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1 All authors: Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-chyo, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-0841, Japan.
Received February 11, 2002;
accepted after revision June 6, 2002.
Address correspondence to T. Yamagami.
Abstract
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SUBJECTS AND METHODS. Ninety-three patients (64 men and 29 women; age range, 38-83 years; mean age, 62.2 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system with the catheter tip fixed at the gastroduodenal artery with microcoils and a mixture of n-butyl cyanoacrylate and iodized oil. The rates of successful implantation and complications closely associated with this technique and management of the complications were reviewed.
RESULTS. Percutaneous port-catheter placement was successfully performed in all patients. However, in eight patients, complications occurred: hepatic arterial obstruction (n = 5, 5.4%); catheter dislocation (n = 2, 2.2%); recanalization of the gastroduodenal artery (n = 1, 1.1%); or movement of n-butyl cyanoacrylate (n = 1, 1.1%). In five of the eight patients with complications, hepatic arterial—infusion chemotherapy was continued either after observation of the patient to ensure that stability had been established or after treatment using comparatively easy interventional techniques. In three (3.2%) of the 93 patients, planned hepatic arterial—infusion chemotherapy could not be performed because of complications associated with the technique.
CONCLUSION. Fixation of the catheter tip in the gastroduodenal artery using a combination of microcoils and a mixture of n-butyl cyanoacrylate and iodized oil is a useful and safe technique in percutaneous port-catheter placement for repeated hepatic arterial infusion chemotherapy.
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Among the various interventional techniques [7,8,9,10,11,12,13,14,15], fixed-catheter-tip implantation [7, 8] is particularly advantageous, especially for preventing catheter dislocation. In this technique, a side hole is made in the indwelling catheter at site of the common hepatic artery ostium. The end hole of the catheter is then closed with a microcoil. The tip of the indwelling catheter is fixed to the gas-troduodenal artery with microcoils via a microcatheter, which is introduced into the gastroduodenal artery through the side hole of the indwelling catheter.
However, catheter dislocation has occurred in some patients. Through trial and error, we noticed (as described in our previous report [8]) that fixing the catheter tip with n-butyl cyanoacrylate resulted in fewer catheter dislocations than did fixation with microcoils alone. However, large studies using n-butyl cyanoacrylate in percutaneous catheter placement have been rare [8]. The aim of our article is to describe the efficacy of and results achieved by adding n-butyl cyanoacrylate to microcoils during fixation of the catheter tip to the gastroduodenal artery.
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Procedures
After obtaining written informed consent from the patients, we
percutaneously placed a long-term indwelling catheter for frequent arterial
infusion chemotherapy, according to the procedure described by Arai et al.
[7] (Fig.
1A,1B,1C,1D,1E,1F,1G,1H).
First, a 5-French catheter (Clinical Supply, Gifu, Japan) was inserted via a
branch of the left subclavian artery or of the right femoral artery—both
of which were exposed by minimally invasive surgery after the skin incision
was made with the patients under local anesthesia—and was advanced to
the common hepatic artery via the celiac artery
(Fig. 1A). In most cases, we
used the cutdown technique to insert the catheter from the arterial branch.
Next, a microcatheter (Renegade-18; Boston Scientific, Watertown, MA) was
inserted coaxially, after which branches of the gastroduodenal artery, such as
the posterosuperior pancreaticoduodenal artery, were embolized with microcoils
(Diamond Coil, Boston Scientific; or Trufill, Cordis, Miami, FL) to prevent
infusion of chemotherapeutic agents into the duodenum and pancreas if these
branches arose near the bifurcation.
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Using the catheter-exchange method, an indwelling catheter with a side hole was placed with the tip inserted into the gastroduodenal artery (Fig. 1B). The side hole was placed into the common hepatic artery (Fig. 1C). The distal lumen of the indwelling catheter then was occluded with a 1.2-cm microcoil (Hilal embolization microcoils; Cook Europe, Bjaeverskov, Denmark) through a coaxial microcatheter (Renegade-18; Boston Scientific) that was advanced beyond the side hole inside the indwelling catheter (Fig. 1D).
The gastroduodenal artery was embolized with microcoils (Diamond Coil, Boston Scientific or Trufill, Cordis) through a microcatheter inserted coaxially via the side hole of the indwelling catheter into the gastroduodenal artery outside the catheter (Fig. 1E and 1F). In all patients, 0.5-1.25 mL of n-butyl cyanoacrylate (Histoacryl-Blue; Braun, Melsungen, Germany) mixed with iodized oil (Lipiodol; Laboratoire Guerbet, Roissy, France) was added for sufficient embolization and to fix the catheter tip more securely (Fig. 1F). The ratio of n-butyl cyanoacrylate to iodized oil was 1:1.5. Finally, the proximal end of the indwelling catheter was connected to a port (Septum port, Sumitomo Bakelite, Akita, Japan; or PU Celsite Port, Toray Medical, Tokyo, Japan) implanted subcuntaneously (Fig. 1G).
