British Journal of Radiology 75 (2002),799-804 © 2002 The British Institute of Radiology
Brain infarction after percutaneous implantation of port-catheter system via the left subclavian artery
T Hirota, MD
T Yamagami, MD, PhD
O Tanaka, MD
S Iida, MD
T Kato, MD
T Nakamura, MD, PhD
K Ishihara, MD, PhD
and
T Nishimura, MD, PhD
Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan
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Abstract
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The aim of this study was to evaluate the incidence of brain infarction after percutaneous implantation of a port-catheter system via the left subclavian artery for hepatic arterial infusion chemotherapy. In 90 patients with inoperable liver cancer, a port-catheter system was implanted via the left subclavian artery. In 5 patients (5.6%) brain infarction occurred after port-catheter implantation. In one patient (1.1%) thrombi formed around the catheter, as confirmed by autopsy. The risk of brain infarction should be taken into consideration when a trans-left subclavian arterial access route is used for the percutaneous implantation of a port-catheter system for hepatic arterial infusion chemotherapy.
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Introduction
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Repeated regional intra-arterial chemotherapy has a better response rate than systemic chemotherapy [1, 2]. To facilitate long-term administration of chemotherapeutic agents, the implantation of port-catheter systems has been utilized. These systems allow repetitive hepatic arterial chemotherapy in out-patient clinics, resulting in an improvement in the quality of life of patients [3]. Traditionally, this system has been implanted in the hepatic artery via the gastroduodenal artery during laparotomy [4–8]. In recent years, however, the percutaneous implantation of port-catheter systems using an interventional procedure has become popular [9–24]. The left subclavian [10, 12–14], hypogastric [12], femoral [16, 17] or brachial [18, 19] arteries have each been used as an access route during the percutaneous implantation procedure. Corresponding to the increase in the number of patients with implanted port-catheter systems, the incidences of various complications, including infection, thrombotic catheter occlusion and catheter tip dislocation, have increased [9–11, 13, 16]. Cases of brain infarction arising as a complication of utilizing a left subclavian approach have also been described in the literature [21, 22]. In this report, the relationship between brain infarction and percutaneous port-catheter implantation via the left subclavian artery is evaluated.
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Materials and methods
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Between October 1998 and September 2001, port-catheter systems were percutaneously implanted via the left subclavian artery in 90 patients with unresectable liver cancer; 58 men and 32 women with a mean age of 64 years (range 38–83 years). 39 patients had primary hepatocellular carcinomas and 51 patients metastatic liver cancers originating from colorectal cancer (n=17), breast cancer (n=15), gastric cancer (n=10), lung cancer (n=3), pancreatic cancer (n=2), gall bladder cancer (n=2), ovarian cancer (n=1), and anal cancer (n=1). All port-catheter systems were implanted percutaneously using interventional techniques according to the procedure recommended by Arai et al [12], in which the distal tip of the inserted catheter is fixed in place with embolic agents at an arterial branch, such as the gastroduodenal artery (n=73), the peripheral hepatic artery (n=11), the splenic artery (n=5) and the left gastric artery (n=1), and a side hole is precisely created in the common hepatic artery. Details of this catheter tip fixation method have been described elsewhere [12, 14, 20, 23]. All catheters were inserted from the trunk or the branch of the left subclavian artery by directly exposing the subcutaneous left subclavian region using minimally invasive surgical techniques under local anesthesia. The inserted catheters consisted of Anthron PU catheters (Toray Medical Industries, Tokyo, Japan) (n=83) and Gently catheters (Solution Company Limited, Tokyo, Japan) (n=7). The proximal end of the inserted catheter was connected to a port located in the subcutaneous space. A P-U Celsite port (Toray Medical Industries), Septum Port (Sumitomo Bakelite Company Limited, Akita, Japan), or Derma Port (Nippon Sherwood Medical Industries LTD, Tokyo, Japan) was used. In all cases, anticoagulation medication was not utilized before or after port-catheter placement. The following parameters were investigated: (1) rate of brain infarction; (2) background of patients with brain infarction complications; and (3) subsequent management of brain infarction complications.
