Extrahepatic Perfusion Research Articles

Indocyanine green fluorescence perfusion testing in robot-assisted hepatic arterial infusion pump placement

BackgroundHepatic arterial infusion pump (HAIP) treatment is a technique used to treat liver localized malignancy with intra-arterial chemotherapy. Methylene blue is generally administered to verify hepatic perfusion and exclude inadvertent extrahepatic perfusion. The use of indocyanine green dye (ICG) combined with near-infrared (NIR) fluorescence imaging during robot-assisted HAIP placement may be an attractive alternative by providing high contrast without blue discoloration of the operative field.MethodsData was collected retrospectively from 2 centers in the Netherlands. Intraoperative perfusion of the liver segments and extrahepatic perfusion were assessed using ICG/NIR as well as methylene blue on video imaging and correlated to postoperative 99 m-Tc perfusion scintigraphy.Results13 patients underwent robot-assisted surgery for HAIP placement; median length of stay was 4 days, complications occurred in 4 patients. Hepatic perfusion showed identical patterns when ICG was compared with methylene blue. In 1 patient, additional extrahepatic perfusion was found using ICG, leading to further vessel ligation. Intraoperative ICG perfusion was concordant with 99 m-Tc perfusion scintigraphy.DiscussionLiver and extrahepatic perfusion determined by ICG fluorescence imaging is concordant with blue dye perfusion and 99 m-Tc perfusion scintigraphy. Therefore, ICG fluorescence imaging is deemed a safe and reliable technique for perfusion testing during robot-assisted HAIP placement.Graphical abstract

Planning Angiography for 90 Y-Radioembolization Demonstrates a Variety of Unusual Extrahepatic Perfusion Patterns.

In preparation for 90 Y radioembolization for hepatic malignancies, hepatic angiography is performed with intra-arterial delivery of 99m Tc-macroaggregated albumin (MAA), known as premapping. This initial procedure allows for evaluation of standard/variant hepatic arterial anatomy using MAA as a surrogate marker for the delivery of 90 Y to visualize the likely distribution of 90 Y. Premapping allows for the assessment of at-risk extrahepatic targets and for the quantification of hepatopulmonary shunting. We present cases where MAA scintigraphic images reveal unusual perfusion patterns in hepatic cancers, treated with 90 Y glass microspheres (Therasphere; Boston Scientific, Marlborough, MA).

Extrahepatic perfusion and incomplete hepatic perfusion after hepatic arterial infusion pump implantation: incidence and clinical implications

IntroductionThis study investigates the incidence of extrahepatic perfusion and incomplete hepatic perfusion at intraoperative methylene blue testing and on postoperative nuclear imaging in patients undergoing hepatic arterial infusion pump (HAIP) chemotherapy. MethodsThe first 150 consecutive patients who underwent pump implantation in the Netherlands were included. All patients underwent surgical pump implantation with the catheter in the gastroduodenal artery. All patients underwent intraoperative methylene blue testing and postoperative nuclear imaging (99mTc-Macroaggregated albumin SPECT/CT) to determine perfusion via the pump. ResultsPatients were included between January-2018 and December-2021 across eight centers. During methylene blue testing, 29.3% had extrahepatic perfusion, all successfully managed intraoperatively. On nuclear imaging, no clinically relevant extrahepatic perfusion was detected (0%, 95%CI: 0.0–2.5%). During methylene blue testing, 2.0% had unresolved incomplete hepatic perfusion. On postoperative nuclear imaging, 8.1% had incomplete hepatic perfusion, leading to embolization in only 1.3%. ConclusionMethylene blue testing during pump placement for intra-arterial chemotherapy identified extrahepatic perfusion in 29.3% of patients, but could be resolved intraoperatively in all patients. Postoperative nuclear imaging found no clinically relevant extrahepatic perfusion and led to embolization in only 1.3% of patients. The role of routine nuclear imaging after HAIP implantation should be studied in a larger cohort.

