Hepatic Arterial Port Systems for Treatment of Liver Metastases: Factors Affecting Patency and Adverse Events

Efficacy of Hepatic Arterial Infusion Chemotherapy and Radiofrequency Ablation against Hepatocellular Carcinoma Refractory to Transarterial Chemoembolization and Vascular Variation: A Case Study

Transarterial chemoembolization is often the first-line treatment for multiple hepatocellular carcinomas. However, hepatic arterial infusion chemotherapy is a treatment option for hepatocellular carcinoma refractory to multiple sessions of transarterial chemoembolization. Hepatic arterial infusion chemotherapy requires implantation of an appropriate port into the hepatic artery. However, it may be impossible to implant a port due to hepatic artery variation. We report a case of hepatocellular carcinoma refractory to transarterial chemoembolization and hepatic artery variation treated successfully with hepatic arterial infusion chemotherapy and radiofrequency ablation with complete response after implantation of ports in both liver lobes.

Complications arising from transfemoral, percutaneous implantation of an indwelling port-catheter system for hepatic infusion chemotherapy: Case series of the management and salvage of the system

INTRODUCTION

Regional hepatic arterial infusion of chemotherapy is performed for unresectable liver tumors via percutaneously implanted port-catheter systems; while these port-catheter systems are effective administration routes, they are associated with various complications. Withdrawal of the system is considered if the complications occur, but repeated hepatic arterial infusion of chemotherapy (HAIC) via an implanted port-catheter system is a last-resort treatment for unresectable advanced liver cancer, and the treatment must be continued. We discuss various cases with complications arising in the indwelling port area in hepatic arterial infusion of chemotherapy and report whether the system was salvaged.

METHODS

Between August 2013 and October 2017, eight patients (six males and two females) aged 61-80 years (mean age 76.6 years) with complications arising in a transfemoral indwelling port site for HAIC were referred to our department. All patients requested preservation of the system, especially the catheter. Each patient was assessed for the presence of "gross infection" based on a comprehensive evaluation of clinical findings and blood test results. In cases of "no gross infection," we performed catheter salvage procedures. If there was no clinical improvement following the catheter salvage procedure, the port-catheter system was withdrawn. This research work has been reported in line with the PROCESS criteria.

RESULTS

The port-catheter systems were withdrawn in two patients: one due to lasting infection and the other due to ulcer recurrence. Three cases were treated by removal of hematoma through an incision and ointment. The system was withdrawn in one of these cases due to exacerbation of ulcer; thus, the catheters were salvaged in five patients. None of these five patients experienced a relapse from 3 months to over 1 year after the procedure.

CONCLUSION

The success of subcutaneous HAIC significantly impacts a patient's prognosis, especially for unresectable tumors and residual tumor recurrences. Initially, we chose to preserve the devices without removal, particularly if there was no infection. However, this approach led to a delay in chemotherapy, prolongation of healing time, and additional complications. These cases demonstrate the importance of a thorough consultation with the patient's oncologist to discuss whether or not the device should be conserved.

Hepatic Arterial Infusion Chemotherapy for Liver Metastases from Gastric Cancer: An Analysis in Western Patients

Aims and background

The advantage of administering chemotherapy by hepatic arterial infusion is the achievement of high drug concentrations in the liver. Oxaliplatin, irinotecan and 5-flourouracil are active agents in advanced gastric cancer. Therefore a retrospective analysis was performed to investigate the effects of these drugs administered by hepatic arterial infusion in heavily pretreated gastric cancer patients with predominant hepatic metastases. Very limited data about hepatic arterial infusion exist in western gastric cancer patients.

Methods

Seven patients with advanced gastric cancer were included in the retrospective analysis. All patients had proven progressive disease prior to initiation of hepatic arterial infusion. All had an ECOG performance status of ≤2 and had received at least two previous systemic chemotherapy regimens, including the combination of cisplatin/5-fluorouracil. Patients were given chemotherapy by hepatic arterial infusion: 5-fluorouracil, 600 mg/m2, together with folinic acid, 300 mg/m2/2 h, followed by oxaliplatin, 85 mg/m2/2 h, every 2 weeks.

Results

Fifty-four cycles of hepatic arterial infusion (range, 2–21) with a median treatment duration of 6 cycles were administered in 7 patients. The treatment was feasible and safe, no grade 3–4 toxicity was observed. One patient showed stabilization of liver metastases over 7 months. In 6 of the 7 patients there was radiologically proven progressive disease after a median treatment time of 10 weeks.