A polyurethane-covered catheter (Anthron PU catheter; Toray Medical) with a tapered tip (outer diameter of the shaft, 5 French and that of the tip, 2.7 French; inner diameter of the shaft, 0.035 inch and that of the tip, 0.018 inch) was used as the indwelling catheter, and a side hole was created at the point at which the diameter tapered by clipping the folded indwelling catheter with a pair of small scissors. The length between the side hole and the distal end of the indwelling catheter was designed according to the findings of a previously obtained celiac arteriogram. The redundant distal part of the catheter tip was cut off.
In 80 of the 93 patients, the right gastric artery was embolized with microcoils to prevent infusion of chemotherapeutic agents into the stomach. The embolization was performed as the first step in the port-catheter implantation procedure or as a preparatory procedure on the day before port-catheter implantation. In four of these patients, embolization was unsuccessful. Gastrectomy had been performed previously in the remaining 13 patients (gastric cancer, n = 8; gastric ulcer, n = 5), and the right gastric artery had been ligated at the time of surgery.
In patients with more than two hepatic arteries, the arteries were converted into one hepatic artery. In patients in whom this conversion was accomplished, infusion of the entire liver could be undertaken with a single indwelling catheter. To convert multiple hepatic arteries into one, we embolized all of the hepatic arteries with the exception of the hepatic artery from which the gastroduodenal artery diverged.
All patients were examined with digital subtraction angiography (Fig. 1H) and single-detector helical CT after infusion of contrast material via the port to confirm the patency of the hepatic artery and good distribution of the contrast material to the entire liver and to rule out the possibility of extrahepatic infusion. These studies were done 5-10 days after implantation and every 1-3 months thereafter.
Parameters Investigated
We investigated the rate of success of the fixed-catheter-tip technique of
port-catheter placement using the mixture of n-butyl cyanoacrylate
and iodized oil and the rate of complications closely associated with this
technique. Management was examined in patients with complications.
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In all patients, all branches of the hepatic arteries beyond the proper hepatic artery were well visualized. Branches of the gastroduodenal artery were not evident on arteriography that was performed after the infusion of contrast material via the port just after placement of the indwelling port-catheter system. Thus, the success of implantation was confirmed.
However, as Table 1 shows, eight patients experienced some complications that were closely associated with the technique under study. Hepatic arterial obstruction was seen on follow-up arteriography performed via the port in five (5.4%) of 93 patients (Fig. 2A,2B). In two, the right hepatic artery was obstructed, and in one, the left hepatic artery. In the remaining two, no hepatic arterial branches beyond the point of divergence of the gastroduodenal artery were visualized. The hepatic artery was successfully recanalized by infusing thrombolytics via the port in one patient found to have right hepatic arterial obstruction 7 days after catheter placement and in a patient found to have obstruction of the proper hepatic artery 28 days after catheter placement. However, attempts to treat the hepatic arterial occlusions in the remaining three patients using various thrombolytic methods failed. In the patient with obstruction of the left hepatic artery, tumors were mainly located in the right lobe; thus, repeated hepatic arterial—infusion chemotherapy via the port-catheter system was continued. In the other two patients, further hepatic arterial chemotherapy via the indwelling catheter was not attempted.
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In two patients (2.2%), catheter dislocation (Fig. 3A,3B) was confirmed, one 77 days after catheter placement and the other 283 days after placement. In both patients, the catheter moved proximally to the direction of the celiac artery, and the side hole moved to the celiac axis. Distribution of chemotherapeutic agents to the left gastric artery or to the splenic artery can damage adjacent organs such as the stomach or pancreas, so further hepatic arterial chemotherapy was not attempted. In the patient with the right hepatic arterial obstruction and a dislocated catheter, tumors were mainly located in the right lobe of the liver, which was another reason we abandoned attempts at further hepatic arterial infusion chemotherapy.
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In one patient (1.1%), recanalization of the gastroduodenal artery was revealed on arteriography performed via the port 5 days after the port-catheter implantation (Fig. 4A,4B,4C). Later, successful reembolization was accomplished using a mixture of n-butyl cyanoacrylate and iodized oil. The mixture was delivered via a microcatheter advanced through the 5-French catheter in the celiac artery.
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Migration of the cast of the n-butyl cyanoacrylate and iodized oil mixture to the proper hepatic artery during the procedure occurred in one patient (1.1%). The arteriography via the port showed that the cast had moved into the right hepatic artery 5 days after catheter implantation (Fig. 5A,5B,5C). Although mild stenosis of the right hepatic artery occurred because of this episode, hepatopetal arterial blood flow was sufficient; thus, hepatic arterial—infusion chemotherapy was performed with no need for corrective therapy. Catheter occlusion did not occur in any of the patients.