Starting a successful hepatic artery infusion pump program: A practical guide

Implementation of a successful hepatic artery infusion pump program requires numerous factors to be in place, and the lack of any of these may lead to program failure. First and foremost, hepatic artery infusion pump programs must have adequate surgical expertise in the complex technical aspects of hepatic artery infusion pump implantation and postoperative management. Most new hepatic artery infusion pump programs are initiated by a surgeon and led in conjunction with a medical oncologist. Medical oncology experience in floxuridine dosing is critical in maximizing the treatment doses and the number of cycles administered while avoiding biliary toxicity. This is facilitated by collaboration with an engaged pharmacy team. To have adequate patient volume for a successful program, internal and external stakeholders must have buy-in, including surgical and medical oncology colleagues unfamiliar with hepatic artery infusion pumps, colorectal surgery, and other referring providers. Programmatic support must be obtained from the hospital, cancer center, and department administration. Day-to-day pump access for chemotherapy and maintenance saline fills must be performed by appropriately trained infusion nurses to avoid complications. Nuclear and diagnostic radiology experience is key to identifying extrahepatic perfusion and hepatic artery infusion pump–specific complications. Additionally, skilled interventional radiologists and gastroenterologists are necessary to identify and treat rare complications rapidly. Finally, given the current rapid expansion of hepatic artery infusion pump programs, new programs must identify engaged mentors to help guide patient selection, navigate the nuanced issues that may arise, and provide advice in the case of complications. Although hepatic artery infusion pump dissemination outside of several major tertiary centers previously had stalled, establishing a successful and active hepatic artery infusion pump is feasible with appropriate training, mentorship, and thoughtful assembly of a dedicated multidisciplinary team.

Indocyanine green intraop hepatic artery infusion pump perfusion test offers potential advantages

Background: Hepatic artery infusion (HAI) pumps are utilized in the multimodality treatment of advanced colorectal liver metastases (CRLM) and intra-hepatic cholangiocarcinoma. During surgical implantation, dye is routinely administered into the gastroduodenal artery (GDA) catheter to confirm appropriate hepatic perfusion and a lack of extrahepatic perfusion. The historical standard of care has been administration of methylene blue dye through the catheter. There are potential advantages to other dyes, however, and our center favors indocyanine green (ICG) for this purpose. The video demonstrates multiple surgical cases demonstrating the utility of this approach intraoperatively.

S2856 Poke the Bear and Get the Claws: Life-Threatening Bleeding by Hepatic Artery Infusion Pump Fistula Managed by Over the Scope Clip Closure

Introduction: Hepatic artery infusion (HAI) pumps may be used for regional delivery of chemotherapy for treatment of colorectal cancer liver metastases. Complications are rare, but can include arterial thrombus and catheter dislocation. We present a case of duodenal fistula associated with hepatic artery infusion pump and subsequent closure with over the scope clip. Case Description/Methods: We present the case of a 57-year-old male with stage IV colon adenocarcinoma and liver metastasis who underwent placement of hepatic artery infusion (HAI) pump for local chemotherapy. 6 months later, he presented with 3 days of melena and fatigue with vitals demonstrating heart rate 129 bpm and blood pressure was 111/69 mmHg. Notably, hemoglobin was 9.1 g/dL, down from a baseline of 14.4 g/dL. He was admitted to the surgical oncology service and gastroenterology was consulted for suspected upper GI bleed. Esophagogastroduodenoscopy (EGD) performed the day after admission revealed suspected fistula in the duodenal bulb. Bleeding resolved with proton pump inhibitor therapy alone with plan for outpatient repeat endoscopy. 1 month later the patient presented with anemia, melena and acute blood loss. Repeat EGD demonstrated a bleeding duodenal bulb lesion and hemostasis was achieved by placement of a 12/6t over the scope clip placement. Subsequent CTA scan identified the hepatic artery infusion pump tip adjacent to over the scope clip in the proximal duodenum with no extravasation suggesting resolution of bleeding after clip placement. (Figure) Discussion: We present a rare case of duodenal bleeding due to hepatic artery infusion catheter tip dislocation. A large single center experience of 544 patients over a 15-year period demonstrated the most common complications from HAI to include arterial thrombosis (6%), catheter occlusion/dislodgement (6%) and extrahepatic perfusion (3%)1. Furthermore, literature search for cases from 1975-2022 reveals fewer than 10 cases with this bleeding complication. In this case we demonstrate the successful use of an OTSC to manage bleeding associated from the fistula created by the infusion pump catheter between hepatic artery and duodenal bulb.Figure 1.: A: Index endoscopy showing fistula in the bulb of the duodenum. B: Subsequent endoscopy with bleeding fistula. C: Fistula closure and successful hemostasis with over the scope clip. D: CT scan showing clip with close approximation to the hepatic artery infusion catheter tip.

