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Original Research |
1 Department of Interventional and Diagnostic Radiology, Aichi Cancer Center
Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya 464-8681, Japan.
2 Department of Diagnostic Radiology, National Cancer Center Hospitals, Nagoya,
Japan.
Received April 14, 2005;
accepted after revision October 21, 2005.
Address correspondence to Y. Inaba.
Abstract
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MATERIALS AND METHODS. Between January 1999 and December 2004, 532 patients with unresectable advanced liver cancer underwent radiologic placement of port-catheter systems at our institution. Of these, 18 patients (nine men and nine women; age range, 32-83 years; mean age, 53.8 years) underwent removal of an implanted port-catheter system via the right femoral artery and radiographically guided replacement with a new system to allow continuous hepatic arterial infusion chemotherapy; we retrospectively reviewed these 18 cases. The reasons for removal of the previously implanted systems were as follows: catheter dislodgement (n = 15), catheter obstruction (n = 1), infection related to the implanted port (n = 1), and hemodynamic change (n = 1). Digital subtraction angiography and CT were performed, usually during injection of contrast medium through the implanted port-catheter system, within a few days after the replacement procedure and every 3 months thereafter.
RESULTS. We successfully performed radiologic removal and replacement of the portcatheter system while the patient was under local anesthesia in all 18 patients without complications requiring treatment. The cumulative patency rates of the hepatic artery after removal of the old port-catheter system and replacement with a new port-catheter system were 87.8% and 64.1% at 6 months and 1 year, respectively. Hepatic arterial infusion chemotherapy after replacement was performed 0-68 times (median, 19 times).
CONCLUSION. When an implanted port-catheter system can no longer be used but the patency of the hepatic artery is confirmed and continuous hepatic arterial infusion chemotherapy is required, removal and replacement of the port-catheter system are recommended.
Keywords: chemotherapy • implantable devices • liver cancer • port-catheter system
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Patients
Between January 1999 and December 2004, 532 patients with unresectable
advanced liver cancer underwent radiologically guided placement of
port-catheter systems at our institution. Of those patients, 18 (nine men and
nine women; age range, 32-83 years; mean age, 53.8 years) received a
replacement system after the original device had been removed to allow
continuous hepatic arterial infusion chemotherapy. Seventeen patients had
liver metastases that originated from colorectal cancer (n = 9),
breast cancer (n = 4), gastric cancer (n = 3), or carcinoma
of the papilla of Vater (n = 1), and the remaining patient had
hepatocellular carcinoma.
The reasons for the removal of the previously implanted systems were as follows: catheter dislodgement (n = 15); catheter obstruction (n = 1); infection related to the implanted port (n = 1); and hemodynamic change (n = 1), such as hepatopetal flow of the common hepatic artery that was changed to hepatofugal flow as a result of altered flow in the gastroduodenal artery secondary to stenosis of the celiac artery. All 18 patients had only liver lesions that were well controlled by hepatic arterial infusion chemotherapy, so continuous hepatic arterial infusion chemotherapy was desired if the hepatic artery was patent. That information was obtained from the medical records.
First Placement of Port-Catheter Systems
The placement site of the port-catheter system was originally chosen
according to the following method: All patients underwent angiography before
catheter placement, which was performed using a 5-French angiographic catheter
inserted from the right femoral artery to allow arterial mapping and to
prevent extrahepatic influx of anticancer agents. The extrahepatic arteries
branching from the hepatic artery, such as the right gastric artery, posterior
superior pancreatoduodenal artery, and superior duodenal artery, were
embolized with microcoils (Tornado, Cook; or Trufill, Cordis) through a
2.9-French microcatheter (Jamiro, Kaneka; or Sniper, Clinical Supply) inserted
coaxially [5,
13]. The left gastric artery
and gastroduodenal artery were also embolized when the angiographic catheter
tip was inserted into the splenic artery
[5].
In patients with more than two hepatic arteries, these arteries were converted into a single arterial supply by microcoil embolization so that drugs could be distributed to the entire liver using a single indwelling catheter [5]. A 5-French angiographic catheter was then inserted from the left subclavian artery (n = 14) or the right femoral artery (n = 4) and was advanced to the common hepatic artery via the celiac artery.
