Type III Endoleak Caused by Fabric Tear of a Zenith Endograft after Low-pressure Balloon Modeling

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ulcer, along with oozing blood. Thereafter, the perforated area became infected, and the resulting sepsis caused the patient to deteriorate. The catheter was not surgically removed because the patient had the conditions of sepsis, liver cirrhosis, and postoperative status of partial gastrectomy with Billroth-II reconstruction. No attempt to remove the catheter was planned until his condition improved. However, he died of massive hemorrhage 11 days after the catheter perforation was recognized endoscopically. There are several complications related to hepatic arterial infusion chemotherapy such as catheter occlusion, hepatic arterial occlusion, catheter dislocation, and vascular injury, but duodenal perforation caused by an indwelling catheter is extremely rare (1– 4). Some authors have reported cases in which a surgically placed indwelling catheter perforated the duodenum (5–7). However, to our knowledge, few cases have been reported about duodenal perforation caused by an indwelling catheter implanted by Seldinger’s femoral approach. The process of catheter penetration into the duodenum in our case may have been as follows: the indwelling catheter tip was unstable in CHA and its migration was easy. The catheter tip mechanically stimulated the arterial intima, and the anticancer drug flowing from the tip further damaged the artery. The catheter gradually put pressure on the injured arterial wall and finally penetrated the duodenal wall into its lumen. Surgical removal of the catheter was necessary to prevent bleeding and improve the patient’s status. However, this removal was thought to be very difficult, because he had undergone a partial gastrectomy, as well as risky, because of his sepsis and liver cirrhosis. It was also impossible to remove the catheter with an angiographic technique. Weese et al (8) successfully removed a hepatic arterial infusion catheter from a duodenal ulcer by an endoscopic technique. However, the catheter was surgically advanced into the infraduodenal portion of the gastroduodenal artery, not through the CHA, and the port was placed in the abdominal wall nearby. These situations were far different from our case, in which the catheter was advanced into the CHA through the abdominal aorta via the right femoral artery, so the course of treatment was also different. It is important to know that duodenal perforation caused by an indwelling catheter is a very rare but critical complication of hepatic arterial infusion chemotherapy. When it is caused by a transfemoral approach, no treatment is available.