Hepatic intra-arterial infusion chemotherapy using polymer-coated 2.9 Fr implantable catheter-port system--initial experience]

We developed a new 2.9 Fr implantable catheter-port system (reservoir) to perform arterial infusion chemotherapy in patients with unresectable liver tumors. This study was undertaken to evaluate the feasibility of placing this new reservoir system in patients in whom placement of a 5 Fr-reservoir system would seem to be difficult because of severe stricture, tortuosity or angulation of the hepatic artery. A new reservoir system was successfully implanted in 25 patients during 27 sessions. After a side hole was opened, a 2.9 Fr catheter was inserted in the distal hepatic artery or in the gastroduodenal artery in 24 sessions. The catheter tip was then fixed with coils to prevent catheter dislocation. In the other 3 sessions, a 2.9 Fr catheter was inserted without catheter fixation in the replaced right hepatic artery and a small sized collateral artery towards the liver. Arterial infusion chemotherapy was done without any trouble after 20 sessions. Catheter dislocation was found after 2 sessions in which the catheter tip was not fixed or inadequately fixed. Early arterial occlusion was found after placing a 2.9 Fr catheter in the replaced hepatic artery and the small sized-collateral artery after 4 sessions. In conclusion, although sequellae should be evaluated over a long-term period, implantation of a new 2.9 Fr reservoir system is technically feasible and useful in performing arterial infusion chemotherapy.     

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.     

A safe and simple method of percutaneous transfemoral implantation of a port-catheter access system for hepatic artery chemotherapy infusion]

The purpose of this study was to perform a simple percutaneous transfemoral implantation of a portcatheter access system using a new catheter coating for hepatic artery chemotherapy infusion, and to evaluate the complications of transfemoral infusion port implantation. The methods of treatment for complications were also studied. The port-catheter system was percutaneously implanted via femoral artery access in 180 patients with malignant liver tumors. Blood flow redistribution was performed using embolization coils. An unfixed 5 Fr catheter was placed in a hepatic artery, and connected to a port implanted subcutaneously below the level of the inguinal ligament. The success rate of implantation was 99%. Complications after placement were observed as follows: port system obstruction (9.6%); dislocation of the catheter tip (8.4%); drug toxicity (4.5%); and infection (3.4%). Notable is the avoidance of cerebral infarcts. In 3 of 17 patients with port obstruction, recanalization of the port was achieved. In 11 of 15 patients with catheter dislocation, replacement of the catheter-port system was successful. In 5 patients with hepatic artery occlusion, the replacement of a microcatheter-port access system was achieved, and hepatic artery chemotherapy infusion was resumed. This percutaneous transfemoral implantation of a catheter-port access system would seem to be a very simple and useful method for many clinical doctors, and it may improve the quality of life in patients with an unresectable malignant liver tumor.     

Hepatic arterial catheterization combining interventional radiological and laparotomic approaches

BACKGROUND AND OBJECTIVES: This report describes a modified method of implanting a catheter-port system for hepatic arterial infusion chemotherapy (HAIC) that combines interventional radiological (IVR) and laparotomic approaches. METHODS AND RESULTS: In patients, scheduled for HAIC and laparotomic surgery, we now employ a modified method of implanting the catheter-port system. In our method, an IVR approach is used to implant the catheter-port, and arterial occlusions are primarily carried out using a laparotomic approach. Following celiac and superior mesenteric arteriographies, a tapered microcatheter with a side hole is inserted by a catheter exchange method. The catheter tip is advanced far into the gastroepiploic artery via the gastroduodenal artery (GDA). The side hole is located at the orifice of the proper hepatic artery, and its location is confirmed by injection of contrast media. The microcatheter is connected to the port, and the port is buried in the subcutaneous pocket. During the laparotomy stage, the GDA lumen and the catheter lumen are clipped, and the right gastric artery (RGA) and all small branches supplying the stomach, duodenum, and pancreas are ligated. Among the 13 patients successfully implanted with a port-catheter system using our combined approach, no patients had hepatic artery occlusion or occlusion of the catheter system. CONCLUSIONS: Initial results from a study of a new method of implanting a microcatheter-port system in the hepatic artery using combined IVR and laparotomic approaches suggest that this method may enable operators to avoid complicated selective coiling and may lower the incidence of hepatic artery occlusion in patients receiving long-term HAIC.     

