Radiologic placement of side-hole catheter with tip fixation for hepatic arterial infusion chemotherapy

Catheterization and embolization of a replaced left hepatic artery via the right gastric artery through the anastomosis: a case report

Introduction

Conversion of multiple hepatic arteries into a single vascular supply is a very important technique for repeat hepatic arterial infusion chemotherapy using an implanted port catheter system. Catheterization of a replaced left hepatic artery arising from a left gastric artery using a percutaneous catheter technique is sometimes difficult, despite the recent development of advanced interventional techniques.

Case presentation

We present a case of a 70-year-old Japanese man with multiple hepatocellular carcinomas in whom the replaced left hepatic artery arising from the left gastric artery needed to be embolized. After several failed procedures, the replaced left hepatic artery was successfully catheterized and embolized with a microcatheter and microcoils via the right gastric artery through the anastomosis.

Conclusion

A replaced left hepatic artery arising from a left gastric artery can be catheterized via a right gastric artery by using the appropriate microcatheter and microguidewires, and multiple hepatic arteries can be converted into a single supply.

[Intra-arterial treatment of liver metastases from colorectal carcinoma]

Colorectal carcinoma is a major public health concern with its yearly mondial incidence of about one million cases and yearly mortality of 500,000 cases. The liver is the organ most frequently affected by metastases with a frequency of 40 to 60% (contemporaneous in 25% of cases). While surgical resection is the only curative therapy, many patients are not such candidates due to the infiltrative nature of the liver metastases. Systemic chemotherapy and biotherapy regimens are the conventional treatment options for patients with multiple liver metastases. Under such circumstances, intra-arterial therapy may play a major role. We will review the main types of endovascular therapies for liver metastases from colorectal carcinoma including indications, results and potential complications.

Transcatheter intraarterial therapies: rationale and overview

Transcatheter intraarterial therapies have proved valuable in the battle against primary and secondary hepatic malignancies. The unique aspects of all such therapies are their reduced toxicity profiles and highly effective tumor responses. These unique characteristics coupled with their minimally invasive nature provide an attractive therapeutic option in patients who may have previously had few alternatives. The concept of all catheter-based intraarterial therapies is to selectively deliver anticancer treatment to tumor(s). These therapies, which include transarterial embolization, intraarterial chemoinfusion, transarterial chemoembolization with or without drug-eluting beads, and radioembolization with use of yttrium 90, inflict lethal insult to tumors while preserving normal hepatic parenchyma. This is possible because hepatic neoplasms preferentially derive their blood supply from an arterial source while the majority of noncancerous liver is supplied by the portal vein. As part of the interventional oncology review series, in this article we describe the rationale behind each of these transcatheter therapies and provide a review of the existing medical literature.

Hepatic arterial infusion of 5-fluorouracil for patients with liver metastases from colorectal cancer refractory to standard systemic chemotherapy: a multicenter, retrospective analysis

INTRODUCTION

This retrospective study evaluated the safety and efficacy of hepatic arterial infusion chemotherapy (HAIC) with 5-fluorouracil (5-FU) for patients with liver metastases from colorectal cancer refractory to standard systemic chemotherapy.

PATIENTS AND METHODS

Fifty-five patients who had shown disease progression during the prior standard systemic chemotherapy with oxaliplatin, irinotecan, and 5-FU were enrolled. The treatment was weekly HAIC with 5-FU 1000 mg/m2/5 hours through an indwelling catheter-port system.

RESULTS

No major adverse reaction was observed other than grade 3 leukocytopenia (3.6%) and hyperbilirubinemia (1.8%). The overall response rate and disease control rate were 18.2% and 70.9%, respectively. The median progression-free survival and median overall survival (OS) were 2.8 months, and 6.7 months, respectively. The initial sites of disease progression were liver in 14, other than liver in 27, and both in 6. Multivariate analysis identified Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≤ 1 and number of extrahepatic metastatic sites (NMS) ≤ 1 as favorable prognostic factors for OS (hazard ratio [HR], 8.277; 95% CI, 3.60-19.0; P = .000 for ECOG PS; and HR, 2.456; 95% CI, 1.30-4.61; P = .005 for NMS).

CONCLUSION

HAIC with 5-FU may be a safe and effective treatment for patients with colorectal liver metastases refractory to standard systemic chemotherapy.

Prevention of intraprocedural puncture site bleeding during arterial port implantation by use of a suture-mediated arterial closure system: a prospective randomized trial

PURPOSE

To investigate a modified technique for arterial port placement that uses a suture-mediated closure system with the aim to reduce delays caused by intraprocedural oozing around the catheter.

MATERIALS AND METHODS

Forty consecutive patients (age, 63.9 y ± 11.8) stratified for regional arterial infusion chemotherapy were prospectively randomized to undergo conventional or modified port implantation. Time for device placement, total procedure time, number of catheters, size of largest and final catheters placed, duration of bleeding from puncture site, procedural delays, and time until hemostasis was achieved were recorded.

RESULTS

Time for device placement was 3.7 minutes ± 1.1, with no complications encountered. Total procedure times were 133.0 minutes ± 62.8 for conventional port implantation and 100.0 minutes ± 49.5 for modified implantation (P = .13). No differences were found in the number of catheters or size of largest or final catheter used. Duration of groin bleeding necessitating manual compression was 21.8 minutes ± 24.4 for conventional port implantation, resulting in a mean procedural delay of 6.2 minutes ± 7.0. Hemostasis was achieved after a mean of 17.1 minutes ± 20.9. Groin hematoma was observed in three patients. In contrast, with the modified technique, mean duration of oozing and intraprocedural delays were only 0.2 minutes ± 0.6 and 0.1 minutes ± 0.5, respectively (both P < .0001 vs conventional technique). Hemostasis was achieved within 3.2 minutes ± 4.1 (P < .0001), with no cases of hematoma found.

CONCLUSIONS

Use of a suture-mediated closure system facilitated arterial port implantation by effective prevention of groin bleeding while allowing the use of a sheath.

Advances in regional chemotherapy of the liver

INTRODUCTION

Primary and secondary liver tumors resemble some of the most common causes of cancer and represent a major clinical problem owing to the poor prognosis. First-line therapeutic concepts are mainly based on surgical resection and/or systemic chemotherapy (SCT). However, many patients are not suitable for surgery or have failed SCT, although the total tumor load is still limited, which makes a regional therapy approach appealing.

AREAS COVERED

This review focuses on different types of transarterial instillation of chemotherapy, which encompasses conventional and drug-eluting transarterial chemoembolization (TACE), hepatic arterial infusion (HAI) chemotherapy and isolated hepatic perfusion (ILP).

EXPERT OPINION

TACE can be regarded as the treatment of choice in patients with multinodular hepatocellular carcinoma, but it should still be performed as a lipiodol-based regimen, while the value of doxorubicin-eluting beads needs to be exploited in further randomized controlled trials (RCTs). For patients with colorectal liver metastases, HAI chemotherapy has been challenged by the advent of more effective SCT, but encouraging results have been observed for the combination of the most recent, active drugs given by means of HAI with SCT. Nevertheless, data from RCTs comparing SCT with this transarterial regional therapy approach, as well as with TACE and ILP, are urgently needed.

Efficacy and safety of hepatic arterial infusion of fluorouracil with leucovorin as salvage treatment for refractory liver metastases from colorectal cancer

BACKGROUND/AIMS

Limited options remain for patients with metastatic colorectal cancer (CRC) after failure of standard systemic chemotherapy. Readministration of chemotherapeutic agents by hepatic arterial infusion (HAI) has the rationale of providing higher concentrations of chemotherapeutic agents to hepatic metastases. The present study was conducted to evaluate the efficacy and safety of HAI of fluorouracil with leucovorin (HAI 5-FU/LV) for patients with liver metastases from CRC.

