheter system with subcutaneously implantable port, PORT-A-CATH, was applied for intra-arterial, intravenous and intraperitoneal chemotherapy and hyperalimentation in treating 99 cancer patients. The average implantation period was 135.1 days and this system was applied for more than one year in 5 cases. Any troubles due to port or catheter materials were not observed during the study. Catheter occlusion occurred in 11 cases infection in 7 (catheter-related infection 4, pocket infection 3), and skin necrosis in 4. This system was proved useful to reduce the risk of infection and enabled easy and safe long-term repeated administration, compared to the catheters with external end. Intra-arterial chemotherapy became possible to the outpatients with the use of this system, which seemed to contribute for the improvement of quality of life of the patients.

An alternative method for repair of a leaking arterial chemotherapy infusion catheter

Regional chemotherapy infusion via selective arterial catheterization is frequently complicated by the development of cracks or leaks within the catheter. This frequently necessitates a catheter exchange. Herein, we report an alternative, simpler method for dealing with a defect within an infusion catheter.

The use of the implantable chemoinfusion pump in the treatment of hepatic metastases of colorectal cancer

Fifty-five chemoinfusion devices have been implanted in patients with metastasis of colorectal cancer confined to the liver. There were no episodes of pump malfunction or of catheter clotting. Side effects included gastric ulcers in 13 patients and duodenal ulcers in four patients, including one episode of total gastric obstruction. Chemical hepatitis occurred in 13 patients, sclerosing cholangiolitis in one patient, and duodenal dismotility requiring gastroenterostomy in one patient. The response criterion was taken as reduction by at least 50% of the pretreatment carcinoembryonic antigen level; consequently, the response rate was 88%. Median survival of all patients was 19.2 months from the time of diagnosis of hepatic metastases to death, as determined by the Kaplan-Meier method. Median survival from the time of pump implantation to death was 10.1 months.

[Value of digital subtraction angiography in the imaging of a subcutaneously implanted, intra-arterial chemotherapy catheter]

Intraarterial chemotherapy is already a commonly accepted treatment method in isolated liver metastases. The high risk of transcutaneous injection of chemotherapeutic substances in the implanted catheter system requires a passage examination before the beginning of therapy. 32 digital subtraction angiograms for examination and documentation of the implanted catheter have been performed in 15 patients. The DSA seems to be a good visualisation technique for the implanted chemotherapy catheter systems.

[Demonstration of complications caused by implantable catheter systems in regional arterial infusion therapy of tumors of the pelvis (bladder cancer). Radiologic and nuclear medicine control possibilities]

Loco-regional intra-arterial infusion chemotherapy is gaining momentum in modern tumor therapy. Cytostatica are delivered by an implantable system. Because of high tissue toxicity of chemotherapy functioning of the system must be assured and controls should be simple and reliable. The system implanted in 10 pat. with bladder-cancer (p T3 a-b) was checked by radiological and radionuclide diagnostic means before each chemotherapy. Both techniques proved valuable. Good and deficient functions are demonstrated.

Liver pathology following hepatic arterial infusion chemotherapy. Hepatic toxicity with FUDR

The authors reviewed the liver histopathology and the clinical features of eight patients with liver metastases from colorectal cancer who were treated by hepatic arterial infusion chemotherapy (HAIC) via an implantable pump (Infusaid). Before HAIC, these patients had no evidence of hepatitis, and results of liver biopsies performed on three patients showed only minor morphologic alterations. All the liver tumors responded to HAIC, but all patients developed hepatitis. Clinical findings included nausea, vomiting, abdominal pain and jaundice. Serum transaminases, alkaline phosphatase and bilirubin levels were increased. Clinical observations suggested that 5-fluoro-2'-deoxyuridine (FUDR), the predominant drug given, was the hepatotoxic agent. Toxic effects were hepatocyte necrosis, steatosis, cholestasis, central vein sclerosis, and alterations in the portal triad. In addition, central vein lesions like those in veno-occlusive disease, and micronodular cirrhosis resembling that induced by alcohol, were encountered. Although individual susceptibility to FUDR appeared to vary, portal triad fibrosis was present in all eight cases and, together with central vein sclerosis and cirrhosis, appeared to be related to the dose and duration of HAIC.

