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Objective: To evaluate the technical feasibility and safety considerations of balloon-occluded transarterial chemoembolization (B-TACE) using a newly developed 1.8-French (Fr) tip microballoon catheter for hepatocellular carcinoma (HCC)., Material and Methods: Between February 2013 and May 2013, 31 patients (20 males, 11 females; age range 56-85 years) underwent B-TACE using a 1.8-Fr tip microballoon catheter for unresectable HCC. The technical success rate, procedural complications, and adverse events of B-TACE were retrospectively investigated., Results: A total of 31 patients were subjected to 70 sessions of B-TACE using a 1.8-Fr tip microballoon catheter. The level of B-TACE was sub-subsegmental in 11, subsegmental in 35, segmental in 14, lobar in five, and right inferior phrenic artery in five sessions. The overall technical success rate was 99% (69 out of 70 sessions). As procedural complications, rupturing of the microballoon (n = 3) and aneurysmal dilatation at the site of balloon occlusion (n = 2) were encountered. There were no significant differences in any parameters between blood biochemical examination before and between two to four weeks after the procedure., Conclusion: A 1.8-Fr tip microballoon catheter enables selective catheterization in patients with HCC and B-TACE using the 1.8-Fr tip microballoon catheter is a safe procedure.

Background and Aim: To assess the early response and outcome of hepatic arterial infusion chemotherapy (HAIC) in patients with advanced hepatocellular carcinoma (HCC)., Methods: One hundred sixty-five HCC patients treated with HAIC were reviewed retrospectively. The early response to one course of HAIC treatment was evaluated by the Response Evaluation Criteria in Solid Tumors (RECIST) and changes in α-fetoprotein (AFP) and des-γ-carboxy prothrombin (DCP)., Results: The median survival time (MST) for all patients was 9.5 months. The early imaging response by RECIST was assessed as partial response (PR), stable disease (SD), and progressive disease (PD) in 32 (19.3%), 86 (52.1%), and 47 (28.4%) patients, respectively. Survival correlated with early imaging response (MST in PR, 20.6; SD, 11.4; PD, 5.0 months; P < 0.0001). The MST was also significantly different in patients with AFP ratio of ≤ 1 or > 1 and DCP ratio of ≤ 1 or > 1 (worst MST, 6.5 months in patients with AFP ratio of > 1 and DCP ratio of > 1). Among patients with SD early imaging response, patients with AFP ratio of > 1 and DCP ratio of > 1 had significantly poorer survival than others (MST 7.4 vs. 12.6 months, P = 0.014). The decrease in AFP and DCP in the early stage treatment with HAIC were identified as significant and independent factors associated with survival of not only all patients, but also patients with SD early imaging response., Conclusion: The use of the combination of RECIST and tumor marker ratio could be useful for assessment of the early response to HAIC and prognosis of patients with advanced HCC., (© 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.)

Purpose: To evaluate the characteristics of hepatocellular carcinomas (HCCs) fed by the right renal capsular artery and to assess the tumor response and complications in patients treated with transarterial therapy via the renal capsular arteries with or without other extrahepatic arteries and/or intrahepatic arteries., Materials and Methods: Between March 2006 and May 2012, 24 lesions in 19 patients were treated by transcatheter arterial chemoembolization (23 sessions), transcatheter arterial embolization (two sessions), or transcatheter arterial infusion (one session), with HCCs fed by the right renal capsular artery with or without intrahepatic arteries and/or other collateral arteries. Other intrahepatic lesions were concurrently treated if needed., Results: Tumor size ranged from 10 mm to 107 mm (mean, 30.5 mm). Of the 24 tumors, 12 were located in segment VI, 10 in segment VII, one in the posterior segment, and one in the anterior segment after posterior segment resection. Severe complication occurred in four patients: liver abscess (n = 2), pleural effusion (n = 1), and duodenal ulcer (n = 1). Pleural effusion might be related to chemoembolization via the right renal capsular artery. A complete response was obtained in six sessions and a partial response in eight; 10 sessions were associated with stable disease and two with progressive disease., Conclusions: Precise renal capsular artery knowledge would facilitate successful and safe transarterial therapy for HCCs fed by the renal capsular arteries., (© 2014 SIR Published by SIR All rights reserved.)