METHODS

Fourteen patients with liver metastases from CRC who received HAI 5-FU/LV after failure of systemic chemotherapy containing fluorouracil and leucovorin were identified and their medical records were reviewed.

RESULTS

Of 10 patients evaluable for response, one partial response, six stable disease, and three progressive disease were reported. Additionally, the overall response and disease control rates were 7% and 50%, respectively. The median time to progression was 4.3 months (range, 2.9 to 5.6), to hepatic progression was 5.8 months (range, 4.7 to 6.9), and to extrahepatic progression was 5.8 months (range, 2.3 to 9.2). No grade 3/4 hematologic toxicities occurred and one case of abdominal pain and two cases of oral mucositis were the only grade 3 nonhematologic toxicities. Catheter-related complications occurred in three patients: one thrombosis, one infection, and one displacement.

CONCLUSIONS

HAI 5-FU/LV was well tolerated and showed modest efficacy for patients with liver metastases from refractory CRC. Readministration of previously used chemotherapeutic agents via the hepatic artery could be an effective salvage option and warrants further investigation in a prospective trial.

Percutaneous femoral implantation of an arterial port catheter for intraarterial chemotherapy: feasibility and predictive factors of long-term functionality

PURPOSE

To evaluate the feasibility, functionality, and dysfunctions of an arterial port catheter implanted via the femoral artery.

MATERIALS AND METHODS

From November 2001 to May 2008, 93 consecutive patients (mean age 57 years old) with unresectable hepatic colorectal metastases were referred for intraarterial chemotherapy. The arterial port catheters were percutaneously implanted via the femoral artery. The catheter tips were placed as "free-floating" in the common hepatic artery (technique 1), "fixed" in the gastroduodenal artery (technique 2), or inserted in a segmental hepatic artery (technique 3). Embolization of the right gastric artery was always attempted.

RESULTS

The technical success rate of the femoral approach was 94% (n = 88 of 93). Intraarterial chemotherapy (average 7.3 courses) was administered to 84 patients. Migration and occlusion of the catheters occurred in 12% (n = 10 of 84) and 11% (n = 9 of 84) of patients, and extrahepatic perfusion occurred in 30% (n = 25 of 84) of patients. Catheter migration occurred significantly more frequently with technique 1 (50%; n = 3 of 6) than with technique 2 (11%; n = 7 of 64; P = .03) or technique 3 (0%; n = 0 of 14; P = .02). Occurrence of gastroduodenal ulcerations was significantly lower (P = .01) when embolization of the right gastric artery was performed (8%; n = 4 of 48) than when it was not (28%; n = 11 of 36). The success rate of embolization of the right gastric artery significantly improved (P = .006) from the first half of patients treated to the second half, resulting in a significant (P = .02) decrease in the occurrence of ulcerations from 28% (n = 12 of 42) in the first half of patients treated to 7% (n = 3 of 42) in the second half.

CONCLUSIONS

Percutaneous femoral placement of an arterial port catheter is highly feasible. Right gastric artery embolization and use of techniques 2 and 3 are good predictive factors for long-term functionality.

[Extrahepatic vessels depending on the hepatic artery. Identification and management]

Patients with malignant liver tumors, whether primary tumors or metastases, that are not candidates for surgical treatment can benefit from different endovascular treatments with proven efficacy in local control of the disease. Correct treatment requires a careful angiographic technique and precise knowledge about the vascular anatomy afferent to the lesion. Occasionally, lesions considered relapse are actually areas that were untreated because the afferent pedicle was not adequately detected. On the other hand, some of the complications of endovascular treatments are related with material passing into non-hepatic vessels. Knowing the hepatic vascular anatomy and correctly identifying all the extrahepatic vessels will make it possible to perform safer, more efficacious treatments. In this article, we present different representative examples of extrahepatic vessels that originate in the hepatic artery.

Phase I/II study of hepatic arterial infusion chemotherapy with gemcitabine in patients with unresectable intrahepatic cholangiocarcinoma (JIVROSG-0301)

OBJECTIVES

No established therapy exists for unresectable intrahepatic cholangiocarcinoma (ICC). We conducted a phase I/II study to ascertain the recommended dose (RD) of hepatic arterial infusion using gemcitabine (GEM) for ICC and to assess the efficacy and safety.

METHODS

For patients with unresectable ICC, GEM was administered through the hepatic artery via the port system as a 30-minute infusion on days 1, 8, and 15 every 4 weeks for 5 cycles. In phase I, dosage for levels 1, 2, and 3 was set at 600, 800, and 1000 mg/m, respectively, and was increased in 3 to 6 patients at a time. Maximum tolerated dose was defined as a dosage resulting in dose-limiting toxicity in 2 of 3 patients or 3 of 6 patients, and RD was estimated during the first cycle. In the phase II, more RD patients were added to assess tumor response and toxicity.

RESULTS

During the phase I, 16 patients were enrolled. Maximum tolerated dose was not reached. Assuming RD at 1000 mg/m, the phase II enrolled a total of 13 patients. The following Grade 3 toxicities were observed: neutropenia 20%, increased gamma-glutamyl transpeptidase 8%, increased aspartate aminotransferase 4%, increased alanine aminotransferase 4%, increased bilirubin 4%, nausea 4%, and fatigue 4%. The tumor response rate was 7.7% (complete response 0, partial response 1, stable disease 8, and progressive disease 4).

CONCLUSION

Whereas the toxicity of hepatic arterial infusion with 1000 mg/m GEM for ICC was tolerable, expected efficacy could not be obtained, thus suggesting only minimal activity.

A simplified technique of percutaneous hepatic artery port-catheter insertion for the treatment of advanced hepatocellular carcinoma with portal vein invasion

Objective

We assessed the outcomes of a simplified technique for the percutaneous placement of a hepatic artery port-catheter system for chemotherapy infusion in advanced hepatocellular carcinoma with portal vein invasion.

Materials and Methods

From February 2003 to February 2008, percutaneous hepatic artery port-catheter insertion was performed in 122 patients who had hepatocellular carcinoma with portal vein invasion. The arterial access route was the common femoral artery. The tip of the catheter was wedged into the right gastroepiploic artery without an additional fixation device. A side hole was positioned at the distal common hepatic artery to allow the delivery of chemotherapeutic agents into the hepatic arteries. Coil embolization was performed only to redistribute to the hepatic arteries or to prevent the inadvertent delivery of chemotherapeutic agents into extrahepatic arteries. The port chamber was created at either the supra-inguinal or infra-inguinal region.

Results

Technical success was achieved in all patients. Proper positioning of the side hole was checked before each scheduled chemotherapy session by port angiography. Catheter-related complications occurred in 19 patients (16%). Revision was achieved in 15 of 18 patients (83%).

Conclusion

This simplified method demonstrates excellent technical feasibility, an acceptable range of complications, and is hence recommended for the management of advanced hepatocellular carcinoma with portal vein thrombosis.

Hepatic artery infusion catheter implantation without embolization of the gastroduodenal artery in cases of retrograde blood flow

Between January 2007 and January 2008, a port/catheter system for hepatic arterial infusion chemotherapy was implanted in seven patients with retrograde blood flow in the gastroduodenal artery (GDA). The GDA was not coil-embolized when the catheter tip was positioned in the right gastroepiploic artery. In all cases, implantation of the port/catheter system was successful, and there were no complications. Interventionalists can economize on expensive microcoils by using this simple and time-saving method.