Implementation of a Hepatic Artery Infusion Program: Initial Patient Selection and Perioperative Outcomes of Concurrent Hepatic Artery Infusion and Systemic Chemotherapy for Colorectal Liver Metastases.

Hepatic artery infusion (HAI) combined with systemic chemotherapy is a treatment strategy for patients with unresectable liver-only or liver-dominant colorectal liver metastases (CRLM). Although HAI has previously been performed in only a few centers, this study aimed to describe patient selection and initial perioperative outcomes during implementation of a new HAI program. The study enrolled patients with CRLM selected for HAI after multi-disciplinary review November 2018-January 2020. Demographics, prior treatment, and perioperative outcomes were assessed. Objective hepatic response was calculated according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1. During a 14-month period, 21 patients with CRLM underwent HAI pump placement. Of these 21 patients, 20 (95%) had unresectable disease. Most of the patients had synchronous disease (n = 18, 86%) and had received prior chemotherapy (n = 20, 95%) with extended treatment cycles (median 16; interquartile range, 8-22; range, 0-66). The median number of CRLMs was 7 (range, 2-40). Operations often were performed with combined hepatectomy (n = 4, 19%) and/or colectomy/proctectomy (n = 11, 52%). The study had no 90-day mortality. The overall surgical morbidity was 19%. The HAI-specific complications included pump pocket seroma (n = 2), hematoma (n = 1), surgical-site infection (n = 1), and extrahepatic perfusion (n = 1). HAI was initiated in 20 patients (95%). The hepatic response rates at 3months included partial response (n = 4, 24%), stable disease (n = 9, 53%), and progression of disease (n = 4, 24%), yielding a 3-month hepatic disease control rate (DCR) of 76%. Implementation of a new HAI program is feasible, and HAI can be delivered safely to selected patients with CRLM. The initial response and DCR are promising, even for patients heavily pretreated with chemotherapy.

Is intra-arterial hepatic chemotherapy painful?

Liver metastases are mainly supplied by the hepatic artery, allowing the administration of intra-arterial hepatic chemotherapy (IAHC) while preserving normal parenchyma. The progression-free survival and response rate are prolonged by IAHC which can improve the rate of secondary resectability. Severe abdominal pain requiring high-dose opioids can appear during HIAC administration. This pain is related to extrahepatic infusion and gastroduodenal ulceration. However, intense abdominal pain was observed under oxaliplatin IAHC specifically without any extrahepatic infusion. We retrospectively reviewed the charts of 68 patients who received IAHC in our center between 2011 and 2015. Patient's demographics and disease characteristics were collected. Other variables such as the type, duration, and dosage of the chemotherapy administered, as well as the usage of painkillers before, during, or after intra-arterial administration, were also registered. The mean age of the patients was 59years. 61.7% were male (n = 42). The mean dose of oxaliplatin administered was 162mg per cure over 6.7-h course. Fifty percent were diagnosed with a left colon cancer, and 85.2% had synchronous liver metastasis. While 47% of patients received IAHC as a third-line therapy, the main chemotherapeutic drug was oxaliplatin (85.2% of cases; n = 58), then OPTILIV protocol (5FU, irinotecan, oxaliplatin) (13.3%; n = 9), and mitomycin C (1.5%; n = 1). A dose reduction of 23.6% had been noted in 58.8% (n = 40) cases due to adverse effects. Among patients who received opioids during IAHC (n = 40), 20% required opioids in intercure. Before, during, and after IAHC administration, patients complained of abdominal pain in 8.8%, 58.8%, and 19.1%, and opioids were used in 10.2%, 57.3%, and 19.1%, respectively. The main onset of pain occurs during the third cycle of chemotherapy. Among our patients, 11.7% and 22% had ulcer and extrahepatic perfusion, respectively, while 7.3% of them were asymptomatic. The mean occurrence of these signs was during the fourth cycle of IAHC. 33.8% and 52.9% of patients had abdominal pain while an extended and short infusion time, respectively. Lengthening of the infusion time did not prevent the occurrence of abdominal pain significantly but was nonetheless decreased compared with patients undergoing short infusion durations. Pain was more common in patients who did not have a dose reduction and who presented with ulcer and extrahepatic perfusion. Abdominal pain occurred on average one cycle before ulcer or extrahepatic perfusion diagnosis. In current practice, pain should be an alarming indicator in patients receiving IAHC, as it may be associated with ulcer or extrahepatic perfusion and thus requiring opioids.

