| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Clinical Observations |
1 All authors: Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Asahimachi 67, Kurume, Fukuoka 830-0011, Japan.
Received April 28, 2005;
accepted after revision September 27, 2005.
Address correspondence to S. Nagaoka
(sakae-nagaoka{at}syd.odn.ne.jp).
Abstract
 Top Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CONCLUSION. The temporary indwelling catheter system via the left brachial artery can be used not only for CO2-enhanced sonographically guided aspiration biopsy, radiofrequency ablation, and percutaneous ethanol injection, but also for short-term hepatic arterial infusion chemotherapy and transcatheter arterial chemoembolization.
Keywords: catheters • interventional radiology • hepatocellular carcinoma • liver • port-catheter system • CO2-enhanced sonography
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Hepatic arterial infusion chemotherapy involves the placement of a transbrachial angiographic catheter and the use of an implanted port-catheter system, but the use of such a system is associated with serious complications [5-10]. Recently, the percutaneous femoral or left subclavian approach has been used as a common access route [11, 12] because the use of the axillary or brachial artery is associated with a high frequency of catheter dislocation (2-44%) [13]. In our study, we used a new catheter that we refer to as a temporary indwelling catheter system via the left brachial artery, which is kept outside the skin and does not require subcutaneous implantation. To our knowledge, ours is the first report of such a procedure. The aim of our retrospective study was to evaluate the usefulness of the temporary indwelling catheter system and related complications in patients with HCC and other liver tumors.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
The diagnosis of HCC was made by a combination of sonography, CT, MRI, digital subtraction angiography, and tumor aspiration biopsy. Patients with HCCs smaller than 3 cm in diameter and with fewer than four tumor masses were treated with percutaneous ethanol injection or radiofrequency ablation. When viable portions of the primary tumor or recurrent tumors could not be detected using conventional sonographic biopsy, CO2-enhanced sonographically guided fine-needle aspiration biopsy was performed before treatment with percutaneous ethanol injection or radiofrequency ablation. For patients with HCCs larger than 3 cm in diameter or with more than five tumor masses, the temporary indwelling catheter system was used for hepatic arterial infusion chemotherapy or chemoembolization.
Patient Characteristics
Disease was staged according to the American Joint Committee on Cancer
tumor, node, metastasis (TNM) staging criteria. Five patients were stage I;
40, were stage II; 30 were stage III A, B, and C; and four were stage IV. Four
patients did not have HCC. Catheterization was successful in all patients. The
ages of the patients ranged from 38 to 85 years (median age, 64.7 years); 55
patients were men and 28 were women. Of the 83 patients, 10 (12.0%) were
hepatitis B surface antigen (HBsAg)-positive, 67 (80.7%) were
positive for antibodies to hepatitis C virus (anti-HCV), and six (7.2%) were
negative for both HBsAg and anti-HCV. Using the Child-Pugh risk
grouping ranked by the criteria of Pugh et al.
[14], 54 patients (65.0%) were
Child A, 25 (30.1%) were Child B, and four (4.8%) were Child C. Fifteen
patients had diabetes mellitus, 23 had hypertension, three had atrial
fibrillation, and one patient had a history of lacunar infarction.
