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Published online before print January 22, 2004, 10.1148/radiol.2303021564
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(Radiology 2004;230:792-802.)
© RSNA, 2004

Vascular and Interventional Radiology

Value of Transcatheter Arterial Embolization with Coils and n-Butyl Cyanoacrylate for Long-term Hepatic Arterial Infusion Chemotherapy1

Takuji Yamagami, MD, PhD, Takeharu Kato, MD, Shigeharu Iida, MD, Osamu Tanaka, MD and Tsunehiko Nishimura, MD, PhD

1 From the Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-chyo, Kawaramachi-Hirokoji, Kamigyo, Kyoto 602-8566, Japan. Received November 26, 2002; revision requested February 3, 2003; final revision received August 5; accepted August 22. Address correspondence to T.Y. (e-mail: yamagami@koto.kpu-m.ac.jp).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
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.

© RSNA, 2004

Index terms: Arteries, chemotherapeutic embolization, 952.1264, 952.1266 • Blood, flow dynamics • Hepatic arteries, 952.1264, 952.1266 • Liver neoplasms, 761.33


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Repeat hepatic arterial infusion chemotherapy (HAIC) by means of an implanted port catheter system is widely known as a last-resort treatment for unresectable advanced liver cancer (1,2). In the past, such catheters were placed by means of surgical laparotomy with use of general anesthesia (3–6), making this an invasive procedure. However, recent advancements in interventional techniques have made it possible to implant port catheter systems percutaneously with use of local anesthesia (7–15).

Ideally, to perform long-term HAIC, the following conditions should be met (7): (a) maintenance of distribution of anticancer drugs infused via a single indwelling catheter into the entire tumor-bearing region in the liver after conversion of multiple hepatic arteries into a single vascular supply and occlusion of a parasitic blood supply from extrahepatic arteries to liver segments in which tumors exist and (b) prevention of distribution of anticancer drugs to extrahepatic adjacent organs, such as the stomach, duodenum, or pancreas, which share a common trunk with the vessel to be used for HAIC, to be achieved by occlusion of arteries that supply blood to such organs. Among interventional radiologic techniques that can be used to maintain these conditions, closely planned transcatheter arterial embolization (TAE) with embolic agents performed in various situations is necessary, in addition to percutaneous placement of an indwelling port catheter system.

The purpose of our study was to assess the value of TAE performed in various splanchnic arterial branches to allow the continuous application of repeat HAIC.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Patients
Between April 1998 and March 2002, 128 patients (81 men with an age range of 29–83 years and a mean age of 64.0 years; 47 women with an age range of 39–80 years and a mean age of 60.1 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port catheter system. There were no statistically significant differences between men and women. Forty-five patients had primary liver cancer, and 83 had metastatic liver cancer that originated from colorectal (n = 42), breast (n = 20), gastric (n = 9), pancreatic (n = 4), lung (n = 3), gallbladder (n = 2), ovarian (n = 1), anal (n = 1), and jejunal (n = 1) cancer. All patients had diffuse or multiple (more than five) malignant lesions or a few large (>5-cm) malignant lesions in both the right and left lobes of the liver. Eighty-one of 128 patients had received systemic chemotherapy (n = 46) or other interventional treatments (n = 43; eight patients received both treatments), such as transcatheter hepatic arterial chemoembolization, percutaneous ethanol injection, and radiofrequency ablation, only to develop intractable disease.

Seventeen patients had two or more hepatic arteries clearly visualized at the first angiographic procedure. The replaced right hepatic artery arose from the superior mesenteric artery in 10 patients, from the celiac artery in one patient, and directly from the aorta in one patient. The replaced and accessory left hepatic artery originated from the left gastric artery in six patients and one patient, respectively. Two patients had replaced right and left hepatic arteries. In one patient, a retroportal artery that anastomosed the superior mesenteric artery and right hepatic artery and was not visualized at the first angiographic procedure developed at an interval after port catheter placement.

Procedures
Approval was obtained from the institutional ethics committee before the start of the study. All procedures were performed by one of three experienced interventional radiologists (T.Y., T.K., S.I., with 7–12 years of experience in interventional radiology) at our institution after written informed consent was obtained from each patient. The consent included use of records, images, and data for research purposes.

Catheter Placement
One hundred thirty-two percutaneous port catheter systems were placed for long-term HAIC (in four patients, a second catheter system was inserted). The indwelling catheter was inserted in the left subclavian artery in 123 procedures and in the right (n = 8) or left (n = 1) femoral artery in nine.

For all procedures, we selected the fixed catheter tip method, in which the distal tip of the catheter was fixed at one of the branches of the celiac arterial system with or without embolic agents placed on the outside of the indwelling catheter. A side hole was made in the catheter to infuse anticancer drugs into the hepatic arteries. Details of this method are described elsewhere (7,8,16–18). Microcoils were used as embolic agents. When embolization was insufficient or fixation of the catheter tip was incomplete, n-butyl cyanoacrylate (NBCA) (Histoacryl-Blue; Braun, Melsungen, Germany) mixed with iodized oil (Lipiodol; Laboratoire Guerbet, Roissy, France) was additionally used after microcoils.

A polyurethane-covered catheter with a tapered tip (5-F outer shaft diameter and 2.7-F tip diameter) (Anthron P-U catheter; Toray Medical, Tokyo, Japan) was used as the indwelling catheter in 113 procedures. In 19 procedures, a 5-F catheter was used (Gently; Solution, Tokyo, Japan) in which a side hole was created by the manufacturer.

TAE to Minimize Perfusion to Extrahepatic Organs
One patient did not undergo TAE to minimize perfusion to extrahepatic organs. In that patient, a side hole of the indwelling catheter was created in the replaced right hepatic artery, and no arterial branch that supplied blood into extrahepatic organs arose beyond the side hole. In all other patients, on the day before catheter implantation (n = 98) or as the first step in port catheter implantation (n = 29), all angiographically demonstrated branches that supplied blood to extrahepatic adjacent organs (ie, stomach, duodenum, and pancreas) that arose from the point between the side hole and the bifurcation of the right and left hepatic arteries were embolized to prevent infusion of anticancer drugs into adjacent organs during HAIC. The arterial branch into which the tip of the indwelling catheter was to be inserted was not embolized during this step. Microcoils and/or a mixture of NBCA and iodized oil were used as embolic agents. Microcoils were principally used, but when embolization was not complete with microcoils alone, the NBCA–iodized oil mixture was added.