Adjuvant hepatic arterial infusion pump chemotherapy after resection of colorectal liver metastases; a phase II trial

Introduction: Adjuvant hepatic arterial infusion pump (HAIP) chemotherapy demonstrated promising results with a median overall survival of 67 months (n=785) versus 44 months without HAIP (n=1.583, p<0.001) in a propensity scored analysis in patients with resectable colorectal liver metastases (CRLM).[J Clin Onc;35(17):1938] However, its general application is limited. Previous results from Memorial Sloan Kettering Cancer Center (MSKCC) should be confirmed in a randomized controlled trial (RCT) outside MSKCC. The aim of this study was to investigate the feasibility and safety of HAIP chemotherapy in a multicenter setting in the Netherlands. Materials & Methods: A phase II study was performed in two high-volume centers in the Netherlands. Patients with resectable CRLM without extrahepatic disease were eligible. All patients were scheduled for 6 cycles of adjuvant HAIP chemotherapy with floxuridine, after complete resection of CRLM with pump placement. The main endpoints were feasibility (defined as successful administration of at least one cycle of HAIP chemotherapy) and safety (defined as 90-day postoperative complications). Result(s): Twenty patients with resectable CRLM were included. The median age of patients was 57 years (range 42-75). The median clinical risk score was 2 (range 1-5). All 20 patients (100%) received at least one dose of HAIP chemotherapy at a median of 42.5 days (range 26-57) after surgery. Pump related postoperative complications occurred in 2 patients (10%); replacement of a malfunctioning pump and repositioning of a flipped (upside down) pump. No arterial hemorrhage or dissection, extrahepatic perfusion, catheter related problems, pump pocket hematoma or pump pocket infections were found within 90-days after resection and implantation. Conclusion(s): Adjuvant HAIP chemotherapy in patients with resectable CRLM is safe and feasible as demonstrated in a phase II study of 20 patients. The PUMP trial (NTR 7493) has started to investigate the effectiveness of adjuvant HAIP chemotherapy in a randomized controlled trial.

Adjuvant Hepatic Arterial Infusion Pump Chemotherapy After Resection of Colorectal Liver Metastases: Results of a Safety and Feasibility Study in The Netherlands

BackgroundThe 10-year overall survival with adjuvant hepatic arterial infusion pump (HAIP) chemotherapy after resection of colorectal liver metastases (CRLMs) was 61% in clinical trials from Memorial Sloan Kettering Cancer Center. A pilot study was performed to evaluate the safety and feasibility of adjuvant HAIP chemotherapy in patients with resectable CRLMs.Study DesignA phase II study was performed in two centers in The Netherlands. Patients with resectable CRLM without extrahepatic disease were eligible. All patients underwent complete resection and/or ablation of CRLMs and pump implantation. Safety was determined by the 90-day HAIP-related postoperative complications from the day of pump placement (Clavien–Dindo classification, grade III or higher) and feasibility by the successful administration of the first cycle of HAIP chemotherapy.ResultsA total of 20 patients, with a median age of 57 years (interquartile range [IQR] 51–64) were included. Grade III or higher HAIP-related postoperative complications were found in two patients (10%), both of whom had a reoperation (without laparotomy) to replace a pump with a slow flow rate or to reposition a flipped pump. No arterial bleeding, arterial dissection, arterial thrombosis, extrahepatic perfusion, pump pocket hematoma, or pump pocket infections were found within 90 days after surgery. After a median of 43 days (IQR 29–52) following surgery, all patients received the first dose of HAIP chemotherapy, which was completed uneventfully in all patients.ConclusionPump implantation is safe, and administration of HAIP chemotherapy is feasible, in patients with resectable CRLMs, after training of a dedicated multidisciplinary team.

Is intra-arterial hepatic chemotherapy painful?