|
|
|
In patients who underwent hepatic arterial infusion chemotherapy, the right gastric artery or the accessory left gastric artery was embolized using microcoils (Diamond Coil, Boston Scientific; Trufill, Cordis; or Hilal Embolization Microcoils, Cook Europe). A polyurethane-covered catheter (Anthron P-U Catheter, Toray Medical) with a tapered tip (5- and 3.3-French outer diameters of the shaft and tip, respectively; and 0.040- and 0.032-inch inner diameters of the shaft and tip, respectively) was used as the indwelling catheter. This catheter was tapered to 3.3-French for 60 cm from the tip. A 100-cm-long catheter was used in all patients
Catheterization was performed as follows: First, before catheterization, one or two side holes were manually made with a surgical knife. A 0.025-inch guidewire (Tranvas, Kaneka) was re-shaped into a mild J curve 8 cm from the tip. Second, the guidewire was inserted into the catheter and the catheter was advanced into the iliac artery; then the 4-French catheter and the 4-French introducer were removed. Third, the indwelling catheter was advanced distal to the thoracic aorta. After the tip of guidewire was withdrawn to the celiac artery, the guidewire was twisted clockwise and its tip inserted into the target artery (e.g., the right hepatic artery, left hepatic artery, proper hepatic artery or gastroduodenal artery) via the celiac artery. Next, the catheter was advanced into the target artery and the position of the side hole was adjusted to the target artery. The guidewire was then withdrawn. Figure 1A, 1B shows an arteriogram performed using the temporary indwelling catheter system inserted via the left brachial artery. Fourth, at the left brachial artery, the inserted part of the catheter was held in place with a silk thread (Fig. 2) and an adaptor cap (RV 100, Toray Medical) was connected to the catheter. The injection part of the cap was made of latex rubber. The redundant distal part of the catheter was not cut off. To avoid occlusion of the catheter, 2,000 U of heparin sodium was injected into the catheter after it had been used. When the catheter was not used for more than 3 days, 2,000 units of heparin was injected into the catheter every other day.
Removal of the Temporary Indwelling Catheter System
After the administration of local anesthetic, the catheter was removed
under fluoroscopic guidance. To avoid embolism or embolization, we cleared
away any adhesions around the side holes and the tip of the catheter by
inserting a 0.025-inch guidewire and injecting 5-10 mL of saline.
Examination and Treatment Using the Temporary Indwelling Catheter System
Aspiration biopsy, percutaneous ethanol injection, and radiofrequency
ablation—The temporary indwelling catheter system with
CO2 enhancement was used to detect HCCs that were difficult to
detect with conventional sonography. A bolus injection of CO2 (2-6
mL) was administered through the temporary indwelling catheter system into the
hepatic artery. A gray-scale sonography scanner was used to monitor the flow
of CO2 and to view the enhanced image of the liver tumor. The
CO2 remained in the tumor for 12-15 minutes, which was long enough
to insert a needle to perform aspiration biopsy, percutaneous ethanol
injection, or radiofrequency ablation. Each tumor required performance of
percutaneous ethanol injection two to six times with CO2-enhanced
sonographic guidance.
Hepatic arterial infusion chemotherapy—One course of chemotherapy consisted of the daily administration of cisplatin (10 mg for 30 minutes on days 1-5) and the subsequent infusion of 5-fluorouracil (250 mg for 3 hours on days 1-5). Days 6 and 7 were rest days. On days 1 and 16 only, 20 mg of cisplatin was administered. When two or three courses of hepatic arterial infusion chemotherapy had reduced the number of small HCC nodules and facilitated the performance of selective transcatheter arterial chemoembolization, that procedure was performed, after which the temporary indwelling catheter system was removed. In patients who did not respond to hepatic arterial infusion chemotherapy, port-catheter systems were implanted through the left brachial artery because of the requirement for hepatic arterial infusion chemotherapy treatment as outpatients.
For patients who underwent hepatic arterial infusion chemotherapy, the catheter days using the temporary indwelling catheter system (i.e., the device service interval) was defined as the period from catheterization to removal or port-catheter implantation. When a new catheter was implanted, the proximal end of the indwelling catheter was connected to a port (P-U Celsite Port Brachial, Toray Medical). A brachial pocket was formed where the port reservoir was to be placed. Outpatients were treated with cisplatin (20 mg for 30 minutes) and 5-fluorouracil (250 mg for 2 hours) biweekly.
Transcatheter arterial chemoembolization using temporary indwelling catheter system—Lobar chemoembolization using the temporary indwelling catheter system was performed four times over a period of 2 weeks. An emulsion of epirubicin (20-30 mg per person) and Lipiodol (iodized oil, Guerbet) (2-4 mL) was administered into the feeding artery under fluoroscopic guidance. Finally, for transcatheter arterial chemoembolization, after removal of the temporary indwelling catheter system, we placed a 4-French catheter through a 4-French introducer sheath and used a coaxial catheter to embolize the supply artery of the tumor with the epirubicin-Lipiodol emulsion and a gelatin sponge. The dose of epirubicin was determined on the basis of the remaining hepatic function, whereas the dose of Lipiodol was determined on the basis of the location and size of the tumor.
