Volume 21, Issue 3 , Pages 409-411, March 2010
Implantation of Port-catheter System for Hepatic Arterial Infusion Chemotherapy with Catheter Tip Fixation in a Patient with Celiac Arterial Obstruction
Article Outline
Editor:
Although it is a somewhat cumbersome procedure and requires meticulous care in the retrieval of the once-implanted catheter (1, 2), the fixed catheter tip technique has been given attention as a useful method to percutaneously implant a hepatic arterial infusion port for repeated hepatic arterial infusion chemotherapy (1, 2, 3, 4, 5). With the most common fixed catheter tip method (1, 2, 3, 4, 5), the catheter is inserted through the celiac artery to the gastroduodenal artery and a side hole, is made in the indwelling catheter at the common hepatic artery ostium. The tip of the indwelling catheter is fixed to the gastroduodenal artery outside of the indwelling catheter with microcoils. This method is advantageous, especially from the standpoint of preventing hepatic arterial occlusion and catheter dislocation (2, 3, 4, 5), when compared with the most common interventional radiologic procedure, in which the indwelling catheter tip is positioned in the proper or the common hepatic artery without fixation.
Recently, we encountered a patient who underwent implantation of a hepatic arterial infusion port with use of the fixed catheter tip technique even though the celiac artery was completely obstructed. We report this experience.
The patient was a 66-year-old man with unresectable, multifocal hepatocellular carcinoma that was resistant to previously performed systemic chemotherapy and transhepatic arterial chemoembolization. Previous splanchnic arteriographic studies and contrast medium–enhanced computedtomographic scans demonstrated complete obstruction of the celiac artery. The patient consented to undergo repeated hepatic arterial infusion chemotherapy by using a percutaneously implanted hepatic arterial infusion port. With the patient under local anesthesia and moderate sedation with intravenous administration of 30 mg of pentazocine, the implantation procedure was as follows. As the first step, a cobra-shaped 5-F catheter (Clinical Supply, Gifu, Japan) was inserted from the right femoral artery and its tip positioned in the superior mesenteric artery. Superior mesenteric arteriography showed the development of hepatopetal collateral flow through the pancreaticoduodenal arteries. Splenic and left gastric arteries were visualized on this superior mesenteric arteriogram. We advanced a microcatheter (Renegade-18; Boston Scientific, Watertown, Massachusetts) coaxially from the 5-F catheter with the tip positioned in the superior mesenteric artery and passed the microcatheter through a pancreaticoduodenal artery. The micro–guide wire and microcatheter were then advanced as far as the splenic artery through the origin of the gastroduodenal artery and the common hepatic artery. Then, a second cobra-shaped 4-F catheter (Clinical Supply) for use in inserting coils for catheter tip fixation was advanced from the right femoral artery and inserted into the superior mesenteric artery. A microcatheter was advanced coaxially from the 4-F catheter positioned in the superior mesenteric artery to the common hepatic artery through the pancreaticoduodenal and gastroduodenal arteries. As the third step, after withdrawal of the microcatheter and 5-F catheter, both of which were inserted at the first step, the micro–guide wire was maintained with its tip positioned at the splenic artery. The indwelling catheter was then advanced from the right femoral artery over the micro–guide wire. This polyurethane-covered catheter (Anthron P-U catheter; Toray Medical, Tokyo, Japan) had a tapered tip (outer diameter of the 60-cm proximal shaft was 5 F and that of the 30-cm distal shaft was 2.7 F; inner diameter of the proximal shaft was 0.035 inch and that of the distal shaft was 0.018 inch), and a side hole was created with small surgical scissors. The distance between the side hole and the distal end of the indwelling catheter was 2.5 cm. The indwelling catheter was positioned so that the side hole opened into the proper hepatic artery and the tip of the catheter was in the common hepatic artery. As the fourth step, the distal tip of the indwelling catheter was fixed with two microcoils (Tornado, Cook, Bloomington, Indiana) inserted from the microcatheter that was advanced in the second step around the indwelling catheter in the common hepatic artery. The subsequently performed superior mesenteric arteriogram showed sufficient blood flow in the splenic and left gastric arteries, which were supplied by hepatopetal collateral flow through the dorsal pancreatic artery from the superior mesenteric artery. Finally, the proximal end of the indwelling catheter was connected to a port (P-U Celsite port, Toray Medical) implanted in the subcutaneous space. Digital subtraction angiography via the port helped confirm the patency of the hepatic artery (Figure). Chemotherapy administered via a port was commenced 1 week after implantation. The chemotherapeutic drugs used were 5-fluorouracil (5-hour infusion, 1,000 mg/m2 weekly) and cisplatin (bolus infusion, 10 mg weekly). Currently, 3 months after the procedure, no complications and side effects have been encountered.
