British Journal of Radiology 74 (2001),448-451 © 2001 The British Institute of Radiology
Hepatic arterial occlusion following infusion catheter placement: recanalization using the Palmaz stent
T Tanaka, MD
Y Inaba, MD
Y Arai, MD
K Matsueda, MD
T Aramaki, MD
and
S Dendo, MD
Department of Diagnostic Radiology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-ku, Nagoya 464-8681, Japan
Correspondence: Yoshitaka Inaba, MD
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Abstract
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We report two cases in which hepatic arterial occlusion developed soon after percutaneous catheter placement for hepatic arterial infusion chemotherapy in malignant hepatic neoplasms. A replaced hepatic artery and a proper hepatic artery, respectively, became occluded in these cases. In both, because the tip of a side-holed catheter for arterial infusion was fixed in place, we performed recanalization without removing the indwelling catheter. Despite the presence of the catheter, a stent could be inserted into the occluded portion of the hepatic artery. Recanalization of the hepatic artery was achieved with stent placement, and continuation of hepatic arterial infusion became possible.
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Introduction
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Hepatic arterial occlusion is a major problem in hepatic arterial infusion chemotherapy, necessitating the discontinuation of therapy in many patients [1, 2]. In cases with localized occlusion to the proximal portion of the hepatic artery, induced by mechanical stimulation associated with the catheter placement technique or from the indwelling catheter itself, it is speculated that since the peripheral branches of the hepatic artery are intact, continuation of hepatic arterial infusion via the same route would be feasible if the occlusion is relieved.
We report two cases in which a stent was placed to treat hepatic arterial occlusion developing soon after catheter placement for hepatic arterial infusion, thereby making the continuation of hepatic arterial infusion chemotherapy possible.
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Case 1
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The patient was a 55-year-old woman with metastases from uterine endometrial cancer for whom hepatic arterial infusion chemotherapy via a percutaneously placed catheter was planned. Since the right hepatic artery arose from the coeliac artery, the trunk of the left hepatic artery was embolized with metallic coils, converting the two hepatic arteries into a single artery. On the following day, a 5 F polyurethane catheter (Anthron PU; Toray Industries, Tokyo, Japan) with a side hole was placed in the right hepatic artery from the left subclavian artery. The side hole of the catheter was placed in the trunk of the right hepatic artery. The catheter tip was fixed within the anterosuperior branch of the right hepatic artery with a 0.06 ml mixture (1:1.5) of N-butyl cyanoacrylate (Histoacryl-Blue; Braun, Melsungen, Germany) and iodized oil (Lipiodol Ultra-Fluid; Laboratoire Guerbet, Roissy, France) (NBCA–Lipiodol). The catheter was connected to an implantable port (Sadica port; Clinical Supply, Gifu, Japan), which was embedded subcutaneously in the left anterior chest. An angiogram obtained via the implantable port after catheter placement showed a uniform blood supply to the entire liver. However, another angiogram obtained via the implantable port 3 days later showed that the blood supply to the left lateral segment of the liver had become poor. Coeliac axis angiography was again performed from the right femoral artery, and showed that the proximal portion of the right hepatic artery into which the catheter had been placed was locally occluded, and there was now a collateral circulation through the peribiliary arterial plexus arising from the gastroduodenal artery into the branches of the right and left hepatic arteries (Figure 1a
). The occlusion at the origin of the right hepatic artery was presumably due to a change in the course of the right hepatic artery induced by the presence of the indwelling catheter, resulting in a portion of the vessel lumen becoming stenotic. Percutaneous transluminal angioplasty (PTA) of this occlusion of the right hepatic artery was attempted via a right femoral artery approach. The occlusion was crossed using a 3 F microcatheter (Tracker-18; Target Therapeutics/Boston Scientific, Fremont, CA) and suitable guidewire (Taper-16; Target Therapeutics/Boston Scientific). After the guidewire was exchanged for a 0.018'', 260 cm long supportive guidewire (Platinum Plus; Boston Scientific, Watertown, MA), PTA was performed using a 3.5 mm diameter, 4 cm long balloon (Savvy; Cordis/Johnson & Johnson, Miami, FL) and a 5 mm diameter, 2 cm long balloon (Jupter; Cordis/Johnson & Johnson) through a 7 F guiding catheter (Britetip-Contralatelal II type; Cordis/Johnson & Johnson). However, the stenosis persisted and a 15 mm long Palmaz–Schatz stent (Cordis/Johnson & Johnson) pre-mounted on a 3.5 mm diameter balloon catheter (Powergrip; Cordis/Johnson & Johnson) was then placed at the site of the stenosis in such a way as to press the indwelling catheter into the hepatic artery wall. Coeliac axis injection after stent placement showed recanalization of the right hepatic artery and disappearance of the collateral circulation (Figure 1b). Moreover, a uniform blood supply throughout the liver was shown by angiography via the implantable port (Figure 1c). Good patency of the hepatic artery was maintained during the ensuring 4 months of hepatic arterial infusion chemotherapy.
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Figure 1. Case 1. (a) Coeliac axis angiogram showing occlusion of the proximal portion of the right hepatic artery (arrow). Collateral blood flow into the peripheral branches of the hepatic artery through the peribiliary arterial plexus (arrowheads) arising from the gastroduodenal artery is seen. (b) coeliac axis angiogram after Palmaz stent placement (arrow) showing recanalization of the right hepatic artery and disappearance of the collateral circulation. (c) Angiogram via the implantable port shows that the blood supply was greatly improved throughout the liver.