Upper gastrointestinal endoscopy for diagnosis of complications of regional hepatic chemotherapy

Seven of 26 patients undergoing insertion of "Infusaid" perfusion pumps with hepatic artery catheters for regional hepatic perfusion with 5 fluorodeoxyuridine were diagnosed to have gastritis (n = 5) or penetrating duodenal ulcers with catheter exposure (n = 2). Diagnosis is best achieved by esophagogastroduodenoscopy. The ulcers required removal of the pumps and gastric resections. The gastritis responded only to cessation of drug infusion. These complications represent a significant risk to regional hepatic chemotherapy. Physicians caring for this group of patients will be unable to predict which individuals will suffer these complications when using preoperative or postoperative parameters such as age, sex, tumor type, arterial anatomy or flow patterns on nuclear isotope scanning. A high index of suspicion must be maintained during the critical third and fourth cycles of chemotherapy in all patients undergoing regional hepatic chemotherapy.

Effect of prolonged intra-arterial prostaglandin E1 infusion on canine arterial graft patency

This study examined the effect of long-term intra-arterial prostaglandin (PG) E1 infusion on the patency of canine femoral-artery grafts made of polytetrafluoroethylene and measuring 4 X 90 mm (diameter X length). An infusion catheter was placed proximal to one of the bilateral femoral-artery grafts and connected to a subcutaneously implanted infusion pump to continuously infuse PGE1 (1 ng/kg/min) in seven experimental dogs and vehicle alone in seven control dogs. Two-week graft patency was significantly higher in both infused (86%) and noninfused (100%) limbs of PGE1-treated dogs than in control dogs (29%). Although hind-limb blood flow was increased twofold to threefold by PGE1 infusion, graft patency did not improve. Prostaglandin E1 infusion did not significantly alter systemic platelet aggregation but did cause considerable hind-limb edema. Improved early graft patency, which did not persist beyond four weeks, was apparently related to systemic effects of local PGE1 infusion.

[Continuous intravenous or intra-arterial administration via a subcutaneous implantable infusion chamber. Preliminary clinical experiences with particular reference to intra-arterial chemotherapy]

An infusion chamber was implanted subcutaneously in 18 patients for intravenous systemic treatment and in 20 for intra-arterial treatment of the liver. Intravenous catheters were introduced via the cephalic vein, intra-arterial ones via the gastroduodenal artery, after exclusion of extrahepatic metastases. Six manageable complications were observed during a total implantation time of 102 months for i.v. treatment and usage over 500 days: three temporary occlusions; one infection; two extravasations. The intra-arterial chemotherapy, largely for hepatic metastases of breast carcinoma, was undertaken according to a modified FAM schema (fluorouracil, adriamycin, mitomycin C): It achieved a high response rate with two full and eleven partial remissions. Complications were rare, except for 4 temporary occlusions. Systemic side effects were almost completely absent, local toxicity was low. One problem was the fixation of the needle which connects to the infusion chamber. This was true for both intravenous and intra-arterial treatment.

Ambulatory hepatic artery infusion chemotherapy for cancer of the liver

We have used continuous hepatic arterial infusion chemotherapy to treat 105 patients with cancer of the liver originating from colorectal, other gastrointestinal, and nongastrointestinal sites. The response rate seen in colorectal metastases was two to three times that expected for systemic chemotherapy. The median survival of responders of 16 months was significantly better then for nonresponders (6 months). The median duration of response was 9 months. The results for patients with other tumor types were less encouraging. Although minor problems developed in about 30 percent of the patients, major complications requiring removal of the catheter were not common. Expertise derived from managing many patients and a team approach, with a defined protocol for catheter care and follow-up, contributed to the success of the ambulatory program. However, the role of hepatic arterial infusion chemotherapy remains under debate. At the root of the controversy is the lack of randomized, controlled trials supporting the superiority of hepatic arterial infusion over systemic chemotherapy in the treatment of colorectal liver metastases. This and other issues, including the current liberal use of implanted infusion pumps, should be studied.

Glioblastoma: catheter techniques for isolated chemotherapy perfusion

Techniques have been developed for isolated perfusion of chemotherapeutic agents in patients with glioblastoma. Three catheters that facilitate crossing the carotid siphon have been developed; two are based on an everting or toposcopic principle, and one uses microjets for deflectability and improved mixing. Blood from the ipsilateral jugular vein is aspirated at high volumes (300 ml/min) for extracorporeal circulation through an adsorption column (for recovery of carmustine) or dialysers (for recovery of cisplatin). Preliminary experience in 10 patients suggests that high doses of chemotherapeutic agent can be administered using these catheters, with reduced retinal and systemic toxicity.