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(Radiology. 2000;215:294-299.)
© RSNA, 2000

Technical Developments

Liver Intraarterial Chemotherapy: Use of the Femoral Artery for Percutaneous Implantation of Catheter-Port Systems1

Karin Anna Herrmann, MD, Tobias Waggershauser, MD, Harald Sittek, MD and Maximilian F. Reiser, MD

1 From the Institute of Clinical Radiology, Ludwig-Maximilians-University of Munich, Grosshadern Marchioninistr 15, D-81377 Munich, Germany. Received September 21, 1998; revision requested November 20; final revision received July 8, 1999; accepted July 30. Address reprint requests to K.A.H. (e-mail: herrmann@ikra.med.uni-muenchen.de).


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
To provide intraarterial chemotherapy of the liver in 30 outpatients with colorectal cancer metastases and other malignancies, 32 catheter-port systems were implanted percutaneously via the femoral artery. Mean patency was 229 days. Percutaneous placement was feasible and safe. Compared with surgical placement, the overall complication rate (12%) was comparable or less.

Index terms: Arteries, femoral, 922.1266 • Catheters and catheterization, technology • Chemotherapeutic infusion • Hepatic arteries, 952.1266 • Interventional procedures, technology


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Regional intraarterial chemotherapy has demonstrated better response rates than has systemic chemotherapy, particularly in cases of liver metastases of colorectal cancer (1–8). To facilitate the long-term administration of chemotherapeutic agents, percutaneously implantable catheter-port systems have been developed for long-term use. These systems allow easy and repetitive puncture in infusion therapy without causing much harm to the vessels, and their use is comfortable for the patient. Until now, the implantation of permanent intraarterial catheter systems, particularly in the liver, has been performed surgically. Surgically implanted catheter systems in the gastroduodenal artery (1,9) or via the subclavian, axillary, or brachial arteries into the common hepatic artery (10–14) have considerable complication rates. Moreover, the repair and replacement of malfunctioning port systems has previously required surgery (9,13,15,16). Thus far, percutaneous implantation of catheter-port systems for intraarterial use in various target organs, particularly in regional chemotherapy of the liver, has been successfully performed by radiologists such as Germer et al (17), Wacker et al (18), and Strecker et al (19,20).

To our knowledge, no data have been reported about use of the femoral artery to place a standard permanent polyurethane, stainless steel–braided angiographic catheter in combination with percutaneous implantation of a commonly used catheter-port system for regional intraarterial chemotherapy of the liver. The authors used the latter technique to obviate surgical intervention and simplify the implantation procedure, which would thereby promote acceptance of the procedure by patients.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
From May 1997 through September 1998, 32 percutaneously implantable catheter-port systems (Port-A-Cath; Optimed, Ettlingen, Germany) were placed in 30 patients (20 men and 10 women; age range, 34–81 years; mean age, 57 years) with various primary and metastatic malignancies of the liver. Twenty-seven patients had hepatic metastases that originated from colorectal cancer (n = 22), gastric cancer (n = 2), breast cancer (n = 1), anal cancer (n = 1), or melanoma of the retina (n = 1). Three patients had cholangiocellular carcinoma. In three patients, regional chemotherapy had been performed previously via a surgically implanted port system that repeatedly failed to function. In all other patients, the catheter-port system implanted percutaneously with radiologic guidance was the first method used to administer intraarterial chemotherapy. We obtained informed consent from each patient prior to the procedure.

Catheters
The catheters used for permanent intravascular implantation were commercially available, standard angiographic catheters (Cordis, Rhoden, Netherlands). The configuration of the catheter used depended on the vascular anatomy of the patient. The following catheters were used: Cobra C II (4 F, n = 12), Sidewinder Sim III (4 F, n = 8), Sim III (5 F, n = 2), Sim I and Sim II (4 F, n = 1 for each), Renal Double Curve (4 F, n = 5), and Headhunter H I (4 F, n = 1). All catheters were made of polyurethane with a stainless steel braid. A superselective coaxial catheter (3 F) (Starfast; Nycomed Amersham, Paris, France) was placed in two patients.

Catheter-Port System
The standard catheter-port device consisted of a titanium port reservoir with a silicone rubber membrane at the puncture site and a lateral stem to slip the silicone catheter over. The connection between the silicone catheter and the diagnostic angiographic catheter was reinforced with a small metallic cannula. The port reservoir, the silicone catheter, the cannula, and the suture material were commercially available as part of the standard catheter-port system (Fig 1).



