Usefulness of CT arteriography for transcatheter peripancreatic arterial embolization to patients with advanced pancreatic cancer

We reported previously the clinical benefit of hepatic and splenic arterial infusion chemotherapy (HSAIC) for patients with advanced pancreatic cancer alter transcatheter peripancreatic arterial embolization (TPPAE). TPPAE has two therapeutic purposes: (1) preparation for effective arterial infusion chemotherapy, and (2) transcatheter arterial embolization (TAE) against pancreas head cancer. The present paper describes the advantage of CT arteriography in performing TPPAE for advanced pancreatic cancer. CTA was useful in identifying the arterial blood supply in pancreatic cancer, especially blood vessels branched off from the supramesenteric artery (SMA). Since the anti-tumor effect of TPPAE against pancreas head cancer is dependent mainly on whether the blood supply from SMA could be shut off, it is suggested that CTA is useful to evaluate the embolization effect of TPPAE.     

Advanced pancreatic carcinoma showing a complete response to arterial infusion chemotherapy

We report a patient with advanced carcinoma of the pancreatic body and tail with multiple liver metastases who showed a complete response to hepatic and splenic arterial infusion chemotherapy (HSAIC) with gemcitabine and 5-fluorouracil, following transcatheter peripancreatic arterial embolization (TPPAE) and partial splenic embolization (PSE). Nonresectable advanced pancreatic carcinoma tends to have a low response to medical treatment, with the median survival time being 6 months or less for stage IV cases. We disclose herein that the median survival time of patients receiving HSAIC after TPPAE is more than three times longer than the survival time attained with conventional treatments. However, in patients with advanced carcinoma of the pancreatic tail, for which TTPAE is not applicable, survival times remain low. Thus, in the patient described here, we also performed embolization of the left gastric and short gastric arteries as well as PSE to increase the flow within the great pancreatic and caudal pancreatic arteries via the splenic artery, and gemcitabine and 5-fluorouracil were administered via the splenic artery. As a result of these procedures, marked reduction in the advanced carcinoma of the pancreatic body and tail and of liver metastases was attained.     

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.     

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.     

A case of metastatic liver tumor from colorectal carcinoma--continued arterial infusion chemotherapy through a microcatheter located in replaced right hepatic artery

The patient was a 78-year-old male with a history of colon cancer. After surgical resection of colon cancer, he suffered a multiple liver metastasis. We treated him by arterial infusion chemotherapy with the catheter edge embedded at the common hepatic artery. For a long period, the lesions were defined as partial response on WHO-criteria, but a wide area of the common hepatic artery was shrunk. After changing the treatment to systemic intravenous chemotherapy, the metastatic lesions began to enlarge. Then, we somehow were able to put a microcatheter into the replaced right hepatic artery (rRHA), and could restart arterial infusion chemotherapy. We continued this procedure for over a year without any complication.     

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.     

Movement of the side hole occurring in a port‐catheter system percutaneously implanted for hepatic arterial infusion chemotherapy

The authors report a case in which catheter‐related difficulties occurred with a port‐catheter system implanted to perform repeated hepatic arterial infusion chemotherapy for advanced hepatocellular carcinomas. The port‐catheter system had been percutaneously implanted with the catheter tip fixation method, and a side hole had been created in the indwelling catheter for placement in the common hepatic artery. Four months after port‐catheter placement, however, the indwelling catheter became bent at the location of the side hole in the proper hepatic artery. Subsequently, the side hole moved into the left hepatic artery, resulting in a lack of distribution of chemotherapeutic agents to the tumours in the segments of the liver supplied by the right hepatic artery. This situation was easily corrected with a simple interventional radiological method so that hepatic arterial infusion chemotherapy could be resumed with sufficient distribution over the entire liver. To our knowledge, such a problem involving a port‐catheter system implanted with the catheter tip fixation method and its management thereafter has not been reported in the published literature.     

