Percutaneous implantation of a Port-Catheter System using the left subclavian artery

Dual-phase CT angiography through the port-catheter system for hepatic arterial infusion chemotherapy using multislice CT: assessment of system dysfunction and impact on predicting clinical problems

BACKGROUND

Hepatic arterial infusion (HAI) chemotherapy is being explored for treatment of malignant liver tumors. Maintenance of HAI systems is important for effective treatment.

PURPOSE

To prospectively evaluate the efficacy of dual-phase CT angiography through the port-catheter system for HAI chemotherapy.

MATERIAL AND METHODS

This study enrolled 47 patients receiving HAI chemotherapy for malignant liver tumors who underwent dual-phase CT angiography through the port-catheter system using multislice CT. Using maximum intensity projection images reconstructed from vascular-phase CT imaging, hepatic arterial patency and catheter location were assessed. Using a combination of vascular- and perfusion-phase CT imaging, system dysfunction and clinical problems were evaluated.

RESULTS

Dual-phase CT angiography was conducted 156 times. Stenosis and obstruction of the hepatic artery and catheter dislodgment were observed seven times in four patients and four times in three patients, respectively. Diagnostic accuracy using vascular-phase CT imaging was 100%. In addition, development of collateral blood supply to the liver and extrahepatic perfusion to the stomach were observed three times in three patients and twice in two patients, respectively. Overall, system dysfunction occurred 16 times in 12 patients, and system correction and treatment modification were required 11 times in 10 patients. In assessing system dysfunction and predicting clinical problems, the accuracy of dual-phase CT imaging was 100%.

CONCLUSION

Dual-phase CT angiography through the port-catheter system is helpful for assessing catheter system dysfunction and predicting clinical problems in HAI chemotherapy.

Hepatic arterial infusion chemotherapy with a coaxial reservoir system using a non-braided spiral tip microcatheter

PURPOSE

To evaluate the efficacy and safety of a coaxial reservoir system with a non-braided spiral tip microcatheter and exclusive port for hepatic arterial infusion chemotherapy.

MATERIALS AND METHODS

In vitro evaluation included evaluation of pressure tolerance/flow rate of the coaxial reservoir system, and the strength of connection between the 2.7-F catheter and port. Due to the difficulty of implanting conventional reservoirs, coaxial reservoirs were implanted via the femoral artery of 80 patients. We implanted a non-braided 2.7-F microcatheter with a spiral shaped tip, 5-F catheter, and a port. Clinical assessment included evaluation of technical success and complications.

RESULTS

In vitro evaluation of the coaxial reservoir at its maximum pressure load showed that flow rates for 300 mg I/mL iopamidol contrast medium were 0.25 ± 0.04 mL/s (undiluted), 1.03 ± 0.01 mL/s (50% dilution), and 2.91 ± 0.01 mL/s (30% dilution). Connection strength between the 2.7-F catheter and port was 13.4 ± 0.57 N. Percutaneous port catheter placement was successful in all patients (100%, n = 80). Complications included hepatic arterial occlusion (10%, n = 8), catheter tip dislocation (1.3%, n = 1), and catheter occlusion (1.3%, n = 1).

CONCLUSIONS

A coaxial reservoir system with a non-braided microcatheter and exclusive port is safe and effective for difficulty of implanting conventional reservoir.

A simplified technique of percutaneous hepatic artery port-catheter insertion for the treatment of advanced hepatocellular carcinoma with portal vein invasion

Objective

We assessed the outcomes of a simplified technique for the percutaneous placement of a hepatic artery port-catheter system for chemotherapy infusion in advanced hepatocellular carcinoma with portal vein invasion.

Materials and Methods

From February 2003 to February 2008, percutaneous hepatic artery port-catheter insertion was performed in 122 patients who had hepatocellular carcinoma with portal vein invasion. The arterial access route was the common femoral artery. The tip of the catheter was wedged into the right gastroepiploic artery without an additional fixation device. A side hole was positioned at the distal common hepatic artery to allow the delivery of chemotherapeutic agents into the hepatic arteries. Coil embolization was performed only to redistribute to the hepatic arteries or to prevent the inadvertent delivery of chemotherapeutic agents into extrahepatic arteries. The port chamber was created at either the supra-inguinal or infra-inguinal region.

Results

Technical success was achieved in all patients. Proper positioning of the side hole was checked before each scheduled chemotherapy session by port angiography. Catheter-related complications occurred in 19 patients (16%). Revision was achieved in 15 of 18 patients (83%).

Conclusion

This simplified method demonstrates excellent technical feasibility, an acceptable range of complications, and is hence recommended for the management of advanced hepatocellular carcinoma with portal vein thrombosis.

Side-hole catheter placement for hepatic arterial infusion chemotherapy in patients with liver metastases from colorectal cancer: long-term treatment and survival benefit

OBJECTIVE

The objective of this study was to evaluate retrospectively correlations between catheter placement methods and treatment outcomes of patients treated with hepatic arterial infusion chemotherapy for unresectable liver metastases from colorectal cancer.