Conclusions

Chemotherapy by hepatic arterial infusion is modestly effective in heavily pretreated gastric cancer patients. Hepatic arterial infusion has a very favorable toxicity profile and can be safely administered even in elderly patients. It might be an additional therapeutic option and should be further investigated. The literature on hepatic arterial infusion in gastric cancer patients is reviewed. Free full text available at www.tumorionline.it

The Precision of Hepatic Arterial Infusion Scintigraphy as a Quantitative Biomarker of Tumor Microvasculature

OBJECTIVE

Optimal clinical development of new cancer therapies targeting tumor vasculature requires new target-specific response assays. This clinical study examined the test-retest repeatability of SPECT as an in vivo assay of angiogenic hepatic tumor microvasculature using an intraarterial infusion of 99mTc-macroaggregated albumin (MAA) delivered via a hepatic artery infusion (HAI) pump.

MATERIALS AND METHODS

Patients with primary or secondary cancerous liver tumors with HAI pump-catheter implants placed for HAI chemotherapy underwent hepatic SPECT after separate arterial infusions of 37 and 185 MBq of 99mTc-MAA via an HAI pump. Quantitative measures of hepatic tumor MAA uptake were obtained from paired test-retest SPECT datasets. Repeatability was defined by quotients of paired measurands with 95% CIs and coefficients of repeatability (CRs).

RESULTS

Test-retest HAI pump SPECT yielded highly repeatable measurements in quantitative indexes of tumor microvasculature. Variability in repeat test-retest measurements was small relative to the range of observed measurements between different tumors. The total hepatic tumor microvascular MAA accumulation (percentage injected dose) proved most repeatable, with test-retest value quotients near unity (quotients: median, 1.10 ± 0.09 [SD]; range, 1.03-1.32; 95% CI, 1.07-1.19) and 1.6% CR. Tumor MAA uptake values ranged from 5% to 18% injected dose.

CONCLUSION

This article describes the precision of HAI SPECT as a quantitative biomarker of tumor microvasculature under conditions of repeatability. The results support clinical testing of HAI SPECT as a radiologic response biomarker for angiotropic tumor therapy.

A prototype of injector to control and to detect the release of magnetic beads within the constraints of multibifurcation magnetic resonance navigation procedures

PURPOSE

An injector equipped with a bead capture and a bead detection system is presented. In the context of magnetic resonance navigation (MRN), in which MRI gradients are used to steer intravascular therapeutic carriers, fast and reliable injection is essential. In this paper, we present a prototype of injector to control and to detect the release of magnetic beads.

METHODS

The injector relies on two distinct subsystems: (1) the capture subsystem, which creates local magnetic force to stop the flow of magnetic beads; and (2) the detection subsystem, which detects flowing beads and generates a trigger signal to start MRI gradient pulses. Both systems rely on small microcoils wound on the tubing.

RESULTS

Five-turn microcoils show the best compromise between size and performance. Less than 5 mW of power is required to capture 0.8-mm beads moving in a flow above 5 mL min^-1 or when a gradient above 200 mT m^-1 is applied. The detection system is not sensitive to noise and detects every 0.8-mm bead in flow rates up to 14 mL m^-1 .

CONCLUSION

The prototype of injector shows performance above the requirements inherent to magnetic resonance navigation. This system is a step toward in vivo multibifurcation MRN. Magn Reson Med 77:444-452, 2017. © 2016 Wiley Periodicals, Inc.

Extensive Use of Interventional Therapies Improves Survival in Unresectable or Recurrent Intrahepatic Cholangiocarcinoma

Aim. To assess the outcomes of patients with unresectable intrahepatic cholangiocellular carcinoma (ICC) treated by a tailored therapeutic approach, combining systemic with advanced image-guided local or locoregional therapies. Materials and Methods. Treatment followed an algorithm established by a multidisciplinary GI-tumor team. Treatment options comprised ablation (RFA, CT-guided brachytherapy) or locoregional techniques (TACE, radioembolization, i.a. chemotherapy). Results. Median survival was 33.1 months from time of diagnosis and 16.0 months from first therapy. UICC stage analysis showed a median survival of 15.9 months for stage I, 9 months for IIIa, 18.4 months for IIIc, and 13 months for IV. Only the number of lesions, baseline serum CEA and serum CA19-9, and objective response (RECIST) were independently associated with survival. Extrahepatic metastases had no influence. Conclusion. Patients with unresectable ICC may benefit from hepatic tumor control provided by local or locoregional therapies. Future prospective study formats should focus on supplementing systemic therapy by classes of interventions (“toolbox”) rather than specific techniques, that is, local ablation leading to complete tumor destruction (such as RFA) or locoregional treatment leading to partial remission (such as radioembolization). This trial is registered with German Clinical Trials Registry (Deutsche Register Klinischer Studien), DRKS-ID: DRKS00006237.