Experimental trials of temporary insertion of removable catheter into artery for postoperative prophylactic hepatic arterial infusion chemotherapy

We often experience hepatic metastases after resections for advanced gastrointestinal cancers. Various methods such as resection and hepatic arterial infusion chemotherapy are used when a metastatic tumor is detected on imagings. We have considered postoperative prophylactic hepatic arterial infusion chemotherapy for the prevention of heterochronous hepatic metastases. For this purpose, we conducted experimental trials of temporary insertion of a catheter, which we would be able to remove safely in the near future, into an artery. Laparotomy was done on rabbits under general anesthesia, and a 16 G catheter was inserted into the left renal artery. The proximal site of the artery and the catheter were ligated together with Elastik, and the catheter was fixed with coated VICRYL RAPIDE distal of the insertion point. Upon insertion of the catheters, there was no bleeding, and neither occlusion nor dislocation of the catheter occurred. Two weeks later, the catheters were easily removed without bleeding under laparotomy. At a second-look laparotomy after 2 more weeks, there were no abnormal findings such as hematomas. Therefore, we concluded that our method would be acceptable for the temporary catheter insertion into an artery which could be removed safely and easily when the chemotherapy was finished.     

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.     

Low-molecular-weight heparin and calcium heparin in thrombosis prophylaxis in patients with percutaneous arterial and venous ports for colorectal liver metastases

STUDY OBJECTIVE: The evaluation of low-molecular-weight heparin use to prevent arterial and venous thrombosis in patients with indwelling arterial Port-a-Cath implants. METHODS: From 1996 to March 2003 we placed 370 indwelling hepatic arterial catheters with a minimally invasive approach. The left distal subclavian artery was approached from beneath the left clavicle, then an angiographic study of the tumoral vascular district was performed and the gastroduodenal artery was occluded by an embolus. A polyurethane catheter was introduced distally into the hepatic artery and connected to a reservoir through a 3-4 cm long subcutaneous tunnel. In 90 patients a venous Port-a-Cath was placed for concurrent systemic chemotherapy. All 370 patients received regional chemotherapy and were treated with calcium heparin at a dose of 5000 IU twice a day and with low-molecular-weight heparin at prophylactic doses (dalteparin 2500 IU or nadroparin 3000 IU) during catheter permanence to prevent hepatic artery thrombosis. Intra-arterial trans-port radionuclide scans using technetium-99m-labeled micro-aggregated albumin were performed monthly to check the infusion distribution and hepatic artery patency. In the presence of anomalous patterns, thrombosis, pulmonary embolism or other complications, angiography and/or other diagnostic studies were performed to determine the cause of the vascular event and the local or systemic symptoms. The mean arterial and venous Port-a-Cath permanence times were 6 and 8 months, respectively. RESULTS: We observed episodes of hepatic artery thrombosis in 4.3% of patients. Three of these 17 patients were successfully treated by intra-arterial thrombolysis using urokinase. No venous thrombosis occurred as a consequence of regional and/or systemic chemotherapy, no episodes of arterial thrombosis were registered during arterial catheter permanence, nor did any hemorrhagic complications related to anti-coagulant therapy occur. Five patients treated with low-molecular-weight heparin required treatment suspension due to a platelet count of < 40,000/dL. CONCLUSION: Our experience suggests that low-molecular-weight heparin and/or calcium heparin at prophylactic doses could be useful in the prevention of arterial and venous thrombosis in patients with indwelling arterial catheters or venous Port-a-Cath treated with regional or systemic chemotherapy for hepatic metastases from colorectal cancer. The homogeneity of the patient group and the use of analogous chemotherapeutic drugs (fluoropyrimidines) avoided statistical contamination related to differences between kinds of cancer and between the chemotherapeutic agents used.     

Balloon occluded arterial infusion therapy for malignant hepatic tumors

A number of reports of regional intraarterial infusion chemotherapy for malignant tumors have been published. Balloon occluded arterial infusion was newly developed by us. Balloon catheter is used for temporal occlusion of the hepatic artery during intraarterial infusion of anticancer drugs. Interruption of the arterial blood flow keeps the drugs at high concentration for a long time in the distal artery to the occluded portion. This procedure has been performed in 87 cases of hepatomas and metastatic liver cancers with the sufficiently good results.     

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.     

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.     