Figure.
Arteriogram via the hepatic arterial infusion port in a 66-year-old man with multifocal hepatocellular carcinoma demonstrates patency of the hepatic artery and good hepatic perfusion. The tip of the indwelling catheter was positioned in the common hepatic artery and a side hole opened into the proper hepatic artery (arrow). Note that the tip of the catheter in the common hepatic artery is fixed with two microcoils (arrowhead) and that the right gastric artery that arose from the common hepatic artery was not demonstrated. There are no splenic and left gastric artery distributions, which suggests that the distal edge in the catheter lumen is sufficiently closed by thrombus.
Among various methods to implant hepatic arterial infusion port by using interventional techniques (2, 3, 4, 5), the fixed catheter tip technique as described by Arai et al (2) is advantageous because of the low frequency of hepatic arterial occlusion and catheter dislocation: 5.3% (4) for hepatic arterial obstruction and 2.2% (3) for catheter dislocation. However, all of the methods with a fixed catheter tip technique were based on the premise that the catheter would be implanted through the celiac artery (2, 3, 4, 5).
In the present case, the celiac artery was completely obstructed, making insertion of catheters through the celiac artery impossible. Even in such a situation, the experience with the present case showed that percutaneous port– catheter implantation with the fixed catheter tip technique could be done by fixing the catheter tip to the common hepatic artery with the retrograde approach though the pancreaticoduodenal arcade from the superior mesenteric artery. The catheter tip was embolized with microcoils inserted from another catheter advanced by the retrograde approach from the superior mesenteric artery.
In usual situations, we want to avoid implanting the indwelling catheter through the superior mesenteric artery, considering possible complications related to that strategy. These include possible occlusion of the superior mesenteric artery caused by stimulation due to movement of the positioned catheter or by formation of a thrombus in the origin of the superior mesenteric artery along the indwelling catheter (6). Nevertheless, occasionally it is necessary to insert the implanted catheter through the mesenteric artery to the hepatic artery as in the present patient. On this point, Yamagami et al (7) suggested that catheter implantation through the superior mesenteric artery is feasible and safe because implantation through the superior mesenteric artery was successfully performed without difficulties or complications in all 10 study patients with a replaced common or right hepatic artery that arises from the superior mesenteric artery.
References
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- . Interventional techniques for hepatic arterial infusion chemotherapy. In: Castaneda-Zuniga WR editors. Interventional radiology. 3rd ed.. Baltimore, MD: Williams & Wilkins; 1997;p. 192–205
- . Using n-butyl cyanoacrylate and the fixed-catheter-tip technique in percutaneous implantation of a port-catheter system in patients undergoing repeated hepatic arterial chemotherapy. AJR Am J Roentgenol. 2002;179:1611–1617
- A new percutaneous catheterization ‘side-holed catheter placement with fixation' for a long-term arterial chemotherapeutic infusion: its effectiveness to prevent hepatic arterial occlusion. J Jpn Soc Angiography Interv Radiol. 1996;11:471–476
- . Value of transcatheter arterial embolization with coils and n-butyl cyanoacrylate for long-term hepatic arterial infusion chemotherapy. Radiology. 2004;230:792–802
- . Clinical implications for the management of acute thromboembolic occlusion of the superior mesenteric artery: autopsy findings in 213 patients. Ann Surg. 2005;241:516–522
- . Implantation of a port-catheter system through the superior mesenteric artery for repeated hepatic arterial infusion chemotherapy. J Vasc Interv Radiol. 2007;18:1595–1600
None of the authors have identified a conflict of interest.
PII: S1051-0443(09)01136-1
doi:10.1016/j.jvir.2009.11.004
© 2010 SIR. Published by Elsevier Inc. All rights reserved.
Volume 21, Issue 3 , Pages 409-411, March 2010
