Hepatic arterial flow distribution with hepatic neoplasms: significance in infusion chemotherapy

Hepatic artery radionuclide flow studies and hepatic angiography in eight patients with various hepatic neoplasms were evaluated to determine the patterns of arterial flow distribution in the presence of portal vein occlusion. Increased hepatic arterial blood flow to the lobe or segment supplied by the occluded portal vein was observed in all patients. This phenomenon must be taken into account when positioning catheters for hepatic artery infusion chemotherapy; while it may improve the flow of chemotherapeutic agents to tumors located in the area of an occluded portal vein branch, it may also result in diversion of flow to the normal hepatic parenchyma away from tumors occupying the hepatic segments with patent portal venous flow. Hepatic angiography and radionuclide flow studies provide the necessary information for correct positioning of hepatic artery infusion catheters.     

Percutaneous transluminal angioplasty for hepatic arterial occlusion following hepatic arterial infusion chemotherapy

We report a case in which hepatic arterial occlusion developed during repeated hepatic arterial infusion chemotherapy through an implanted port-catheter system for advanced malignant hepatic neoplasia. After successful recanalization of the hepatic artery by using percutaneous transluminal angioplasty, another port-catheter system was placed percutaneously by interventional radiology techniques, allowing the continuation of hepatic arterial infusion chemotherapy.     

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.     

Complications of hepatic arterial infusion chemotherapy.

Chemotherapy by direct hepatic arterial infusion (HAI) results in reduction in tumor mass in a large percentage of patients. The authors reviewed records for 45 patients with metastatic cancer of the gastrointestinal tract who underwent HAI chemotherapy with floxuridine, administrated via an implanted pump. Twenty-seven of the 45 patients suffered complications, including gastrointestinal ulceration (18%), hepatitis (24%), sclerosing cholangitis (7%), and abscess (2%). The complication rates in this series were similar to those previously reported. The toxicity of HAI chemotherapy continues to limit its efficacy.     

Iatrogenic sclerosing cholangitis following hepatic arterial chemotherapy infusion

A case of common hepatic duct stricture secondary to hepatic artery chemotherapy infusion is described. CT and endoscopic retrograde cholangiopancreatography (ERCP) may be used in concert to differentiate this entity from other causes of jaundice--namely, hepatic replacement by tumor, porta hepatis adenopathy, and chemotherapy hepatotoxicity.     

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.     

Optimal injection protocol for CT evaluation during hepatic arterial infusion chemotherapy

OBJECTIVE: As an imaging modality for follow-up during continuous or repeated hepatic arterial infusion chemotherapy using a hepatic intra-arterial indwelling catheter, the usefulness of CT while infusing contrast through the indwelling catheter (reservoir port) was examined. METHODS: Using reservoir ports implanted in eight patients with hepatic metastasis from colon cancer, radioisotope perfusion scintigraphy (RI), CT (three rates of infusion of contrast were used), and digital subtraction angiography (AG) were performed to compare the modalities' ability to visualize the intrahepatic and abnormal extrahepatic distributions. RESULTS: CT (infusion rate 0.1 mL/sec) was superior to AG and RI in terms of the ability to visualize intrahepatic distribution, particularly in small areas, and facilitated 3D delineation of the distribution. In evaluating extrahepatic distribution, CT also outperformed the other modalities. CONCLUSIONS: For imaging study follow-up during hepatic arterial infusion chemotherapy, CT proved to be more useful than conventional RI and AG.     

Interventional radiologic treatment for hepatic arterial occlusion after repeated hepatic arterial infusion chemotherapy via implanted port-catheter system

The present study evaluated the feasibility of interventional radiologic treatments for hepatic arterial occlusion after hepatic arterial infusion chemotherapy (HAIC) via an implanted port-catheter system. Treatment for hepatic arterial occlusion was attempted in seven patients with unresectable liver cancer. In six, the obstructed hepatic artery was recanalized. In three patients, the recanalized hepatic artery again became obstructed. However, by performing additional interventional radiologic procedures, secondary patency of the hepatic artery was successfully obtained in two patients. In conclusion, when hepatic arterial occlusion occurs, HAIC can be resumed in the attempt to recanalize the hepatic artery.     