Liver metastases are mainly supplied by the hepatic artery, allowing the administration of intra-arterial hepatic chemotherapy (IAHC) while preserving normal parenchyma. The progression-free survival and response rate are prolonged by IAHC which can improve the rate of secondary resectability. Severe abdominal pain requiring high-dose opioids can appear during HIAC administration. This pain is related to extrahepatic infusion and gastroduodenal ulceration. However, intense abdominal pain was observed under oxaliplatin IAHC specifically without any extrahepatic infusion. We retrospectively reviewed the charts of 68 patients who received IAHC in our center between 2011 and 2015. Patient’s demographics and disease characteristics were collected. Other variables such as the type, duration, and dosage of the chemotherapy administered, as well as the usage of painkillers before, during, or after intra-arterial administration, were also registered. The mean age of the patients was 59 years. 61.7% were male (n = 42). The mean dose of oxaliplatin administered was 162 mg per cure over 6.7-h course. Fifty percent were diagnosed with a left colon cancer, and 85.2% had synchronous liver metastasis. While 47% of patients received IAHC as a third-line therapy, the main chemotherapeutic drug was oxaliplatin (85.2% of cases; n = 58), then OPTILIV protocol (5FU, irinotecan, oxaliplatin) (13.3%; n = 9), and mitomycin C (1.5%; n = 1). A dose reduction of 23.6% had been noted in 58.8% (n = 40) cases due to adverse effects. Among patients who received opioids during IAHC (n = 40), 20% required opioids in intercure. Before, during, and after IAHC administration, patients complained of abdominal pain in 8.8%, 58.8%, and 19.1%, and opioids were used in 10.2%, 57.3%, and 19.1%, respectively. The main onset of pain occurs during the third cycle of chemotherapy. Among our patients, 11.7% and 22% had ulcer and extrahepatic perfusion, respectively, while 7.3% of them were asymptomatic. The mean occurrence of these signs was during the fourth cycle of IAHC. 33.8% and 52.9% of patients had abdominal pain while an extended and short infusion time, respectively. Lengthening of the infusion time did not prevent the occurrence of abdominal pain significantly but was nonetheless decreased compared with patients undergoing short infusion durations. Pain was more common in patients who did not have a dose reduction and who presented with ulcer and extrahepatic perfusion. Abdominal pain occurred on average one cycle before ulcer or extrahepatic perfusion diagnosis. In current practice, pain should be an alarming indicator in patients receiving IAHC, as it may be associated with ulcer or extrahepatic perfusion and thus requiring opioids.

Adjuvant hepatic arterial infusion pump chemotherapy and resection versus resection alone in patients with low-risk resectable colorectal liver metastases \u2013 the multicenter randomized controlled PUMP trial

BackgroundRecurrences are reported in 70% of all patients after resection of colorectal liver metastases (CRLM), in which half are confined to the liver. Adjuvant hepatic arterial infusion pump (HAIP) chemotherapy aims to reduce the risk of intrahepatic recurrence. A large retrospective propensity score analysis demonstrated that HAIP chemotherapy is particularly effective in patients with low-risk oncological features. The aim of this randomized controlled trial (RCT) --the PUMP trial-- is to investigate the efficacy of adjuvant HAIP chemotherapy in low-risk patients with resectable CRLM.MethodsThis is an open label multicenter RCT. A total of 230 patients with resectable CRLM without extrahepatic disease will be included. Only patients with a clinical risk score (CRS) of 0 to 2 are eligible, meaning: patients are allowed to have no more than two out of five poor prognostic factors (disease-free interval less than 12 months, node-positive colorectal cancer, more than 1 CRLM, largest CRLM more than 5 cm in diameter, serum Carcinoembryonic Antigen above 200 μg/L). Patients randomized to arm A undergo complete resection of CRLM without any adjuvant treatment, which is the standard of care in the Netherlands. Patients in arm B receive an implantable pump at the time of CRLM resection and start adjuvant HAIP chemotherapy 4–12 weeks after surgery, with 6 cycles of floxuridine scheduled. The primary endpoint is progression-free survival (PFS). Secondary endpoints include overall survival, hepatic PFS, safety, quality of life, and cost-effectiveness. Pharmacokinetics of intra-arterial administration of floxuridine will be investigated as well as predictive biomarkers for the efficacy of HAIP chemotherapy. In a side study, the accuracy of CT angiography will be compared to radionuclide scintigraphy to detect extrahepatic perfusion. We hypothesize that adjuvant HAIP chemotherapy leads to improved survival, improved quality of life, and a reduction of costs, compared to resection alone.DiscussionIf this PUMP trial demonstrates that adjuvant HAIP chemotherapy improves survival in low-risk patients, this treatment approach may be implemented in the standard of care of patients with resected CRLM since adjuvant systemic chemotherapy alone has not improved survival.Trial registrationThe PUMP trial is registered in the Netherlands Trial Register (NTR), number: 7493. Date of registration September 23, 2018.