Occlusion of the left superficial femoral artery during hepatic arterial infusion of chemotherapy for liver metastases from colon cancer 18 months after the implantation of a port system: a case report

We report a case of complication of a catheter port system. A 67-year-old male who had undergone left hemicolorectomy and partial hepatectomy for liver metastases from colon cancer underwent hepatic arterial infusion (HAI) of chemotherapy by a percutaneously implanted catheter port system to prevent recurrence. Eighteen months after the implantation of a port system he complained of intermittent claudication. Intravenous digital subtraction angiography (IV-DSA) showed occlusion of the left superficial femoral artery. The catheter was removed and a femoro-popliteal bypass with an artificial graft was constructed. Thrombus was found around the indwelling catheter at the insertion site. After the operation his complaint disappeared and has been alive without recurrence for 6 years.     

Evaluation of hepatic artery infusion chemotherapy for liver metastasis of colorectal cancer using a side-hole catheter

In our department forty cases of hepatic artery infusion chemotherapy using a side-hole catheter were analyzed with liver metastasis of colorectal cancer from December 2000 to December 2003. This easily placed catheter is able to inject the agent effectively from the side hole. The efficacy of high dose 5-FU (1,000 mg/m2/week) of hepatic artery injected chemotherapy was evaluated. The catheter was inserted from femoral or the left subclavian artery, and the side hole positioned at the base of proper hepatic artery or common hepatic artery. This method resulted in catheter trouble only 18% of the time. As for arterial infusion chemotherapy, system management and an evaluation of the drug distribution is essential. The one-year survival rate was 71.9%, the 50% survival time was 23.4 months, and the response rate was 71%. In conclusion, this therapy was effective and useful for hepatic metastasis.     

A complication with hepatic arterial infusion chemotherapy--a case of sepsis related to catheter tip dislocation to the duodenal bulb

Extra-arterial dislocation of a catheter is one of the complications with hepatic arterial infusion chemotherapy. The authors report a case of sepsis related to catheter tip dislocation to the duodenal bulb. A 69-year-old man underwent sigmoidectomy for sigmoid colon cancer and partial hepatectomy for synchronous metastasis to the liver. We performed hepatic arterial catheterization via the femoral artery, and the patient underwent prophylactic hepatic arterial infusion chemotherapy with 5-FU. Thirty months later, computed tomography during arteriography (CTA) using a port system revealed the dislocation of catheter tip to the duodenal bulb. He showed no symptoms, so we kept him under observation. Sepsis occurred because of the dislocated catheter 39 months later. After removal of the catheter, the symptoms of sepsis disappeared.     

Hepatic arterial cannulation using the side holed catheter

BACKGROUND: Hepatic arterial infusion chemotherapy (HAIC) has been recognized as one of the effective treatments for patients with hepatic metastatic tumor. However it is difficult to perform HAIC in the long term without complications. This report describes the laparotomic approach using the side holed catheter, which is a novel method of implanting a catheter-port system. METHODS AND RESULTS: We designed a new anti-thrombotic catheter for HAIC. This catheter is tapered from 5F (diameter of shaft) to 3.3F (diameter at tip), and a side hole is opened 7 cm from the tip of catheter. This catheter is inserted from the gastroduodenal artery to the common hepatic artery (CHA), and the tip is put in the aorta or in the splenic artery. The side hole is adjusted distal to the CHA. In our surgical department, our new catheter was inserted in four patients at the time of their abdominal surgery. The cannulation was performed successfully in all patients. In two of them, HAIC was finished without problems at 6 months after starting, and two were still treated by HAIC at 9 and 8 months after starting. CONCLUSIONS: Initial results from a study of a new method of implanting a catheter-port system in the hepatic artery using the new tapering side hole catheter suggest that this method may enable operators to avoid complicated selective coiling and may lower the incidence of hepatic artery occlusion in patients receiving long-term HAIC.     

Adjuvant hepatic arterial infusion after curative resection of colorectal liver metastases using removable intra-arterial catheters with shape-memory alloy

BACKGROUND AND OBJECTIVES: Although there are some reports that adjuvant hepatic arterial infusion (HAI) chemotherapy reduces the hepatic recurrence following curative resection of colorectal liver metastases, problems of indwelling catheters after chemotherapy cessation remains unsolved. The usefulness of adjuvant HAI was investigated using a removable port-catheter system. METHODS: Spiral catheterstrade mark were attempted to be placed in 17 patients who underwent curative hepatectomy. The catheter contains a special shape-memory alloy at its tip, which allows stable fixation to the vascular wall without coiling so the catheter can be removed if necessary. 5-fluorouracil (5-FU) in total dose of 12 g was intra-arterially administered. RESULTS: W spiral catheterstrade mark were successfully placed in the hepatic artery by percutaneous approach in 82% of the patients. All patients underwent scheduled chemotherapy without serious adverse events. Reservoir-catheter system was removed easily and uneventfully after discontinuation of the chemotherapy. 3D-CT angiography revealed that the hepatic artery was well preserved with short-term chemotherapy. Postoperative hepatic recurrence was observed only in 18% of the patients with the median follow-up time of 19.9 months. CONCLUSIONS: Prophylactic 5-FU HAI using W spiral cathetertrade mark and subsequent catheter extirpation is a promising strategy following curative resection of colorectal liver metastases.     