Complications Associated with Temporary Indwelling Catheter System
The frequency of complications associated with the temporary indwelling
catheter system, such as hematoma, bleeding, hepatic artery occlusion,
dislocation of the catheter, infection, and thrombosis, was reported. Hematoma
was defined as a left brachial induration with a palpable liquid collection of
more than 2 cm in diameter around the device. Un-controllable bleeding was
defined as bleeding that could not be stopped by manual pressure for more than
10 minutes. Brachial artery thrombosis was diagnosed by the absence of a
radial pulse in a routine check every morning and evening.
Dislocation of the catheter was detected as follows: For patients treated with hepatic arterial infusion chemotherapy, digital subtraction angiography was performed within 3 days after the procedure and within 14 days through the temporary indwelling catheter system to visualize other organs; this allowed detection of catheter displacement. For patients injected with CO2, digital subtraction angiography confirmed catheter displacement when the distribution of CO2 over the whole liver could not be detected. For patients treated by chemoembolization, the position of the catheter was confirmed under fluoroscopic guidance before every treatment.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Temporary indwelling catheter system for hepatic arterial infusion chemotherapy and transcatheter arterial chemoembolization— Thirty patients were treated with hepatic arterial infusion chemotherapy. In 15 of these patients, transcatheter arterial chemoembolization was performed after hepatic arterial infusion chemotherapy followed by removal of the temporary indwelling catheter system. In these patients, short-term hepatic arterial infusion chemotherapy reduced the number of small HCC nodules and facilitated the performance of selective transcatheter arterial chemoembolization. In the other 15 patients, who showed no improvement after hepatic arterial infusion chemotherapy, the port-catheter systems were implanted through the left brachial artery, and hepatic arterial infusion chemotherapy was provided on an outpatient basis. For implantation, new catheters were used. Seven of these 15 patients required replacement of the artery (Figs. 3A and 3B), and an alternative port-catheter system was implanted in these seven patients through the femoral artery (Figs. 3C and 3D).
|
|
|
|
Number of Catheter Days
All catheterization procedures were performed using interventional
radiology, and no interventional complications occurred. The mean time for the
procedure was 51 minutes (range, 15-210 minutes). The catheter tip was placed
into the right hepatic artery (27 patients), the left hepatic artery (19
patients), the middle hepatic artery (two patients), the proper hepatic artery
(10 patients), the gastroduodenal artery (21 patients), the common hepatic
artery (two patients), the inferior phrenic artery (one patient), and one
additional artery (one patient).
In one patient with occlusion of the celiac axis, the tip of the catheter was placed at the gastroduodenal artery through the inferior pancreaticoduodenal artery from the superior mesenteric artery (Fig. 4A, 4B). The number of catheter days associated with various therapies is shown in Table 1. For all patients, the number of catheter days was 18.6 days (range, 1-43 days). For aspiration biopsy, the number of catheter days was 7.2 days (range, 1-18 days). The catheter was removed after the pathologic diagnosis was established.
|
|
|
A second CO2-enhanced sonographically guided fine-needle aspiration biopsy was required for diagnosis in one patient. In one patient, no tumor staining was detected, and CO2-enhanced sonographically guided fine-needle aspiration biopsy could not be performed. The day after the procedure, the temporary indwelling catheter system was removed from this patient.
In eight patients, the catheter was removed within 10 days after the procedure. For patients treated with CO2-enhanced sonographically guided percutaneous ethanol injection or radiofrequency ablation, the number of catheter days was 20.4 days (range, 1-43 days), whereas for patients treated with hepatic arterial infusion chemotherapy and chemoembolization, the number of catheter days was 21.1 days (range, 4-42 days) and 18.6 days (range, 14-25 days), respectively. For patients treated with hepatic arterial infusion chemotherapy, the number of catheter days was the time from catheterization to removal of the temporary indwelling catheter system or implantation of the port-catheter system.
