Percutaneously implantable catheter-port system for chemotherapeutic infusion through the hepatic artery

Percutaneous Implantation of a Microcatheter-Port System for Hepatic Arterial Infusion Chemotherapy of Unresectable Liver Tumors: Technical Feasibility, Functionality, and Complications

To evaluate the feasibility and safety of percutaneously implanted arterial port catheter systems for hepatic arterial infusion of chemotherapy (HAI) in patients with unresectable liver malignancies. From October 2010 to August 2018, arterial port catheters for HAI were percutaneously implanted in 43 patients with unresectable liver malignancies. Three different catheter placement techniques were compared: a conventional end-hole catheter placed in the common hepatic artery (technique 1, n = 16), a side-hole catheter with the tip fixed in the gastroduodenal artery (technique 2, n = 18), and a long-tapered side-hole catheter with the tip inserted distally in a segmental hepatic artery (technique 3, n = 6). Catheter implantation was successful in 40 (93%) of the 43 patients. Complications related to catheter placement were observed in 10 (23%) patients; 5 (83%) of the 6 major complications were resolved, as well as all 4 minor complications. Catheter migration and occlusion occurred in 9 (22.5%) patients. Catheter migration was more frequent with technique 1 (n = 6) than with technique 2 (n = 1), although the difference was not significant (p = 0.066). Percutaneous arterial port catheter implantation for HAI is highly feasible and carries a low risk of complications.

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.

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.

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.

Coil embolization of an arteriobiliary fistula caused by hepatic intra-arterial chemotherapy

Arteriobiliary fistula is a rare complication of hepatic intra-arterial chemotherapy. We report successful coil embolization of an arteriobiliary fistula. An 80-year-old woman underwent percutaneous placement of an indwelling catheter into the replaced right hepatic artery for intra-arterial chemotherapy of liver metastases. Coil embolization of the left hepatic artery was not performed. The patient complained of abdominal pain during intra-arterial chemotherapy. Angiography revealed a fistula between the replaced right hepatic artery and the common bile duct. The fistula was successfully treated by coil embolization via the indwelling catheter, and the indwelling catheter was removed. Although such complications usually herald the termination of intra-arterial chemotherapy, the patient underwent percutaneous implantation of a new catheter-port system, and intra-arterial chemotherapy was restarted.

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.

Complications After Percutaneous Transaxillary Implantation of a Catheter for Intraarterial Chemotherapy of Liver Tumors:Clinical Relevance and Management in 204 Patients

OBJECTIVE

The purposes of the study were to evaluate the complications of patients who underwent percutaneous transaxillary implantation of a permanent catheter-port system for intraarterial hepatic chemotherapy and determine their clinical relevance and specific management. SUBJECTS AND METHODS. Catheter-port systems were placed in 204 patients with liver tumors (86.7% from colorectal metastases). Under sonographic and fluoroscopic guidance, a 5.8-French catheter was placed in the hepatic artery and connected to a subcutaneous reservoir after embolization of the gastroduodenal and right gastric arteries. Floxuridine plus dexamethasone and systemic low-dose heparin were administered. During the follow-up period, complications were classified as clinically not significant (type 1), clinically significant not requiring interruption of intrahepatic chemotherapy (type 2), clinically significant needing temporary suppression of intrahepatic chemotherapy (type 3), and clinically significant causing permanent suppression of intrahepatic chemotherapy (type 4).

RESULTS

No complications occurred during the implantation procedures. The mean number of intrahepatic chemotherapy cycles was 8.1. The mean follow-up period was 270 days. Primary and secondary patency rates of the system were 71.6% and 91.2%, respectively. Temporary suppression of intrahepatic chemotherapy was necessary in 19.6% of the patients and definitive suppression, in 8.8%. Hepatic artery thrombosis, not recanalized by local thrombolysis, was the main cause of permanent intrahepatic chemotherapy interruption (4.4%). Catheter occlusions and cerebral complications were not observed. In 91.2% of the patients, intrahepatic chemotherapy could be completed.

