British Journal of Radiology (2007) 80, e33-e37
© 2007 British Institute of Radiology
doi: 10.1259/bjr/36527189
Percutaneous transluminal angioplasty using a pull-through technique for hepatic arterial occlusion at the time of port-catheter implantation
R Yoshimatsu, MD
T Yamagami, MD, PhD
T Katou, MD, PhD
T Hirota, MD
T Matsumoto, MD
and
T Nishimura, MD, PhD
Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-chyo, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan
Correspondence: Rika Yoshimatsu, Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-chyo, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan. E-mail: rika442{at}koto.kpu-m.ac.jp
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Abstract
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We report a successful percutaneous transluminal angioplasty using a pull-through technique for the treatment of a hepatic arterial occlusion caused by iatrogenic subintimal dissection during the percutaneous placement of a port-catheter system.
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Introduction
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Recently, hepatic arterial infusion chemotherapy (HAIC) via an indwelling port-catheter system has been adopted for the treatment of unresectable advanced liver cancer [1, 2]. However, hepatic arterial occlusion during procedures for the implantation of such catheters has been encountered, sometimes making it impossible to continue interventional radiological procedures and treatments [3, 4]. If occlusion is limited to the proximal portion of the hepatic artery and the patency of the peripheral branches is maintained, recanalization of the hepatic artery might allow the procedure and subsequent continuous treatment to be completed [5, 6].
We present a case of hepatic arterial occlusion caused by iatrogenic subintimal dissection during percutaneous port-catheter implantation in which a successful recanalization was obtained by percutaneous transluminal angioplasty. During the angioplasty, the devices were advanced over a guide wire inserted from the femoral artery and pulled out of the left subclavian artery using the pull-through technique.
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Case report
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The patient was a 59-year-old man with multiple hepatocellular carcinomas that were resistant to treatment, including previously performed transhepatic arterial chemoembolisation. After obtaining informed consent from the patient, we performed repeated HAIC using an implanted port-catheter system.
Two embolisation procedures were performed in preparation for HAIC using a port-catheter implantation. First, the right gastric artery was embolised with micro-coils to prevent the infusion of anti-cancer drugs into adjacent organs during HAIC. Next, because this patient had a replaced right hepatic artery originating from the superior mesenteric artery and a replaced left hepatic artery arising from the left gastric artery, these two aberrant arteries were embolised with micro-coils, while care was taken to embolise the vessels distal to any extrahepatic branches of the aberrant hepatic artery and proximal to the first bifurcation of the intrahepatic segment of the aberrant hepatic artery. Hepatic arterial flow was thus redistributed to allow complete hepatic coverage via a single infusion catheter (Figure 1a
). A superior mesenteric arterial portography revealed a portal venous obstruction caused by a portal thrombus.
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Figure 1. Images taken from a 59-year-old man with multiple hepatocellular carcinomas. (a) Common hepatic arteriogram obtained from a 5-French catheter inserted from the left femoral artery after embolisation of the replaced right (large arrowhead) and left (small arrowhead) hepatic arteries shows the successful conversion of the three hepatic arteries into one. Note that the right gastric artery was embolised using micro-coils (arrow). (b) A subintimal dissection occurred (arrow) in the common hepatic artery when a 5-French catheter was advanced from a branch of the left subclavian artery to the common hepatic artery. (c) Coeliac arteriogram obtained from a 5-French catheter inserted from the left femoral artery just after the subintimal dissection had occurred shows the complete obstruction of the common hepatic artery (arrowhead). (d) Superior mesenteric arteriogram obtained from a 5-French catheter inserted from the left femoral artery shows the development of hepatopetal collateral flow through the pancreaticoduodenal arteries (arrow). (e) A radiograph shows a snare catheter (arrow) capturing the distal tip of the micro-guide wire that had been inserted through the pancreaticoduodenal artery via the femoral artery and passed the obstructed segment of the common hepatic artery. (f) A radiograph shows the performance of percutaneous transluminal angioplasty for the obstructed segment in the common hepatic artery using an angioplasty balloon catheter (arrowhead) advanced from the left femoral artery over the micro-guide wire, which had been passed from the femoral artery and pulled out of the left subclavian artery with tension maintained at both ends. (g) Arteriogram via the port catheter after catheter placement confirmed the patency of the hepatic artery and good hepatic perfusion. The tip of the indwelling catheter was positioned in the gastroduodenal artery and a side hole was opened into the common hepatic artery.