Of course, TAE was not performed for arterial branches that were occluded in a previously performed TAE procedure or were ligated during a previous surgical laparotomy. For example, in patients who had undergone gastrectomy, TAE of the right gastric artery was not undertaken. In the patient with a falciform artery as visualized at hepatic arteriography, this vessel was embolized.

TAE to Allow Perfusion of the Entire Tumor-bearing Region with One Catheter
In 16 of the 17 patients who had two or more hepatic arteries, to redistribute hepatic arterial flow to allow complete hepatic coverage by means of a single infusion catheter, all hepatic arteries were embolized except that from which the gastroduodenal artery arose. Care was taken to embolize 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. In one exception, almost all tumors existed in the right lobe. In this patient, the proper hepatic artery was embolized, and two hepatic arteries were converted into the right hepatic artery, which arose from the superior mesenteric artery. The indwelling catheter was inserted into the right hepatic artery.

Furthermore, we performed embolization when hepatopetal flow from a parasitic artery (ie, right inferior phrenic artery) was confirmed by means of selective arteriography from each parasitic artery at the time of port catheter placement. These TAE procedures were performed by using 0.035-inch stainless steel coils, microcoils, and/or a mixture of NBCA and iodized oil.

Imaging to Evaluate Intra- and Extrahepatic Distribution
All patients were examined with digital subtraction angiography, or DSA, after 8–10 mL of iopamidol (Schering, Berlin, Germany) (370 mg of iodine per milliliter) was infused via the port catheter at an injection rate of 0.8–1.0 mL/sec. DSA was performed to confirm the patency of the hepatic artery, rule out inflow to extrahepatic arterial branches, and identify the position of the indwelling catheter. In addition, helical computed tomography (CT) was performed while contrast material was infused via the port catheter to confirm good distribution of the contrast agent over the entire liver and to rule out extrahepatic infusion. CT was started 10 seconds after injection of 25–30 mL of iopamidol (150 mg of iodine per milliliter) at a rate of 1 mL/sec via the port catheter. The CT unit used was an X Vigor Laudator (Toshiba Medical Systems, Tokyo, Japan). Helical CT images were obtained in the entire liver during a single breath hold. Arteriographic images obtained with and without use of helical CT were acquired 2–10 days after implantation and every 1–3 months thereafter. Such intervals depended on the clinical circumstances of each patient, which varied.

Parameters Investigated
The following parameters were investigated retrospectively by three authors (T.Y., S.I., O.T.) in consensus: (a) variations in methods selected for percutaneous port catheter placement; (b) details of embolic materials used (ie, coils and/or NBCA, number of coils, and administration rate of NBCA–iodized oil mixture) for TAE of all splanchnic arteries, details of embolized arteries, and frequency of recanalization of each such artery; (c) ability to prevent gastrointestinal symptoms after HAIC by avoiding inflow of anticancer drugs into extrahepatic adjacent organs and to maintain distribution of contrast agents in the entire liver and management of difficulties in satisfying these two elements; (d) complications related to the implantation of the port catheter system or to long-term HAIC and management of such complications; and (e) final success in performing scheduled HAIC efficiently while maintaining distribution over the entire liver via a single route without gastrointestinal symptoms caused by inflow of anticancer drugs.

Statistical Analysis
We analyzed the following two statistical elements with the Fisher exact probability test: (a) rate of recanalization of previously embolized arteries by comparing those in which coils were used as the embolic agent with those in which NBCA was used either alone or with coils; and (b) frequency of development of heterogeneously poor distribution of contrast material in certain areas of the liver as shown at arteriography with or without use of helical CT when comparing patients who had one hepatic artery with those who had two or more hepatic arteries. Differences were considered to be significant when the P value was less than .05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Methods of Percutaneous Port Catheter Placement
As shown in Table 1, the port catheter system was implanted according to 10 categories. The fixed catheter tip method that involved the gastroduodenal artery with the side-hole opening in the common hepatic artery was used most commonly and was performed in 105 of the 132 procedures (Figs 1–5). In four procedures, the catheter tip was not fixed because of strong hepatopetal flow through the gastroduodenal artery. In the remaining 23 procedures, we did not use the most commonly applied method for various reasons. In 18 of those 23 procedures, it was difficult or impossible to advance the catheter into the gastroduodenal artery, mainly because of unfavorable anatomy. In four procedures, a second port catheter system was inserted because the initial indwelling catheter malfunctioned. In these cases, the gastroduodenal artery had already been embolized at the time of first port catheter placement (Fig 2). In one procedure, the catheter tip was fixed in the left gastric artery with the side-hole opening to the celiac artery, and the arterial branches that supplied blood to the liver and pancreas were not embolized. This patient had unresectable pancreatic cancer with liver metastasis, and we desired distribution of anticancer drugs into both liver and pancreas. In patients in categories 4, 6, and 8, the peripheral branch of the hepatic artery that supplied blood to the liver segment with the main tumors was avoided when the catheter tip was inserted.


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  		TABLE 1. Procedures Preformed to Implant Port Catheter System for Percutaneous HAIC

 


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  		Figure 1.  Schematic of desired catheter position and occluded vessels for infusion with fixed catheter tip method involving the gastroduodenal artery (F). Catheter tip (straight white arrow) is located in the gastroduodenal artery. Side hole (large black arrow) through which anticancer drugs are infused via the port catheter and distributed to intrahepatic arterial branches is opened toward the common hepatic artery (D). Inside lumen of the catheter tip is occluded with the microcoil (curved arrow). Catheter tip is tightly fixed in the gastroduodenal artery with microcoils (small thick arrows) and NBCA-iodized oil (arrowhead) placed on the outside of the catheter. Right gastric artery (G) and branches of the pancreaticoduodenal arcade are embolized with microcoils (small thin arrows). A = celiac artery, B = left gastric artery, C = splenic artery, E = proper hepatic artery, H = dorsal pancreatic artery.