Subsequently, using the catheter-exchange method, a 5-French indwelling catheter (Anthron P-U catheter, Toray; or W spiral catheter, Piolax) with (n = 16) or without (n = 2) a side hole was inserted. The tips of these catheters were tapered to 2.7-French and 20 cm in length; the catheters were inserted into the gastroduodenal artery (n = 9), the splenic artery (n = 1), the peripheral branch of the hepatic artery (n = 2), the right hepatic artery (n = 3), the common hepatic artery (n = 2), or the accessory left gastric artery arising from the left hepatic artery (n = 1). In 12 of the 18 patients who had catheters inserted into the gastroduodenal artery (n = 9), splenic artery (n = 1), and others (n = 2), the artery around the tip of indwelling catheter was embolized using microcoils and a mixture (1:1.5) of n-butyl cyanoacrylate (Histoacryl, Braun) and iodized oil (Lipiodol Ultrafluide, Laboratoire Guerbet) through a microcatheter inserted coaxially via a 5-French angiographic catheter inserted from the femoral artery. The catheter tip was also fixed in these 12 patients.
In four of the remaining six patients in whom the catheter tip was not fixed, a W spiral catheter was used; the spiral-shaped tip of this catheter has the function of securing it. The side hole of the catheter was placed into the common hepatic artery or the celiac artery. Finally, the proximal end of the indwelling catheter was connected to a port implanted in a subcutaneous pocket created in the left chest wall or the right upper thigh.
Removal and Replacement of Port-Catheter Systems
Written informed consent was obtained from all the patients before these
procedures. All the procedures were performed in an angiographic suite by
interventional radiologists with the patient under local anesthesia. On the
same day as the procedure or the day before the procedure, all patients
underwent angiography using a 5-French angiographic catheter inserted from the
right femoral artery to confirm patency of the hepatic arteries.
In the four patients in whom the catheter had previously been implanted from the right femoral artery, after opening the subcutaneous space housing the port, the indwelling catheter was directly withdrawn from the right femoral artery with the port.
In the 14 patients in whom the port-catheter system was previously implanted via the left subclavian artery, a 5-French hook-shaped catheter was first inserted from a right femoral artery through a 6-French sheath introducer and was then wrapped around the indwelling catheter. The hook-shaped catheter was then pulled to relocate the indwelling catheter tip to the aorta. After the hook-shaped catheter was withdrawn, a 5-French basket retriever was inserted via the right femoral artery through the sheath introducer to capture the distal tip of the indwelling catheter. After a small incision was made at the insertion site in the left chest wall, the implanted port was withdrawn, the proximal part of the indwelling catheter was cut, and the port was removed from the catheter. The indwelling catheter captured by the basket retriever was then withdrawn from the right femoral artery. Subsequently, replacement with a new port-catheter system was performed using the same methods described earlier.
The total time required for the procedure ranged from 107 to 225 minutes (mean, 155 minutes). Catheters were inserted from the left subclavian artery (n = 15), the right femoral artery (n = 1), and the left inferior epigastric artery (n = 2). In three of four patients in whom the first placement procedure was from the right femoral artery and had been performed at another institution, replacement was from the left subclavian artery. The catheters were advanced via the celiac artery (n = 16) or through the pancreaticoduodenal arcade via the superior mesenteric artery in cases of celiac artery stenosis (n = 2). Catheter tips were inserted into the gastroduodenal artery (n = 2), the splenic artery (n = 3), the peripheral branch of the hepatic artery (n = 6), the right hepatic artery (n = 5), the common hepatic artery (n = 1), and the middle hepatic artery (n =1) (Table 1).
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In one patient, because selecting a placement site for the catheter was difficult using the method mentioned earlier, placement was performed as follows: We first selected the celiac artery with a 5-French angiographic catheter (inserted via the femoral artery) and then inserted an indwelling catheter (Anthron P-U catheter, Toray) using the catheter-exchange method. A 2.9-French microcatheter (Sniper, Clinical Supply) was inserted coaxially into the right hepatic artery through the indwelling catheter, which was thereby relocated to the aorta. Finally, the proximal end of the microcatheter was connected directly to the implanted port using a connecting device. In six of 18 patients, the tip of the indwelling catheter was fixed using microcoils and a mixture of n-butyl cyanoacrylate and iodized oil. In eight of 12 patients in whom the catheter tip was not fixed, a W spiral catheter was used.
Using this system, hepatic arterial infusion chemotherapy was started a few days after the procedure, depending on the clinical circumstances. The details of hepatic arterial infusion chemotherapy and management of this system have been reported previously [7]. Digital subtraction angiography and CT were performed during injection of contrast medium through the implanted port-catheter system within a few days after the procedure and every 3 months thereafter to confirm that the catheter and hepatic artery were patent and that the entire liver was perfused adequately. These investigations were also performed whenever patients reported any symptoms that might be related to hepatic arterial infusion chemotherapy.