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  		Figure 1. Schematic depicts arrangement of the various catheter-port system components before placement into the subcutaneous pocket.

 
Technical Procedure
After the common femoral artery was punctured with use of the Seldinger technique, the standard angiographic catheter was advanced into the respective target vessel with fluoroscopic guidance, and visceral arteriography was performed to assess variant arterial supply. The final position of the catheter tip, and thereby the region of perfusion, was chosen according to the anatomy of each patient and the location of the metastatic lesion at contrast material–enhanced computed tomography. The catheter tip was placed into the right hepatic artery (n = 18), the proper hepatic artery (n = 10), and the common hepatic artery (n = 4). The latter position was used in one patient with hepatopetal flow in the gastroduodenal artery, in one patient in whom the gastroduodenal artery was occluded after an interventional procedure, and in two patients with a nonfunctioning surgically implanted catheter-port system with a ligature on the gastroduodenal artery (Fig 2). In three of the 18 patients, the catheter was advanced into the right hepatic artery via a hepatomesenteric trunk. The correct position of the catheter was verified with digital subtraction angiography.



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  		Figure 2. Posteroanterior nonsubtracted radiograph in a 77-year-old male patient after left hepatic lobectomy. A nonfunctioning surgically implanted catheter-port system (arrowheads) is in the gastroduodenal artery. A functioning percutaneously implanted catheter-port system (arrow) is in the right hepatic artery.

 
The catheter-port systems were implanted percutaneously in outpatient procedures, and no conscious sedation or antibiotic treatment was administered. The following procedure was used to insert the catheter-port system. An incision approximately 3 cm long was made in the skin distally to the groin at the anterior surface of the thigh, starting from the cutaneous puncture site and leading medially and laterally along the inguinal fold. A subcutaneous pocket was then formed wherein the port reservoir was to be placed (Fig 3). The end of the angiographic catheter was cut off distally to the puncture site. To create the connection between the angiographic catheter and the port reservoir, a metal cannula approximately 1.5 cm (0.5 inch) long with an outer diameter of 0.95 mm (0.037 inch; lumen, 0.025 inch) was introduced into the lumen of the angiographic catheter. The tip of the silicone catheter was slipped over the end of the angiographic catheter and attached over the metal cannula with a nonresorbable, polyester fiber thread impregnated with polytetrafluoroethylene (Tevdek II 1-4; Deknatel, Lübeck, Germany) (Fig 1). With the superselective coaxial catheters, no cannula was used.



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  		Figure 3. Frontal schematic depicts arrangement in the groin of components of the catheter-port system. AC = angiographic catheter, C = connection site with cannula, F = femur, FA = femoral artery, I = incision, PR = port reservoir, PS = puncture site, SC = silicone catheter, SP = symphysis pubis.

 
The coaxial catheter was cut off at a length equal to that of the angiographic catheter, and the ligature was placed over the site of connection with the silicone catheter. The latter was then tailored to bridge the subcutaneous distance between the extravascular portion of the catheter and the port reservoir. The silicone catheter portion was positioned to form a slight loop to allow movement over the hip joint and prevent tension in the main catheter (Figs 3, 4). The orientation of the stem of the port reservoir must not promote kinking of the catheter. Tunneling was not necessary, and the port reservoir was not fixed to the subcutaneous tissue with an extra suture. Final port angiography helped verify the integrity of the system and correct position of the catheter. When necessary, malposition or dysfunction was corrected before the subcutaneous pocket was closed with an intracutaneous suture of the skin made of monofilament polypropylene (Deklene II 3-0; Deknatel). A compression bandage was applied in only two patients, who had slight bleeding from the arterial puncture site during the intervention. The catheter-port system was ready for immediate use.



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  		Figure 4. Fluoroscopic image depicts a catheter-port system in the right side of the groin in a 60-year-old male patient with hepatic metastasis of colon cancer. Angiographic catheter (arrowheads), connection cannula (wide black arrow), silicone catheter portion (small open arrows), stem (large open arrow), and port reservoir (thin black arrow) with needle for angiographic study.