Complications related to hepatic arterial infusion chemotherapy for liver metastasis from colorectal cancer

We evaluated the complications of hepatic arterial infusion (HAI) chemotherapy in patients (pts) with hepatic metastasis from colorectal cancer. The subjects consisted of 61 pts with hepatic metastasis from colorectal cancer, who were treated by combined chemotherapy with 5-FU and CDDP weekly or continuously. Indwelling route of catheter: 30 via gastroduodenal artery (GDA) at the time of laparotomy ('LP'), 21 via femoral artery (FA) and catheter tip in PHA ('PHA'), 10 via FA and catheter tip is inserted with steel coil into the GDA ('GDA-coil'). Complications resulting in interruption of therapy occurred in 19 pts (31%), and the 'GDA-coil' method had a lower rate of complication than others. There was no difference in the incidence rate of complications between the two chemotherapy regimens. The complications of this therapy were: 8 (13%) cases of hepatic arterial occlusion, 3 (5%) cases of duodenal ulcer, 4 (7%) cases of catheter tip dislocation, 2 (3%) cases of catheter tip dislocation to the duodenal bulb, and 1 (2%) case of liver abscess. Hepatic arterial occlusion occurred frequently in LP. Up to 67% of patients with duodenal ulcer had hepatic arterial occlusion at the same time. All pts with catheter tip dislocation were 'PHA', and all pts with catheter tip dislocation to the duodenal bulb were 'LP'. In conclusion: 1. The best indwelling route for the catheter is by the 'GDA-coil' method. 2. To diagnose complications soon, regular CTA or DSA is necessary.     

Continuous infusion chemotherapy using an infusional port in colorectal cancer with liver metastases

Chemotherapy for colorectal cancer with liver metastases following surgical operation for primary tumor should be selected following surgical intervention. Continuous infusion chemotherapy using an infusional port was selected for unresectable metastasis due to colorectal cancer in our department. The catheter was placed in the hepatic artery through a gastroduodenal by operative procedure. 5-fluorouracil (5-FU) and mitomycin C (MMC) were used as chemotherapeutic agents. After MMC was given at 10 mg/body by bolus, administration of 5-FU was continuously infused at 250 mg/day for 2 weeks, followed by a 2-week interval. Drug administration was done by implanted pump hepatic arterial infusion. Seventeen of the patients with liver metastasis underwent this chemotherapy from 1986 through 1990. Results of the infusion chemotherapy were as follows. Value of serum CEA decreased until two courses were given in all cases. In 11 cases, the tumor size on CT was remarkably smaller. In these patients, however, there were many complications due to the catheter used for catheter replacement, drug leakage, drug extravasation and so on. We concluded that although this chemotherapy was very effective, the method should be improved in terms of the material, the location of catheter tip and the like.     

Repeated hepatic arterial infusion chemotherapy using an implanted port system in patients with unresectable malignant liver neoplasms: significant factors affecting early hepatic arterial occlusion

The purpose of this study was to identify significant factors affecting early hepatic arterial occlusion in patients who received repeated hepatic arterial infusion chemotherapy using an implanted port system. Eighty-five patients with unresectable liver neoplasms who underwent implantation of the port system were studied. Arterial infusion chemotherapy was performed every 1-4 weeks. Arterial occlusion was evaluated by hepatic arteriography performed via the port every 3 months. Twenty variables were analyzed using univariate and multivariate analyses to identify significant factors affecting early hepatic arterial occlusion. Hepatic arterial occlusion was found in 25.9% (22/85) of the patients. Thirteen of them experienced early arterial occlusion within 6 months. The mean survival period was significantly worse in patients who experienced early arterial occlusion than those who did not (16 months vs. 26 months, p<0.05). In the multivariate analysis, the following 3 variables had independent value for early arterial occlusion; i). diameter of the common hepatic artery, ii). gender, and iii). previous systemic chemotherapy. Early arterial occlusion affects therapeutic effects and survival in patients who undergo arterial infusion chemotherapy with an implanted port. Factors demonstrated here are important to classify patients at risk of early hepatic arterial occlusion.     