Evaluation
Outcome was evaluated in terms of the success rate for removal and
replacement of the port-catheter systems, complications of the procedure, and
number of sessions of hepatic arterial infusion chemotherapy after replacement
with the new systems. The cumulative patency rate of the hepatic artery
confirmed by digital subtraction angiography was calculated according to the
Kaplan-Meier method.
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Hepatic arterial occlusion and catheter dislodgement are the most common complications that require hepatic arterial infusion chemotherapy to be stopped, with prevalences of 0-17% and 2.2-14.3%, respectively, recently reported during use of nonsurgically inserted port-catheter systems [6-12]. However, placement of a side-hole catheter with tip fixation is reported to be associated less frequently with hepatic arterial occlusion (5.4% [6]) or catheter dislodgement (2.2-2.8% [6, 7]). Accordingly, for the initial placement procedure, we usually insert the tip of a side-hole catheter into the deep portion of the gastroduodenal artery and fix it using microcoils and a mixture of n-butyl cyanoacrylate and iodized oil.
Although various complications such as catheter dislodgement can preclude the continued use of an implanted port-catheter system, we aim to continue to treat patients with hepatic arterial infusion chemotherapy if the hepatic artery is patent. A dislodged catheter causes flow into the extrahepatic arteries, resulting in reduced concentrations of drug in the liver. We overcome this complication by embolizing extrahepatic arteries, such as the left gastric artery, splenic artery, or dorsal pancreatic artery [5], if possible. However, in the present study, we removed implanted port-catheter systems and replaced them with new systems because catheter dislodgement was too great to be overcome by embolizing extrahepatic arteries.
We decided to remove the original implanted port-catheter system when replacing it with a new system to minimize the disturbance associated with replacement, the unnecessary stimulation of the artery, and the possibility of infection, and because this was generally the patient's request. Although we anticipated that removal of indwelling catheters with fixed tips would be difficult, it was possible to safely remove the catheter in all nine patients.
We removed implanted catheters via the right femoral artery in all patients. Particularly when the catheter is originally implanted from the left subclavian artery, removal should be performed via the femoral artery to prevent brain infarction due to release of thrombus around the indwelling catheter and subsequent vertebral arterial embolization [14]. We successfully removed implanted port-catheter systems in all patients without complications (such as brain infarction, hemorrhage, hematoma, infection, or pseudoaneurysm) requiring treatment and with the patient under local anesthesia.
We performed removal and replacement on the same day. After deciding the position of catheter tip insertion based on angiography performed before replacement, we inserted new catheters from the left subclavian artery in many patients because this was the approach artery that had been used previously and patients had therefore previously experienced the procedure. Although the risk of complications such as hemorrhage, hematoma, and pseudoaneurysm is higher if the same route is used, we successfully performed removal and replacement of portcatheter systems using this approach without observing complications requiring treatment.
When an old system was replaced with a new system, the catheter tip was inserted into another artery because we had already embolized the gastroduodenal artery. Replacement of a side-hole catheter with its tip fixed and inserted into another artery was possible in only six of the 18 patients. In one of the remaining 12 patients in whom the tip was inserted into the peripheral branch of the hepatic artery, a second replacement procedure was required because the catheter became dislodged 7 days after the first replacement procedure.
In the present study, at 1 year after replacement, a 64.1% cumulative patency rate for the hepatic artery was achieved. This patency rate is lower than previously reported cumulative patency rates for first placement (81.4% [7] and 86.3% [8]). We think that this discrepancy results from nonfixation of the catheter tip, injury of the hepatic artery caused by prior hepatic arterial infusion chemotherapy, or both. Nonetheless, because we could perform hepatic arterial infusion chemotherapy a median of 19 times after port-catheter system replacement, it seems to be worth continuing hepatic arterial infusion chemotherapy when this therapy is needed in situations such as absence of extrahepatic lesions or when liver metastases are thought to be the prognosis-limiting factor.
In conclusion, although the retrospective design of this study meant that many limitations exist, it is noteworthy that we could safely remove and replace port-catheter systems so that hepatic arterial infusion chemotherapy could continue. Attempting these procedures appears worthwhile if continuing treatment using an implanted port-catheter system is not possible, the hepatic artery is confirmed patent, and continuous hepatic arterial infusion chemotherapy is required.
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