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AJR 2005; 184:220-224
© American Roentgen Ray Society

Efficacy of the Left Gastric Artery as a Route for Catheterization of the Right Gastric Artery

Takuji Yamagami1, Takeharu Kato1, Shigeharu Iida1, Tatsuya Hirota1 and Tsunehiko Nishimura1

1 All authors: Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-chyo, Kawaramachi-Hirokoji, Kamigyo, Kyoto 602–8566, Japan.

Received December 3, 2003; accepted after revision June 3, 2004.

 
Address correspondence to T. Yamagami (yamagami{at}koto.kpu-m.ac.jp).


Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
OBJECTIVE. Our aim was to evaluate the efficacy of the left gastric artery as a route for embolization of the right gastric artery before port-catheter implantation for hepatic artery infusion chemotherapy.

MATERIALS AND METHODS. In 88 patients (61 men and 27 women; mean age, 63.4 years; range, 25–83 years) with unresectable advanced liver cancer, retrograde catheterization of the right gastric artery through the left gastric artery was performed to embolize the right gastric artery.

RESULTS. The right gastric artery was successfully catheterized and embolized in 79 patients (89.8%). In two of the nine patients in whom the procedure was not successful, we found that no right gastric artery existed after we succeeded in retrograde advancement of the microcatheter toward the hepatic site. The only procedure-related complication was misplacement of a microcoil into the hepatic artery site in two patients.

CONCLUSION. The left gastric artery is an appropriate route for selective embolization of the right gastric artery as preparation for long-term hepatic artery infusion chemotherapy.


Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Long-term hepatic artery infusion chemotherapy via an implanted port-catheter system is well known as a last-resort treatment for unresectable advanced liver cancer [1, 2]. In the past, such catheters were placed by surgical laparotomy with the patient under general anesthesia [3–6], making this procedure invasive. However, recent advancements in interventional techniques allow the implantation of port-catheter systems percutaneously with the patient under local anesthesia [7–14].

A frequent complication is reactive gastric or duodenal mucosal lesions resulting from chemical irritants caused by infusion of chemotherapeutic agents into adjacent organs through arteries originating from the common hepatic artery [15–24]. A gastric mucosal lesion caused by inflow of chemotherapeutic agents into the right gastric artery is one such complication [15–24]. To prevent this complication, researchers have noted the efficacy of selectively embolizing the right gastric artery at the time of implantation of the port-catheter system [21, 25–27].

However, the origin of the right gastric artery is, in many cases, slender and angulated, with anatomic variations [26, 28–31]. Thus, the usual method of inserting a catheter selectively into the right gastric artery through the hepatic artery is occasionally difficult, with resultant failure to embolize the right gastric artery [26]. In 2001, Hashimoto et al. [32] discovered a new approach to the right gastric artery—through a microcatheter advanced via the left gastric artery—and reported their experience with 22 patients. Also, at our institution, we had found such a retrograde approach through trial and error before their study [32] was published. Beginning in May 2000, when we recognized the usefulness of such an approach, we routinely selected it as the method of choice [26]. The present study evaluated this approach for embolization of the right gastric artery with a larger number of subjects.


Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
The study included all 88 consecutive patients (61 men and 27 women; mean age, 63.4 years; range, 25–83 years) who presented between May 2000 and August 2003 with unresectable advanced liver cancer and underwent right gastric arterial embolization through a microcatheter advanced from the left gastric artery site to prevent infusion of chemotherapeutic agents into the stomach wall during long-term hepatic artery infusion chemotherapy. In 41 patients, this right gastric artery embolization was performed as the first step in percutaneous port-catheter implantation on the same day as the implantation, and in 47 patients it was performed the previous day.

Of the 88 patients, 36 had primary liver cancer and 52 had metastatic liver cancer that originated from cancer of the colon or rectum (n = 33), breast (n = 10), gallbladder (n = 4), pancreas (n = 3), anus (n = 1), or stomach (n = 1). All patients had diffuse or multiple (more than five) malignant lesions or a few huge malignant lesions in both the right and left lobes of the liver, making surgical resection impossible. Most of these patients had received systemic chemotherapy or other interventional treatments, only to develop intractable disease.

Parameters Investigated
The following parameters were retrospectively investigated: the rate of success of embolization of the right gastric artery through a microcatheter advanced via the left gastric artery, management of the right gastric artery after failure to advance the microcatheter using this route, and complications related to this procedure.