 
The patients were mobilized immediately after the intervention. There were no restrictions on patient activity at any time after the device was in place. Bed rest was not necessary. By choice, most patients stayed at home until the onset of chemotherapy, which was 0–10 days after implantation (mean, 3 days) because the departments of radiology and internal medicine did not coordinate scheduling of the procedures. We regularly flushed the catheter system with 10 mL of saline solution at the end of each chemotherapeutic cycle, before final withdrawal of the port needle, but not between two chemotherapeutic cycles. Patients did not receive any anticoagulation therapy systemically or via the catheter system. At the end of the study, no patients were lost to follow-up. Correct functioning of each catheter-port system was verified with digital subtraction angiography prior to each chemotherapeutic treatment cycle. At each angiographic study, patients were examined clinically for the occurrence of negative side effects, such as peripheral embolization, occlusion, or mesenteric ischemia. They were also asked to complete a questionnaire regarding their satisfaction with the percutaneously implanted catheter-port system and the presence of local complications, such as hematoma, infection, pain, restriction of motion, dysesthesia, and overall long-term discomfort. The patients rated these complications as absent, mild, or important. Mild hematoma was defined as discoloration of the skin without subcutaneous swelling or induration for a maximum of 1 week. Important hematoma was defined as subcutaneous induration with palpable liquid collection around the device of more than 2 cm in diameter.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
In all patients, implantation of the catheter-port was successful. All implantation procedures were performed in the interventional radiology suite with a mean procedure time of 47 minutes (range, 20–150 minutes). No periinterventional complications were noticed. The mean follow-up of the systems was 229 days (range, 13–479 days). The primary patency rate was 88% (28 of 32 cases), and the secondary patency rate was 97% (31 of 32 cases).

Complications occurred in four (12%) of 32 cases. In all but one case, the complications could be managed by replacing the system or by using interventional maneuvers. Two occlusions (two of 32 cases, 6%) of the catheter were observed. One was found on day 13 in one of the two patients with an implanted superselective coaxial catheter. The occlusion was a result of a 2-hour interruption in chemotherapy with a subsequent reflux of blood into the catheter. Because lytic therapy with 10,000 IU of urokinase in a water solution of 2 mL was not successful in this patient, the coaxial system was removed, and a new catheter system was implanted. In the second case of occlusion, neither lytic therapy nor mechanical recanalization with a guide wire was successful. For mechanical recanalization, we punctured the port reservoir with a needle (outer diameter, 0.037 inch) and introduced a 0.025-inch guide wire through the needle into the port reservoir and the catheter. The guide wire also passed through the cannula at the catheter junction. During manipulations with the guide wire in the hepatic artery, a dissection of the hepatic artery occurred. Since the patient did not want to continue chemotherapy, the port system was entirely removed.

Displacement of the catheter was observed in two cases (two of 32 cases, 6%) at the first and third angiographic follow-up study. In one of the patients, the catheter tip was dislocated into the gastroduodenal artery and could be repositioned into the common hepatic artery by using an interventional maneuver with a gooseneck snare. To do this, an 8-F, 60-cm-long sheath (Optimed) was introduced via the contralateral femoral artery into the hepatic artery. A gooseneck snare was advanced through the sheath into the gastroduodenal artery. The dislocated catheter tip was then fixed within the loop of the gooseneck snare and drawn back into the common hepatic artery. The gastroduodenal artery was subsequently embolized to avoid further dislodgement or malperfusion. In the other patient, the catheter tip of the catheter-port system was displaced into the splenic artery. Because its position could not be corrected with interventional maneuvers, the catheter was withdrawn and replaced with a new one.

The overall removal rate was 22% (seven of 32 cases). In three of these patients (9%), removal was due to catheter-related complications. In the other four patients, the referring doctors wanted the system removed; in all four cases, the device was functioning normally at the time of removal. One of the latter patients experienced a septic episode while having a central venous catheter implanted. Both the central venous catheter and the percutaneously implanted catheter-port system were withdrawn. Microbacterial analysis did not reveal contamination of either device. A second patient was able to undergo hemihepatectomy owing to successful reduction in stage of disease as a result of the intraarterial regional chemotherapy. The surgeons requested preoperative withdrawal of the percutaneously implanted catheter-port system. A third patient requested that chemotherapy be stopped and wanted the system removed; the superselective catheter was functioning correctly at the time of removal. In the fourth patient, regional chemotherapy was stopped and changed to systemic chemotherapy because of diffuse metastatic spread of disease.

All removal procedures were uncomplicated. Both the port reservoir and the catheter could be easily withdrawn without peripheral embolization or damage to the vessels or surrounding tissue. Ingrowth of the catheters with fibrous fixation to the subcutaneous tissue was not observed. After the catheters were removed, compression was not necessary since bleeding did not occur. Mean procedure time for the withdrawal or replacement of a catheter system was approximately 40 minutes (range, 20–90 minutes). The mean primary patency rate for the seven removed systems was 105 days (range, 13–197 days).