Objective: The purpose of this study was to retrospectively compare the subclavian and femoral approaches to a fixed-catheter-tip method of implantation of a port-catheter system for hepatic arterial infusion chemotherapy with respect to complications and dysfunctions., Materials and Methods: Between April 2006 and April 2012, 153 patients (104 men, 49 women; age range, 23-82 years; mean, 65 years) with unresectable malignant liver tumors underwent percutaneous implantation of indwelling port-catheter systems by the fixed-catheter-tip method via the left subclavian or femoral artery. The success of implantation and outcome of complications were investigated and compared between these approach routes., Results: The overall technical success rate of port-catheter system implantation with the fixed-catheter-tip method was 99% (152 of 153 patients). Seventy-five patients underwent implantation with a port-catheter system via the left subclavian artery, and 77 patients via the femoral artery. Catheter dislocation occurred in 3.9% of the patients; hepatic artery obstruction, 2.6%; catheter occlusion, 3.9%; bleeding at the puncture site, 3.9%; cerebral infarction, 1.3%; and infection related to port-catheter implantation, 2.6%. No significant differences in complications and port-catheter system dysfunction between the left subclavian and femoral approaches to port-catheter system implantation with the fixed-catheter-tip method were seen in any of the parameters. In addition, cerebral infarction occurred exclusively with the left subclavian approach, whereas infection occurred exclusively with the femoral approach., Conclusion: Implantation of the port-catheter system with the fixed-catheter-tip method is equally feasible via both the left subclavian and the femoral approaches.

We used a retrospective non-randomised study to investigate the clinical effect of selective embolisation of the right gastric artery before hepatic arterial infusion chemotherapy (HAIC) using a port-catheter system. We evaluated whether the hepatic artery or the left gastric artery is the better approach for selecting the right gastric artery. A total of 367 patients (244 men and 123 women; mean age, 64.1 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In 294 of these patients, right gastric arterial embolisation with microcoils was attempted before placement of the port-catheter system to prevent gastric mucosal lesions. Approach was either through the hepatic artery (175 patients) or through the left gastric artery (119 patients), with success rates in catheterising the right gastric artery of 78.3% and 77.3%, respectively. If the attempt was unsuccessful, the catheter was redirected to the alternative approach, which increased the final success rate to 96.3%. Only seven patients experienced gastroduodenal mucosal lesions acutely after HAIC, as revealed by endoscopy. Embolisation of the right gastric artery is a feasible procedure that can reduce the incidence of gastric mucosal lesions associated with HAIC. Approach through either the hepatic artery or the left gastric artery is equally acceptable.

Aim: To retrospectively investigate persistent hepatofugal blood flow in the gastroduodenal artery after implantation of a port-catheter system for repeated hepatic arterial infusion chemotherapy using a modified fixed catheter tip method., Materials and Methods: A port-catheter system was percutaneously implanted in 150 patients (90 men and 60 women; mean age 64.6 years) with unresectable liver cancer. The persistence of blood flow beyond the end hole of the indwelling catheter via the port obtained immediately and 1-10 days after port-catheter placement was investigated using arteriography., Results: In all cases, port-catheter placement was successfully performed. In 64 (42.7%) of the 150 participants, the gastroduodenal artery was detected on arteriography just after implantation. However, arteriography obtained 1-10 days (mean 4.3 days) after implantation revealed the gastroduodenal artery in only two of the 64 participants. In these two patients, persistent blood flow disappeared spontaneously 12 and 15 days after implantation, respectively., Conclusion: Closure of the lumen of the distal tip of the catheter beyond the side hole most often occurs spontaneously just after implantation. However, the findings of the present study indicate that closure will occur within 15 days at the latest. This suggests that delaying chemotherapy for about 2 weeks after implantation may be advisable.