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We evaluated other complications unrelated to the technique of fixing the catheter tip with n-butyl cyanoacrylate and iodized oil. In two patients, brain infarction was shown on brain CT or MR imaging to be located mainly in the posterior arterial territory. We strongly suspected this complication was related to catheter placement via the left subclavian artery in both patients. Clinical symptoms occurred 8 days after port-catheter placement in one of these patients and 211 days after the procedure in the other patient. Conservative treatment that included the use of anticoagulant medication was effective. All other complications caused directly by percutaneous implantation of the port-catheter system were minor, such as transient subcutaneous hematoma.
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A review of large published studies [9,10,11,12,13,14] found more than 30 procedures of percutaneous port-catheter placement described for hepatic arterial—infusion chemotherapy, with the most common interventional procedure involving positioning the indwelling catheter in the proper or the common hepatic artery. These studies showed that dislocation of the indwelling catheter occurs at a relatively high rate—in 5.6-43.8% of patients [9,10,11,12,13,14]. The rate of hepatic arterial obstruction is also relatively high, ranging from 0% to 22.2% [9,10,11,12,13,14].
In comparison, data from our study showed lower rates: 2.2% (2/93) for catheter dislocation and 5.4% (5/93) for arterial obstruction. It follows from these results that the fixed-catheter-tip technique using n-butyl cyanoacrylate added to the microcoils is useful in preventing the complications of dislocation or hepatic arterial obstruction. Other complications related to the technique were only minor, such as movement of n-butyl cyanoacrylate and recanalization of the gastroduodenal artery. These complications resolved with careful observation of the patients alone or were easily corrected with simple interventional techniques. In the three patients with hepatic arterial obstruction, further hepatic arterial—infusion chemotherapy was successfully performed. As a result, in five (62.5%) of the eight patients with complications and in 90 (96.8%) of the entire 93 patients in whom an indwelling catheter was placed, planned hepatic arterial infusion chemotherapy could be performed without a problem. It can be concluded from the results of our study that fixation of the catheter tip to the gastroduodenal artery using a combination of microcoils and a mixture of n-butyl cyanoacrylate and iodized oil is useful and safe for catheter placement in hepatic arterial—infusion chemotherapy.
Theoretically, the fixed-catheter-tip technique can prevent dislocation of the indwelling catheter, which is one of the more frequent complications, because the catheter tip is tightly fixed in an arterial branch. However, a few cases of catheter dislocation have occurred [8]. In response, we added a mixture of n-butyl cyanoacrylate and iodized oil to the microcoils for a stronger fixation of the catheter tip. In our previous study [8], we found a significantly higher rate of catheter dislocation in patients in whom fixation of the catheter tip was performed without the mixture than in those in whom the mixture was used to strengthen fixation.
Hepatic arterial occlusion, another frequent complication, often interferes with effective hepatic arterial—infusion chemotherapy. The low frequency of hepatic arterial occlusion shown in our present study indicates that this problem also can be resolved using the catheter-fixation technique. According to Seki et al. [15], hepatic artery patency was statistically higher in a group of patients with port-catheter systems that had been implanted with the catheter tip fixed with microcoils alone or with n-butyl cyanoacrylate in addition to microcoils than in the group in whom the catheter tip had been placed in the proper or common hepatic artery without fixation. This finding leads us to speculate that a principal cause of hepatic arterial occlusion is thrombotic occlusion due to mechanical stimulation of the vascular endothelium of the common or proper hepatic artery, which results from movement of the unfixed tip of the percutaneously placed catheter [15]. Hence, development of methods to fix the distal tip of the indwelling catheter in the gastroduodenal artery to prevent movement of the catheter in the hepatic artery has decreased the rate of hepatic arterial occlusion.
Most researchers studying percutaneous port-catheter implantation using the fixed-catheter-tip technique have focused on catheter fixation with microcoils alone [15,16,17]. To our knowledge, no large study in the English-language literature has described the use of n-butyl cyanoacrylate in percutaneous catheter placement, with the exception of our previous article [8].
N-butyl cyanoacrylate is widely used as a permanent embolic agent, especially in intracerebral interventional radiology procedures such as the embolization of arteriovenous malformation [18, 19]. Adding iodized oil to the n-butyl cyanoacrylate permits the embolized vessel to be visualized on imaging. Also, the adhesion time can be adjusted according to the concentration of the mixed iodized oil. Thus, organ infarction, a potential complication caused by possible transarterial embolization of two peripheral arterial branches using n-butyl cyanoacrylate, can be prevented by hastening the adhesion time [7]. N-butyl cyanoacrylate has been used as a liquid acrylic adhesive material in the field of surgery. Our study shows that n-butyl cyanoacrylate is useful not only as an embolic agent but as an adhesive agent in the field of interventional radiology.
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