MATERIALS AND METHODS

This study involved 135 patients with liver metastases from colorectal cancer who underwent intrahepatic chemotherapy using catheter-port systems. Complications, treatment discontinuation, hepatic progression, and survival of patients treated with each method were evaluated retrospectively using the Kaplan-Meier method. Conventional 5-French end-hole catheter placement (n = 10) was compared with three side-hole catheter placement methods: 5-French side-hole catheter placement with a fixed catheter tip (original fixed catheter tip method, n = 77); long tapered side-hole catheter placement using a fixed catheter tip method (modified fixed catheter tip method, n = 24); and long tapered side-hole catheter inserted distally in the hepatic artery (long tapered catheter placement method, n = 24).

RESULTS

The following treatment outcomes were significantly better for patients treated using the original or modified fixed catheter tip or long tapered catheter placement method than for those treated using the conventional method, respectively: hepatic arterial patency (1 year: 76.3%, 95.0%, and 94.4% vs 38.9%; p = 0.0014, 0.0007, and 0.0006), catheter stability (1 year: 96.7%, 95.5%, and 95.2% vs 42.9%; p < 0.0001, p = 0.0003, and p = 0.0009), time to treatment discontinuation (medians: 11.7, 14.4, and 12.4 vs 3.2 months; p < 0.0001, 0.0002, and 0.0019), time to hepatic progression (medians: 14.7, 15.7, and 15.8 vs 5.5 months; p = 0.0049, 0.0141, and 0.0004), and overall survival (medians: 21.1, 22.5, and 23.1 vs 13.1 months; p = 0.0146, 0.0036, and 0.0017).

CONCLUSION

Compared with the conventional method, side-hole catheter placement methods allowed long-term intrahepatic chemotherapy and resulted in improved survival.

Placement of a long tapered side-hole catheter in the hepatic artery: technical advantages, catheter stability, and arterial patency

OBJECTIVE

The purpose of this study was to evaluate the technical advantages, safety, and efficacy of placing a catheter distally in the hepatic artery using a long tapered side-hole catheter with an implantable port for hepatic arterial infusion chemotherapy.

SUBJECTS AND METHODS

Fifty patients with unresectable malignant liver tumors underwent radiologic implantation of catheter-port systems using the long tapered catheter placement method. A 2.7-French distal shaft of the catheter was inserted distally in the hepatic artery with its side hole located proximally, and a 5-French proximal shaft was placed in the aorta; the catheter tip was not fixed. Technical success, complications including catheter stability and hepatic artery patency, and tumor response were assessed and compared with the following two historical controls: 35 patients with a 5-French catheter inserted simply in the hepatic artery (conventional method), and 131 patients with a 5-French catheter, the tip of which was fixed in the gastroduodenal artery (the fixed-catheter-tip method).

RESULTS

The technical success rate using the long tapered catheter placement method was 92% (46/50 patients), whereas the feasibility of the fixed-catheter-tip method was confined to 79% of historical controls (131/166 patients). Among patients in whom the gastroduodenal artery was present, a decreased frequency of gastroduodenal artery embolization was seen using the long tapered catheter placement method (39%; 17/44 patients) compared with the conventional method (p = 0.0112) and the fixed-catheter-tip method (p < 0.0001). Cumulative stability rates of the catheter (6 months, 94.9%; 1 year, 94.9%; 2 years, 86.2%) and cumulative patency rates of the hepatic artery (6 months, 89.9%; 1 year, 89.9%; 2 years, 83.5%) were significantly higher using the long tapered catheter placement method than using the conventional method (p = 0.0208 and p = 0.0066, respectively) but were similar to those using the fixed-catheter-tip method. The time of hepatic tumor progression was significantly longer using the long tapered catheter placement method than using the conventional method (p = 0.0299) but was comparable to the time using the fixed-catheter-tip method.

CONCLUSION

The long tapered catheter placement method should find wider application in hepatic arterial infusion chemotherapy because it is useful in preventing catheter dislodgment and hepatic artery occlusion.

Comparisons of outcomes and survivals for two central venous access port systems

BACKGROUND

This study compares the outcomes and survivals between two central venous access port systems.

STUDY DESIGN

Medical records from 298 cancer patients who had received open-end (Deltec, N = 159) or closed-end (Groshong, N = 139) port catheter insertions were retrospectively reviewed.

METHODS

The infection, thrombosis, and surgical complication rates (chi-square test), as well as mean catheter-indwelling-days (t-test) were compared. Kaplan Meier analysis and stratified log rank test were used to compare actuarial survival rates. Cox proportion hazard model was applied to analyze the outcomes predictors.

