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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.

Objective: To retrospectively evaluate the frequency and risk factors for developing thrombus in a systemic vein such as the infrarenal inferior vena cava or the iliac vein, in which a balloon-occluded retrograde transvenous obliteration (B-RTO) catheter was indwelled., Materials and Methods: Forty-nine patients who underwent B-RTO for gastric varices were included in this study. The B-RTO procedure was performed from the right femoral vein, and the B-RTO catheter was retained overnight in all patients. Pre- and post-procedural CT scans were retrospectively compared in order to evaluate the development of thrombus in the systemic vein in which the catheter was indwelled. Additionally, several variables were analyzed to assess risk factors for thrombus in a systemic vein., Results: In all 49 patients (100%), B-RTO was technically successful, and in 46 patients (94%), complete thrombosis of the gastric varices was achieved. In 6 patients (12%), thrombus developed in the infrarenal inferior vena cava or the right common-external iliac vein. All thrombi lay longitudinally on the right side of the inferior vena cava or the right iliac vein. One of the aforementioned 6 patients required anticoagulation therapy. No symptoms suggestive of pulmonary embolism were observed. Prothrombin time-international normalized ratio and the addition of 5% ethanolamine oleate iopamidol, on the second day, were related to the development of thrombus., Conclusion: Development of a thrombus in a systemic vein such as the inferior vena cava or iliac vein, caused by indwelling of the B-RTO catheter, is relatively frequent. Physicians should be aware of the possibility of pulmonary embolism due to iliocaval thrombosis.

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.

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.

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.

In four patients with a celiac artery that was too narrow through which to advance a catheter to the hepatic artery, a port-catheter system for hepatic arterial infusion chemotherapy was implanted with use of a pull-through technique. The indwelling catheter was advanced over a guide wire inserted from the femoral artery and through the celiac origin in a retrograde fashion via the superior mesenteric artery and pancreaticoduodenal collateral vessels. It was then pulled out via the infusion catheter access artery. In all cases, implantation with the fixed catheter tip technique was successful without complications.

Purpose: To evaluate the efficacy of hepatic port-catheter system placement without distal catheter tip occlusion or gastroduodenal artery embolization distal to the catheter tip., Material and Methods: A port-catheter system was percutaneously implanted in 29 patients (16 men, 13 women; mean age 65.6 years) with unresectable liver cancer. Persistent blood flow through the end hole of the catheter was verified immediately and 1-10 days after catheter placement., Results: In all cases, percutaneous port-catheter placement was successfully performed. In seven of 29 (24.1%) patients, flow through the end hole of the catheter was verified immediately after the procedure. However, no flow was seen 1-10 days after the procedure., Conclusion: It is not necessary to occlude the end hole of the catheter tip and embolize the gastroduodenal artery beyond the catheter tip when placing a port-catheter system for repeated 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.

The authors report a case in which catheter-related difficulties occurred with a port-catheter system implanted to perform repeated hepatic arterial infusion chemotherapy for advanced hepatocellular carcinomas. The port-catheter system had been percutaneously implanted with the catheter tip fixation method, and a side hole had been created in the indwelling catheter for placement in the common hepatic artery. Four months after port-catheter placement, however, the indwelling catheter became bent at the location of the side hole in the proper hepatic artery. Subsequently, the side hole moved into the left hepatic artery, resulting in a lack of distribution of chemotherapeutic agents to the tumours in the segments of the liver supplied by the right hepatic artery. This situation was easily corrected with a simple interventional radiological method so that hepatic arterial infusion chemotherapy could be resumed with sufficient distribution over the entire liver. To our knowledge, such a problem involving a port-catheter system implanted with the catheter tip fixation method and its management thereafter has not been reported in the published literature.

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.

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.