Procedures
Port-catheter implantation.—The indwelling catheter was inserted from the left subclavian artery (n = 81) or the right femoral artery (n = 7) with the patient under local anesthesia. For all patients, the port-catheter was implanted using the fixed-catheter-tip technique. Arterial branches used for fixing the catheter tip were the gastroduodenal artery (n = 85) and the peripheral branch of the hepatic artery (n = 3). Details of the methods of port-catheter placement with the fixed-catheter-tip technique are described elsewhere [7, 8, 33, 34]. Follow-up arteriography, which was performed while contrast agents were infused manually via the port, took place every 2–5 months after port-catheter placement.

Right gastric artery embolization.—Embolization of the right gastric artery using retrograde catheterization via the left gastric artery was performed as follows (Figs. 1A, 1B, 1C, and 1D). First, a 5-French catheter was advanced through the sheath introducer inserted from the femoral artery and was positioned in the celiac axis or the origin of the left gastric artery. Next, a microcatheter (Renegade-18, Boston Scientific) was coaxially advanced into the left gastric artery from the 5-French catheter with use of a microguidewire (GT wire, Terumo; or Transend, Boston Scientific), and selective gastric arteriography was performed to show the course of the anastomosis of the right gastric artery with the left gastric artery. The microcatheter was then further advanced into the right gastric artery to the junction with the hepatic artery. When the course of the gastric artery was too tortuous for easy advancement of the microcatheter, the patient swallowed effervescent granules (Baros, Horii) to distend the stomach with gas and straighten the artery, assisting advancement of the microcatheter from the left to the right gastric artery. After a microcoil (Diamond Coil, Boston Scientific; or Trufill, Cordis) was loaded into an introducer for easy transfer to the microcatheter, the microcoil was delivered through the microcatheter using a coil pusher (Coil Pusher-16, Boston Scientific) and was positioned in the right gastric artery at the point nearest the hepatic artery. After the coil pusher was removed, arteriography was performed via the microcatheter that had been advanced through the left gastric artery. If residual blood flow was seen in the right gastric artery, additional microcoils were positioned. These procedures were performed by one of three experienced interventional radiologists in the interventional radiology suite after written informed consent had been obtained from the patient.



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  		Fig. 1A. —62-year-old man with liver metastasis from colon cancer. Arteriogram obtained via 5-French catheter placed at left gastric artery (arrow) shows gastric artery running toward hepatic site (arrowheads).

 


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  		Fig. 1B. —62-year-old man with liver metastasis from colon cancer. Arteriogram obtained via microcatheter (arrows) coaxially advanced from 5-French catheter (arrowhead) placed at left gastric artery shows communication between left and right gastric arteries. Gaseous distention of stomach is achieved with effervescent granules.

 


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  		Fig. 1c. —62-year-old man with liver metastasis from colon cancer. Arteriogram obtained after microcatheter had been advanced to embolization point in right gastric artery shows that right gastric artery arises opposite branching of gastroduodenal artery from common hepatic artery (arrow).

 


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  		Fig. 1D. —62-year-old man with liver metastasis from colon cancer. Arteriogram obtained via port after percutaneous implantation of indwelling port-catheter system shows that implantation has been precise. All hepatic artery branches are shown. Distal tip of catheter is fixed to gastroduodenal artery with microcoils and N-butyl cyanoacrylate–Lipiodol ([iodized oil] Laboratoire Guerbet) mixture (small arrows). Right gastric artery (large arrow) is successfully embolized with five microcoils, and branch arising from gastroduodenal artery (medium arrow) is embolized with one microcoil.

 


Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Technical Results
Overall, retrograde catheterization via the left gastric artery toward the hepatic site was successful in 81 (92%) of the 88 patients. In two of the 81 patients, advancement of the microcatheter and embolization required gaseous distention of the stomach. However, in two patients in whom the microcatheter was successfully advanced via the left gastric artery toward the hepatic site, arteriography via the microcatheter revealed direct inflow into liver parenchyma. Figures 2A and 2B shows one of these patients. In these two patients, arteriography revealed lack of a right gastric artery, and this finding was afterward confirmed by common hepatic arteriography. In summary, the right gastric artery was successfully embolized in 79 of the 81 patients for whom the microcatheter was successfully advanced through the left gastric artery toward the hepatic site.