Embolisation of the right gastric artery in patients undergoing hepatic arterial infusion chemotherapy using two possible approach routes

We used a retrospective non-randomised study to investigate the clinical effect of selective embolisation of the right gastric artery before hepatic arterial infusion chemotherapy (HAIC) using a port-catheter system. We evaluated whether the hepatic artery or the left gastric artery is the better approach for selecting the right gastric artery. A total of 367 patients (244 men and 123 women; mean age, 64.1 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In 294 of these patients, right gastric arterial embolisation with microcoils was attempted before placement of the port-catheter system to prevent gastric mucosal lesions. Approach was either through the hepatic artery (175 patients) or through the left gastric artery (119 patients), with success rates in catheterising the right gastric artery of 78.3% and 77.3%, respectively. If the attempt was unsuccessful, the catheter was redirected to the alternative approach, which increased the final success rate to 96.3%. Only seven patients experienced gastroduodenal mucosal lesions acutely after HAIC, as revealed by endoscopy. Embolisation of the right gastric artery is a feasible procedure that can reduce the incidence of gastric mucosal lesions associated with HAIC. Approach through either the hepatic artery or the left gastric artery is equally acceptable.

Clinical application of a new indwelling catheter with a side-hole and spirally arranged shape-memory alloy for hepatic arterial infusion chemotherapy

A new indwelling catheter, G-spiral (GSP), was developed for hepatic arterial infusion chemotherapy (HAIC) by way of an implanted catheter-port system (CPS). Here we evaluated its physical properties and the outcomes of its clinical use. The GSP vessel-fixing power and its ability to follow a guidewire were determined with a vascular in vitro model, and Student t test was used to determine statistical significance (P < 0.05). A retrospective analysis was performed to evaluate the technical success rate and to identify the clinical complications associated with radiologic CPS implantation with GSP in 65 patients with unresectable hepatic tumors. The mean vessel-fixing power of the GSP (14.4 g) significantly differed from that of a GSP with a cut shape-memory alloy (3.3 g). The mean resistance to following the guidewire displayed by the GSP (88.5 g) was significantly less than that for a 5F W-spiral (106.3 g) or 4F Cobra-type angiographic catheter (117.8 g). The CPS was placed successfully in 64 of 65 cases (98.5%). Hepatic artery occlusion was observed in one case. Occlusion, cracking, and infection of CPS were observed in one, two, and one case, respectively. The GSP is a highly useful indwelling catheter that can be used for HAIC.

Safety and efficacy assessment of flow redistribution by occlusion of intrahepatic vessels prior to radioembolization in the treatment of liver tumors

We evaluated the feasibility, safety, and efficacy of radioembolization (administered from one or two vascular points) after the redistribution of arterial blood flow in the liver in patients with hepatic neoplasms and arterial anatomic peculiarities (AAP). Twenty-four patients with liver neoplasms and AAP (graded according to Michel's classification) were included in the study. During pretreatment angiographic planning, all extrahepatic vessels that could feed the tumor were embolized and the intrahepatic vessels occluded in order to redistribute blood flow. The distribution of microspheres was initially assessed by using technetium-99m-labeled macroaggregated albumin ((99m)Tc-MAA) from one of two vascular points before the administration of yttrium-90 ((90)Y)-radiolabeled resin microspheres. Perfusion of lesions situated in the redistributed segments (L-RS) and nonredistributed segments (L-NRS) were compared by assessing the distribution of (99m)Tc-MAA by SPECT/CT. Perfusion was graded as normal, reduced, or absent. (90)Y resin microspheres were then injected from the same arterial sites as (99m)Tc-MAA and the tumor response recorded 3 months later. The tumor response in L-RS was compared with that in L-NRS and graded as better, similar, or worse. Among 11 patients with type I AAP in whom mainly vessels in segments I-III or IV were occluded, perfusion of L-RS was graded as similar (n = 7) or reduced (n = 4). Among the remaining 13 patients with AAP types III (n = 3), V (n = 4), VIII (n = 3), and others (n = 3) in which aberrant arteries were occluded, perfusion of L-RS was graded as similar (n = 9), reduced (n = 3), or absent (n = 1). Overall, (99m)Tc-MAA was present in the L-RS of 95.8% patients and the distribution of (99m)Tc-MAA in L-RS and L-NRS were graded as similar in 66.6% of patients. Compared with lesions in the L-NRS, tumor response in L-RS was similar in 23 cases and worse in 1 case. No complications were recorded after the administration of (90)Y resin microspheres. Redistribution of flow in L-RS is feasible and enables a safe and effective delivery of (90)Y resin microspheres that are able to be distributed via intrahepatic collaterals and access the microvasculature of L-RS.

Dysfunction of a port-catheter system percutaneously implanted for hepatic arterial infusion chemotherapy due to a fibrin sheath

Catheter-related difficulties occurred with a port-catheter system percutaneously implanted by the fixed catheter tip technique for repeated hepatic arterial infusion chemotherapy (HAIC) for unresectable metastatic liver cancer. A side hole in the indwelling catheter opened into the common hepatic artery. Four years and 3 months later, an occluded hepatic artery was diagnosed by arteriography with contrast medium infused via the port. Conversely, celiac arteriography performed from a catheter newly inserted from the femoral artery showed no such occlusion. A new port-catheter system replaced the original one to continue HAIC. Examination revealed a fibrin sheath covering the withdrawn catheter.

Evaluation of non-target arterial patency after implantation of hepatic arterial catheter using a modified implantation technique with the fixed catheter tip method

AIM

To retrospectively investigate persistent hepatofugal blood flow in the gastroduodenal artery after implantation of a port-catheter system for repeated hepatic arterial infusion chemotherapy using a modified fixed catheter tip method.

MATERIALS AND METHODS

A port-catheter system was percutaneously implanted in 150 patients (90 men and 60 women; mean age 64.6 years) with unresectable liver cancer. The persistence of blood flow beyond the end hole of the indwelling catheter via the port obtained immediately and 1-10 days after port-catheter placement was investigated using arteriography.

RESULTS

In all cases, port-catheter placement was successfully performed. In 64 (42.7%) of the 150 participants, the gastroduodenal artery was detected on arteriography just after implantation. However, arteriography obtained 1-10 days (mean 4.3 days) after implantation revealed the gastroduodenal artery in only two of the 64 participants. In these two patients, persistent blood flow disappeared spontaneously 12 and 15 days after implantation, respectively.

CONCLUSION

Closure of the lumen of the distal tip of the catheter beyond the side hole most often occurs spontaneously just after implantation. However, the findings of the present study indicate that closure will occur within 15 days at the latest. This suggests that delaying chemotherapy for about 2 weeks after implantation may be advisable.

Use of N-butyl cyanoacrylate in implantation of a port-catheter system for hepatic arterial infusion chemotherapy with the fixed-catheter-tip method: is it necessary?

OBJECTIVE

The purpose of our study was to evaluate the usefulness of N-butyl cyanoacrylate (NBCA) in addition to microcoils in the percutaneous implantation of a port-catheter system for repeated hepatic arterial infusion chemotherapy with the fixed-catheter-tip method.

MATERIALS AND METHODS

We retrospectively studied 166 consecutive patients with unresectable advanced liver cancer for whom a port-catheter system was percutaneously implanted with its tip fixed at the gastroduodenal artery with microcoils. In 107 patients, NBCA was also used for catheter tip fixation. We compared this group with a control cohort of 59 patients who did not receive NBCA. Outcomes, including rate of success in implantation, details of embolic agents for fixation, and occurrence of complications related to catheter placement that would prohibit continuation of chemotherapy if not corrected, were compared.