Is There Any Evidence for a Role of Local Treatment in Cholangiocarcinoma?

Background

Most cholangiocarcinomas (CCA) are locally advanced and unresectable at the time of diagnosis. Currently, chemotherapy combining gemcitabine with a platinum agent is the recommended first-line treatment regimen for advanced biliary tract cancer. However, median overall survival is only approximately 1 year. As the hepatic tumor burden is the limiting factor for the prognosis of these patients, local tumor control is essential.

Methods

We present and discuss the current evidence for such therapy options for patients with CCA.

Results

Local and locoregional therapies have been shown to be well tolerated and can contribute to tumor control in the context of a comprehensive oncologic treatment strategy, and may prolong survival of patients with advanced CCA. Unfortunately, only few high-quality clinical trials are available.

Conclusion

Randomized prospective clinical trials enrolling larger numbers of patients need to be carried out to elucidate the precise value of these treatments alone as well as in combination with systemic chemotherapy.

Isolated hepatic artery thrombosis leading to multiple liver infarcts in a non-transplant patient

Patient: Female, 62

Final Diagnosis: Hepatic artery thrombosis

Symptoms: Abdominal pain • Nausea • Vomiting

Medication: —

Clinical Procedure: —

Specialty: Surgery

Interventionally implanted port catheter systems for hepatic arterial infusion of chemotherapy in patients with primary liver cancer: a phase II-study (NCT00356161)

BACKGROUND

Hepatic arterial infusion (HAI) of chemotherapy requires the implantation of a transcatheter application system which is traditionally performed by surgery. This procedure, but particularly the adjacent drug application via pump or port is often hampered by specific complications and device failure. Interventionally implanted port catheter systems (IIPCS) facilitate the commencement of HAI without need for laparatomy, and are associated with favorable complication rates. We here present an evaluation of the most important technical endpoints associated with the use of IIPCS for HAI in patients with primary liver cancers.

METHODS

70 patients (pts) with hepatocellular (HCC, n=33) and biliary tract cancer (BTC, n=37) were enrolled into a phase II -study. Of those, n=43 had recurrent disease and n=31 suffered from liver-predominant UICC-stage IVb. All pts were provided with IIPCSs before being treated with biweekly, intraarterial chemotherapy (oxaliplatin, 5-Flourouracil, folinic acid). The primary objective of the trial was defined as evaluation of device-related complications and port duration.

RESULTS

Implantation of port catheters was successful in all patients. Mean treatment duration was 5.8 months, and median duration of port patency was not reached. Disease-progression was the most common reason for treatment discontinuation (44 pts., 63%), followed by chemotherapy-related toxicity (12 pts., 17%), and irreversible device failure (5 pts., 7%). A total of 28 port complications occurred in 21 pts (30%). No unexpected complications were observed.

CONCLUSIONS

HAI via interventionally implanted port catheters can be safely applied to patients with primary liver tumors far advanced or/and pretreated.

Hepatic arterial infusion with oxaliplatin and 5-FU/folinic acid for advanced biliary tract cancer: a phase II study

BACKGROUND

Effective and tolerable chemotherapy with gemcitabine and cisplatin for advanced biliary tract cancer (BTC) has been established recently. However, overall prognosis is still poor, and additional therapeutic approaches are needed for patients with locally advanced, irresectable and/or pretreated tumors. Hepatic arterial infusion (HAI) of chemotherapy represents a safe and well-established treatment modality, but data on its use in patients with BTC are still sparse.

METHODS

Patients with irresectable BTC predominant to the liver were included in a prospective, open phase II study investigating HAI provided through interventionally implanted port catheters. Intraarterial chemotherapy consisted of biweekly oxaliplatin (O) 85 mg/m(2) and folinic acid (F) 170 mg/m(2) with 5-FU (F) 600 mg/m(2).

RESULTS

Between 2004 and 2010, 37 patients were enrolled. A total of 432 cycles of HAI were applied with a median of 9 (range 1-46) cycles. Objective response rate was 16 %, and tumor control was achieved in 24 of 37 (65 %) patients. Median progression-free survival was 6.5 months (range 0.5-26.0; 95 % CI 4.3-8.7), median overall survival was 13.5 (range 0.9-50.7; 95 % CI 11.1-15.9) months. The most frequent adverse event was sensory neuropathy grade 1/2 in 10/14 patients.