RESULTS

The total catheter-indwelling-day was 116,603 days in general for this cohort. The Groshong catheters (569 +/- 386.1 days) had longer (P < 0.001) mean catheter-indwelling-day than did Deltec catheters (239 +/- 235.6 days). But the per 1,000 catheter day infection (Deltec 0.18, Groshong 0.16), thrombosis (Deltec 0.07, Groshong 0.06), and surgical complication rates (Deltec 0.07, Groshong 0.02) were equivalent (P > 0.05) between two groups. Patients with leukemia were at higher risk (odds ratio 13.4, P = 0.009) to develop adverse events. However, two types of catheters had similar actuarial survival rates at end of follow up (P > 0.05).

CONCLUSION

We found infection, thrombosis occlusion, surgical complication, and actuarial device survival rates were similar between Deltec and Groshong groups. Hematogenous malignancy was a risk factor for catheter failure.

Catheter Redundancy in the Aortic Arch Increases the Risk of Stroke in Left Subclavian Arterial Port–Catheter Systems

PURPOSE

The stroke rate after left subclavian arterial port-catheter placement was compared in two groups: one with minimal redundancy of the catheter and one with pronounced redundancy in the aortic arch designed to minimize the likelihood of catheter dislocation.

MATERIALS AND METHODS

One hundred forty-eight patients (102 men, 46 women; age range, 26-83 years; mean age, 64.3 years) with inoperable advanced liver cancers underwent percutaneous implantation of port-catheter systems via the left subclavian artery. In 33 patients, a pronounced redundancy of the catheter was intentionally looped in the aortic arch. Redundancy was intentionally avoided in the remaining 115 patients. The rates of brain infarction complications in these two groups were retrospectively compared.

RESULTS

Among the 33 patients with pronounced redundant catheter looping, brain infarctions occurred in four cases (12.1%). In contrast, brain infarctions occurred in only three of the 115 patients with minimal redundant catheter looping (2.6%). The frequency of brain infarction complications was significantly higher in the patients with pronounced redundant catheter looping in the aortic arch than in patients with minimal pronounced redundant catheter looping (P = .044, Fisher exact test).

CONCLUSION

Catheter redundancy in the aortic arch increases the risk of stroke in patients undergoing implantation of port-catheter systems via a left subclavian arterial approach for repeated hepatic arterial infusion chemotherapy.

Evaluation of a microcatheter-arterial port system for intraarterial therapy in an animal model

A new microcatheter-arterial port system for transarterial regional therapy was evaluated in a swine model. Subclavian or femoral access was followed by superselective catheterization of target arteries (hepatic, n = 6; splenic, n = 3). A hemostatic sleeve was placed at the arterial puncture site. Implantation into the target vessel succeeded in all nine placements (100%). After animal movement, no microcatheter tip moved by more than 10 mm. A small hematoma developed at one of the subclavian insertion sites. This system holds promise for transarterial therapies for regional cancer therapy.

Continuous arterial infusion strategies using implanted ports

Surgically implanted ports have been used in continuous or repetitive intra-arterial (IA) chemotherapeutic infusions for patients with multiple liver metastases from colorectal cancer. Recently, a percutaneous implantation procedure was developed, facilitating safe and less invasive IA infusions in the treatment of various disease conditions. This article focuses on the interventional techniques for percutaneous implantation of a vascular access device, consisting of an indwelling catheter and an implantable port, to perform IA infusions. Additionally, we describe details of the alteration of blood flow by coil-embolization that can be performed to obtain selective drug distribution to the target area and to avoid side effects caused by the administration of the chemotherapeutic agent into nontarget areas.

Arterial port catheter system placement using a translumbar aortic route

RATIONALE AND OBJECTIVES

Implantable ports for arterial infusion hold promise in a growing number of clinical applications, including regional chemotherapy and gene therapy. Percutaneous placement of arterial infusion ports has been described clinically; however, existing sites of access pose unique anatomic challenges. The feasibility of translumbar aortic placement of a port-catheter system for long-term arterial infusion was assessed.

MATERIALS AND METHODS

Eight swine underwent placement of a percutaneously implantable arterial port-catheter system using a translumbar aortic approach for catheter placement. The tip of the catheter was positioned in the left or right hepatic artery and the port reservoir implanted in the paraspinal subcutaneous tissues. Patency and position of the port-catheter system were assessed at 7 to 10 days and 28 days. The insertion procedure was modified in two animals by introducing tissue adhesive around the catheter to prevent dislodgment.

RESULTS

Immediate technical success was achieved in 6 of 8 animals (75%). Catheters were dislodged into the aorta in two animals on the day of the procedure, extravascular in four animals and intra-aortic in one animal by day 10. One animal died at 21 days of sepsis. The port-catheter systems remained functional at 28 days with catheters positioned within the left or right hepatic artery in three animals, including two animals in which the catheter had been fixated within the paraspinal soft tissues with tissue adhesive.

CONCLUSIONS

A translumbar aortic route for percutaneous placement of arterial infusion port-catheter systems is feasible in swine and holds potential as an ancillary access site in a clinical setting if the obstacle of catheter fixation can be overcome.