RESULTS

In all, port-catheter placement was successful. However, 38 complications occurred in 32 patients. Catheter dislocation occurred in nine. Hepatic artery obstruction or severe stenosis was seen in 10. Recanalization of a once-embolized gastroduodenal artery was found in two patients. The rate of dislocation did not differ significantly between patients in whom NBCA was and those in whom it was not used. However, hepatic artery obstruction appeared at a significantly higher rate, and recanalization of a gastroduodenal artery at a significantly lower rate, in patients in whom the catheter tip was fixed with NBCA.

CONCLUSION

The use of NBCA correlated with a higher rate of hepatic artery obstruction. The use of NBCA should not always be required in port-catheter implantation with the fixed-catheter-tip method.

Percutaneous catheter placement for hepatic arterial infusion chemotherapy

Hepatic arterial infusion chemotherapy employs a hepatic artery catheter as a conduit to achieve a high concentration of antineoplastic agents to liver tumors. Historically, this catheter placement has been performed via laparotomy. However, it may now be performed using less-invasive percutaneous image guided procedures. There are many anatomical hepatic arterial variations and complicated blood flow patterns. Various techniques are required to ensure high concentration of antineoplastic agents in liver tumors. These techniques are composed of arterial redistribution by embolization, percutaneous catheter placement applying "tip-fixation method," and evaluation and management of flow patterns that reflect drug distribution. The role of interventional radiologists in hepatic arterial infusion chemotherapy is to create and manage the access to achieve these objectives.

Side-hole catheter placement for hepatic arterial infusion chemotherapy in patients with liver metastases from colorectal cancer: long-term treatment and survival benefit

OBJECTIVE

The objective of this study was to evaluate retrospectively correlations between catheter placement methods and treatment outcomes of patients treated with hepatic arterial infusion chemotherapy for unresectable liver metastases from colorectal cancer.

MATERIALS AND METHODS

This study involved 135 patients with liver metastases from colorectal cancer who underwent intrahepatic chemotherapy using catheter-port systems. Complications, treatment discontinuation, hepatic progression, and survival of patients treated with each method were evaluated retrospectively using the Kaplan-Meier method. Conventional 5-French end-hole catheter placement (n = 10) was compared with three side-hole catheter placement methods: 5-French side-hole catheter placement with a fixed catheter tip (original fixed catheter tip method, n = 77); long tapered side-hole catheter placement using a fixed catheter tip method (modified fixed catheter tip method, n = 24); and long tapered side-hole catheter inserted distally in the hepatic artery (long tapered catheter placement method, n = 24).

RESULTS

The following treatment outcomes were significantly better for patients treated using the original or modified fixed catheter tip or long tapered catheter placement method than for those treated using the conventional method, respectively: hepatic arterial patency (1 year: 76.3%, 95.0%, and 94.4% vs 38.9%; p = 0.0014, 0.0007, and 0.0006), catheter stability (1 year: 96.7%, 95.5%, and 95.2% vs 42.9%; p < 0.0001, p = 0.0003, and p = 0.0009), time to treatment discontinuation (medians: 11.7, 14.4, and 12.4 vs 3.2 months; p < 0.0001, 0.0002, and 0.0019), time to hepatic progression (medians: 14.7, 15.7, and 15.8 vs 5.5 months; p = 0.0049, 0.0141, and 0.0004), and overall survival (medians: 21.1, 22.5, and 23.1 vs 13.1 months; p = 0.0146, 0.0036, and 0.0017).

CONCLUSION

Compared with the conventional method, side-hole catheter placement methods allowed long-term intrahepatic chemotherapy and resulted in improved survival.

Impact of multislice CT angiography on planning of radiological catheter placement for hepatic arterial infusion chemotherapy

The objective of this study was to assess prospectively the role of multislice CT angiography (MSCTA) on planning of radiological catheter placement for hepatic arterial infusion chemotherapy (HAIC). Forty-six patients with malignant liver tumors planned for HAIC were included. In each patient, both MSCTA and intra-arterial digital subtraction angiography (DSA) were performed, except one patient who did not undergo DSA. Comparison of MSCTA and DSA images was performed for the remaining 45 patients. Detectability of anatomical variants of the hepatic artery, course of the celiac trunk, visualization scores of arterial branches and interobserver agreement, presence of arterial stenosis, and technical outcome were evaluated. Anatomical variations of the hepatic artery were detected in 19 of 45 patients (42%) on both modalities. The course of the celiac trunk was different in 12 patients. The visualization scores of celiac arterial branches on MSCTA/DSA were 3.0 +/- 0/2.9 +/- 0.2 in the celiac trunk, 3.0 +/- 0/2.9 +/- 0.3 in the common hepatic artery, 2.9 +/- 0.2/2.9 +/- 0.3 in the proper hepatic artery, 2.9 +/- 0.3/2.9 +/- 0.4 in the right hepatic artery, 2.8 +/- 0.4/2.9 +/- 0.4 in the left hepatic artery, 2.9 +/- 0.2/2.9 +/- 0.3 in the gastroduodenal artery, 2.1 +/- 0.8/2.2 +/- 0.9 in the right gastric artery, and 2.7 +/- 0.8/2.6 +/- 0.8 in the left gastric artery. No statistically significant differences exist between the two modalities. Interobserver agreement for MSCTA was equivalent to that for DSA. Two patients showed stenosis of the celiac trunk on both modalities. Based on these imaging findings, technical success was accomplished in all patients. In conclusion, MSCTA is accurate in assessing arterial anatomy and abnormalities. MSCTA can provide adequate information for planning of radiological catheter placement for HAIC.

Hepatic arterial infusion chemotherapy through a port-catheter system as preoperative initial therapy in patients with advanced liver dysfunction due to synchronous and unresectable liver metastases from colorectal cancer

PURPOSE

We retrospectively evaluated the safety and efficacy of preoperative initial hepatic arterial infusion chemotherapy (HAIC) through a port-catheter system in patients with liver dysfunction due to synchronous and unresectable liver metastases. The aim of HAIC was to improve patients' clinical condition for later surgical removal of primary colorectal cancer.

METHODS

Port-catheter systems were placed radiologically in 21 patients (mean age 58.6 +/- 8.1 years) with liver dysfunction due to synchronous liver metastases from colorectal cancer. Initial HAIC of 1,000 mg/m(2) 5-fluorouracil was administered weekly as a 5 hr continuous infusion through this system. Surgical removal of the primary lesion was planned after HAIC improved the liver function.

RESULTS

Port-catheter system placement was successful in all patients without severe complications. Patients were followed up for a median of 309 days (range 51-998 days). After starting HAIC, no severe adverse events that caused drug loss and treatment postponement or suspension were observed in any of the patients. HAIC was performed a mean of 4.5 +/- 3.0 times and the liver function improved in all patients. Curative (n = 18) or palliative (n = 1) surgical removal of the primary lesion was performed. The remaining 2 patients died because extrahepatic metastases developed and their performance status worsened; thus, surgery could not be performed. The median survival times of all patients and the operated patients were 309 and 386 days, respectively.

CONCLUSION

Initial HAIC administration is a safe and efficacious method for improving liver function prior to operative resection of primary colorectal cancer in patients with liver dysfunction due to synchronous and unresectable liver metastases.

Clinical Utility of Coaxial Reservoir System for Hepatic Arterial Infusion Chemotherapy

PURPOSE

To test the feasibility and clinical utility of a reservoir with coaxial catheters (a 2.9-F microcatheter and a 5-F catheter) and a port (ie, coaxial reservoir) that was developed to perform repeated hepatic arterial infusion chemotherapy (HAIC) in patients with unresectable liver neoplasms.