Intrahepatic arterial flow distribution after ligation of a right replaced hepatic artery. A case report

A basic requirement for arterial chemotherapy of liver tumors is complete catheter perfusion of the liver. In cases with atypical anatomy of the hepatic artery, it is frequently impossible to obtain this goal by means of a single catheter. In a patient with a right replaced hepatic artery, the aberrant vessel was ligated and the left hepatic artery was perfused through a catheter inserted into the gastroduodenal artery. Perfusion scans performed through the catheter 14 and 135 days after arterial ligation showed a fall in the arterial flow to the right liver (right/left ratio 0.43 and 0.60). In contrast, a nearly complete perfusion of the liver (0.91 right/left ratio) was obtained 28 days after ligation, when the perfusion scan was performed immediately after catheter infusion of 90,000,000 degradable starch microspheres (DSM: diameter = 40 m). DSM administration is supposed to increase back pressure in the lobe receiving native circulation, thus activating intrahepatic collateral flow to the ischemic lobe. As regards regional treatment of liver tumors, obvious conclusions are to be drawn.     

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.     

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.     

Complications related to arterial infusion chemotherapy in patients with hepatic metastasis from colorectal cancer

Complications of hepatic arterial infusion chemotherapy were analyzed in 30 cases with hepatic metastasis from colorectal cancer from July 1993 to February 2000 in our department. Thirty patients were treated with three kinds of arterial infusion course that mainly consisted of 5-FU. Complications resulting in interruption of therapy occurred in 10 patients (33%), and there was no difference in the incidence rate of complications among the three chemotherapy regimens. The complications with our therapy were hepatic arterial occlusion in two patients, catheter tip dislocation in four patients, fistulus between the hepatic artery and common bile duct in two patients, and fistulus between the hepatic artery and duodenal bulb in two patients. Four patients who had severe complications with fistulus all underwent hepatectomy, especially right hepatic lobectomy in two cases. Sixty percent of our patients had complications after hepatectomy, so regular GIF and DSA are necessary to prevent severe complications after hepatectomy.     

Cases of postoperative hepatic metastasis from gastric cancer in which hepatic arterial infusion chemotherapy with 5-FU, adriamycin and cisplatin was performed after TS-1 chemotherapy

The prognosis of patients with hepatic metastasis of gastric cancer is poor, and standard therapies for patients are not established. Here we present two cases of hepatic metastasis from gastric cancer. In both cases, no other organ metastasis except the liver was confirmed, in which hepatic arterial infusion chemotherapy with 5-FU, adriamycin and cisplatin (FAP) were performed because TS-1 chemotherapy was not an effective chemotherapy. Case 1: An 80-year-old man had distal gastrectomy for type 2 gastric cancer (Stage II) in January 2001. A liver S8 metastatic recurrence was discovered in the 18th month post operation. After chemotherapy with TS-1 for 5 courses, a hepatic arterial infusion treatment was performed for 7 courses. The effect was PR, but the treatment was canceled because of a catheter obstruction. The patient is living without recurrence. Case 2: This case was a 73-year-old man who had distal gastrectomy for type 0 IIc gastric cancer (Stage IA) in May 1999. Multiple hepatic metastases recurred in the 32nd month post operation. After chemotherapy with TS-1 for 2 courses, a hepatic arterial infusion treatment was performed for 10 courses. The effect was CR, but a peritoneal recurrence was discovered, and a systemic chemotherapy was performed. The patient is living without recrudescence of hepatic metastasis. The hepatic arterial infusion chemotherapy with FAP was effective for gastric cancer patients with liver metastasis because TS-1 chemotherapy was not an effective chemotherapy. It is necessary to consider combined chemotherapy in addition to systemic chemotherapy.     

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.     

Novel chemoradiotherapy for locally advanced pancreatic cancer using arterial infusion chemotherapy following the alteration of peripancreatic blood flow

Radiotherapy employing intraoperative radiation therapy (IORT) in combination with postoperative external beam radiation therapy (EBRT) is an effective treatment for unresectable pancreatic cancer. To achieve an even greater therapeutic outcome, 13 patients with unresectable pancreatic cancer were treated by IORT in combination with EBRT plus locally intensive arterial infusion chemotherapy. In order to increase drug delivery to the primary tumor, the splenic and major pancreatic arteries, except for the gastroduodenal artery (GDA), were embolized by radiological intervention prior to the arterial infusion chemotherapy, and the administration of gemcitabine, CDDP, and 5-FU to the primary tumors via GDA was followed during EBRT. The values of serum tumor markers were decreased in all patients, and tumor regression was detected on CT scans in 6 patients. The evaluation of survival benefit of this treatment modality is ongoing, but it did not prolong the survival time of patients with second stage lymph node metastases. One of the advantages of this method was able to perform also in charge of hepatic arterial infusion chemotherapy concurrently, but we experienced liver abscess in 2 patients.