The present study evaluated the feasibility of interventional radiologic treatments for hepatic arterial occlusion after hepatic arterial infusion chemotherapy (HAIC) via an implanted port-catheter system. Treatment for hepatic arterial occlusion was attempted in seven patients with unresectable liver cancer. In six, the obstructed hepatic artery was recanalized. In three patients, the recanalized hepatic artery again became obstructed. However, by performing additional interventional radiologic procedures, secondary patency of the hepatic artery was successfully obtained in two patients. In conclusion, when hepatic arterial occlusion occurs, HAIC can be resumed in the attempt to recanalize the hepatic artery.

Purpose: To assess the value of transcatheter arterial embolization (TAE) of splanchnic arterial branches to allow continuous application of repeat hepatic arterial infusion chemotherapy (HAIC)., Materials and Methods: In 128 patients with unresectable advanced liver cancer, percutaneous implantation of a port catheter system and TAE of splanchnic arteries with coils and/or n-butyl cyanoacrylate (NBCA) were performed. Parameters included (a) methods selected for catheter placement; (b) embolic materials used (coils and/or NBCA, number of coils, administration rate of NBCA-iodized oil) for TAE of splanchnic arteries, details of embolized arteries, and frequency of recanalization; (c) ability to prevent gastrointestinal symptoms by avoiding inflow of anticancer drugs into extrahepatic adjacent organs and to maintain distribution of contrast agents in liver, as well as management of difficulties encountered; (d) complications related to catheter system implantation or to long-term HAIC and management of such complications; and (e) final success in performing scheduled HAIC while maintaining distribution over liver via a single route without gastrointestinal symptoms caused by inflow of anticancer drugs. Fisher exact test was used to compare recanalization rate between coil-embolized and NBCA- or NBCA-coil-embolized arteries, and frequency of heterogeneously poor distribution was compared between patients with single and those with multiple hepatic arteries., Results: Embolization was successful during first catheterization in 326 arteries and during follow-up in 10. In 119 (93.0%) of 128 patients, repeat HAIC was effective until death or the time of this writing (observation period, 2-47 months). HAIC was continued in two patients, although anticancer drugs did not distribute to all liver tumors. Arteries once embolized with coils alone spontaneously recanalized at a significantly higher rate than those with NBCA (eight of 192 vs one of 144, P =.048). Rate of heterogeneously poor distribution was significantly higher in those with two or more hepatic arteries than in those with one (seven of 17 vs nine of 111, P =.001)., Conclusion: TAE for various splanchnic organs is useful for efficient performance of long-term HAIC., (Copyright RSNA, 2004)

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.

Our objective was to evaluate the feasibility and safety of a new method in approaching the access route percutaneously for the implantable port-catheter system for repeated hepatic arterial infusion chemotherapy. Fifteen patients underwent port-catheter system placement via the left subclavian artery with the catheter tip fixed within the gastroduodenal artery with embolic materials and a catheter side hole opening to the common hepatic artery. Before port-catheter placement, the right gastric artery was embolized via the femoral catheter access. Then a 0.035-in. guide wire was inserted from the right femoral artery to the left subclavian artery. The guide wire was left in place during puncture by the needle as an access route for catheter placement. At the time of puncture, the tip of the puncture needle was aimed at the guide wire placed in the subclavian artery beforehand. In all 15 patients the procedure was successfully completed in a reasonable time (mean time 95.0 min, range 50-240 min). Complications occurred in two patients: a transient numbness of the arm in 1 patient and a mild hematoma detected in the subcutaneous pocket in another patient. This experience indicates the possibility of using a targeting guide wire in puncture of the subclavian artery as an access route for catheter placement.

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 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.

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 developed a guide wire with multiple markers for use during implantation of the port-catheter system for intraarterial infusion chemotherapy. With the markers on this guide wire, the distance from the common hepatic artery to the right gastroepiploic artery can be precisely measured. From this measurement, it is possible to determine the distance from the side hole to the catheter tip; unneeded catheter can be cut off with surgical scissors. In all eight cases in which this guide wire was used, we implanted the port-catheter system in the ideal position.