As of September 1998, 145 port angiographic studies were performed as follow-up examinations at a mean interval of 4 weeks between each study. At the time of each angiographic examination, the patients were examined clinically for the occurrence of negative side effects. No patients showed signs of peripheral arterial embolization, occlusion, mesenteric ischemia, or embolic effects. At all follow-up examinations, we did not find infection, leakage, kinking, or disconnection of any catheter-port system.

According to the patient questionnaires, all patients were entirely satisfied with the system. No patient reported restriction of motion or discomfort owing to the port reservoir in the groin. After implantation of a catheter-port system, one patient rated a hematoma in the groin as important, but this could not be verified at any clinical follow-up examination, and it did not require surgical intervention. Immediately after implantation, mild hematoma was reported in 10 of 32 cases (31%), but no hemorrhage at the implantation or puncture site was found at the first follow-up examination in any of these cases. In six of 32 cases (19%), mild pain was reported initially, and dysesthesia was reported in two (6%). No patient rated overall discomfort as mild, severe, or important.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Permanent percutaneously implanted catheter-port systems are widely used and have proved to be advantageous for repeated external arterial or central venous access for regional or systemic chemotherapy and prolonged parenteral nutrition (2,6,16,21–26). In the past, the majority of catheter-port devices developed for intraarterial regional chemotherapy have necessitated surgical implantation (eg, Infusaid pump; Infusaid, Norwood, Mass) (3–5,7,11,15,23,27–31) and the Port-A-Cath (16,22,23,32–35). For regional intraarterial chemotherapy of the liver, the most common site of surgical implantation is the gastroduodenal artery (1,3,4,8,9,16,23,24,27,28,30,33,35). This requires laparotomy and extensive dissection to expose the gastroduodenal artery. Other sites of catheter placement include the brachial, axillary, or subclavian arteries (10–14,17,18,31,32,36–38). Complications vary depending on the technique and the approach (Table).


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  		Complications in Surgically and Interventionally Implanted Catheter-Port Systems for Intraarterial Use
 
Few reports of placement of an intraarterial catheter-port with fluoroscopic guidance in the interventional radiology suite have been published. Wacker et al (18) used the subclavian artery for minimally invasive catheter implantation. Other authors (19,20) used a Strecker-Port (Cook Europe, Bjaeverskov, Denmark), a special device placed with fluoroscopic guidance to provide intraarterial regional treatment of various regions of the body via the femoral artery. We found the latter difficult to place owing to the particular configuration of this system, especially in obese patients.

Catheter-port systems are associated with various complications after both surgical and radiologic implantation, such as catheter dislocation, occlusion, and infection. Dislocation is one major problem with such systems and occurs in between 2% (24) and 44% (10,12,15,16,23,32,33,39) of cases. The frequency of dislocation appears to be particularly high when the axillary or brachial artery is used (10,12,32). According to Strecker et al (19), catheter-related dislocation (in their study, 9%) could be due to the catheter material, which should not be too soft and flexible. In our study, we used the common femoral artery for catheter placement into the hepatic artery. Use of the combination of a braided polyurethane diagnostic angiographic catheter and a portion of a silicone catheter seems to be advantageous because it preserves both stability at the catheter tip and flexibility over the hip joint. Displacement occurred in two of our cases (6%), into the splenic artery in one case and into the gastroduodenal artery in the other. In the first patient, repositioning of the catheter tip was not possible with interventional techniques, and the system had to be withdrawn. Retrospectively, we believe this displacement into the splenic artery was probably due to too much tension on the indwelling catheter. Therefore, optimal catheter configuration is crucial. In the second patient, catheter displacement into the gastroduodenal artery was corrected with an interventional procedure. Embolization of the gastroduodenal artery was not accompanied by any side effects. Preventive embolization of the gastroduodenal artery may be useful if the catheter can be placed close to the gastroduodenal artery alone (11,32,37).

Thrombotic complications such as catheter occlusion and occlusion of the hepatic artery are also commonly associated with both surgically and radiologically implanted catheter-port systems (1,7,9,10,12,13,23,24,35,39) (Table). Catheter placement via the brachial artery can also be accompanied by thrombosis or occlusion of the brachial artery (12,13,38). In our patient group, one case of catheter occlusion was caused by blood reflux into a 3-F superselective catheter. As reported by Strum et al (40), catheters with small diameters have higher occlusion rates. Niederhuber et al (26) also found that small-bore catheters have an inferior patency rate. Owing to the higher resistance of small catheters (40), drug infusion may also be difficult. Some infusion pumps may stop at pressure levels that are too high, as was the case with the second superselective catheter system we implanted. Therefore, on the basis of results in our study and the literature, we do not recommend the use of superselective coaxial systems for permanent implantation in this context.