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  		Fig. 2A. —70-year-old man with liver metastasis of colon cancer. Arteriogram obtained via 5-French catheter placed at left gastric artery (large arrow) shows gastric artery running toward hepatic site (small arrow).

 


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  		Fig. 2B. —70-year-old man with liver metastasis of colon cancer. Arteriogram obtained after retrograde advancement of microcatheter through left gastric artery shows direct inflow of gastric artery into liver parenchyma. There is no right gastric artery in this patient.

 

Of the seven patients for whom retrograde catheterization was not successful, catheterization was achieved for six when the approach was changed to antegrade through the hepatic artery. In one of these six patients, anastomoses between the left and right gastric arteries did not exist, resulting in failure to advance the microcatheter through the left gastric artery to the right gastric artery. In the remaining patient, the right gastric artery could not selectively be catheterized even after the approach route had been changed.

The number of coils used was 2.4 ± 1.0 (mean ± SD; range, 1–7; median, 2). In three patients, because embolization was insufficient with microcoils alone, we added N-butyl-2cyanoacrylate (Histoacryl-Blue, Braun) mixed with iodized oil (Lipiodol, Laboratoire Guerbet). The ratio of N-butyl-2cyanoacrylate to Lipiodol ranged from 1:1 to 1.5.

Complications
A procedure-related complication that occurred in two patients involved misplacement of a coil into the hepatic artery. The coil was successfully retrieved with the microsnare kit (Amplatz Goose Neck Microsnare Kit, Microvena) in both patients. After retrieval of the misplaced microcoil, new microcoils were correctly placed into the right gastric artery. No other complications related to this procedure occurred.

Follow-Up
In all patients except the one for whom we failed to selectively catheterize the right gastric artery, the right gastric artery could not be visualized through arteriography performed via the port immediately after port-catheter placement, suggesting successful embolization. In one patient, however, follow-up arteriography via the port 57 days after embolization revealed recanalization of the right gastric artery. In this patient, gastrointestinal symptoms developed, with gastric mucosal lesions shown on endoscopy, and reembolization was required. Gastrointestinal symptoms were not induced by hepatic artery infusion chemotherapy in any other patients.


Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The right gastric artery is usually small (< 2 mm in diameter), angulated, and rich in anatomic variations [21]. Hence, it is sometimes difficult to selectively advance catheters through the hepatic artery into the right gastric artery. Regarding anatomic variations, the most common reported sites of origin of the right gastric artery are the proper hepatic artery, with a frequency of 40–52% [21, 26, 30, 31], and the right or left hepatic artery, with a frequency of 21–42% [21, 26, 30, 31]. The origin has also been reported to be the common hepatic artery (1.5–10%) [26, 30, 31] and gastroduodenal artery (1.5–2.7%) [26, 31].

As is commonly known, the right gastric artery generally anastomoses with the left gastric artery [29]. This fact led us to speculate that advancing the microcatheter to the right gastric artery through the left gastric artery would be possible, even though the hepatic artery was usually used for this purpose. Hashimoto et al. [32] were the first to report attempted catheterization of the right gastric artery through the left gastric artery. They succeeded in selectively catheterizing the right gastric artery, using this route in 12 (86%) of 14 patients with smooth anastomoses between the right and left gastric arteries. In our previous study [26] of embolization of the right gastric artery in 75 patients, the approach was through the hepatic artery in the first consecutive 43 of the 75 patients and through the left gastric artery in the second consecutive 32. The success rate for embolization was significantly higher with the latter approach than with the former—that is, 72.1% (31/43) versus 93.8% (30/32).

Our present study was comparably successful in embolizing the right gastric artery through the left gastric artery (i.e., 89.8% [79/88] of the entire group and 91.9% of the 86 patients having a right gastric artery). There were no serious complications, although the number of subjects was greater than in previous studies [26, 32]. The good results of these previous studies and the present study confirmed that advancement of microcatheters via the left gastric artery into the right gastric artery is a useful and safe method to prepare for long-term hepatic artery infusion chemotherapy. This approach may also be used as an alternative when the usual route through the hepatic artery fails [26]. In addition, to our knowledge there have been no reports of the use of intragastric gas, as we described, for difficulty in advancing the microcatheter through the left gastric artery toward the right gastric artery. A limitation is that this route cannot be used when the anastomosis between the right and left gastric arteries is too small to allow advancement of the microcatheter or is nonexistent.


References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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