Complications Associated with Catheterization
Complications occurred in eight patients (9.6%). These included bleeding in
two cases (2.4%), hematoma formation in two patients (2.4%), occlusion of the
catheter in one patient (1.2%), stenosis of the proper hepatic artery in one
patient (1.2%), and dislocation of the catheter in one patient (1.2%);
infection was suspected in one patient (1.2%). In the two patients who
experienced bleeding, hemostasis was achieved by compression and suturing of
the skin. In patients with bleeding or hematoma, transfusion or surgical
evacuation was not needed. Occlusion of the catheter was due to the lack of
heparin injection for 4 days; the catheter was removed and the temporary
indwelling catheter system was reinserted. None of the patients developed
brachial artery thrombosis, a transient ischemic attack, or cerebral
infarction.
In the patient who developed stenosis of the proper hepatic artery, ERCP revealed invasion of the common bile duct by HCC and hemobilia. It was unclear whether stenosis of the proper hepatic artery was due to encasement or injury. In the patient with a displaced catheter, although the side holes were dislocated into the gastroduodenal artery, repositioning into the common hepatic artery was possible by withdrawing the catheter. In the patient in whom infection was suspected, tenderness in the left brachial artery to the axillary artery appeared after 4 days of catheterization. In this patient, the tenderness improved soon after removal of the catheter at 6 days after insertion.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
However, insertion of the temporary indwelling catheter system via the left brachial artery minimizes the limitations on patients, and several sessions of CO2-guided percutaneous ethanol injection or radiofrequency ablation can be performed. Furthermore, conventional port-catheter systems require implantation and removal of the port, even for short-term treatments. Such procedures are unnecessary with the temporary indwelling catheter system, which therefore lessens the physical burden on patients.
The use of 3.3-French long tapered catheters has several advantages. Such catheters can be advanced to a distal artery, and a long tapered catheter makes it possible to catheterize a replaced artery from the left brachial artery in hepatic arterial infusion chemotherapy. Hepatic arteries show various variations, and the ratio of a replaced right hepatic artery and accessory right hepatic artery from the superior mesenteric artery can be 5-15%, and that of a replaced left hepatic artery and accessory left hepatic artery from the left gastric artery is 11.5-23% [18]. Indeed, 23% of patients who were treated with hepatic arterial infusion chemotherapy had a replaced artery: In 20% of patients, the replacement was of a right hepatic artery from the superior mesenteric artery, and in 3% of patients, it involved a left hepatic artery from the left gastric artery.
In comparing the complications reported in the studies listed in Table 2, we note that several authors have reported a high rate of complications with hepatic arterial infusion chemotherapy performed through transbrachial angiographic catheter placement (not implanted) [5-10]—complications such as dislocation, hepatic artery stenosis, and hepatic artery thrombosis. It is possible that the long tapered catheter that we used decreased occlusion of hepatic arteries and decreased distal catheter dislocation, thereby stabilizing the system [19]. In our study, the most common complication (4.8%) was bleeding and formation of hematomas. Compared with other studies, the rate of bleeding and hematomas was relatively low, and four patients with complications of bleeding or hematoma were classified as Child class C.
|
In comparing the present study with previous studies, we recognize some concerns with our approach. First, few studies have reported complications of an implanted port-catheter system. Dislocation of the catheter, thrombosis, and cerebral infarction may be related to the duration of implantation or catheterization. Second, the sample size was small and had a potential bias in patient selection; 92.3% of patients had chronic liver disease. For use in the implanted port-catheter system, the safety and usefulness of our long tapered catheter should be evaluated further. However, major complications were not detected in patients treated using the temporary indwelling catheter system or in 15 patients implanted with port-catheter systems based on our catheter.
The advantages of prophylactic hepatic arterial infusion chemotherapy for metastatic liver tumor from a primary colorectal cancer using the port-catheter system have been reported, including the regional arterial infusion of a protease inhibitor and antibiotics for severe pancreatitis and the hepatic arterial infusion of antibiotics or amphotericin B for multiple liver abscess [20, 21]. Hence, the temporary indwelling catheter system may be appropriate for short-term catheter-based treatment, not only for patients with liver tumor but also for patients with benign diseases such as liver abscess and pancreatitis.
In conclusion, compared with other catheter systems, the temporary indwelling catheter system is convenient and its use is associated with a reduced incidence of catheter dislocation, hepatic artery stenosis, and thrombosis, suggesting that various therapies for both liver tumors and other diseases will be facilitated by this system.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