MATERIALS AND METHODS

The coaxial reservoir was implanted in 64 patients with unresectable liver neoplasms as a result of difficulty in implanting a conventional reservoir with a 5-F catheter. The 2.9-F microcatheter tip was inserted into the gastroduodenal artery (n = 22), pancreaticoduodenal arcade (n = 20), or peripheral hepatic artery (n = 22) through the 5-F catheter, and a side hole created in the leading end of the microcatheter was oriented toward the proper hepatic artery. Technical success was defined by implantation of the coaxial reservoir and initiation of HAIC. The study endpoint was interruption of HAIC or death. Technical success and early and delayed complications were recorded.

RESULTS

The technical success rate was 100%. HAIC was repeated every 1-4 weeks during the mean follow-up period of 14.1 months. Arterial infusion chemotherapy was interrupted in 17 patients (27%) as a result of hepatic arterial occlusion (16%, n = 10), catheter dislocation (3%, n = 2), catheter occlusion (3%, n = 2), wound infection (3%, n = 2), or breakage of the port (2%, n = 1). Patency rates of the hepatic artery were 96%, 82%, and 50% at 6 months, 1 year, and 2 years after reservoir implantation, respectively.

CONCLUSION

Implantation of the coaxial reservoir is feasible, safe, and useful in expanding the indication of HAIC to patients with unresectable liver neoplasms.

Arterial Infusion of 5-Fluorouracil Combined with Concurrent Radiotherapy for Unresectable Pancreatic Cancer: Results from a Pilot Study

OBJECTIVE

Systemic chemotherapy and chemoradiotherapy, the standard treatments, do not satisfactorily improve the poor prognosis of unresectable pancreatic cancer. The authors administered arterial infusion of 5-fluorouracil (5-FU) combined with concurrent radiation therapy to enhance the antitumor effect of chemotherapy. The purpose of this study was to examine the efficacy and safety of this combined therapy.

MATERIALS AND METHODS

One or two catheters were placed into the pancreas-supplying arteries angiographically. To obtain adequate drug distribution, the positions of the catheters were determined in accordance with the results of CT during arterial injection of contrast material. A dose of 333 mg/m2/d of 5-FU was continuously infused for 5 days a week for 5 weeks, with concurrent radiation therapy (50 Gy at 2.0 Gy per fraction). Twenty patients with unresectable pancreatic cancer were enrolled in this study.

RESULTS

Of the 20 patients, 19 (95%) completed the scheduled course of this combined therapy. Fourteen patients showed a partial response (response rate, 70%). Serum cancer antigen 19-9 (CA 19-9) levels were reduced by more than 50% in 16 of 18 patients (80%). The 1-year and 3-year survival rates were 40% and 17%, respectively, with a median survival time of 11.0 months. Grade 3 or worse nonhematologic toxicity was observed in 11 patients (55%), but there were no life-threatening toxicities or complications.

CONCLUSION

Arterial infusion of 5-FU combined with concurrent radiation therapy is tolerable and can produce a high response rate with encouraging survival duration for unresectable pancreatic cancer.

Value of Micronester coils in port-catheter implantation for continuous hepatic arterial infusion chemotherapy with fixed catheter tip method

To retrospectively evaluate the use of Micronester coils in port-catheter implantation with the fixed catheter tip method in comparison with other previously used coils. The cohort of this study was 143 consecutive patients with unresectable advanced liver cancer for whom a port-catheter system was percutaneously implanted. In the most recent 32 patients, Micronester coils were used for catheter tip fixation. Details of embolic agents for fixation, persistent blood flow beyond the distal end of the indwelling catheter, and complications were compared between cases without and with Micronester coils. In all, percutaneous port-catheter placement was successful. Mean number of coils used for fixation was 4.2 without Micronester coils vs. 2.5 with Micronester coils. N-butyl cyanoacrylate (NBCA)-Lipiodol was additionally used for catheter tip fixation in 85.6% of 111 procedures without Micronester coils and in 50% of 32 using Micronester coils. The gastroduodenal artery beyond the distal end was not detected at the final examination after any procedure. Catheter dislocation occurred in five and hepatic arterial obstruction or severe stenosis in eight. The number of coils used and necessity of NBCA-Lipiodol could be decreased with usage of Micronester coils without decreasing fixation ability compared to other coils.

Outcomes of hepatic artery infusion therapy for hepatic metastases from colorectal carcinoma after radiological placement of infusion catheters

AIM

The aim of this study is to evaluate the safety and efficacy of hepatic artery infusion (HAI) of 5-fluorouracil (5FU) for patients with liver metastases from colorectal carcinoma after radiological placement of infusion catheters.

METHODS

Forty-two patients with liver metastases from colorectal carcinoma received radiological placement of infusion catheters using the distal fixation method. They received continuous HAI of 5FU 1,000-1,500mg for 5h weekly or biweekly. Tumor status was assessed by chest-abdominal computed tomography (CT) scan after every 10 infusions. Hepatic perfusion was checked by CT arteriography via the infusion port after every 10 infusions.

RESULTS

Radiological placements of catheters were performed successfully in all cases. Each patient received an average of 36 treatments (range: 10-98). Catheter failure was found in 3 patients (7.1%). Nine incidents of grade 1 toxicity were observed in 8 patients (19.0%). There was a complete response in 6 patients, partial remission in 18, stable disease in 9, and progression of disease in 9 (response rate: 57.1%). Overall median survival time was 29.1 months. Using Cox's proportional hazard model, lymph node metastases in primary colorectal carcinoma and pre-treatment serum CEA affected overall survival (P=0.011, P=0.005).

CONCLUSIONS

HAI after radiological placement of infusion catheters is a safe and effective treatment particularly for patients with no lymph node metastasis in primary carcinoma or with a low pre-treatment serum CEA level.

Temporary indwelling catheter system via the left brachial artery: evaluation in 83 patients with hepatic tumors

OBJECTIVE

The purpose of our study was to evaluate retrospectively the usefulness and complications associated with a temporary indwelling catheter system through the brachial artery for patients with liver tumors.

CONCLUSION

The temporary indwelling catheter system via the left brachial artery can be used not only for CO2-enhanced sonographically guided aspiration biopsy, radiofrequency ablation, and percutaneous ethanol injection, but also for short-term hepatic arterial infusion chemotherapy and transcatheter arterial chemoembolization.

Placement of a long tapered side-hole catheter in the hepatic artery: technical advantages, catheter stability, and arterial patency

OBJECTIVE

The purpose of this study was to evaluate the technical advantages, safety, and efficacy of placing a catheter distally in the hepatic artery using a long tapered side-hole catheter with an implantable port for hepatic arterial infusion chemotherapy.

SUBJECTS AND METHODS

Fifty patients with unresectable malignant liver tumors underwent radiologic implantation of catheter-port systems using the long tapered catheter placement method. A 2.7-French distal shaft of the catheter was inserted distally in the hepatic artery with its side hole located proximally, and a 5-French proximal shaft was placed in the aorta; the catheter tip was not fixed. Technical success, complications including catheter stability and hepatic artery patency, and tumor response were assessed and compared with the following two historical controls: 35 patients with a 5-French catheter inserted simply in the hepatic artery (conventional method), and 131 patients with a 5-French catheter, the tip of which was fixed in the gastroduodenal artery (the fixed-catheter-tip method).