A novel arterial infusion chemotherapy for the treatment of patients with advanced pancreatic carcinoma after vascular supply distribution via superselective embolization

BACKGROUND: Patients with American Joint Committee on Cancer Stage IV advanced pancreatic carcinoma have been treated by systemic chemotherapy, intraarterial chemotherapy, radiation therapy, and multidisciplinary treatment using a combination of these. However, the outcome has not always been satisfactory. In the current study the authors describe the method and results of a new chemotherapy for advanced pancreatic carcinoma. METHODS: To restrict the blood flow into the pancreas (mainly to the great pancreatic artery and the caudal pancreatic artery), the peripancreatic blood vessels were embolized superselectively with microcoils. In 31 patients with advanced pancreatic carcinoma, the catheter tip for the arterial infusion chemotherapy was placed in the splenic artery just proximal to the branching of the great pancreatic artery when the treatment was given for primary tumors, and in the common hepatic artery when the treatment was given for a metastatic liver lesion. The other end of the catheter was connected to an implanted injection port embedded in the femoral region, and 5-fluorouracil and cisplatin were administered by continuous arterial infusion. RESULTS: Of the 31 patients with advanced pancreatic carcinoma, 23 (74%) underwent hemodynamic change and arterial infusion chemotherapy, with a response rate of 73.9% (complete response rate of 8.7% and a partial response rate of 65.2%) and a mean survival period of 18.26 +/- 10.06 months. The 1-year, 2-year, and 3-year survival rates were 90.9%, 42. 8%, and 18.3%, respectively, with a mean survival period of 19.0 months. Of these 23 patients, the 16 patients with liver metastases had a response rate of 68.8% and a mean survival period of 16.25 +/- 8.35 months, whereas the 7 patients without liver metastases had a response rate of 87.5% and a mean survival period of 22.86 +/- 12.69 months. CONCLUSIONS: In patients with Stage IV advanced pancreatic carcinoma, arterial infusion chemotherapy after hemodynamic change was found to be effective against both primary tumors and metastatic liver lesions. The authors believe that the treatment presented in the current study should be attempted, even in patients with advanced pancreatic carcinoma, as long as the blood vessels for vascular supply distribution exist.     

Dislocation of an indwelling catheter from digestive organs in arterial infusion chemotherapy

An indwelling catheter was dislocated into the duodenum during the course of hepatic arterial infusion for multiple metastases of colon cancer to the liver. A possible cause of extravascular dislocation includes an exposure to highly concentrated anticancer due to defective positioning of the catheter side hole and bending of the catheter. A dislocation of the hepatic arterial infusion catheter into the digestive tract is a serious complication and accounts for 10% of all dislocations. Although countermeasures consisting of monitoring progress, laparotic catheter extraction and endoscopic catheter extraction, a monitoring process is selected in nearly all cases. Even though hepatic arterial infusion has established as being effective against liver tumors, there is a possibility of encountering more of these cases in the future along with an increase in the number of cases and a prolongation of treatment that improves prognoses. In the case, a catheter extravascular dislocation has occurred in addition to complications stemming from the dislocation itself. There was also a risk of exacerbation of prognosis resulting from being forced to discontinue the treatment. It is therefore necessary to pay close attention to positioning of the catheter side hole and its immobilization.     

Prophylactic hepatic arterial infusion chemotherapy after resection of colorectal liver metastases using removable W-spiral catheter

The authors investigated the usefulness of W-Spiral Catheters for adjuvant hepatic arterial infusion (HAI) chemotherapy following curative resection of colorectal liver metastases. The catheter has a special shape-memory alloy in its tip, which allows preferable fixation without coils and removal of the catheter if desired. A W-spiral catheter was successfully placed in 13 out of 16 patients who had undergone curative hepatectomy. In the remaining 3 cases in which the hepatic artery was smaller in diameter, a catheter was placed using the conventional GDA coiling method. Removal of the W-Spiral Catheter was attempted in 10 of the 13 patients with a Spiral Catheter after termination of HAI chemotherapy. In all cases, the catheters were easily and uneventfully removed, and 3D-CT angiography revealed that the hepatic artery was well preserved in most cases. These findings suggest that a new approach to prophylactic HAI chemotherapy with W-Spiral Catheters and subsequent removal of the catheters is reasonable and desirable.     