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Results
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Of 90 patients with port-catheter systems implanted via the left subclavian artery, 5 cases (5.6%; 4 men, 1 woman) suffered brain infarction complications (Table 1
). The mean age of these patients was 60 years (range 43–70 years). A diagnosis of brain infarction was established on the basis of clinical symptoms and/or radiological findings, such as CT or MRI. Four cases were diagnosed by the presence of both CT or MRI and clinical symptoms, and one case was diagnosed on the basis of clinical symptoms alone. All symptoms had a sudden onset (mean onset time 164 days past implantation; range 8–307 days; median 211 days). None of the brain infarctions occurred during the port-catheter implantation procedure.
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Table 1. Details of cases with brain infarction complications occurring after implantation of port-catheter systems via the left subclavian artery
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Brain CT or MRI revealed that brain infarctions were mainly located in posterior circulation territories, such as the cerebellum, occipital lobe, thalamus (Figure 1) and other regions. In two cases (patients 4 and 5), brain infarction occurred in bilateral areas. In these two cases the inserted catheters produced a more pronounced redundant catheter looping in the aortic arch (Figure 2) than is usually observed after catheter implantation (Figure 3). The catheters also passed through the region where the left common carotid and the right brachiocephalic artery begin, as observed using digital subtraction aortic arteriography. In two other cases (patients 1 and 2), the port-catheters also produced a more pronounced redundant catheter looping in the aortic arch than usual, but the brain infarctions occurred in the left side regions. In the remaining case (patient 3), no pronounced redundant catheter looping in the aortic arch was observed.
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Figure 2. 60-year-old male with unresectable hepatocellular carcinoma (patient number 4, Table 1 ). (a) Posteroanterior chest radiograph shows the inserted catheter and a pronounced redundant catheter looping in the aortic arch (arrow). (b) Anteroposterior digital aortic arteriography performed after the onset of brain infarction shows a pronounced redundant catheter looping in the inserted catheter (arrow) in the aortic arch. This passes through the region where the left common carotid (arrowhead) and the right brachiocephalic artery (open arrow) originate.
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Figure 3. 55-year-old male with unresectable liver metastases originating from colon cancer. Posteroanterior chest radiograph shows no pronounced redundant catheter looping (arrow) in the inserted catheter in the aortic arch. Note that the patient did not exhibit any brain infarction complications.
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In all five cases, arterial stenosis or occlusion was not observed in the bilateral vertebral and internal carotid arteries at MR angiography performed after brain infarction. 5-fluorouracil, cisplatin (CDDP), and mitomycin-C (MMC) had been administered through the implanted reservoir prior to brain infarctions. None of the cases had hyperlipidaemia or cardiac disorders. Two cases had vascular disorders (diabetes and hypertension). No abnormal blood data, such as activated partial thromboplastin time, prothrombin time, fibrinogen degradation products or fibrinogen, were observed prior to the implantation procedure. In one case, where an autopsy was performed, old thrombi were found adherent to the inserted catheter (Anthron PU Catheter). Autopsies were not performed in the other four cases.
Almost all symptoms were improved by conservative treatment including the administration of anticoagulation medication. In one case, however, left hemiparesis persisted in spite of conservative treatment, and infusion therapy was discontinued because of the formation of brain infarction sequela.
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Discussion
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Hepatic arterial infusion chemotherapy using port-catheter systems is widely used for the treatment of patients with advanced, unresectable liver cancer. Port-catheter systems can be implanted during surgical laparotomy [4–8] or interventional procedures [9–24]. Since implantation during surgical laparotomy necessitates the use of general anesthesia and is invasive [1, 4], the use of percutaneous or minimally invasive surgical implantation techniques using interventional procedures has been increasing in parallel with the rapid development of interventional techniques [9–24].