 


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  		Figure 2a.  Images in a 67-year-old man with liver metastasis from the colon. (a) Arteriogram obtained just after implantation shows correct positioning of port catheter system. Catheter tip is fixed to gastroduodenal artery with six microcoils (long arrow) and NBCA-iodized oil (arrowhead). Right gastric artery is embolized with four microcoils (short arrow). (b) Arteriogram obtained 61 days after implantation shows movement of side hole to celiac arterial site. Blood flow into left gastric artery (arrow) and splenic artery (arrowhead) is shown. Right hepatic artery is not visualized. (c) Superior mesenteric arteriogram shows dilated retroportal artery (arrow) that developed after catheter placement. (d) Celiac arteriogram obtained after TAE of retroportal artery with four microcoils (arrows) and NBCA-iodized oil, which were inserted from the microcatheter advanced in retrograde through the proper hepatic artery via a 5-F catheter located in the celiac artery into the retroportal artery, shows all hepatic arteries converted into a single route via the celiac artery. Note enlarged right inferior phrenic artery (arrowhead). (e) Arteriogram obtained after indwelling catheter was replaced by a second one. Tip is fixed in the splenic artery with four microcoils and NBCA-iodized oil with the side-hole opening in the celiac artery. Good patency of all hepatic arterial branches is shown. Note that left gastric artery (arrowhead) and right inferior phrenic artery (arrow) are both embolized with three microcoils. (f) Transverse CT images obtained during arteriography after implantation of second catheter system shows good distribution of contrast agent over entire liver.

 


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  		Figure 2b.  Images in a 67-year-old man with liver metastasis from the colon. (a) Arteriogram obtained just after implantation shows correct positioning of port catheter system. Catheter tip is fixed to gastroduodenal artery with six microcoils (long arrow) and NBCA-iodized oil (arrowhead). Right gastric artery is embolized with four microcoils (short arrow). (b) Arteriogram obtained 61 days after implantation shows movement of side hole to celiac arterial site. Blood flow into left gastric artery (arrow) and splenic artery (arrowhead) is shown. Right hepatic artery is not visualized. (c) Superior mesenteric arteriogram shows dilated retroportal artery (arrow) that developed after catheter placement. (d) Celiac arteriogram obtained after TAE of retroportal artery with four microcoils (arrows) and NBCA-iodized oil, which were inserted from the microcatheter advanced in retrograde through the proper hepatic artery via a 5-F catheter located in the celiac artery into the retroportal artery, shows all hepatic arteries converted into a single route via the celiac artery. Note enlarged right inferior phrenic artery (arrowhead). (e) Arteriogram obtained after indwelling catheter was replaced by a second one. Tip is fixed in the splenic artery with four microcoils and NBCA-iodized oil with the side-hole opening in the celiac artery. Good patency of all hepatic arterial branches is shown. Note that left gastric artery (arrowhead) and right inferior phrenic artery (arrow) are both embolized with three microcoils. (f) Transverse CT images obtained during arteriography after implantation of second catheter system shows good distribution of contrast agent over entire liver.

 


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  		Figure 2c.  Images in a 67-year-old man with liver metastasis from the colon. (a) Arteriogram obtained just after implantation shows correct positioning of port catheter system. Catheter tip is fixed to gastroduodenal artery with six microcoils (long arrow) and NBCA-iodized oil (arrowhead). Right gastric artery is embolized with four microcoils (short arrow). (b) Arteriogram obtained 61 days after implantation shows movement of side hole to celiac arterial site. Blood flow into left gastric artery (arrow) and splenic artery (arrowhead) is shown. Right hepatic artery is not visualized. (c) Superior mesenteric arteriogram shows dilated retroportal artery (arrow) that developed after catheter placement. (d) Celiac arteriogram obtained after TAE of retroportal artery with four microcoils (arrows) and NBCA-iodized oil, which were inserted from the microcatheter advanced in retrograde through the proper hepatic artery via a 5-F catheter located in the celiac artery into the retroportal artery, shows all hepatic arteries converted into a single route via the celiac artery. Note enlarged right inferior phrenic artery (arrowhead). (e) Arteriogram obtained after indwelling catheter was replaced by a second one. Tip is fixed in the splenic artery with four microcoils and NBCA-iodized oil with the side-hole opening in the celiac artery. Good patency of all hepatic arterial branches is shown. Note that left gastric artery (arrowhead) and right inferior phrenic artery (arrow) are both embolized with three microcoils. (f) Transverse CT images obtained during arteriography after implantation of second catheter system shows good distribution of contrast agent over entire liver.

 


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  		Figure 2d.  Images in a 67-year-old man with liver metastasis from the colon. (a) Arteriogram obtained just after implantation shows correct positioning of port catheter system. Catheter tip is fixed to gastroduodenal artery with six microcoils (long arrow) and NBCA-iodized oil (arrowhead). Right gastric artery is embolized with four microcoils (short arrow). (b) Arteriogram obtained 61 days after implantation shows movement of side hole to celiac arterial site. Blood flow into left gastric artery (arrow) and splenic artery (arrowhead) is shown. Right hepatic artery is not visualized. (c) Superior mesenteric arteriogram shows dilated retroportal artery (arrow) that developed after catheter placement. (d) Celiac arteriogram obtained after TAE of retroportal artery with four microcoils (arrows) and NBCA-iodized oil, which were inserted from the microcatheter advanced in retrograde through the proper hepatic artery via a 5-F catheter located in the celiac artery into the retroportal artery, shows all hepatic arteries converted into a single route via the celiac artery. Note enlarged right inferior phrenic artery (arrowhead). (e) Arteriogram obtained after indwelling catheter was replaced by a second one. Tip is fixed in the splenic artery with four microcoils and NBCA-iodized oil with the side-hole opening in the celiac artery. Good patency of all hepatic arterial branches is shown. Note that left gastric artery (arrowhead) and right inferior phrenic artery (arrow) are both embolized with three microcoils. (f) Transverse CT images obtained during arteriography after implantation of second catheter system shows good distribution of contrast agent over entire liver.