CONCLUSIONS

Using a minimal invasive technique, repetitive HAI with OFF is feasible and results in clinically relevant tumor control with low toxicity in patients with liver predominant advanced BTC.

Hepatic arterial infusion chemotherapy with a coaxial reservoir system using a non-braided spiral tip microcatheter

PURPOSE

To evaluate the efficacy and safety of a coaxial reservoir system with a non-braided spiral tip microcatheter and exclusive port for hepatic arterial infusion chemotherapy.

MATERIALS AND METHODS

In vitro evaluation included evaluation of pressure tolerance/flow rate of the coaxial reservoir system, and the strength of connection between the 2.7-F catheter and port. Due to the difficulty of implanting conventional reservoirs, coaxial reservoirs were implanted via the femoral artery of 80 patients. We implanted a non-braided 2.7-F microcatheter with a spiral shaped tip, 5-F catheter, and a port. Clinical assessment included evaluation of technical success and complications.

RESULTS

In vitro evaluation of the coaxial reservoir at its maximum pressure load showed that flow rates for 300 mg I/mL iopamidol contrast medium were 0.25 ± 0.04 mL/s (undiluted), 1.03 ± 0.01 mL/s (50% dilution), and 2.91 ± 0.01 mL/s (30% dilution). Connection strength between the 2.7-F catheter and port was 13.4 ± 0.57 N. Percutaneous port catheter placement was successful in all patients (100%, n = 80). Complications included hepatic arterial occlusion (10%, n = 8), catheter tip dislocation (1.3%, n = 1), and catheter occlusion (1.3%, n = 1).

CONCLUSIONS

A coaxial reservoir system with a non-braided microcatheter and exclusive port is safe and effective for difficulty of implanting conventional reservoir.

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.

Phase II feasibility study on the combination of two different regional treatment approaches in patients with colorectal "liver-only" metastases: hepatic interstitial brachytherapy plus regional chemotherapy

The aim of this study was to evaluate the feasibility, safety, and efficacy of combined treatment with hepatic interstitial brachytherapy (HIB) and hepatic arterial infusion (HAI) of chemotherapy after interventional implantation of port catheter systems. Thirty-three patients with unresectable "liver-only" metastases of colorectal cancer were treated with both HIB and HAI during the course of their disease. All 33 patients had recurrent disease and 27 had received previous chemotherapy. Of these, 15 received HAI first and were then consolidated with HIB, 9 started with HIB and were continued with HAI, and 9 received first HIB and subsequently HAI after hepatic disease progression. Patients were evaluated for treatment characteristics, side effects, and efficacy. Comparisons between treatment groups were also performed. The median tumor diameter of metastases treated with brachytherapy was 4.6 cm (range: 1-12 cm). The median minimal irradiation dose inside the tumor margin was 18 Gy administered to a mean of two metastases in 69 interventions. Minor (n = 4) and major (n = 3) complications occurred in 10% of interventions. WHO grade III adverse events of the regional chemotherapy were observed in seven patients; grade IV, in one patient. At a median follow-up of 28 months (range: 7-74 months), the median time to disease progression after first treatment was 10.5 months (range: 1-35 months). Of 138 metastases treated by brachytherapy, 16 local recurrences were seen (mean, 12.3 months; range, 3-45 months). No signs of hepatic failure were observed in any of our patients. In conclusion, combinations of two minimally invasive therapeutic methods are feasible, with acceptable complication rates, and provide promising results in colorectal cancer patients with unresectable hepatic 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.

Interventionally implanted port catheter systems for hepatic arterial infusion of chemotherapy in patients with colorectal liver metastases: a Phase II-study and historical comparison with the surgical approach

BACKGROUND

The high complication rates of surgically implanted port catheter systems (SIPCS) represents a major drawback in the treatment of isolated liver neoplasms by hepatic arterial infusion (HAI) of chemotherapy. Interventionally implanted port catheter systems (IIPCS) have evolved into a promising alternative that enable initiation of HAI without laparatomy, but prospective data on this approach are still sparse. Aim of this study was to evaluate the most important technical endpoints associated with the use of IIPCS for the delivery of 5-fluorouracil-based HAI in patients with colorectal liver metastases in a phase 2-study, and to perform a non-randomised comparison with a historical group of patients in which HAI was administered via SIPCS.