04:21 PM Abstract No. 121 Quantitative and qualitative 99mTc MAA SPECT/CT imaging predicts response to therapy for patients treated with Yttrium-90 (90Y) radioembolization

Selective 90Y radioembolization therapy for hepatic malignancies involves planning angiography and 99mTc macroaggregated albumin scintigraphy (99mTc -MAA) to assess lung shunt fraction and extrahepatic perfusion. The purpose of this study is to assess the relationship between tumor MAA uptake by SPECT/CT and response following radioembolization. 22 patients with primary hepatic malignancies (non-colorectal) or hepatic colorectal metastases underwent 99mTc -MAA hepatic artery perfusion with SPECT/CT. Qualitative evaluation and quantitative evaluation with tumor to disease free liver parenchyma background ratios (TBR) of SPECT were correlated with CT response. Post-radioembolization Bremsstrahlung SPECT imaging was also performed to assess for similar correlations. The mean MAA tumor TBR in the patients that did not progress was 11.0 ±13.8 (n=14), significantly higher than the TBR of patients that progressed (2.7±1.3 (n=8) (P<0.05). The pattern of 99mTc -MAA distribution was predictive of therapy response. In all cases, intense homogeneous uptake was seen in patients who responded; absent uptake was seen in those who progressed. Uptake on post-radioembolization Bremsstrahlung SPECT did not correlate with response. Our findings suggest that the pattern of uptake on planning 99mTc -MAA imaging can predict response to subsequent radioembolization. Bremsstrahlung SPECT imaging, which is not typically performed, did not correlate with response. Evaluation of 99mTc -MAA uptake on routine pre-therapy studies could potentially serve as a critical decision node in the pre-treatment assessment of patients for radioembolization. Such analysis would extend the utility of this routine study beyond a simple assessment for extrahepatic perfusion, thereby leveraging information inherent to the scan.

03:36 PM Abstract No. 329 Feasibility of single-session in-room Yttrium-90 radioembolization (RE) diagnostic angiography and treatment

To determine the feasibility and safety of performing same day diagnostic angiography with in-room planar nuclear medicine imaging and immediate dose calculation followed by Y90 treatment A single-institution prospective IRB-approved clinical trial was performed from June 2017 to June 2018. All adult patients scheduled for Y90 resin RE for primary or metastatic tumors with less than 50% liver tumor burden were eligible for this study. All patients underwent diagnostic angiography with in-room cone-beam CT or CT angiography to confirm treatment plan volumes and assess extrahepatic perfusion at the time of 99mTc-MAA (MAA) injection. MAA was administered and in-room planar imaging with portable gamma camera (Ergo, Digirad, Poway, CA) was performed for lung shunt calculation. Dosimetry was then calculated using BSA or partition method (PM) using preprocedure cross-sectional imaging and the Y90 activity was prepared in hospital radiopharmacy. Prior to Y90 administration, all lung doses were confirmed to be less than 30 Gy per package insert. Post procedure follow up was recorded at 1, 3, 6 months. The study included 12 patients. For process optimization, the first 2 patients had in-room imaging, dose calculation and preparation without treatment. The subsequent 10 patients all received the Y90 treatment in the same single session. Seven patients had metastatic disease and 3 had primary liver malignancy. Eight patients received lobar treatments and 2 patients had 2 segmental treatments each. Median delivered activity per patient was 29.5 mCi (10-81.6). In 9 cases PM was used for dosimetry for higher calculated activity. The median shunt fraction was 2% (0.4-7.5). Median time from MAA injection to shunt calculation was 26 (18-32) minutes. Median total in-room time 143 (118-269) minutes and median procedure times were and 110 (75-225) minutes. No grade 3 or higher toxicities or GI ulcers occurred. The preprocedural plan for treatment was successfully completed in all patients without modification. In carefully selected patients, in-room diagnostic angiography, planar shunt fraction imaging and activity preparation with immediate Y90 administration is safe and feasible.