 


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  		Figure 2e.  Images in a 67-year-old man with liver metastasis from the colon. (a) Arteriogram obtained just after implantation shows correct positioning of port catheter system. Catheter tip is fixed to gastroduodenal artery with six microcoils (long arrow) and NBCA-iodized oil (arrowhead). Right gastric artery is embolized with four microcoils (short arrow). (b) Arteriogram obtained 61 days after implantation shows movement of side hole to celiac arterial site. Blood flow into left gastric artery (arrow) and splenic artery (arrowhead) is shown. Right hepatic artery is not visualized. (c) Superior mesenteric arteriogram shows dilated retroportal artery (arrow) that developed after catheter placement. (d) Celiac arteriogram obtained after TAE of retroportal artery with four microcoils (arrows) and NBCA-iodized oil, which were inserted from the microcatheter advanced in retrograde through the proper hepatic artery via a 5-F catheter located in the celiac artery into the retroportal artery, shows all hepatic arteries converted into a single route via the celiac artery. Note enlarged right inferior phrenic artery (arrowhead). (e) Arteriogram obtained after indwelling catheter was replaced by a second one. Tip is fixed in the splenic artery with four microcoils and NBCA-iodized oil with the side-hole opening in the celiac artery. Good patency of all hepatic arterial branches is shown. Note that left gastric artery (arrowhead) and right inferior phrenic artery (arrow) are both embolized with three microcoils. (f) Transverse CT images obtained during arteriography after implantation of second catheter system shows good distribution of contrast agent over entire liver.

 


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  		Figure 2f.  Images in a 67-year-old man with liver metastasis from the colon. (a) Arteriogram obtained just after implantation shows correct positioning of port catheter system. Catheter tip is fixed to gastroduodenal artery with six microcoils (long arrow) and NBCA-iodized oil (arrowhead). Right gastric artery is embolized with four microcoils (short arrow). (b) Arteriogram obtained 61 days after implantation shows movement of side hole to celiac arterial site. Blood flow into left gastric artery (arrow) and splenic artery (arrowhead) is shown. Right hepatic artery is not visualized. (c) Superior mesenteric arteriogram shows dilated retroportal artery (arrow) that developed after catheter placement. (d) Celiac arteriogram obtained after TAE of retroportal artery with four microcoils (arrows) and NBCA-iodized oil, which were inserted from the microcatheter advanced in retrograde through the proper hepatic artery via a 5-F catheter located in the celiac artery into the retroportal artery, shows all hepatic arteries converted into a single route via the celiac artery. Note enlarged right inferior phrenic artery (arrowhead). (e) Arteriogram obtained after indwelling catheter was replaced by a second one. Tip is fixed in the splenic artery with four microcoils and NBCA-iodized oil with the side-hole opening in the celiac artery. Good patency of all hepatic arterial branches is shown. Note that left gastric artery (arrowhead) and right inferior phrenic artery (arrow) are both embolized with three microcoils. (f) Transverse CT images obtained during arteriography after implantation of second catheter system shows good distribution of contrast agent over entire liver.

 


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  		Figure 3a.  Arteriograms in a 58-year-old man with hepatocellular carcinoma complicated by duodenal mucosal lesion. (a) Image obtained just after implantation shows correct positioning of port catheter system. Note that right gastric artery is embolized with two microcoils (arrow). (b) Image obtained 56 days after implantation shows newly visualized branch of the pancreaticoduodenal arcade (arrow). Note that left hepatic artery is obstructed. (c) Image obtained with microcatheter advanced into newly visualized branch of the pancreaticoduodenal arcade via a 5-F catheter positioned in the celiac artery shows inflow into duodenum and pancreas. (d) Image obtained after six-microcoil embolization of the branch of the pancreaticoduodenal arcade shows no blood flow into this branch (arrow). Note that multiple tumor stains are seen in both right and left hepatic lobes and that tumor in left lobe is supplied with blood from right hepatic artery through intrahepatic collateral vessels.

 


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  		Figure 3b.  Arteriograms in a 58-year-old man with hepatocellular carcinoma complicated by duodenal mucosal lesion. (a) Image obtained just after implantation shows correct positioning of port catheter system. Note that right gastric artery is embolized with two microcoils (arrow). (b) Image obtained 56 days after implantation shows newly visualized branch of the pancreaticoduodenal arcade (arrow). Note that left hepatic artery is obstructed. (c) Image obtained with microcatheter advanced into newly visualized branch of the pancreaticoduodenal arcade via a 5-F catheter positioned in the celiac artery shows inflow into duodenum and pancreas. (d) Image obtained after six-microcoil embolization of the branch of the pancreaticoduodenal arcade shows no blood flow into this branch (arrow). Note that multiple tumor stains are seen in both right and left hepatic lobes and that tumor in left lobe is supplied with blood from right hepatic artery through intrahepatic collateral vessels.

 


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  		Figure 3c.  Arteriograms in a 58-year-old man with hepatocellular carcinoma complicated by duodenal mucosal lesion. (a) Image obtained just after implantation shows correct positioning of port catheter system. Note that right gastric artery is embolized with two microcoils (arrow). (b) Image obtained 56 days after implantation shows newly visualized branch of the pancreaticoduodenal arcade (arrow). Note that left hepatic artery is obstructed. (c) Image obtained with microcatheter advanced into newly visualized branch of the pancreaticoduodenal arcade via a 5-F catheter positioned in the celiac artery shows inflow into duodenum and pancreas. (d) Image obtained after six-microcoil embolization of the branch of the pancreaticoduodenal arcade shows no blood flow into this branch (arrow). Note that multiple tumor stains are seen in both right and left hepatic lobes and that tumor in left lobe is supplied with blood from right hepatic artery through intrahepatic collateral vessels.

 


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  		Figure 3d.  Arteriograms in a 58-year-old man with hepatocellular carcinoma complicated by duodenal mucosal lesion. (a) Image obtained just after implantation shows correct positioning of port catheter system. Note that right gastric artery is embolized with two microcoils (arrow). (b) Image obtained 56 days after implantation shows newly visualized branch of the pancreaticoduodenal arcade (arrow). Note that left hepatic artery is obstructed. (c) Image obtained with microcatheter advanced into newly visualized branch of the pancreaticoduodenal arcade via a 5-F catheter positioned in the celiac artery shows inflow into duodenum and pancreas. (d) Image obtained after six-microcoil embolization of the branch of the pancreaticoduodenal arcade shows no blood flow into this branch (arrow). Note that multiple tumor stains are seen in both right and left hepatic lobes and that tumor in left lobe is supplied with blood from right hepatic artery through intrahepatic collateral vessels.

 


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  		Figure 4a.  Images in a 67-year-old man with liver metastasis from the colon. (a) Transverse CT image obtained during arteriography with infusion of contrast agents via the port catheter performed 236 days after implantation shows poor distribution into posterior segment of the liver (arrows). (b) Arteriogram shows correct positioning of port catheter system. Note radiopaque NBCA-iodized oil casts of right inferior phrenic artery (arrows). (c) Transverse CT image obtained during arteriography with infusion of contrast agents via the port catheter performed after embolization of right inferior phrenic artery shows good distribution over entire liver, including posterior segment in which tumors exist.