RESULTS

The technical success rate using the long tapered catheter placement method was 92% (46/50 patients), whereas the feasibility of the fixed-catheter-tip method was confined to 79% of historical controls (131/166 patients). Among patients in whom the gastroduodenal artery was present, a decreased frequency of gastroduodenal artery embolization was seen using the long tapered catheter placement method (39%; 17/44 patients) compared with the conventional method (p = 0.0112) and the fixed-catheter-tip method (p < 0.0001). Cumulative stability rates of the catheter (6 months, 94.9%; 1 year, 94.9%; 2 years, 86.2%) and cumulative patency rates of the hepatic artery (6 months, 89.9%; 1 year, 89.9%; 2 years, 83.5%) were significantly higher using the long tapered catheter placement method than using the conventional method (p = 0.0208 and p = 0.0066, respectively) but were similar to those using the fixed-catheter-tip method. The time of hepatic tumor progression was significantly longer using the long tapered catheter placement method than using the conventional method (p = 0.0299) but was comparable to the time using the fixed-catheter-tip method.

CONCLUSION

The long tapered catheter placement method should find wider application in hepatic arterial infusion chemotherapy because it is useful in preventing catheter dislodgment and hepatic artery occlusion.

Pseudo-occlusion of the hepatic artery during hepatic arterial infusion chemotherapy

Hepatic arterial occlusion (HAO) is frequently encountered in patients receiving hepatic arterial infusion chemotherapy (HAIC) via an implanted port-catheter system. Usually, HAO precludes continuation of HAIC, and treatment for liver metastases is changed to systemic chemotherapy. However, two cases were encountered in which, even though HAO was diagnosed by arteriography via the port, the hepatic artery was actually patent. These cases illustrate that arteriography via the port is insufficient to confirm HAO.

Radiologic removal and replacement of port-catheter systems for hepatic arterial infusion chemotherapy

OBJECTIVE

The purpose of our study was to retrospectively evaluate the safety and efficacy of radiologic removal and replacement of port-catheter systems.

MATERIALS AND METHODS

Between January 1999 and December 2004, 532 patients with unresectable advanced liver cancer underwent radiologic placement of port-catheter systems at our institution. Of these, 18 patients (nine men and nine women; age range, 32-83 years; mean age, 53.8 years) underwent removal of an implanted port-catheter system via the right femoral artery and radiographically guided replacement with a new system to allow continuous hepatic arterial infusion chemotherapy; we retrospectively reviewed these 18 cases. The reasons for removal of the previously implanted systems were as follows: catheter dislodgement (n = 15), catheter obstruction (n = 1), infection related to the implanted port (n = 1), and hemodynamic change (n = 1). Digital subtraction angiography and CT were performed, usually during injection of contrast medium through the implanted port-catheter system, within a few days after the replacement procedure and every 3 months thereafter.

RESULTS

We successfully performed radiologic removal and replacement of the portcatheter system while the patient was under local anesthesia in all 18 patients without complications requiring treatment. The cumulative patency rates of the hepatic artery after removal of the old port-catheter system and replacement with a new port-catheter system were 87.8% and 64.1% at 6 months and 1 year, respectively. Hepatic arterial infusion chemotherapy after replacement was performed 0-68 times (median, 19 times).

CONCLUSION

When an implanted port-catheter system can no longer be used but the patency of the hepatic artery is confirmed and continuous hepatic arterial infusion chemotherapy is required, removal and replacement of the port-catheter system are recommended.

Techniques for the placement of hepatic artery catheters for regional chemotherapy in unresectable liver metastases

AIMS

For patients with unresectable liver metastases from colorectal cancer (CRC), hepatic artery infusion chemotherapy (HAIC) can produce higher response rates as compared to systemic chemotherapy. However, the added morbidity and early dysfunction after catheter placement have negatively influenced the outcomes of randomized studies.

METHODS

Between July 1998 and March 2006, 29 patients with unresectable liver metastases from CRC were included in three different HAIC protocols. A catheter was laparoscopically placed in the gastroduodenal artery, retrograde to the common hepatic artery and was attached to a subcutaneous access port. Perioperative parameters and catheter-associated adverse events during chemotherapy were studied.

RESULTS

Mean operating time was 106+/-29 min and median duration of hospitalization was 2 days (range: 1-13). No major perioperative complications occurred but there was 1 death (3.6%) 1 week after surgery due to hemorrhagic shock after necrosis and rupture of the hepatic artery. During a median follow-up of 10 months (range: 0-35) we observed 5 (17%) catheter-associated adverse events, but in only 2 patients (7%) this resulted in a loss of catheter function before the end of chemotherapy. Overall median duration of HAIC was 8 months (range: 1-28).

CONCLUSION

Laparoscopic placement of a hepatic artery catheter is associated with a low operative morbidity. The observed functionality of the hepatic artery ports in our series is encouraging for the use in future studies of HAIC.

Colorectal liver metastases: regional chemotherapy via transarterial chemoembolization (TACE) and hepatic chemoperfusion: an update

Liver metastasis is one of the main problems encountered in colorectal cancer management as the liver is the most common metastatic site. Several treatment options are available, among which transarterial chemotherapy has proved effective in achieving some local tumour control, improving the quality of life through symptomatic control as well as survival time. The present paper is intended to provide an overview of the techniques, indications and results of regional chemotherapy, which comprises transarterial chemoembolization (TACE) and chemoperfusion. This treatment approach has symptomatic, palliative, adjuvant and potentially curative objectives. We reviewed the studies involving TACE and chemoperfusion of colorectal liver metastases during the last few years to update the previous reviews published on this subject. The results achieved were so variable, due to the variations in patient selection criteria and regimens used between the different studies. The median survival ranged from 9 to 62 months and the morphological response ranged from 14 to 76%. Technical aspects, results, and complications of this modality will be demonstrated with a detailed analysis and comments.

Fixation methods for implantable port chamber: comparative study using glue, self-stabilizing leg and suture fixations in rabbits

Objective

To evaluate the fixation strength and tissue reaction of the glue fixation and self-stabilizing leg fixation methods and to compare the results with those of the conventional tagging suture fixation method.

Materials and Methods

Twelve healthy rabbits were selected and three different methods of implanting the port chamber were employed on the back of each rabbit. A total of thirty six port chambers were implanted with these three different methods, viz. the glue fixation method using tissue adhesive, the self-stabilizing leg method using a self-expandable stabilizing leg, and the suture fixation method. The fixation strength and the gross and histopathologic changes of each fixation method were evaluated at three days, one week, two weeks and four weeks after port implantation.

Results

The glue fixation method showed a good fixation strength, which was similar to that of the tagging suture method (p = 0.3486). Five of the six ports (83%) implanted with the glue fixation method which were examined after two weeks showed cracks on the external surface, but this had no adverse effects on their function. A large amount of granulation tissue reaction was found at the bottom of the chamber (p = 0.0025). The fixation with the self-stabilizing leg showed relatively lower fixation strength (p = 0.0043), but no turning-over of the chamber occurred. The fixation strength improved with time after the first week, and minimal granulation tissue reaction was observed with this method.

Conclusion

The glue fixation method exhibited equal fixation strength compared to the suture fixation, but showed cracking and a large amount of granulation tissue, whereas the fixation with a self-stabilizing leg showed weaker fixation strength.

Arterial Embolization for Salvage of Hepatic Artery Infusion Pumps

PURPOSE

Hepatic artery infusion pumps (HAIPs) ideally provide for homogenous perfusion of the liver with chemotherapeutic agents. Perfusion of extrahepatic organs or asymmetric liver perfusion (ie, "misperfusion") is diagnosed by nuclear scintigraphy and precludes the use of HAIPs. The purpose of this study is to report experience in salvaging HAIPs with arterial embolization.

MATERIALS AND METHODS

A single-center HAIP database was retrospectively reviewed for cases from 1999 to 2005 to identify patients who underwent angiography to treat misperfusion documented by nuclear scintigraphy. Patient demographics, nuclear scintigraphic findings before and after embolization, angiographic findings, embolization variables, and outcomes were recorded. Technical success (defined by cessation of flow to the vessel responsible for misperfusion) and clinical success (ie, successful use of the pump) were calculated.