METHODS

41 patients with isolated liver metastases of colorectal cancer were enrolled into a phase II-study and provided with IIPCS between 2001 and 2004 (group A). The primary objective of the trial was defined as evaluation of device-related complications and port duration. Results were compared with those observed in a pre-defined historical collective of 40 patients treated with HAI via SIPCS at our institution between 1996 and 2000 (group B).

RESULTS

Baseline characteristics were balanced between both groups, except for higher proportions of previous palliative pre-treatment and elevated serum alkaline phosphatase in patients of group A. Implantation of port catheters was successful in all patients of group A, whereas two primary failures were observed in group B. The frequency of device-related complications was similar between both groups, but the secondary failure rate was significantly higher with the use of surgical approach (17% vs. 50%, p < 0.01). Mean port duration was significantly longer in the interventional group (19 vs. 14 months, p = 0.01), with 77 vs. 50% of devices functioning at 12 months (p < 0.01). No unexpected complications were observed in both groups.

CONCLUSION

HAI via interventionally implanted port catheters can be safely provided to a collective of patients with colorectal liver metastases, including a relevant proportion of preatreated individuals. It appears to offer technical advantages over the surgical approach.

Complications of transfemoral removal of percutaneous transfemorally implanted port-catheter systems

Our purpose is to evaluate the feasibility and safety of the withdrawal procedure of percutaneous transfemorally implanted port-catheter systems. Thirty-seven patients (17.7%) underwent the withdrawal procedure of this port-catheter system among 209 patients. The reasons for withdrawal were as follows: termination of intra-arterial chemotherapy (n = 7), obstruction of hepatic artery (n = 5), port infection (n = 4), catheter infection (n = 4), catheter obstruction (n = 4), lower-limb palsy and pain (n = 2), exposure of the port due to skin defect (n = 2), patient's desire (n = 2), side effect of chemotherapy (n = 1), no effectiveness of chemotherapy (n = 1), hematoma at the puncture site (n = 1), duodenum perforation by the catheter (n = 1), intermittent claudication due to severe stenosis of right common iliac artery (n = 1), dissection of common hepatic artery (n = 1), and broken catheter (n = 1). In thirty-four of the 37 cases, the port-catheter system was successfully withdrawn without any complications. Clinical success rate was 91.9%. Complications occurred in three cases (8.1%), which were a pseudoaneurysm, thromboembolism of the right common iliac artery, and continuous bleeding from the subcutaneous pocket where the port system was placed for 1 month. In 15 cases, correction of the catheter tip or exchange for dislocation of the tip had to be done without withdrawal. It is not rare to withdraw port-catheter systems in cases of infection or hematoma around the system. Although withdrawal of a percutaneous transfemorally implanted port-catheter system is a relatively safe procedure, the port-catheter system should not be removed unless absolutely indicated.

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.

Fusion imaging using a hybrid SPECT-CT camera improves port perfusion scintigraphy for control of hepatic arterial infusion of chemotherapy in colorectal cancer patients

PURPOSE

Exclusive and homogeneous perfusion of the liver is considered essential for the efficacy of hepatic arterial infusion of chemotherapy (HAI). The aim of this study was to evaluate port perfusion scintigraphy in colorectal cancer patients using a hybrid SPECT-CT system for control of minimally invasive intra-arterial port systems within the scope of a phase II trial.

METHODS

In 24 consecutive patients, the perfusion territories of intra-arterial hepatic port systems were assessed by port scintigraphy with( 99m)Tc-labelled macroaggregated albumin employing planar imaging, SPECT and SPECT-CT (acquired with a hybrid SPECT-CT camera). The results of blinded reading of the scintigraphic modalities concerning the intra- and extrahepatic perfusion pattern were compared with combined image analysis (angiography and contrast-enhanced dedicated CT) and patient history for validation.

RESULTS

Extrahepatic perfusion was correctly seen in three patients, while suspected extrahepatic perfusion could be excluded in one. In 46 liver lobes, perfusion patterns were correctly visualised by SPECT-CT in 100% of cases (planar, 67%; SPECT, 86%). Assessing the perfusion pattern inside the liver on a segmental basis (segments, n=138), SPECT-CT revealed correct segmental assignment of tracer distribution in 100% and was significantly superior to SPECT alone (accuracy, 84%; p<0.001). The scintigraphic findings resulted in changes in therapeutic management in 8/24 patients (33%); in two of these the relevant findings were visualised only by SPECT-CT.

CONCLUSION

In patients receiving HAI, port perfusion scintigraphy by fusion imaging with a hybrid SPECT-CT system provides important information for therapy optimisation and appears to be superior to SPECT alone.