 


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  		Figure 4b.  Images in a 67-year-old man with liver metastasis from the colon. (a) Transverse CT image obtained during arteriography with infusion of contrast agents via the port catheter performed 236 days after implantation shows poor distribution into posterior segment of the liver (arrows). (b) Arteriogram shows correct positioning of port catheter system. Note radiopaque NBCA-iodized oil casts of right inferior phrenic artery (arrows). (c) Transverse CT image obtained during arteriography with infusion of contrast agents via the port catheter performed after embolization of right inferior phrenic artery shows good distribution over entire liver, including posterior segment in which tumors exist.

 


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  		Figure 4c.  Images in a 67-year-old man with liver metastasis from the colon. (a) Transverse CT image obtained during arteriography with infusion of contrast agents via the port catheter performed 236 days after implantation shows poor distribution into posterior segment of the liver (arrows). (b) Arteriogram shows correct positioning of port catheter system. Note radiopaque NBCA-iodized oil casts of right inferior phrenic artery (arrows). (c) Transverse CT image obtained during arteriography with infusion of contrast agents via the port catheter performed after embolization of right inferior phrenic artery shows good distribution over entire liver, including posterior segment in which tumors exist.

 


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  		Figure 5a.  Arteriograms in 48-year-old woman with liver metastasis from the breast. (a) Replaced right hepatic artery (arrow) arises from superior mesenteric artery. (b) Common hepatic artery arises from celiac artery. Note that falciform artery (arrow) arises from middle hepatic artery. (c) Replaced left hepatic artery arises from left gastric artery, which directly arises from the aorta. (d) Image obtained 2 days after catheter placement following successful conversion of three hepatic arteries into one by means of embolization of replaced right (large arrowhead) and left hepatic arteries (small arrowhead). Right hepatic artery is poorly visualized. Note that right gastric artery (small thick arrow) and falciform artery (curved arrow) are embolized with a microcoil and that right inferior phrenic artery is embolized with NBCA-iodized oil (long thin arrow) (ratio 1:4). (e) Superior mesenteric arteriogram shows recanalization of replaced right hepatic artery, which was embolized with two microcoils. (f) Arteriogram obtained after additional embolization of recanalized replaced right hepatic artery with three microcoils (arrow) and NBCA-iodized oil (arrowhead) (administration rate, 1:1.5) shows good distribution into all intrahepatic arterial branches.

 


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  		Figure 5b.  Arteriograms in 48-year-old woman with liver metastasis from the breast. (a) Replaced right hepatic artery (arrow) arises from superior mesenteric artery. (b) Common hepatic artery arises from celiac artery. Note that falciform artery (arrow) arises from middle hepatic artery. (c) Replaced left hepatic artery arises from left gastric artery, which directly arises from the aorta. (d) Image obtained 2 days after catheter placement following successful conversion of three hepatic arteries into one by means of embolization of replaced right (large arrowhead) and left hepatic arteries (small arrowhead). Right hepatic artery is poorly visualized. Note that right gastric artery (small thick arrow) and falciform artery (curved arrow) are embolized with a microcoil and that right inferior phrenic artery is embolized with NBCA-iodized oil (long thin arrow) (ratio 1:4). (e) Superior mesenteric arteriogram shows recanalization of replaced right hepatic artery, which was embolized with two microcoils. (f) Arteriogram obtained after additional embolization of recanalized replaced right hepatic artery with three microcoils (arrow) and NBCA-iodized oil (arrowhead) (administration rate, 1:1.5) shows good distribution into all intrahepatic arterial branches.

 


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  		Figure 5c.  Arteriograms in 48-year-old woman with liver metastasis from the breast. (a) Replaced right hepatic artery (arrow) arises from superior mesenteric artery. (b) Common hepatic artery arises from celiac artery. Note that falciform artery (arrow) arises from middle hepatic artery. (c) Replaced left hepatic artery arises from left gastric artery, which directly arises from the aorta. (d) Image obtained 2 days after catheter placement following successful conversion of three hepatic arteries into one by means of embolization of replaced right (large arrowhead) and left hepatic arteries (small arrowhead). Right hepatic artery is poorly visualized. Note that right gastric artery (small thick arrow) and falciform artery (curved arrow) are embolized with a microcoil and that right inferior phrenic artery is embolized with NBCA-iodized oil (long thin arrow) (ratio 1:4). (e) Superior mesenteric arteriogram shows recanalization of replaced right hepatic artery, which was embolized with two microcoils. (f) Arteriogram obtained after additional embolization of recanalized replaced right hepatic artery with three microcoils (arrow) and NBCA-iodized oil (arrowhead) (administration rate, 1:1.5) shows good distribution into all intrahepatic arterial branches.

 


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  		Figure 5d.  Arteriograms in 48-year-old woman with liver metastasis from the breast. (a) Replaced right hepatic artery (arrow) arises from superior mesenteric artery. (b) Common hepatic artery arises from celiac artery. Note that falciform artery (arrow) arises from middle hepatic artery. (c) Replaced left hepatic artery arises from left gastric artery, which directly arises from the aorta. (d) Image obtained 2 days after catheter placement following successful conversion of three hepatic arteries into one by means of embolization of replaced right (large arrowhead) and left hepatic arteries (small arrowhead). Right hepatic artery is poorly visualized. Note that right gastric artery (small thick arrow) and falciform artery (curved arrow) are embolized with a microcoil and that right inferior phrenic artery is embolized with NBCA-iodized oil (long thin arrow) (ratio 1:4). (e) Superior mesenteric arteriogram shows recanalization of replaced right hepatic artery, which was embolized with two microcoils. (f) Arteriogram obtained after additional embolization of recanalized replaced right hepatic artery with three microcoils (arrow) and NBCA-iodized oil (arrowhead) (administration rate, 1:1.5) shows good distribution into all intrahepatic arterial branches.