RESULTS

During the study period, 475 HAIPs were implanted. Of those, 43 (9%) had abnormal nuclear scintigraphic findings of misperfusion, but only 32 (7%) had angiographic abnormalities. In eight of 32 cases, hepatic arterial thrombosis and extravasation at the catheter tip were found, which precluded salvage by embolization. In 24 of 32 cases, a vessel presumed responsible for the misperfusion was identified and targeted for embolization. Technical success and clinical success were achieved in 21 of 24 patients (87.5%) and 19 of 24 patients (79%), respectively, who underwent 27 embolization procedures. The three technical failures (12.5%) were the result of inability to catheterize the identified vessel.

CONCLUSIONS

Percutaneous arterial embolization of a vessel to correct misperfusion shown by nuclear scintigraphy is safe and effective. This approach can be expected to result in HAIP salvage in the majority of patients.

Withdrawal of port-catheter system for hepatic arterial infusion chemotherapy implanted with fixed catheter tip method

PURPOSE

To evaluate the feasibility and safety of a method to withdraw port-catheter systems implanted by the fixed catheter tip method.

MATERIALS AND METHODS

Retrospective review was conducted of 14 cases of unresectable advanced liver cancer in which it was necessary to attempt 15 withdrawals of percutaneously placed implantable port-catheter systems. Reasons for withdrawal, withdrawal success, complications, and subsequent treatment of patient were evaluated.

RESULTS

In 14 of the 15 procedures (93.3%), the port-catheter system was successfully retrieved. Because continuation of hepatic arterial infusion chemotherapy was necessary in 10 procedures, a second implantation was performed after withdrawal of the initial catheter. Only one complication occurred, in which the indwelling catheter was broken in the aorta during withdrawal.

CONCLUSION

When retrieval of a port-catheter system implanted with the fixed catheter tip method is necessary, withdrawal can be accomplished safely with high frequency.

Comparison of Fusion Imaging Using a Combined SPECT/CT System and Intra-arterial CT: Assessment of Drug Distribution by an Implantable Port System in Patients Undergoing Hepatic Arterial Infusion Chemotherapy

Hepatic arterial infusion (HAI) chemotherapy is effective for treating primary and metastatic carcinoma of the liver. We compared the perfusion patterns of HAI chemotherapy on intra-arterial port-catheter computed tomography (iapc-CT) and fused images obtained with a combined single-photon emission computed tomography/computed tomography (SPECT/CT) system. We studied 28 patients with primary or metastatic carcinoma of the liver who bore an implantable HAI port system. All underwent abdominal SPECT using Tc-99m-MAA (185 Mbq); the injection rate was 1 mL/min, identical to the chemotherapy infusion rate, and 0.5 mL/sec for iapc-CT. Delivery was through an implantable port. We compared the intrahepatic perfusion (IHP) and extrahepatic perfusion (EHP) patterns of HAI chemotherapy on iapc-CT images and fused images obtained with a combined SPECT/CT system. In 23 of 28 patients (82%), IHP patterns on iapc-CT images and fused images were identical. In 5 of the 28 patients (18%), IHP on fusion images was different from IHP on iapc-CT images. EHP was seen on fused images in 12 of the 28 patients (43%) and on iapc-CT images in 8 patients (29%). In 17 patients (61%), upper gastrointestinal endoscopy revealed gastroduodenal mucosal lesions. EHP was revealed on fused images in 10 of these patients; 9 of them manifested gastroduodenal toxicity at the time of subsequent HAI chemotherapy. Fusion imaging using the combined SPECT/CT system reflects the actual distribution of the infused anticancer agent. This information is valuable not only for monitoring adequate drug distribution but also for avoiding potential extrahepatic complications.

A new method using J-type long sheath for implantation of indwelling catheters for trans-femoral hepatic arterial infusion

PURPOSE

For implantation of a catheter-port system for hepatic arterial infusion chemotherapy, catheterization via the femoral artery is occasionally difficult. The purpose of this study was to determine the usefulness of a J-type long sheath, which facilitates difficult trans-femoral catheterization.

MATERIALS AND METHODS

We applied this technique to 15 patients for difficult trans-femoral catheterization for catheter-port system placement.

RESULTS

We successfully implanted a catheter-port system in all patients using this technique without significant complications.

CONCLUSION

We emphasize that our new technique using a J-type long sheath seems to be a reasonable option when trans-femoral catheterization is difficult.

Movement of the side hole occurring in a port-catheter system percutaneously implanted for hepatic arterial infusion chemotherapy

The authors report a case in which catheter-related difficulties occurred with a port-catheter system implanted to perform repeated hepatic arterial infusion chemotherapy for advanced hepatocellular carcinomas. The port-catheter system had been percutaneously implanted with the catheter tip fixation method, and a side hole had been created in the indwelling catheter for placement in the common hepatic artery. Four months after port-catheter placement, however, the indwelling catheter became bent at the location of the side hole in the proper hepatic artery. Subsequently, the side hole moved into the left hepatic artery, resulting in a lack of distribution of chemotherapeutic agents to the tumours in the segments of the liver supplied by the right hepatic artery. This situation was easily corrected with a simple interventional radiological method so that hepatic arterial infusion chemotherapy could be resumed with sufficient distribution over the entire liver. To our knowledge, such a problem involving a port-catheter system implanted with the catheter tip fixation method and its management thereafter has not been reported in the published literature.

Influence of hepatopetal flow of the retroportal artery on efficiency of repeated hepatic arterial infusion chemotherapy

Few reports have described the influence of the retroportal artery on the distribution of anticancer drugs in the liver during repeated hepatic arterial infusion chemotherapy. This report describes two patients in whom poor distribution was observed in the right lobe of the liver, which was confirmed at superior mesenteric arteriography to be caused by inflow of the retroportal artery to the right hepatic artery. The retroportal artery was successfully embolized, resulting in improvement of distribution in the right lobe of the liver in both cases.

Influence of Extrahepatic Arterial Inflow into the Posterior Segment or Caudate Lobe of the Liver on Repeated Hepatic Arterial Infusion Chemotherapy

PURPOSE

For therapeutic effectiveness of repeated hepatic arterial infusion chemotherapy (HAIC) for unresectable advanced liver malignancies, distribution of anticancer drugs via an indwelling catheter should be uniform throughout the entire liver. It was investigated how an extrahepatic artery entering the posterior segment or caudate lobe of the liver influences performance of repeated HAIC.

MATERIALS AND METHODS

One hundred ninety-five patients with unresectable advanced liver cancer underwent placement of a percutaneously implantable port-catheter system and were followed arteriographically with and without computed tomography (CT). The frequency of poor distribution in the posterior segment or caudate lobe of the liver was observed on CT during arteriography via the port for HAIC. The correlation between poor distribution and various factors including the number of intrahepatic arteries was studied, and the management of such poor distribution is described.

RESULTS

In 34 of 195 patients (17.4%), poor distribution was observed in the posterior segment and/or caudate lobe of the liver. The rate of poor distribution was significantly higher in those with two or more hepatic arteries than in those with one (13 of 35 vs 21 of 160; P = .0007, chi2 test). Other evaluated factors were not significantly correlated with such poor distribution. The right inferior phrenic artery was successfully embolized in 22 patients with tumors in segments with poor distribution. Good distribution throughout the entire liver was achieved in 21 patients (95.5%).

CONCLUSION

Inflow of the right inferior phrenic artery into the liver occasionally prevents distribution of anticancer drugs throughout the entire liver during performance of long-term HAIC.