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1 week later, port-catheter placement using the fixed catheter tip technique was attempted under local anaesthesia. Details of the fixed catheter tip technique are described elsewhere [7, 8]. As the first step of this procedure, a 5-French catheter was advanced from a branch of the left subclavian artery to the common hepatic artery via the coeliac artery. However, a subintimal dissection occurred in the common hepatic artery due to technical problems (Figure 1b
), resulting in a hepatic arterial occlusion (Figure 1c). To enable the port-catheter system to be implanted, we subsequently performed a percutaneous transluminal angioplasty to recanalize the hepatic arterial occlusion.
A superior mesenteric arteriography showed the development of hepatopetal collateral flow through the pancreaticoduodenal arteries (Figure 1d). Hence, to avoid the insertion of the guide wire into the subintimal space by approaching from a coeliac arterial site, which might have led to a worsening of the subintimal dissection, we selected a retrograde approach from the superior mesenteric arterial site. We advanced a micro-catheter coaxially from a 5-French catheter that had been inserted into the femoral artery and whose tip had been positioned in the superior mesenteric artery, and passed the micro-catheter through the pancreaticoduodenal artery. We then advanced the micro-catheter as far as the origin of the gastroduodenal artery, which branches off from the common hepatic artery. Then, the micro-guide wire was successfully advanced to the descending aorta through the narrow segment, followed by the advancement of the micro-catheter over the micro-guide wire.
The pancreaticoduodenal artery collateral through which the micro-guide wire had been inserted was so tortuous that it was impossible to advance the angioplasty balloon catheter. Consequently the following procedure was performed: (1) A 90° angled loop (4 mm in diameter) Amplatz goose-neck snare catheter (Microvena, White Bear Lake, MN) was inserted into a micro-catheter that had been coaxially advanced from a 5-French catheter inserted in the left subclavian artery, and the snare catheter was advanced as far as the descending aorta. (2) We used the snare catheter to grasp the distal tip of the micro-guide wire that had been inserted into the femoral artery and passed through the obstructed segment of the common hepatic artery via the pancreaticoduodenal artery (Figure 1e). (3) The snare catheter in the micro-catheter, which maintained tight capture of the distal tip of the micro-guide wire, was moved through the descending aorta, and finally the tip of the captured micro-guide wire was pulled extracorporeally out of the sheath that had been positioned in the left subclavian artery. (4) After the removal of the 5-French catheter inserted from the left subclavian artery, an angioplasty balloon catheter 3 mm in diameter and 2 cm long (Slalom-Thrill; Cordis, Miami, FL) was advanced over the micro-guide wire, which was passed from the femoral artery and pulled out of the left subclavian artery maintaining tension at both ends, to the obstructed segment in the common hepatic artery, where it dilated the obstructed segment (Figure 1f).
A digital subtraction angiography obtained immediately after the angioplasty, via the 5-French catheter inserted from the left subclavian access along the pull-through micro-guide wire with its tip positioned at the origin of the common hepatic artery, showed recanalization and an improvement in blood flow in the common hepatic artery, in which a slight stenosis persisted.
Subsequently, the indwelling catheter (Piolax W spiral; Piolax medical devices, Yokohama, Kanagawa, Japan) was advanced from the left subclavian artery over the micro-guide wire, which was passed from the femoral artery and pulled out of the left subclavian artery, with tension maintained at both ends; its tip was positioned at the gastroduodenal artery. A side hole created in the catheter was opened in the common hepatic artery to administer HAIC. The tip of the indwelling catheter was not fixed to effectively infuse the anti-cancer drugs into the liver via the hepatopetal blood flow toward the liver through the gastroduodenal artery. The proximal end of the indwelling catheter was connected to a port (P-U Celsite port; Toray, Tokyo, Japan) implanted in the subcutaneous space. Digital subtraction angiography via the port confirmed the patency of the hepatic artery (Figure 1g). HAIC was commenced 1 week after the implantation of the port-catheter system.