Complications of long term transbrachial hepatic arterial infusion chemotherapy.

A total of 127 transbrachial hepatic artery catheters were placed in 75 patients for prolonged infusion of chemotherapeutic agents for primary and secondary tumors of the liver. Hepatic or celiac artery catheterization was possible in 97.4% of patients. The most frequent major complication was partial or complete arterial thrombosis (30 patients). bleeding at the arteriotomy site and pseudoaneurysm also occurred. Minor complications included displacement of catheter from the hepatic artery in 46, cracks or leaks in the catheter at the arteriotomy site in 21, and clotted catheter in 10 instances. Infection occurred in four patients and loss of radial pulse in seven. In view of a significant increase in survival, the complications did not contraindicate long term intraarterial infusion of chemotherapeutic agents. The no. 5 French blue thin wall 1.24-1.70 mm tubing proved to be easiest to use and least prone to complications. Proper management of these patients by a team approach (nurse, oncologist, and radiologist) helps to minimize the frequency and severity of complications.     

Value of transcatheter arterial embolization with coils and n-butyl cyanoacrylate for long-term hepatic arterial infusion chemotherapy

PURPOSE: To assess the value of transcatheter arterial embolization (TAE) of splanchnic arterial branches to allow continuous application of repeat hepatic arterial infusion chemotherapy (HAIC). MATERIALS AND METHODS: In 128 patients with unresectable advanced liver cancer, percutaneous implantation of a port catheter system and TAE of splanchnic arteries with coils and/or n-butyl cyanoacrylate (NBCA) were performed. Parameters included (a) methods selected for catheter placement; (b) embolic materials used (coils and/or NBCA, number of coils, administration rate of NBCA-iodized oil) for TAE of splanchnic arteries, details of embolized arteries, and frequency of recanalization; (c) ability to prevent gastrointestinal symptoms by avoiding inflow of anticancer drugs into extrahepatic adjacent organs and to maintain distribution of contrast agents in liver, as well as management of difficulties encountered; (d) complications related to catheter system implantation or to long-term HAIC and management of such complications; and (e) final success in performing scheduled HAIC while maintaining distribution over liver via a single route without gastrointestinal symptoms caused by inflow of anticancer drugs. Fisher exact test was used to compare recanalization rate between coil-embolized and NBCA- or NBCA-coil-embolized arteries, and frequency of heterogeneously poor distribution was compared between patients with single and those with multiple hepatic arteries. RESULTS: Embolization was successful during first catheterization in 326 arteries and during follow-up in 10. In 119 (93.0%) of 128 patients, repeat HAIC was effective until death or the time of this writing (observation period, 2-47 months). HAIC was continued in two patients, although anticancer drugs did not distribute to all liver tumors. Arteries once embolized with coils alone spontaneously recanalized at a significantly higher rate than those with NBCA (eight of 192 vs one of 144, P =.048). Rate of heterogeneously poor distribution was significantly higher in those with two or more hepatic arteries than in those with one (seven of 17 vs nine of 111, P =.001). CONCLUSION: TAE for various splanchnic organs is useful for efficient performance of long-term HAIC.     

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

PURPOSE: To investigate the technical outcome of radiologic catheter placement with use of a side-hole catheter with distal fixation for hepatic arterial infusion chemotherapy. MATERIALS AND METHODS: Between January 1993 and September 1999, 426 patients were referred to our department to undergo intraarterial infusion chemotherapy for unresectable malignant liver tumors. A subclavian artery was exposed under local anesthesia and a catheter was inserted. After inserting the tip of the side-hole catheter into the gastroduodenal artery, splenic artery, or peripheral branch of the hepatic artery, the catheter tip was fixed to the vessel with use of coils and a mixture of n-butyl cyanoacrylate (NBCA) and iodized oil. The proximal end of the catheter was connected to an implanted port, and the port system was embedded subcutaneously. RESULTS: Placement was successful in 425 of 426 patients (99.8%) in a mean time of 76 minutes. Catheter dislodgement was noted in 12 patients (2.8%). Cumulative patency rates of the hepatic artery calculated according to the Kaplan-Meier method for the entire group were 91.0%, 81.4%, and 58.1% at 6 months and 1 and 2 years, respectively. Complications related to catheter placement were observed in nine cases and included dysfunction of the implanted system (n = 3), significant bleeding around the implanted port (n = 2), improper infusion of NBCA and iodized oil (n = 2), and cerebral infarction (n = 2). CONCLUSION: Radiologic catheter placement via a subclavian artery with side-hole catheter placement with distal fixation for hepatic arterial infusion chemotherapy is a highly successful procedure with a reduced risk of catheter dislodgment and arterial occlusion.     