Lytic therapy with tissue plasminogen activator, urokinase, or streptokinase has been reported to be useful in cases of catheter occlusion (16,18,19,40,41), but this method is not always successful (9,16,41). In cases of thrombosis of the catheter in our study, lytic therapy was not effective. In one case, we attempted mechanical recanalization with a guide wire that was also not effective and resulted in dissection of the hepatic artery. To ensure the continuity of chemotherapy after catheter occlusion, the function of the systems could be restored only by replacing the malfunctioning components or the entire system. For this purpose, the pocket was reopened, and the angiographic catheter was cut off proximally to the connection site to introduce a guide wire into the hepatic artery. The previously described procedure was used to reimplant the new catheter.

To prevent catheter thrombosis, administration of warfarin sodium has been recommended (42). Wacker et al (18) performed continuous catheter perfusion with heparin because of the high spontaneous thrombosis rate with a catheter with a very small lumen. Other authors, however, do not consider systemic or other type of anticoagulation therapy necessary. Strecker et al (19) do not believe the use of warfarin sodium is indicated because of the potential side effects of anticoagulation therapy and the increased need for blood parameter analysis. Niederhuber et al (26) believe that patency is excellent without continuous treatment with heparin in the catheter.

Some authors (10,12,13,18,32,37) report hepatic arterial thrombosis after port implantation. Oberfield et al (10) found partial or complete occlusions of the hepatic artery in 39.6% of all patients as did Ekberg et al (13) in 59% of their patients. The material and thickness of the indwelling catheters (12,18,43) and the relation between the size of the catheter and the lumen of the target vessel are important in this context. In addition, the toxic effects of the chemotherapeutic agents have been blamed for some of the damage to the vessel wall of the hepatic artery (1,18,38,39,44,45). In our patient group, we did not use any anticoagulation therapy, and we did not observe any type of vascular occlusion, which suggests that the catheter material we used was not thrombogenic.

Infection is another complication in permanently implanted catheter systems that often makes removal of the device necessary (9,19,24,33,46). Infection rates range from 0% (26) to 7.6% (10,11,19,23,24). Infection and sepsis during chemotherapy can be caused by use of inappropriate hygienic measures and can be treated successfully with antibiotic therapy (46). Strecker et al (19) noticed that after an infected catheter-port system was removed and replaced with a new one, however, infection recurred in some patients. In our study patients, infection was not observed. Infection rates after radiologic implantation are not higher than those after surgical implantation (Table). Therefore, interventional radiology suites seem to provide sufficient hygienic conditions for this type of intervention.

Compared with surgical implantation, radiologic implantation of catheter-port systems is a quick and simple procedure that does not require general anesthesia and can be performed in outpatients. Patency rates are equal to those for surgically implanted systems. Radiologic placement is also possible in patients with anatomic vascular variations, such as a hepatomesenteric trunk. In contrast to the surgical method, catheter-port systems placed radiologically cause less morbidity in the case of dysfunction, because the systems can be removed or repositioned more easily. Complicated surgical revisions or corrections requiring laparotomy as proposed by Doughty et al (47) can be avoided. Radiologic placement does not allow performance of preventive cholecystectomy to avoid cholecystitis, but this does not seem to be a crucial problem.

The relatively low complication rate increases patient acceptance of this procedure. Placement of the catheter-port system on the anterior surface of the thigh below the groin seems to be well accepted, even in very active patients. Its superficial placement allows easy palpation and puncture, even in obese patients, and provides little risk for dislocation or disconnection of the port needle from the reservoir during chemotherapy. All the components of such systems are well accepted in clinical applications, and they are commercially available, which makes this system safe and relatively inexpensive.

Our results indicate that percutaneous implantation of a catheter-port system via the femoral artery is easy to perform, simplifies intraarterial chemotherapy of the liver with equal patency rates and fewer complications as compared with surgical placement, and is well accepted by patients.


   Footnotes
 
Author contributions: Guarantors of integrity of entire study, K.A.H., M.F.R.; study concepts and design, K.A.H., T.W.; definition of intellectual content, K.A.H., T.W., M.F.R.; literature research, K.A.H.; clinical studies, T.W., K.A.H.; data acquisition, K.A.H., T.W.; data analysis, K.A.H.; statistical analysis, K.A.H.; manuscript preparation, K.A.H.; manuscript editing, K.A.H., M.F.R.; manuscript review, M.F.R., H.S.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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