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Case 2
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The patient was a 56-year-old man with hepatocellular carcinoma and tumour thrombus in the portal vein trunk for whom hepatic arterial infusion chemotherapy via a percutaneously placed catheter was planned. No aberrant hepatic arteries were noted. A 5 F polyurethane catheter with a side hole (Anthron; Toray Industries) was placed in the hepatic artery from the left subclavian artery. The side hole was positioned in the common hepatic artery and the tip was inserted into the gastroduodenal artery. After placing coils around the catheter tip to fix it within the gastroduodenal artery, 0.1 ml of NBCA–Lipiodol was injected to secure the fixation but this refluxed into the proper hepatic artery. Injection of contrast medium via the indwelling catheter showed complete occlusion of this artery (Figure 2a). Angiography was again performed via a right femoral approach. It waspossible to traverse the occluded portion ofthe proper hepatic artery using a 3 F microcatheter (Tracker-18; Target Therapeutics/Boston Scientific) coaxially. Angiography via this catheter showed that the NBCA–Lipiodol induced occlusion was limited to the proximal portion of the proper hepatic artery, with the peripheral branches of the hepatic artery intact. Collateral blood flow into the peripheral branches of the hepatic artery, through the peribiliary arterial plexus arising from the arterial arcade of the pancreatic head, was seen on superior mesenteric arteriography. After the guidewire was exchanged for a 0.014'', 190 cm long supportive guidewire (Hi-Torque Traverse; Guidant, Santa Clara, CA), PTA was performed using a 3.0 mm diameter, 2 cm long balloon (Savvy; Cordis/Johnson & Johnson) through a 7 F guiding catheter (Triguide-C1 type; Medi-tech/Boston Scientific, Watertown, MA). A 15 mm long Palmaz–Schatz stent (Cordis/Johnson & Johnson) pre-mounted on a 4.0 mm diameter balloon catheter (Powergrip; Cordis/Johnson & Johnson) was then placed at the site of occlusion. As the stenting site was slightly narrow, additional dilatation of the stent was performed using a 5 mm diameter, 2 cm long balloon (Jupter; Cordis/Johnson & Johnson). These procedures resulted in recanalization of the proper hepatic artery and disappearance of the collateral circulation (Figure 2b). Good patency of the hepatic artery was maintained for 16 months after stent placement during continuation of the hepatic arterial infusion chemotherapy.
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Figure 2. Case 2. (a) Angiogram from the indwelling catheter with the side hole positioned in the common hepatic artery showing occlusion of the proper hepatic artery. (b) Angiogram from the indwelling catheter after Palmaz stent (arrow) placement shows recanalization of the proper hepatic artery.
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Discussion
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Repeated hepatic arterial infusion has become easy since the introduction of hepatic arterial infusion chemotherapy using an implantable catheter port system, with good therapeutic results in malignant hepatic neoplasms [3–5]. Hepatic arterial occlusion is the major problem interfering with the continuation of this treatment, one cause being intimal injury due to mechanical stimulation by the catheter tip [6]. In many cases, this kind of hepatic arterial occlusion is localized to the proximal portion of the hepatic artery. To prevent the occlusion, catheter placement methods have been developed in which the tip of a side-holed catheter is fixed to the gastroduodenal or other artery [6–9]. This has reduced the incidence of hepatic arterial occlusion from approximately 20% to 5% [6]. It is surmised that when the occlusion is limited to the proximal portion of the hepatic artery, continuation of the hepatic arterial infusion via the same route would be feasible if the distal portion of the hepatic artery is intact and the hepatic artery can be recanalized by relieving this localized occlusion.
The placement of metallic stents to treat arterial occlusive lesions has been described in the coronary, iliac, renal, femoral and other arteries [10–13]. Metallic stents may also be effective in treating proximal occlusions of the hepatic artery. Three cases have already been reported in which stents were placed in the hepatic artery to treat hepatic arterial occlusion or intimal dissection occurring at the time of hepatic arterial infusion chemotherapy for malignant neoplasms of the liver [14, 15]. Localized occlusions related to the catheter placement technique were present in the proximal portion of the hepatic artery. In these three cases, after the catheter for hepatic arterial infusion was removed, a stent was placed at the occluded site of the hepatic artery and the hepatic arterial infusion was then resumed.
In both of the present cases, the tip of the catheter for hepatic arterial infusion was fixed within either a peripheral branch of the hepatic artery or in the gastroduodenal artery using NBCA–Lipiodol. In both cases we attempted to perform recanalization without removing the indwelling catheter and found that the stent could be placed into the occluded portion of the hepatic artery despite the presence of the catheter. Moreover, in one of our cases the stent was placed in such a way as to press the indwelling catheter against the vessel wall. Stent placement was successful in both cases, with subsequent recanalization of the hepatic artery and disappearance of the collateral circulation that had developed in response to the hepatic arterial occlusion. Furthermore, the hepatic arterial infusion could be continued from the indwelling catheter, with no further occlusion of the hepatic artery during prolonged chemotherapy.
Received for publication October 10, 2000.
Revision received January 2, 2001.
Accepted for publication January 24, 2001.
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Abstract
Introduction