Among the various interventional techniques used to implant port-catheter systems, the procedure of Arai et al [12], which was employed in the present study, is advantageous with regard to the low frequency of hepatic arterial occlusion and inserted catheter tip dislocation during long-term infusion chemotherapy [14, 19]. Access routes for the percutaneous implantation of port-catheter systems include the left subclavian [10, 12–14], hypogastric [12], femoral [16, 17] or brachial [18, 19] arteries. The use of the former two access routes is advantageous compared with the latter two access routes [12] because of the lack of motion in the regions through which the catheter must pass. With the latter two routes, the motions of the left shoulder and femoral joints can cause catheter tip dislocation and mechanical stimulation to the endothelium of the vascular wall. The access route via the hypogastric artery is slightly difficult and complicated for technical reasons [12]. Consequently, the left subclavian artery is the most widely used access route.
Brain infarction can be clinically categorized into several subtypes on the basis of size and location of the affected cerebral arteries and their pathogenesis (lacunar, atherothrombotic or cardioembolic infarction) [25]. The frequency of brain infarction among stroke-free subjects aged over 40 years has been reported to be 0.97% [25].
Brain infarction sometimes occurs after implantation of port-catheter systems via the left subclavian artery because arterial branches running into the intra-cerebral area, such as the left vertebral artery, are located near the inserted catheter. However, only a few reports of this complication have been described [21, 22]. In the present study, brain infarction complications occurred in 5 (5.6%) out of 90 cases. While a direct relationship between brain infarctions and port-catheter placements could not be confirmed, the presence of old thrombi around the implanted port-catheter was revealed during an autopsy in one case. Furthermore, in two cases where pronounced redundant catheter looping in the aortic arch and bilateral brain infarction complications were observed, the inserted catheters were in contact with the endothelium of the arterial branches, which may flow into bilateral intracranial territories. In these two cases, a relationship between the implanted port-catheter systems and the brain infarction complications was strongly suspected. Munemori et al [24] reported one case in which thrombi were observed on the surface of the abdominal aortic wall along the implanted catheter during an autopsy after the implantation of a port-catheter system via the right femoral artery. Based on our experiences and the results of Munemori et al [24], the occasional formation of thrombi around the implanted port-catheter and on the surface of the vascular wall along the implanted catheter seems likely, even when polyurethane-covered catheters, which have excellent anticoagulation properties, are used.
Possible causes of brain infarction attributable to port-catheter systems implanted via the left subclavian artery include: (1) flow of thrombi, formed by endothelial injury to the vascular wall during the interventional procedure, into the brain; (2) flow of thrombi, formed by mechanical stimulation of the vascular wall and the alteration of blood flow by the implanted port-catheter, into the brain; and (3) thrombi adherent around the port-catheter are released and flow into the brain; and (4) the presence of a hypercoagulable state associated with the malignancy and the use of therapeutic agents.
Previous researchers have described that the activation of the coagulation system initiated by cancer cells leads to a state of chronic disseminated intravascular coagulation in patients with malignancy [26, 27]. Moreover, thrombotic microangiopathy has been described as a complication of chemotherapy, especially when agents such as CDDP, bleomycin, or MMC are used [26]. Therefore, patients with advanced cancer who are receiving hepatic arterial infusion chemotherapy may exhibit a more coagulable and thrombophilic state than normal subjects. Thus, when hepatic arterial infusion chemotherapy using a port-catheter system implanted via the left subclavian artery is utilized, the possibility of brain infarction complications should be considered. To avoid brain infarction complications, the use of anti-coagulation medication before and after the implantation of port-catheter systems, proper positioning of the port-catheters to avoid redundant catheter looping in the aortic arch, and the use of alternative access routes, may be necessary. To our knowledge, this report may be the first large study to evaluate the relationship between brain infarction and the implantation of port-catheter systems via the left subclavian artery.
Received for publication January 22, 2002.
Revision received June 7, 2002.
Accepted for publication June 20, 2002.
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Abstract
Introduction
