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

Techniques and status of hepatic arterial infusion chemotherapy for primary hepatobiliary cancers

Primary hepatobiliary cancers (PHCs), which mainly include hepatocellular carcinoma (HCC) and biliary tract cancers (BTCs), are mostly diagnosed in the advanced stage and are not candidates for curative surgery or ablation, resulting in a dismal prognosis. Targeted therapies with or without programmed death receptor 1 (PD-1)/PD-L1 inhibitors have been incorporated into first-line treatments for advanced HCC. Systemic chemotherapy is still the mainstay treatment for advanced BTCs, and combining it with PD-1/PD-L1 inhibitors has resulted in prolonged patient survival. Intra-arterial therapies, including trans-arterial chemoembolization, selective internal radiation therapy, and hepatic arterial infusion chemotherapy (HAIC), have been explored and used for advanced hepatobiliary cancers for many years with positive results, particularly when combined with systemic treatments. Recently, an increasing number of phase II/III trials have demonstrated the efficacy and safety of HAIC for the treatment of advanced HCC with portal vein tumor thrombosis and/or a large tumor burden, for the neoadjuvant and adjuvant treatment of HCC with high-risk factors, and for treating advanced intrahepatic and perihilar cholangiocarcinoma. However, the techniques and regimens used for HAIC are diverse and differ greatly between various regions and centers worldwide. This review focuses on these diverse techniques and regimens, as well as the updated evidence on HAIC regarding the treatment of PHCs.

Intraarterial Therapies for the Management of Hepatocellular Carcinoma

Image-guided locoregional therapies play a crucial role in the management of patients with hepatocellular carcinoma (HCC). Transarterial therapies consist of a group of catheter-based treatments where embolic agents are delivered directly into the tumor via their supplying arteries. Some of the transarterial therapies available include bland embolization (TAE), transarterial chemoembolization (TACE), drug-eluting beads-transarterial chemoembolization (DEB-TACE), selective internal radioembolization therapy (SIRT), and hepatic artery infusion (HAI). This article provides a review of pre-procedural, intra-procedural, and post-procedural aspects of each therapy, along with a review of the literature. Newer embolotherapy options and future directions are also briefly discussed.

Hepatic Arterial Infusion of Chemotherapy for Advanced Hepatobiliary Cancers: State of the Art

Simple Summary

Liver functional failure is one of the leading causes of cancer-related death. Systemic chemotherapy usually offers a modest benefit in terms of disease control rate, progression-free survival, and overall survival at the cost of a significant percentage of adverse events. Liver malignancies are mostly perfused by the hepatic artery while the normal liver parenchyma by the portal vein network. On these bases, the therapeutic strategy consisting of hepatic arterial infusion of chemotherapy takes place. This review aims to summarize the current knowledge on this approach from different points of view, such as techniques, drugs pharmacology and pharmacokinetics, and clinical outcomes for advanced hepatobiliary cancers. Most of the collected studies have several limitations: non-randomized retrospective design, a relatively small number of patients, the hepatic arterial administration of different chemotherapeutic agents, as well as its combination with a great heterogeneity of systemic agents. However, despite these limitations, the presented data show favorable results in terms of safety and efficacy for hepatic arterial infusion of chemotherapy, with respect or in alternative to the gold standard treatment, even when they are combined with systemic treatments. Therefore, this therapeutic strategy may be an alternative or an integrative treatment option for advanced hepatobiliary cancers. Further and larger prospective, randomized, multi-center studies, with well-defined inclusion criteria and treatment strategies, are required to confirm the presented data.

Abstract

Liver functional failure is one of the leading causes of cancer-related death. Primary liver tumors grow up mainly in the liver, and thus happens for liver metastases deriving from other organs having a lower burden of disease at the primary site. Systemic chemotherapy usually offers a modest benefit in terms of disease control rate, progression-free survival, and overall survival at the cost of a significant percentage of adverse events. Liver malignancies are mostly perfused by the hepatic artery while the normal liver parenchyma by the portal vein network. On these bases, the therapeutic strategy consisting of hepatic arterial infusion (HAI) of chemotherapy takes place. In literature, HAI chemotherapy was applied for the treatment of advanced hepatobiliary cancers with encouraging results. Different chemotherapeutic agents were used such as Oxaliplatin, Cisplatin, Gemcitabine, Floxuridine, 5-Fluorouracil, Epirubicin, individually or in combination. However, the efficacy of this treatment strategy remains controversial. Therefore, this review aims to summarize the current knowledge on this approach from different points of view, such as techniques, drugs pharmacology and pharmacokinetics, and clinical outcomes for advanced hepatobiliary cancers.

Evaluation of percutaneous unilateral trans-femoral implantation of side-hole port-catheter system with coil only fixed-catheter-tip for hepatic arterial infusion chemotherapy

Background

The technique for arterial infusion chemotherapy (HAIC) is not standardized which limits its widely application. The aim of this study was to evaluate the long-term functionality and complications of port-catheter system using percutaneous unilateral trans-femoral implantation with coil only fixed-catheter-tip method.

Methods

From January 2013 to January 2017, 205 consecutive patients (138 men; aged 28–88 years; mean, 59.1 ± 11.2 years) with unresectable malignant liver tumors underwent percutaneous implantation of side-hole infusion port-catheter into hepatic artery using coil only fixed-catheter-tip method via the unilateral femoral artery. Technical success, procedure time, duration of port functionality, and complications of port dysfunction were investigated.

Results

Implantation technical success was 98.5% and the procedure time was 59.1 ± 10.2 min. Predictable functionality of the port-catheter system at 6-, 12-, and 24 months were 97.5, 89.9, 70.5%, respectively. Complications of port irreversible dysfunction were hepatic artery obstruction (4.0%), catheter occlusion (3.5%), and catheter dislocation (0.5%). Median 5 HAIC cycles (range: 1–14 cycles) were received via port.

Conclusion

Percutaneous unilateral trans-femoral implantation of a side-hole port-catheter with coils only fixed-catheter-tip method is a simple and feasible interventional technique for HAIC which offers long-term functionality.

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.

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.

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.