 


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  		Figure 5e.  Arteriograms in 48-year-old woman with liver metastasis from the breast. (a) Replaced right hepatic artery (arrow) arises from superior mesenteric artery. (b) Common hepatic artery arises from celiac artery. Note that falciform artery (arrow) arises from middle hepatic artery. (c) Replaced left hepatic artery arises from left gastric artery, which directly arises from the aorta. (d) Image obtained 2 days after catheter placement following successful conversion of three hepatic arteries into one by means of embolization of replaced right (large arrowhead) and left hepatic arteries (small arrowhead). Right hepatic artery is poorly visualized. Note that right gastric artery (small thick arrow) and falciform artery (curved arrow) are embolized with a microcoil and that right inferior phrenic artery is embolized with NBCA-iodized oil (long thin arrow) (ratio 1:4). (e) Superior mesenteric arteriogram shows recanalization of replaced right hepatic artery, which was embolized with two microcoils. (f) Arteriogram obtained after additional embolization of recanalized replaced right hepatic artery with three microcoils (arrow) and NBCA-iodized oil (arrowhead) (administration rate, 1:1.5) shows good distribution into all intrahepatic arterial branches.

 


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  		Figure 5f.  Arteriograms in 48-year-old woman with liver metastasis from the breast. (a) Replaced right hepatic artery (arrow) arises from superior mesenteric artery. (b) Common hepatic artery arises from celiac artery. Note that falciform artery (arrow) arises from middle hepatic artery. (c) Replaced left hepatic artery arises from left gastric artery, which directly arises from the aorta. (d) Image obtained 2 days after catheter placement following successful conversion of three hepatic arteries into one by means of embolization of replaced right (large arrowhead) and left hepatic arteries (small arrowhead). Right hepatic artery is poorly visualized. Note that right gastric artery (small thick arrow) and falciform artery (curved arrow) are embolized with a microcoil and that right inferior phrenic artery is embolized with NBCA-iodized oil (long thin arrow) (ratio 1:4). (e) Superior mesenteric arteriogram shows recanalization of replaced right hepatic artery, which was embolized with two microcoils. (f) Arteriogram obtained after additional embolization of recanalized replaced right hepatic artery with three microcoils (arrow) and NBCA-iodized oil (arrowhead) (administration rate, 1:1.5) shows good distribution into all intrahepatic arterial branches.

 
TAE in Splanchnic Arteries
We succeeded in selective catheterization of all arteries for which TAE was attempted, with the exception of seven cases. In these patients, who had not undergone gastrectomy, we failed to advance the microcatheter into the right gastric artery, which resulted in unsuccessful embolization.

Table 2 shows all embolized arterial branches. Three hundred twenty-six arterial branches were embolized successfully during initial port catheter placement. During the follow-up period, 10 separate arteries were embolized, for which additional TAE was found to be necessary by means of arteriography with and/or without use of CT scans obtained during infusion of contrast agents via the port catheter.


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  		TABLE 2. Embolization of Arterial Branches

 
Details of 10 newly embolized arteries are provided here. Three branches of the pancreaticoduodenal arcade, such as the dorsal pancreatic artery, had newly developed in two patients, and one retroportal artery that arose from the superior mesenteric artery had newly developed in a third patient. Although they were not detected at the first procedure, they potentially could have existed at that time. One right gastric artery could not be embolized at the first attempt. Five right inferior phrenic arteries were suspected of supplying blood to the posterior segment of the liver (ie, segments VI and VII according to Couinaud segmental nomenclature) by means of follow-up CT arteriography performed during infusion of contrast agents via the port catheter. This suspicion was confirmed by means of right inferior phrenic arteriography.

Vortx-Diamond (Boston Scientific, Watertown, Mass) or Trufill (Cordis, Miami, Fla) microcoils were used. In four replaced right hepatic arteries, nine Vortx-35 (0.035-inch) stainless steel coils (Boston Scientific) were used. In one case, Liquid Coil-18 (Boston Scientific) was used in the right inferior phrenic artery. The numbers of coils used (mean ± SD) are shown in Table 3. The ratio of NBCA to iodized oil was 1:3–4 in the right inferior phrenic artery and 1:1–2 in the other arteries.


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  		TABLE 3. Number of Coils Used

 
Of the 336 arterial branches that were embolized successfully, nine (2.7%) were recanalized. Of 192 arteries embolized with coils alone, eight (4.2%) were recanalized, while only one (0.7%) of 144 arteries embolized with the NBCA–iodized oil mixture alone or with the coils were recanalized. The former rate was significantly higher than the latter rate according to the results of the Fisher exact probability test (P = .048). The artery that was recanalized with NBCA after TAE was the gastroduodenal artery, which had been embolized with six microcoils and NBCA.

As shown in Table 4, additional TAE was performed in eight of nine recanalized arterial branches. In six of these arteries, recanalization was considered to interfere with continuation of HAIC. One gastroduodenal artery and one branch of the pancreaticoduodenal arcade were reembolized to prevent gastroduodenal mucosal lesions and damage to the pancreas in the event of intraarterial infusion of chemotherapeutic agents to adjacent organs supplied by the common hepatic artery.


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  		TABLE 4. Recanalized Arteries after Port Catheter Placement and Management Thereafter

 
Prevention of Gastrointestinal Symptoms after HAIC
Pancreatitis was not a complication in any patient. Gastrointestinal symptoms developed acutely after HAIC in seven (5.5%) of the 128 patients. Gastric mucosal lesions were shown at endoscopy in five patients. Three were among the seven patients (42.9%) in whom TAE of the right gastric artery could not be accomplished. HAIC was abandoned in two patients because of severe gastric mucosal lesions, but in one patient, embolization of the right gastric artery that could not be accomplished in the first trial was successful in the second, and HAIC was resumed. In the remaining two of those five patients, both gastric ulcer and gastritis occurred. Arteriography performed while contrast material was infused via the port catheter showed recanalization of the right gastric artery in one of these patients; in the other patient, the right gastric artery was embolized sufficiently. In both cases, HAIC was withdrawn, and the gastric ulcers were treated. In addition, in the patient whose right gastric artery was recanalized, additional TAE was performed. After an interval, HAIC was resumed.

In the two patients with duodenal mucosal lesions, new development and/or recanalization of branches of the pancreaticoduodenal arcade were shown at arteriography, all of which were embolized and resulted in resumption of HAIC. Figure 3 shows results of arteriography in one of these patients.

Distribution of Contrast Agents in the Liver
In all cases, all branches of the hepatic arteries or all branches that supplied blood to the segments that included tumors in categories 4, 6, and 8 beyond the proper hepatic artery were well visualized at arteriography, which was performed after contrast material was infused via the port catheter just after placement and which demonstrated success of the procedure.