Complications related to hepatic arteria infusion chemotherapy for liver metastasis

Complications from hepatic arterial infusion chemotherapy were analyzed in 27 cases with liver metastasis from colorectal cancer from December 1994 to April 2002 in our department. The method used to place the catheter was laparotomy (LP) in 11 patients, intervention radiology (IVR) in 16 patients. Complications resulting in interruption of therapy occurred in 7 (26%) patients, and the IVR method was associated with a lower rate of complications than the LP method. The complications with the LP method were 3 (11%) cases of hepatic arterial occlusion, and 2 (7.4%) cases of catheter tip dislocation. The best indwelling route for the catheter thus seems to be the IVR method. The IVR method is our first choice for all patients now.     

Hepatic arterial infusion chemotherapy using W-spiral (WS) catheter

The authors investigated the usefulness of W-Spiral (WS) catheters for hepatic arterial infusion (HAI) chemotherapy especially from the viewpoint of a removable catheter after cessation of chemotherapy. A WS catheter was successfully inserted into the hepatic artery without a coil fixation in 40 out of 47 patients with hepatic malignant disease. A stable position of the catheter tip was maintained throughout the period in all cases. In 20 patients, the catheter was easily and uneventfully removed after chemotherapy, which resulted in improved patients' quality of life. An electron microscope examination revealed that there was no fibrin network formation on the surface of the catheter. Stenosis of the hepatic artery was confirmed in 7 out of 12 patients with 5 Fr catheter by 3DCT angiography, whereas patency of the artery was well preserved in 7 of 8 cases with 3.3 Fr catheter. This catheter has a special shape-memory alloy in its tip, which allows a preferable fixation without coils and removal of the catheter if desired. HAI using this catheter and subsequent removal of it is a reasonable strategy especially for patients who need limited courses of chemotherapy.     

Evaluation of hepatic arterial infusion chemotherapy using removable W-spiral catheter

The authors analyzed the 62 patients who underwent hepatic arterial infusion (HAI) chemotherapy using W-spiral (WS) catheter. The catheter was successfully inserted into the hepatic artery without a coil fixation in 57 cases. After cessation of chemotherapy, the catheter was removed in 32 cases without difficulty, which resulted in improved patients' quality of life as well as preservation of patency of hepatic arteries. This catheter has a special shape-memory alloy in its tip, which allows preferable fixation without coils and removal of the catheter if desired. HAI using this catheter and subsequent removal of it is a reasonable strategy in the era with potent systemic chemotherapy.     

A devised method of hepatic and splenic arterial infusion chemotherapy after transcatheter peripancreatic arterial embolization for patients with advanced pancreatic cancer

We previously reported the clinical efficacy based on hepatic and splenic arterial infusion chemotherapy (HSAIC) for patients with advanced pancreatic cancer after transcatheter peripancreatic arterial embolization (TPPAE). However, this medical treatment pointed out a few problems in which the method had its complexity and a limited use of embolus micro-coil numbers. Then, we tried to improve the method in solving those problems. In order to reduce the embolus micro-coil numbers for TPPAE, we divided the micro-coil into several parts. We also devised the method of HSAIC. We used one catheter with a side hole, so that the catheter was able to supply a therapeutic drug for arterial infusion chemotherapy, both to the common hepatic artery and splenic artery. The effective rate for eleven cases was 72.7%, and there were no significant differences from the cases treated with the conventional method of TPPAE-HSAIC. Therefore, the devised treatment was considered to be an easy and useful method for TPPAE and HSAIC.     

Treatment interruptions and complications with two continuous hepatic artery floxuridine infusion systems in colorectal liver metastases.

Continuous hepatic artery floxuridine infusion benefits patients with colorectal liver metastases. Implanted infusion pumps are more expensive but may result in fewer treatment interruptions than when using an external pump connected to a port. We have assessed device-related complications, treatment interruptions and added nurse interventions in 95 patients undergoing a total of 959 treatment cycles via either implanted pump (64 patients) or port (31 patients). Compared with the implanted pump, the port was associated with a significant increase (P < 0.003) in catheter blockage (24/31 vs 2/64 patients), treatment interruption (15/265 vs 12/694 treatments) and added nurse intervention (80/265 vs 20/694 treatments). Survival in patients with colorectal liver metastases is limited and the complications of treatment should be kept to a minimum. An implanted subcutaneous infusion pump offers the benefit of a 3-fold lower incidence of treatment interruption and a 30-fold lower incidence of catheter blockage than when continuous infusion chemotherapy is given via an external infusion device.