CONCLUSION

Percutaneous implantation of a removable and reimplantable catheter-port system for intrahepatic chemotherapy can be a safe procedure to treat unresectable liver metastases from colorectal cancer. Technical and pharmacologic complications with variable clinical relevance occurred, and various specific management strategies were necessary to reduce their incidence.

J-tipped guidewire as a target for puncture of the subclavian artery in the placement of a reservoir port and catheter system

The aim of this study was to verify the feasibility of using a J-tipped guidewire as a target for puncture of the subclavian artery in the placement of a reservoir port and catheter system (RPCS). Twenty-five patients with various hepatic malignancies underwent percutaneous implantation of an RPCS through the left subclavian artery for regional chemotherapy. To successfully puncture the left subclavian artery, a J-tipped guidewire was used as a target with fluoroscopic guidance. Technical success and complication rates, and numbers of puncture failures, were retrospectively analyzed. Implantation of the RPCS was successful in all patients. Eight (32%) patients had minor complications and no patient had major complications. The number of puncture failures per patient was 0 to 1 (mean=0.32). The J-tipped guidewire is a safe and appropriate target for puncture of the subclavian artery in the placement of an RPCS.

Comparison of high-resolution contrast-enhanced 3D MRA with digital subtraction angiography in the evaluation of hepatic arterial anatomy

AIM

To evaluate the validity of high-resolution contrast-enhanced three-dimensional magnetic resonance angiography (MRA) in defining hepatic arterial anatomy and to compare this with digital subtraction angiography (DSA).

MATERIALS AND METHODS

MRA and DSA were performed in 30 patients. MRA was performed with breath-hold, gadolinium-enhanced, three-dimensional, fast low-angle shot sequence with a 512 pixel matrix. MRA was compared with DSA in terms of image quality and depiction of hepatic arterial anatomy. The agreement in image quality between MRA and DSA was determined with the kappa statistic.

RESULTS

With respect to image quality, there was excellent or good correlation between MRA and DSA for the common hepatic artery (kappa=0.85), proper hepatic artery (kappa=0.72), gastroduodenal artery (kappa=0.70), left hepatic artery (kappa=0.49), left gastric artery (kappa=0.50), splenic artery (kappa=0.84), and superior mesenteric artery (kappa=0.88). Poor correlation was found for the right hepatic artery (kappa=0.18) and right gastric artery (kappa=0.38). With regard to hepatic arterial anatomy, MRA correlated correctly with DSA in 28 of the 29 cases, i.e. 97% of patients.

CONCLUSION

MRA is a useful technique for the evaluation of the hepatic artery, and for the vast majority of patients, MRA can replace intra-arterial DSA.

Intraarterial chemotherapy of liver metastases: implantation of a microcatheter-port system with use of modified fixed catheter tip technique

A new method was developed to implant a microcatheter-port system for repeat intraarterial chemotherapy of liver metastases. The microcatheter-port system was successfully implanted in all 20 patients reported in this study, and the only complications were one early occlusion of the hepatic artery and one dislocation of the implanted catheter.

Complications encountered with a transfemorally placed port-catheter system for hepatic artery chemotherapy infusion

A port-catheter system was implanted via femoral artery access for hepatic artery chemotherapy infusion. Implantation was attempted in 90 patients and was successful in 88. Blood flow redistribution was performed using embolization coils. In the first ten patients a soft heparin-coated infusion catheter was used. For the following 78 patients we used a stiffer catheter coated with fluorine-acryl-styrene-urethane-silicone (FASUS) copolymer. The catheter was connected to a port implanted subcutaneously below the level of the inguinal ligament. Complications during the procedure and after placement were observed in 7 of 90 patients and 24 of 88 patients, respectively. These included catheter obstruction (11%), dislocation of the catheter tip (10%), drug toxicity (5.7%), and catheter infection (3.4%). In 6 of 10 patients with catheter obstruction, recanalization of the port system was achieved. In 7 of 9 patients with dislocation of the indwelling catheter tip, replacement of the port system was successful. Our complications appear to be comparable with those encountered with the subclavian/brachial approach when the new catheter coating is used. Notable is the avoidance of cerebral infarcts.