Objective: The purpose of our study was to evaluate the usefulness of N-butyl cyanoacrylate (NBCA) in addition to microcoils in the percutaneous implantation of a port-catheter system for repeated hepatic arterial infusion chemotherapy with the fixed-catheter-tip method., Materials and Methods: We retrospectively studied 166 consecutive patients with unresectable advanced liver cancer for whom a port-catheter system was percutaneously implanted with its tip fixed at the gastroduodenal artery with microcoils. In 107 patients, NBCA was also used for catheter tip fixation. We compared this group with a control cohort of 59 patients who did not receive NBCA. Outcomes, including rate of success in implantation, details of embolic agents for fixation, and occurrence of complications related to catheter placement that would prohibit continuation of chemotherapy if not corrected, were compared., Results: In all, port-catheter placement was successful. However, 38 complications occurred in 32 patients. Catheter dislocation occurred in nine. Hepatic artery obstruction or severe stenosis was seen in 10. Recanalization of a once-embolized gastroduodenal artery was found in two patients. The rate of dislocation did not differ significantly between patients in whom NBCA was and those in whom it was not used. However, hepatic artery obstruction appeared at a significantly higher rate, and recanalization of a gastroduodenal artery at a significantly lower rate, in patients in whom the catheter tip was fixed with NBCA., Conclusion: The use of NBCA correlated with a higher rate of hepatic artery obstruction. The use of NBCA should not always be required in port-catheter implantation with the fixed-catheter-tip method.

Background: L-asparaginase is a key drug in the treatment of childhood acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL). However, L-asparaginase can cause a fatal complication of pancreatitis, and an effective treatment for L-asparaginase-associated pancreatitis (AAP) has not been developed to date. The authors investigated whether rapidly treating children with AAP by continuous regional arterial infusion (CRAI) of protease inhibitor and antibiotic would quickly resolve AAP., Methods: Between 2000 and 2007, 104 pediatric patients with ALL or LBL were treated at the authors' affiliated hospitals with intensive regimens that included Escherichia coli-derived L-asparaginase. Six of 104 patients developed severe AAP. One patient was treated with intravenous infusion of protease inhibitor, and the remaining 5 patients received CRAI of protease inhibitor and antibiotic within 48 hours of the onset of AAP., Results: The patient who received intravenous protease inhibitor had pseudocyst formation and developed a subsequent leukemic recurrence after the interruption of chemotherapy for 4.5 months. In the other patients, AAP subsided within 2 to 6 days after the start of CRAI, and serious complications did not emerge. Significantly, chemotherapy could be resumed within 4 weeks (range, 12-23 days) after the onset of AAP, and the patients were in complete remission from 4 months to 44 months with further chemotherapy that excluded L-asparaginase., Conclusions: The current results indicated that early introduction of CRAI of protease inhibitor and antibiotic is suitable for treating severe AAP., ((c) 2008 American Cancer Society.)

To retrospectively evaluate the use of Micronester coils in port-catheter implantation with the fixed catheter tip method in comparison with other previously used coils. The cohort of this study was 143 consecutive patients with unresectable advanced liver cancer for whom a port-catheter system was percutaneously implanted. In the most recent 32 patients, Micronester coils were used for catheter tip fixation. Details of embolic agents for fixation, persistent blood flow beyond the distal end of the indwelling catheter, and complications were compared between cases without and with Micronester coils. In all, percutaneous port-catheter placement was successful. Mean number of coils used for fixation was 4.2 without Micronester coils vs. 2.5 with Micronester coils. N-butyl cyanoacrylate (NBCA)-Lipiodol was additionally used for catheter tip fixation in 85.6% of 111 procedures without Micronester coils and in 50% of 32 using Micronester coils. The gastroduodenal artery beyond the distal end was not detected at the final examination after any procedure. Catheter dislocation occurred in five and hepatic arterial obstruction or severe stenosis in eight. The number of coils used and necessity of NBCA-Lipiodol could be decreased with usage of Micronester coils without decreasing fixation ability compared to other coils.