As shown in Table 5, however, contrast agents were distributed poorly in part of the liver in 16 patients, although no hepatic arterial obstruction or catheter dislocation was noticed with the imaging techniques described above. Such poor distribution was found in 10 patients during the first imaging session, which was performed 2–10 days after implantation, and in six patients during follow-up arteriography with or without the use of CT, which was performed every 1 to 3 months after implantation.


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  		TABLE 5. Patients with Heterogeneously Poor Distribution of Contrast Agent Infused in the Liver via the Port

 
In seven (41.2%) of the 17 patients with two or more hepatic arteries that had been converted into one at the time of catheter placement, heterogeneously poor distribution of contrast material was seen at imaging. However, this event occurred in only nine (8.1%) of 111 patients with a single hepatic artery. This rate was significantly higher in the cohort with two or more hepatic arteries (P = .001, Fisher exact probability test).

In seven of 12 patients in whom poor distribution of contrast material was limited to the posterior segment (ie, segments VI and VII) of the liver, the tumor was not located in that segment, making correction unnecessary. On the other hand, in the five patients with tumors in the posterior segment, TAE of the right inferior phrenic artery enabled distribution to the entire liver (Fig 4). In two of the three patients with poor distribution in the right lobe (segments V–VIII) of the liver, the heterogeneous distribution was caused by recanalization of the embolized replaced right hepatic artery (Fig 5). In the remaining patient, the heterogeneous distribution was caused by development of a retroportal artery that arose from the superior mesenteric artery, which had not been visualized at port catheter placement (Fig 2).

With additional embolization of the replaced right hepatic artery or new embolization of the retroportal artery, good distribution of contrast material in the entire liver was achieved. In one of the two patients with three hepatic arteries for whom TAE of the replaced right and left hepatic arteries was performed, poor distribution of contrast agents was detected in the lateral and posterior segments (segments II, III, VI, VII) of the liver. Because the main tumor existed in the anterior and medial segment of the liver area, repeat HAIC via the port catheter continued without correction of heterogeneous distribution.

Other Complications
With regard to complications correlated with the indwelling port catheter but not directly with TAE (Table 6), hepatic arterial obstruction occurred during the follow-up period in nine (6.8%) of 132 procedures (proper hepatic artery, n = 6; right hepatic artery, n = 2; left hepatic artery, n = 1). In one patient with left hepatic arterial obstruction, distribution to tumors in the entire liver was sufficiently maintained through intrahepatic collateral vessels; thus, HAIC was continued without any therapy. The hepatic artery was recanalized successfully by infusing thrombolytics via the port catheter, and HAIC was continued in three cases. In one patient with partial hepatic arterial obstruction, HAIC was continued because the main tumors existed in the area that was supplied by the patent hepatic artery. In the remaining four patients, HAIC with use of the port catheter system was discontinued.


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  		TABLE 6. Characteristics of Patients with Complications Related to Placement of Port Catheter System but Not Directly Related to TAE

 
Catheter dislocation was seen in five (3.8%) of 132 procedures. In two procedures, HAIC was continued after correction of the dislocation by performing a relatively easy interventional procedure (8). In one procedure, a new port catheter system was inserted, and HAIC was continued (Fig 2). HAIC was withdrawn in the remaining two procedures.

Infection from the port catheter system occurred in one patient. After the implanted port catheter system was removed and antibiotics were administered, another port catheter system was inserted, and HAIC was restarted. In the patient in whom the distal site of the implanted catheter was broken in the subcutaneous space and in the patient in whom the catheter lumen was obstructed due to coagulation, the first port catheter system was removed and replaced, resulting in the successful continuation of HAIC.

Brain infarction, which was suspected but not confirmed to be related to catheter placement, occurred in three patients in whom the catheter was inserted via the left subclavian artery. In all such patients, conservative treatment that included the use of anticoagulant medication was effective.

HAIC Overall Success
As of March 2002, 44 of the 128 patients had died; the survival period after port catheter system placement ranged from 2 to 44 months (mean, 17.3 months). The 84 surviving patients were observed from 3 to 47 months (mean, 14.7 months) from the time of placement. Until the time of patient death or the most recent observation, repeat HAIC via the port catheter could be performed almost completely as scheduled in 119 (93.0%) of 128 patients while adhering to the following requirements. Infused drugs were distributed (which was simulated by the use of contrast agents) to all liver tumors through a single hepatic artery into which the indwelling catheter was inserted, and no severe symptoms were induced by inflow of anticancer drugs into adjacent organs. Among these patients, 17 experienced complications or difficulties that interfered with HAIC, but these were corrected with various interventional procedures, including TAE with coils and an NBCA–iodized oil mixture. Specifically, these measures were undertaken to prevent distribution of anticancer agents into adjacent organs in eight patients, to prevent heterogeneous distribution in the liver in eight, and to correct complications related to port catheter placement in seven. These measures were applied in four patients for two purposes and in one patient for all three purposes. HAIC was continued in two patients, although anticancer drugs did not distribute to all liver tumors. As a result, in only seven (5.5%) of 128 patients, scheduled HAIC was incomplete because of complications or difficulties that occurred in the port catheter system: two because of a severe gastric mucosal lesion induced by HAIC and five because of complications related to port catheter system placement, as shown in Table 6.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
Among various methods for percutaneous implantation of a port catheter system for repeat HAIC (7–19), implantation with the fixed catheter tip technique (7,8,16–19) is advantageous, especially from the standpoint of preventing catheter dislocation and hepatic arterial occlusion caused by mechanical stimulation of the vascular wall of the common or proper hepatic artery by movement of the catheter tip. According to a review of large published studies of percutaneous port catheter placement (9–14), catheter dislocation and hepatic arterial obstruction occur at rates ranging from 5.6%–43.8% and 0%–22.2%, respectively. In comparison, previous reports involving use of the fixed catheter tip technique showed lower rates: 2.2%–4.4% (8,17,18) for catheter dislocation and 5.4% (17) for hepatic arterial obstruction (3.8% and 6.8%, respectively, in the present study).