Radiofrequency Ablation Therapy of Remnant Colorectal Liver Metastases after a Course of Hepatic Arterial Infusion Chemotherapy

The present study evaluated the feasibility of combined therapy employing repeated hepatic arterial infusion chemotherapy (HAIC) via a port-catheter system and radiofrequency (RF) ablation for unresectable metastatic liver cancer from the colo-rectum. RF ablation was performed for six patients with liver malignancies that had been well controlled and had decreased in number and size with repeated HAIC. After RF ablation subsequent to repeated HAIC, all six patients had stable disease or complete or partial remission as documented by follow-up contrast-enhanced computed tomographic (CT) imaging. Fluorodeoxyglucose positron emission tomography (18F) showed complete response in all ablated lesions. In conclusion, RF ablation after a course of HAIC achieved complete necrosis in residual lesions after HAIC therapy.

Management of End Hole in Placement of Port-Catheter System for Continuous Hepatic Arterial Infusion Chemotherapy Using the Fixed Catheter Tip Method

OBJECTIVE

The purpose of our study was to compare persistent hepatofugal blood flow in the gastroduodenal artery after implanting a port-catheter system for repeated hepatic arterial infusion chemotherapy using either the original or the modified fixed catheter tip method. With the original method the lumen of the catheter tip is closed with a microcoil; with the modified method it is left open. Persistent hepatofugal blood flow can induce reactive gastric or duodenal mucosal lesions.

MATERIALS AND METHODS

A port-catheter system with the catheter tip fixed to the gastroduodenal artery by embolic agents was percutaneously implanted in 156 patients (102 men, 54 women; mean age, 63.2 years) with unresectable liver cancer. In 98 patients the original method was used, and in 58 patients the modified method was used. Existence of persistent blood flow beyond the indwelling catheter tip as shown on arteriography via the port performed immediately and 2-10 days after port-catheter placement was compared between these two groups.

RESULTS

In all cases, percutaneous port-catheter placement was successfully performed. In one (1.0%) of 98 procedures involving the original method, the gastroduodenal artery was detected on arteriography just after implantation, compared with 23 (39.7%) of 58 procedures using the modified method. However, arteriography performed 2-10 days (mean, 5.02 days) after implantation detected the gastroduodenal artery in only one case.

CONCLUSION

This retrospective study indicates that closure of the end hole appears to occur spontaneously shortly after implantation. Thus, such closure is not always necessary to avoid persistent hepatofugal blood flow in the gastroduodenal artery.

Catheter Redundancy in the Aortic Arch Increases the Risk of Stroke in Left Subclavian Arterial Port–Catheter Systems

PURPOSE

The stroke rate after left subclavian arterial port-catheter placement was compared in two groups: one with minimal redundancy of the catheter and one with pronounced redundancy in the aortic arch designed to minimize the likelihood of catheter dislocation.

MATERIALS AND METHODS

One hundred forty-eight patients (102 men, 46 women; age range, 26-83 years; mean age, 64.3 years) with inoperable advanced liver cancers underwent percutaneous implantation of port-catheter systems via the left subclavian artery. In 33 patients, a pronounced redundancy of the catheter was intentionally looped in the aortic arch. Redundancy was intentionally avoided in the remaining 115 patients. The rates of brain infarction complications in these two groups were retrospectively compared.

RESULTS

Among the 33 patients with pronounced redundant catheter looping, brain infarctions occurred in four cases (12.1%). In contrast, brain infarctions occurred in only three of the 115 patients with minimal redundant catheter looping (2.6%). The frequency of brain infarction complications was significantly higher in the patients with pronounced redundant catheter looping in the aortic arch than in patients with minimal pronounced redundant catheter looping (P = .044, Fisher exact test).

CONCLUSION

Catheter redundancy in the aortic arch increases the risk of stroke in patients undergoing implantation of port-catheter systems via a left subclavian arterial approach for repeated hepatic arterial infusion chemotherapy.

Percutaneous Femoral Catheter Placement for Long-Term Chemotherapy Infusions: Preliminary Technical Results

OBJECTIVE

The purpose of our study was to evaluate the feasibility and usefulness of using a port-catheter system equipped with a W-spiral catheter for hepatic chemotherapy; this novel catheter does not require fixation by pericatheter embolization and can be safely withdrawn when not needed.

SUBJECTS AND METHODS

Sixty-one patients (40 men and 2l women; mean age, 59 years) with advanced liver cancers (primary hepatic or biliary cancer [n = 31] and metastatic liver cancer [n = 30]) underwent percutaneous port-catheter placement with the tip of W-spiral catheter inserted into the right gastroepiploic artery and the side-hole opened at the common hepatic artery after embolization of the right gastric artery, pancreaticoduodenal arteries, or aberrant hepatic arteries. Pericatheter embolization for preventing catheter dislodgement was not performed. The technical success of port-catheter placement, clinical patency of the port-catheter system, and technical success of port-catheter removal were evaluated.

RESULTS

Percutaneous port-catheter placement using this method was successfully performed in 59 (97%) of 61 patients. Subsequently, chemotherapy was successfully performed through the port in 57 (93%) of 61 patients. Complications during and after the procedure were observed in two (3%) of 61 patients and 12 (20.7%) of 58 patients. Hepatic artery thrombosis occurred in two (3.4%) of 58 patients. The port-catheter removal and the catheter replacement were performed in eight and four patients, respectively, who wanted the procedure. It was completed successfully without any complications.

CONCLUSION

This method of implantation of a port-catheter system appeared to offer clinical advantages of safe catheter removal, femoral artery access, and an acceptable complication rate.

Evaluation of a microcatheter-arterial port system for intraarterial therapy in an animal model

A new microcatheter-arterial port system for transarterial regional therapy was evaluated in a swine model. Subclavian or femoral access was followed by superselective catheterization of target arteries (hepatic, n = 6; splenic, n = 3). A hemostatic sleeve was placed at the arterial puncture site. Implantation into the target vessel succeeded in all nine placements (100%). After animal movement, no microcatheter tip moved by more than 10 mm. A small hematoma developed at one of the subclavian insertion sites. This system holds promise for transarterial therapies for regional cancer therapy.

Catheter position for adequate intra-arterial chemotherapy for advanced pancreatic cancer: evaluation with CT during arterial injection of contrast material

PURPOSE

To identify the drug infusion vessel for use in obtaining the best drug distribution in arterial infusion chemotherapy for advanced pancreatic cancer.

MATERIALS AND METHODS

In 16 cases of advanced pancreatic cancer (pancreatic head, n = 12; pancreatic body and/or tail, n = 4), computed tomography during arterial injection of contrast material was performed at the time of angiography. The sites of catheter placement were celiac artery, superior mesenteric artery, and their branches, such as gastroduodenal artery, inferior pancreatico-duodenal artery, or dorsal pancreatic artery.

RESULTS

In the cases of pancreatic head cancer, all except one with hepatomesenteric vascular variation were supplied by the celiac artery and superior mesenteric artery (dual supply). In the cases of pancreatic body and/or tail cancer, two were supplied by celiac artery alone and two showed dual supply. In the cases of pancreatic head cancer, when the areas supplied by the main trunk were compared with those supplied by its branches, three of nine cases on the celiac artery side and four cases on the superior mesenteric artery side showed that the areas were not consistent, with a partial defect observed in the areas supplied by branches of the superior mesenteric artery. In the cases of pancreatic body and/or tail cancer, on both sides, one of two cases was not consistent.

CONCLUSIONS

To achieve optimal drug distribution in arterial infusion chemotherapy for advanced pancreatic cancer, drug infusion via both the celiac artery and superior mesenteric artery is required in the majority of cases. In many cases, optimal drug distribution is not attainable with drug infusion via a branch; therefore, drug infusion should be administered via the main trunk.