Between March 1999 and March 2006, 292 patients at the authors' institution required placement of a percutaneously implantable port-catheter system through which repeated hepatic arterial infusion chemotherapy would be administered. In 10 patients, the port-catheter system was implanted through the superior mesenteric artery. In these patients, implantation through the superior mesenteric artery instead of the celiac artery was necessary because all hepatic arteries arose from the superior mesenteric artery or because the blood supply to almost all tumors was from a hepatic artery arising from the superior mesenteric artery. Implantation of the port-catheter system was successful without complications in these 10 patients.

Purpose: To retrospectively evaluate results of selective embolization of the accessory left gastric artery prior to repeated hepatic arterial infusion chemotherapy using a port-catheter system., Material and Methods: Of 22 patients with unresectable advanced liver cancer who underwent percutaneous implantation of a port-catheter system, an accessory left gastric artery was revealed by arteriography in 16 patients before and in six patients after port-catheter implantation. The right gastric artery was embolized to prevent gastric mucosal lesions in all 22 patients. In addition, the accessory left gastric artery was selectively embolized for the same purpose using from one to six microcoils, which were from 3 to 5 mm in diameter. Within 10 days after implantation, arteriography was performed while contrast material was infused via the port., Results: Selective embolization of the accessory left gastric artery was successful in all 22 patients. No complication related to embolization of this artery occurred in any patient. A gastrointestinal mucosal lesion developed in only one case during hepatic arterial infusion chemotherapy, but was unrelated to the accessory left gastric artery., Conclusion: Prophylactic embolization of the accessory left gastric artery is useful to avoid development of a gastrointestinal mucosal lesion resulting from hepatic arterial infusion chemotherapy.

Purpose: To evaluate the feasibility and safety of a method to withdraw port-catheter systems implanted by the fixed catheter tip method., Materials and Methods: Retrospective review was conducted of 14 cases of unresectable advanced liver cancer in which it was necessary to attempt 15 withdrawals of percutaneously placed implantable port-catheter systems. Reasons for withdrawal, withdrawal success, complications, and subsequent treatment of patient were evaluated., Results: In 14 of the 15 procedures (93.3%), the port-catheter system was successfully retrieved. Because continuation of hepatic arterial infusion chemotherapy was necessary in 10 procedures, a second implantation was performed after withdrawal of the initial catheter. Only one complication occurred, in which the indwelling catheter was broken in the aorta during withdrawal., Conclusion: When retrieval of a port-catheter system implanted with the fixed catheter tip method is necessary, withdrawal can be accomplished safely with high frequency.

We report a case in which hepatic arterial occlusion developed during repeated hepatic arterial infusion chemotherapy through an implanted port-catheter system for advanced malignant hepatic neoplasia. After successful recanalization of the hepatic artery by using percutaneous transluminal angioplasty, another port-catheter system was placed percutaneously by interventional radiology techniques, allowing the continuation of hepatic arterial infusion chemotherapy.

Few reports have described the influence of the retroportal artery on the distribution of anticancer drugs in the liver during repeated hepatic arterial infusion chemotherapy. This report describes two patients in whom poor distribution was observed in the right lobe of the liver, which was confirmed at superior mesenteric arteriography to be caused by inflow of the retroportal artery to the right hepatic artery. The retroportal artery was successfully embolized, resulting in improvement of distribution in the right lobe of the liver in both cases.

Purpose: For therapeutic effectiveness of repeated hepatic arterial infusion chemotherapy (HAIC) for unresectable advanced liver malignancies, distribution of anticancer drugs via an indwelling catheter should be uniform throughout the entire liver. It was investigated how an extrahepatic artery entering the posterior segment or caudate lobe of the liver influences performance of repeated HAIC., Materials and Methods: One hundred ninety-five patients with unresectable advanced liver cancer underwent placement of a percutaneously implantable port-catheter system and were followed arteriographically with and without computed tomography (CT). The frequency of poor distribution in the posterior segment or caudate lobe of the liver was observed on CT during arteriography via the port for HAIC. The correlation between poor distribution and various factors including the number of intrahepatic arteries was studied, and the management of such poor distribution is described., Results: In 34 of 195 patients (17.4%), poor distribution was observed in the posterior segment and/or caudate lobe of the liver. The rate of poor distribution was significantly higher in those with two or more hepatic arteries than in those with one (13 of 35 vs 21 of 160; P = .0007, chi2 test). Other evaluated factors were not significantly correlated with such poor distribution. The right inferior phrenic artery was successfully embolized in 22 patients with tumors in segments with poor distribution. Good distribution throughout the entire liver was achieved in 21 patients (95.5%)., Conclusion: Inflow of the right inferior phrenic artery into the liver occasionally prevents distribution of anticancer drugs throughout the entire liver during performance of long-term HAIC.