The fixed catheter tip technique involving the gastroduodenal artery, which we employed most commonly, has another advantage in that reactive gastroduodenal mucosal lesions and/or damage to the pancreas caused by the intraarterial infusion of chemotherapeutic agents to adjacent organs supplied from the common hepatic artery can be prevented by means of embolization of the gastroduodenal artery during placement of the indwelling catheter. By performing additional TAE of small branches of the pancreaticoduodenal arcade and the gastric arteries, damage to the adjacent organs, including the stomach, can be further prevented.

Gastrointestinal mucosal lesions that might interfere with continuation of HAIC, which are caused by distribution of chemotherapeutic agents into adjacent organs through arterial branches originating from the common hepatic artery, have been reported to occur in 3.2%–47.5% of patients without embolization of arteries that supply adjacent organs (20–23). Thus, we planned strategies to embolize such arteries aggressively. As a result, only two (1.6%) of 128 patients discontinued scheduled HAIC because of gastrointestinal mucosal lesions. Previous reports have also described the efficacy of selective TAE for arteries that supply blood to extrahepatic adjacent organs to avoid reactive gastric or duodenal mucosal lesions resulting from infusion of chemotherapeutic agents into these organs (7,16,20,24,25). Inaba et al (25) reviewed 217 patients who underwent repeat HAIC and found that only five (2.6%) of 192 patients in whom the right gastric artery was sufficiently embolized before long-term HAIC developed gastric mucosal lesions, whereas nine (36.0%) of 25 patients without sufficient embolization developed such lesions.

It is also important to maintain good distribution of anticancer drugs over the entire liver (7). Two elements may contribute to the heterogeneous distribution of drugs in the liver: the existence of two or more arteries (7,26) and inflow of parasitic blood supply into the liver (7,27).

In general, only one implanted catheter is used. Hence, in patients with two or more hepatic arteries, attempts should be made to convert multiple arteries into a single hepatic artery (7,26). Our success in obtaining such good distribution with a single indwelling catheter in 16 of 17 patients with two or more hepatic arteries indicates the necessity and effectiveness of embolization to convert multiple hepatic arteries into one for long-term HAIC. We did note a poorly enhanced area in the posterior segment (ie, segments VI and VII) caused by inflow from the right inferior phrenic artery into this area in some of the 16 cases, but the area was small.

Poor distribution of anticancer drugs in part of the liver via the port catheter, which is caused by inflow from a parasitic artery, is also a problem in performance of repeat HAIC (7,27). The most common source of parasitic blood supply is the right inferior phrenic artery (27). This artery is known to potentially communicate with the intrahepatic artery in the posterior segment (27,28). Thus, if there is an imbalance of blood flow between the intrahepatic artery and right inferior phrenic artery and a decrease in blood flow through the intrahepatic artery, blood from the right inferior phrenic artery would enter the posterior segment of the liver easily. Then, tumors existing at the posterior segment would receive blood supply more predominantly from the right inferior phrenic artery than from the intrahepatic artery. Hence, we aggressively embolized the right inferior phrenic artery when images showed such a situation either at the time of port catheter placement or thereafter. The result was good distribution of contrast agent infused via the port catheter and through the intrahepatic artery over all tumors in the entire liver in all but one patient.

A poorly enhanced area was observed significantly more frequently in patients with two or more hepatic arteries (all having a replaced right hepatic artery) in whom embolization was performed to converge multiple hepatic arteries into a single vascular supply than in patients who originally had a single hepatic artery. These results show that even after redistribution of multiple hepatic arteries into one, physiologic communication remains between intra- and extrahepatic arteries or between replaced (right and/or left) hepatic arteries and other arteries that arise normally. Hence, especially in patients with two or more hepatic arteries, distribution in the liver should be monitored not only immediately after port catheter placement but also periodically thereafter.

In the present study, nine (2.7%) of 336 embolized arteries recanalized. This low rate might be largely attributed to the aggressive use of an NBCA–iodized oil mixture as the embolic agent, which was used to embolize 144 (42.9%) arteries. The fact that only one (0.7%) of 144 arteries recanalized in which TAE was performed with single or combined use of NBCA supports this strategy. NBCA–iodized oil is also useful in embolization of long segmental arteries in a cast, as indicated by the 14 right inferior phrenic arteries embolized successfully with the single use of NBCA–iodized oil mixture without recanalization.

This is a nonprospective, nonrandomized, and observational study. Hence, the limitation lies mainly in lack of a control population (ie, patients receiving HAIC without TAE), which resulted from HAIC procedures at our institution. Here, the fixed catheter tip technique has been exclusively used in port catheter placement with the combination of closely planned TAE of various splanchnic arteries, as described in this report. However, we believe that our study is important for interventional radiologists in the hepatobiliary field because some of the information presented here has never or seldom been seen, to our knowledge. We are aware of no reports in the English language of studies that include a large number of subjects, as in our study, that deal with TAE of various splanchnic arteries performed so aggressively with comprehensive management strategies. Also, there are few or no reports on the effectiveness of embolization for hepatic arterial redistribution in patients with multiple hepatic arteries or parasitic arteries with hepatopetal flow (26), especially studies of arteriography with helical CT performed to elucidate the effect of such redistribution. In addition, such information on NBCA used in the splanchnic arteries as evaluated in this report has been very scant.

We want to reiterate that efficient performance of long-term HAIC requires not only a technique to implant the port catheter system precisely but also careful planning to maintain good distribution of anticancer drugs in the entire tumor-bearing region of the liver through a single route without distribution into adjacent organs, with the assistance of TAE performed in various splanchnic arterial branches. Moreover, difficulties or complications that interfere with continuation of HAIC can be corrected through various interventional radiologic procedures that principally include TAE. Additionally, use of NBCA as an embolic agent is useful to improve the quality of embolization.


   FOOTNOTES
 
Abbreviations: HAIC = hepatic arterial infusion chemotherapy, NBCA = n-butyl cyanoacrylate, TAE = transcatheter arterial embolization

Author contributions: Guarantors of integrity of entire study, T.Y., T.N.; study concepts, T.Y., T.K., T.N.; study design, T.Y., O.T.; literature research, T.Y., T.K.; clinical studies, T.Y., T.K., S.I., O.T.; data acquisition, T.Y., T.K., S.I.; data analysis/interpretation, T.Y., S.I., O.T.; statistical analysis, T.Y., T.N.; manuscript preparation, T.Y.; manuscript definition of intellectual content and editing, T.Y., T.K., T.N.; manuscript revision/review, all authors; manuscript final version approval, T.Y., T.N.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 

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