Extravasation of a percutaneous femoral hepatic infusion device.

Extravasation of a percutaneous femoral hepatic infusion device.

Angiographic identification of extrahepatic perfusion after hepatic arterial pump placement: implications for surgical prevention

BackgroundHepatic arterial infusion (HAI) chemotherapy is an effective treatment for patients with liver malignancy. Extrahepatic perfusion (EHP) after HAI pump placement requires correction prior to starting chemotherapy. The aim of this study was to define the origin of arterial branches causing EHP in order to determine if alterations in surgical technique during pump placement might prevent EHP. MethodsA prospectively maintained, single-centre HAI database was reviewed for all patients (2008–2011) with EHP. The origin of arterial branches causing EHP was classified anatomically and patient outcomes were analysed. ResultsOf the 327 patients with pumps implanted, 24 evidenced EHP. The arterial branch responsible for EHP perfused the duodenum, pancreas and/or stomach. The branch responsible for EHP arose from the proper hepatic artery (PHA), 1st, 2nd, or 3rd order hepatic artery branches in 7, 10, 5 and 2 patients, respectively. The majority of branches beyond the PHA causing EHP (13/17) originated from the right hepatic artery. In 18 patients, aberrant branches were successfully treated with embolization. ConclusionThese findings provide the anatomic basis for prevention of up to one-third of the cases of EHP intra-operatively, decreasing the number of patients who will require additional procedures for correction of EHP post-operatively.

Dual-phase CT angiography through the port-catheter system for hepatic arterial infusion chemotherapy using multislice CT: assessment of system dysfunction and impact on predicting clinical problems

Hepatic arterial infusion (HAI) chemotherapy is being explored for treatment of malignant liver tumors. Maintenance of HAI systems is important for effective treatment. To prospectively evaluate the efficacy of dual-phase CT angiography through the port-catheter system for HAI chemotherapy. This study enrolled 47 patients receiving HAI chemotherapy for malignant liver tumors who underwent dual-phase CT angiography through the port-catheter system using multislice CT. Using maximum intensity projection images reconstructed from vascular-phase CT imaging, hepatic arterial patency and catheter location were assessed. Using a combination of vascular- and perfusion-phase CT imaging, system dysfunction and clinical problems were evaluated. Dual-phase CT angiography was conducted 156 times. Stenosis and obstruction of the hepatic artery and catheter dislodgment were observed seven times in four patients and four times in three patients, respectively. Diagnostic accuracy using vascular-phase CT imaging was 100%. In addition, development of collateral blood supply to the liver and extrahepatic perfusion to the stomach were observed three times in three patients and twice in two patients, respectively. Overall, system dysfunction occurred 16 times in 12 patients, and system correction and treatment modification were required 11 times in 10 patients. In assessing system dysfunction and predicting clinical problems, the accuracy of dual-phase CT imaging was 100%. Dual-phase CT angiography through the port-catheter system is helpful for assessing catheter system dysfunction and predicting clinical problems in HAI chemotherapy.

From the Angio Suite to the γ-Camera: Vascular Mapping and 99mTc-MAA Hepatic Perfusion Imaging Before Liver Radioembolization—A Comprehensive Pictorial Review

Endovascular mapping and conjoint (99m)Tc-macroaggregated albumin ((99m)Tc-MAA) hepatic perfusion imaging provide essential information before liver radioembolization with (90)Y-loaded microspheres in patients with primary and secondary hepatic malignancies. The aims of this integrated procedure are to determine whether there is a risk for excessive shunting of (90)Y-microspheres to the lungs; to detect extrahepatic perfusion emerging from the injected vascular territory, which might lead to nontargeted radioembolization; to reveal incomplete coverage of the liver parenchyma involved by the tumor, which may be related to anatomic or acquired variants of the arterial vasculature; and to aid in calculation of the (90)Y-microsphere dose to be delivered to the liver. This pictorial essay presents an integrated comprehensive review of the anatomic, angiographic, and nuclear imaging aspects of planned liver radioembolization. The relevant anatomy of the liver, including the standard and the variant arterial vasculature, will be shown using digital subtraction angiography, SPECT/CT, contrast-enhanced CT, and anatomic illustrations. Technical details that will optimize the imaging protocols and important imaging findings will be discussed. From the angio suite to the γ-camera-the goal of this review is to help the reader better understand how the technical details of the angiographic procedure are reflected in the imaging findings of the (99m)Tc-MAA hepatic perfusion study. In addition, the reader should learn to better recognize the pertinent findings and their clinical implications. This knowledge will enable the reader to provide a more useful interpretation of this complex multidisciplinary procedure.