Objective: The purpose of our study was to compare persistent hepatofugal blood flow in the gastroduodenal artery after implanting a port-catheter system for repeated hepatic arterial infusion chemotherapy using either the original or the modified fixed catheter tip method. With the original method the lumen of the catheter tip is closed with a microcoil; with the modified method it is left open. Persistent hepatofugal blood flow can induce reactive gastric or duodenal mucosal lesions., Materials and Methods: A port-catheter system with the catheter tip fixed to the gastroduodenal artery by embolic agents was percutaneously implanted in 156 patients (102 men, 54 women; mean age, 63.2 years) with unresectable liver cancer. In 98 patients the original method was used, and in 58 patients the modified method was used. Existence of persistent blood flow beyond the indwelling catheter tip as shown on arteriography via the port performed immediately and 2-10 days after port-catheter placement was compared between these two groups., Results: In all cases, percutaneous port-catheter placement was successfully performed. In one (1.0%) of 98 procedures involving the original method, the gastroduodenal artery was detected on arteriography just after implantation, compared with 23 (39.7%) of 58 procedures using the modified method. However, arteriography performed 2-10 days (mean, 5.02 days) after implantation detected the gastroduodenal artery in only one case., Conclusion: This retrospective study indicates that closure of the end hole appears to occur spontaneously shortly after implantation. Thus, such closure is not always necessary to avoid persistent hepatofugal blood flow in the gastroduodenal artery.

Objective: Our aim was to evaluate the efficacy of the left gastric artery as a route for embolization of the right gastric artery before port-catheter implantation for hepatic artery infusion chemotherapy., Materials and Methods: In 88 patients (61 men and 27 women; mean age, 63.4 years; range, 25-83 years) with unresectable advanced liver cancer, retrograde catheterization of the right gastric artery through the left gastric artery was performed to embolize the right gastric artery., Results: The right gastric artery was successfully catheterized and embolized in 79 patients (89.8%). In two of the nine patients in whom the procedure was not successful, we found that no right gastric artery existed after we succeeded in retrograde advancement of the microcatheter toward the hepatic site. The only procedure-related complication was misplacement of a microcoil into the hepatic artery site in two patients., Conclusion: The left gastric artery is an appropriate route for selective embolization of the right gastric artery as preparation for long-term hepatic artery infusion chemotherapy.

The purpose of the present study is to evaluate the feasibility of a method developed to withdraw a port-catheter system that had been implanted with use of the fixed catheter tip technique. Withdrawal of an implanted catheter was required in four patients with advanced liver cancer in whom port-catheter systems had been implanted for performance of repeated hepatic arterial infusion. In all patients, port-catheter systems were successfully removed without complications. In conclusion, an implanted port-catheter system can be removed even when implanted with the fixed catheter tip technique.

Objective: The purpose of our study was to evaluate whether the hepatic artery or the left gastric artery is the better route of approach for selective embolization of the right gastric artery before hepatic arterial infusion chemotherapy using a port-catheter system., Subjects and Methods: Eighty-six patients (56 men, 30 women; mean age, 62.1 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In the 75 patients who had not undergone gastrectomy, right gastric artery embolization was performed before port-catheter system placement to prevent gastric mucosal lesions. In 43 patients, the approach for embolization was through a microcatheter inserted from the hepatic artery site, and in the remaining 32 patients, the approach was from the left gastric artery. The success rates of these two groups were compared., Results: Embolization was successfully accomplished at the first attempt in 72.1% of the 43 patients in whom the microcatheter was inserted from the hepatic artery site. In contrast, in 93.8% of 32 patients, embolization was successfully performed through the left gastric artery. The success rate of embolization was significantly higher in the latter group (p = 0.0173, chi-square test). A second attempt in which the catheter was redirected to another approach, performed on the same day in a majority of patients, resulted in successful embolization in an additional eight patients, with a final success rate of 92.0%., Conclusion: Embolization of the right gastric artery using microcoils through a microcatheter advanced through the left gastric artery may be the preferred method for the preparation of repeated hepatic artery infusion.