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Discussion
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In recent years, HAIC via an indwelling port-catheter system has become widely used as a treatment for unresectable advanced liver cancer [1, 2]. Port-catheter system placement was previously performed during surgical laparotomy. The percutaneous implantation of port-catheters using interventional radiological procedures, however, has been increasing. Access for insertion is undertaken from the left subclavian artery [4, 7–9], the femoral artery [10, 11], or the inferior epigastric artery [7]. However, paralleling the increase in implantation with interventional radiological procedures, reports describing complications have also been increasing [5, 6, 8, 10, 12, 13]. Subintimal dissection is one such complication caused by catheterization [12].
The incidence of subintimal dissection of the coeliac artery and its branches as a result of catheterization has been reported to be between 0.5% and 2.7% [14–17]. If subintimal dissection results in hepatic arterial occlusion, the hepatic artery can be recanalized in most cases by interrupting the catheterization and observing for some interval. However, previous reports described spontaneous recanalization rates of between 64% and 72.5%, and complete obstructions remained in nearly 30% of the patients [14, 15, 17]. If the occlusion is limited to the proximal portion of the hepatic artery and the patency of the peripheral branches is maintained, recanalization of the occluded segment of the hepatic artery should be utilized, and many cases of recanalization for stenosis after liver transplantation with interventional radiological treatments have been reported [18–21].
Although there have been few case reports describing interventional radiological treatments performed for hepatic arterial occlusion or stenosis related to HAIC using implanted port-catheter systems, such cases have recently increased [5, 6, 12, 13]. At the present time, 12 such cases have been reported. The reported causes of stenosis were the chemical mechanism of anti-cancer infusion [5, 6, 13], formation of thrombus [6] and subintimal dissection caused by the catheterization [12]. The interventional radiological treatments that had been used consisted of percutaneous transluminal angioplasty, stent placement and catheter-directed thrombolysis. Of these 12 cases, only one case failed recanalization [6].
In the patient reported here, the balloon catheter could not be advanced via a one-sided transfemoral approach because of the high-grade tortuosity of the collateral vessel used for the insertion. Hence, we used a pull-through technique for the second attempt, in which the balloon catheter and the angioplasty device were advanced over a guide wire that had been inserted via the femoral artery and pulled out extracorporeally from the left subclavian artery while maintaining tension on the guide wire from both ends. In the event of difficulty in the advancement of devices when only a single access point is used because of severe, tortuous, or long segments of stenosis, this dual-access technique, called the pull-through technique, is known to be effective in some vascular interventional radiological procedures. Effective use of this technique has been reported in percutaneous transluminal angioplasty and stent placement for stenosis of the common iliac artery or superior vena cava [22–25]. To our knowledge, this technique has not been used in percutaneous transluminal angioplasty of the hepatic artery.
In the present case, the pull-through technique also played an important role in the implantation of the port-catheter system that was subsequently performed after the recanalization of the common hepatic artery by the percutaneous transluminal angioplasty. The indwelling catheter was easily advanced over the guide wire, which had been inserted via the femoral artery and pulled out extracorporeally from the left subclavian artery while maintaining tension on the guide wire from both ends. Furthermore, by leaving the guide wire used in the angioplasty procedure, unnecessary manipulation of the vessel was reduced and the burden to the stenosed vessel was minimized at the time of the port-catheter implantation. In other words, if the guide wire inserted during the angioplasty had been withdrawn, a second guide wire would have needed to be advanced from the left subclavian approach through the coeliac artery again to the previously injured common hepatic artery.
In conclusion, in cases where iatrogenic subintimal dissection in the hepatic artery has occurred, percutaneous transluminal angioplasty for hepatic arterial stenosis may be an effective and safe procedure enabling subsequent treatment. If the passage of the device through the stenosis in an antegrade way from the coeliac arterial site seems difficult, a retrograde approach via the pancreaticoduodenal arcade should be considered, and the pull-through technique is useful for advancing the balloon catheter during percutaneous transluminal angioplasty.
Additionally, the present results indicate that even when iatrogenic subintimal dissection in the hepatic artery occurs during the implantation of a port-catheter for HAIC, implantation might be possible after recanalization of the once-occluded hepatic artery using percutaneous transluminal angioplasty.
Received for publication November 9, 2005.
Accepted for publication March 20, 2006.
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Abstract
Introduction