Development of extrahepatic arterial blood supply to the liver during hepatic arterial infusion chemotherapy

The aim of this study was to evaluate the correlation of development of the collateral circulation to the liver during hepatic arterial infusion chemotherapy (HAIC) with the presence of hepatic tumours adjacent to the hepatic surface, and with pretreatment occlusion of aberrant hepatic arteries. In 102 patients with unresectable malignant hepatic tumours treated with HAIC using an implantable port system, development of collaterals to the liver was assessed with CT arteriography using the implantable port and pre- and postoperative angiography. Aberrant hepatic arteries, if present, were occluded prior to treatment for hepatic arterial redistribution. Collaterals to the liver were seen in 29 patients, who had 35 areas with collateral perfusion: 22 areas were in the right posterosuperior area, 6 in the left peripheral area and 7 in the right or left lobar area. Collaterals were revealed more frequently in patients with hepatic tumours adjacent to the hepatic surface than in those without hepatic tumours in peripheral areas in the liver (p < 0.0001). In addition, collaterals developed more frequently in patients with an aberrant hepatic arterial anatomy compared with those with conventional anatomy (p = 0.0007). Our results indicated that patients with hepatic tumours adjacent to the hepatic surface and with pretreatment occlusion of aberrant hepatic arteries had the potential to develop collaterals to the liver during HAIC. Received 4 November 1997; Revision received 24 February 1998; Accepted 2 June 1998     

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

The purpose of the present study is to evaluate the feasibility of a method developed to withdraw a port-catheter system that had been implanted with use of the fixed catheter tip technique. Withdrawal of an implanted catheter was required in four patients with advanced liver cancer in whom port-catheter systems had been implanted for performance of repeated hepatic arterial infusion. In all patients, port-catheter systems were successfully removed without complications. In conclusion, an implanted port-catheter system can be removed even when implanted with the fixed catheter tip technique.     

Bile duct complications of hepatic arterial infusion chemotherapy evaluated by helical CT

AIM: To describe the imaging findings of bile duct complications of hepatic arterial infusion chemotherapy (HAIC) using helical CT, to set diagnostic criteria, to develop a CT grading system, and to correlate these with clinical findings and laboratory data. METHODS: Follow-up helical CT of the abdomen was performed every 3 months for 60 patients receiving HAIC. Three radiologists reviewed all CT studies before and after treatment, using either the picture archiving and communication system or hard copies. The findings of bile duct abnormalities were correlated with findings from other imaging techniques, clinical symptoms and laboratory data. RESULTS: Bile duct abnormalities developed in 34 (57%) of cases either during HAIC or 1 to 12 months after treatment. In 14 (41%) of these 34 patients, enhancement of the hepatic parenchyma along the dilated bile duct or in the segmental or lobar distribution was observed. In 43 cases (72%), normal or abnormal alkaline phosphatase levels were consistent with normal or abnormal CT findings, respectively. Increasing alkaline phosphatase and bilirubin levels were related to CT grade. CONCLUSION: Imaging findings of bile duct complications of HAIC are similar to those of primary sclerosing cholangitis, and correlate well with abnormal clinical and laboratory data. In the presence of such clinical abnormalities, thin-section helical CT with careful review of the imaging studies helps to determine the correct diagnosis, monitor the changes and guide appropriate treatment.