Objective: The purpose of our study was to evaluate the usefulness of adding n-butyl cyanoacrylate to microcoils to fix the catheter tip in percutaneous implantation of a port-catheter system for hepatic arterial-infusion chemotherapy., Subjects and Methods: Ninety-three patients (64 men and 29 women; age range, 38-83 years; mean age, 62.2 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system with the catheter tip fixed at the gastroduodenal artery with microcoils and a mixture of n-butyl cyanoacrylate and iodized oil. The rates of successful implantation and complications closely associated with this technique and management of the complications were reviewed., Results: Percutaneous port-catheter placement was successfully performed in all patients. However, in eight patients, complications occurred: hepatic arterial obstruction (n = 5, 5.4%); catheter dislocation (n = 2, 2.2%); recanalization of the gastroduodenal artery (n = 1, 1.1%); or movement of n-butyl cyanoacrylate (n = 1, 1.1%). In five of the eight patients with complications, hepatic arterial-infusion chemotherapy was continued either after observation of the patient to ensure that stability had been established or after treatment using comparatively easy interventional techniques. In three (3.2%) of the 93 patients, planned hepatic arterial-infusion chemotherapy could not be performed because of complications associated with the technique., Conclusion: Fixation of the catheter tip in the gastroduodenal artery using a combination of microcoils and a mixture of n-butyl cyanoacrylate and iodized oil is a useful and safe technique in percutaneous port-catheter placement for repeated hepatic arterial infusion chemotherapy.

The aim of this study was to evaluate the incidence of catheter tip dislocation in patients with percutaneously implanted port-catheters for hepatic arterial chemotherapy with catheter tip fixation. Forty-seven patients (31 men and 16 women; mean age 66 years) with unresectable advanced liver cancers (primary liver cancer, n=19; metastatic liver cancer, n=28) underwent percutaneously implantable port-catheter system placement with the tip fixed at the gastroduodenal artery with coils and side hole opened at the common hepatic artery. In 39 patients, n-butyl cyanoacrylate (NBCA) mixed with Lipiodol was added for fixation. The position of the side hole after the indwelling port-catheter system was investigated, and the correction method in cases with catheter dislocation was determined. In 2 (25%) of the 8 patients without NBCA fixation, dislocation of the catheter was noted, in contrast to none (0%) of 37 patients with NBCA fixation. Two patients in whom NBCA was used could not undergo long-term intra-arterial chemotherapy because of hepatic arterial thrombotic occlusion which occurred after placement of the indwelling catheter, and were excluded from the evaluation. Fixation of the catheter tip with combined use of coils and NBCA--Lipiodol mixture to the gastroduodenal artery is important to prevent dislocation of the port-catheter system.

We used a new type of sheath-introducer to facilitate the percutaneous procedure of hepatic arterial catheter implantation with left subclavian arterial access. Insertion into the descending aorta was easy without any additional catheters because the sheath could be manipulated to the aortic arch. After hepatic arterial catheterization, the sheath was slid safely away by fitting a 5 F catheter to the end of the indwelling catheter. The procedures of sheath insertion and removal were successful in all 29 cases, without any complications. The sickle-tip sheath is a useful optional device for trans-subclavian catheterization to the hepatic artery.

Two new experimental models of transplantable mouse sarcoma 180 were developed in ICR mice in order to examine the optimum transplantation sites and methods. The cervicodorsal hypoderm was evaluated as the best transplantation site for mouse sarcoma 180 among seemingly usable transplantation sites such as groin, armpit, cervicodorsal, abdominal and lumbodorsal hypoderms by hypodermic transplantation. In addition, the lung transplantation model was established by monitoring the survival period as a reliable parameter for evaluation of anti-tumor effects.