Percutaneous Femoral Implantation of an Arterial Port Catheter for Intraarterial Chemotherapy: Feasibility and Predictive Factors of Long-term Functionality

To evaluate the feasibility, functionality, and dysfunctions of an arterial port catheter implanted via the femoral artery. From November 2001 to May 2008, 93 consecutive patients (mean age 57 years old) with unresectable hepatic colorectal metastases were referred for intraarterial chemotherapy. The arterial port catheters were percutaneously implanted via the femoral artery. The catheter tips were placed as "free-floating" in the common hepatic artery (technique 1), "fixed" in the gastroduodenal artery (technique 2), or inserted in a segmental hepatic artery (technique 3). Embolization of the right gastric artery was always attempted. The technical success rate of the femoral approach was 94% (n = 88 of 93). Intraarterial chemotherapy (average 7.3 courses) was administered to 84 patients. Migration and occlusion of the catheters occurred in 12% (n = 10 of 84) and 11% (n = 9 of 84) of patients, and extrahepatic perfusion occurred in 30% (n = 25 of 84) of patients. Catheter migration occurred significantly more frequently with technique 1 (50%; n = 3 of 6) than with technique 2 (11%; n = 7 of 64; P = .03) or technique 3 (0%; n = 0 of 14; P = .02). Occurrence of gastroduodenal ulcerations was significantly lower (P = .01) when embolization of the right gastric artery was performed (8%; n = 4 of 48) than when it was not (28%; n = 11 of 36). The success rate of embolization of the right gastric artery significantly improved (P = .006) from the first half of patients treated to the second half, resulting in a significant (P = .02) decrease in the occurrence of ulcerations from 28% (n = 12 of 42) in the first half of patients treated to 7% (n = 3 of 42) in the second half. Percutaneous femoral placement of an arterial port catheter is highly feasible. Right gastric artery embolization and use of techniques 2 and 3 are good predictive factors for long-term functionality.

Development of New Hepaticoenteric Collateral Pathways after Hepatic Arterial Skeletonization in Preparation for Yttrium-90 Radioembolization

Development of new hepaticoenteric anastomotic vessels may occur after endovascular skeletonization of the hepatic artery. Left untreated, they can serve as pathways for nontarget radioembolization. The authors reviewed the incidence, anatomy, management, and significance of collateral vessel formation in patients undergoing radioembolization. One hundred thirty-eight treatments performed on 122 patients were reviewed. Each patient underwent a preparatory digital subtraction angiogram (DSA) and embolization of all hepaticoenteric vessels in preparation for yttrium-90 ((90)Y) administration. Successful skeletonization was verified by C-arm computed tomography (CACT) and technetium-99m macroaggregated albumin ((99m)TcMAA) scintigraphy. During the subsequent treatment session, DSA and CACT were repeated before administration of (90)Y, and the detection of extrahepatic perfusion prompted additional embolization. Forty-two patients (34.4%) undergoing 43 treatments (31.2%) required adjunctive embolization of hepaticoenteric vessels immediately before (90)Y administration. Previous scintigraphy findings showed extrahepatic perfusion in only three cases (7.1%). Vessels were identified by DSA in 54.1%, by CACT in 4.9%, or required both in 41.0%. The time interval between angiograms did not correlate with risk of requiring reembolization (P = .297). A total of 19.7% of vessels were new collateral vessels not visible during the initial angiography. Despite reembolization, three patients (7.1%) had gastric or duodenal ulceration, compared with 1.3% who never had visible collateral vessels, all of whom underwent whole-liver treatment with resin microspheres (P = .038). Development of collateral hepaticoenteric anastomoses occurs after endovascular skeletonization of the hepatic artery. Identified vessels may be managed by adjunctive embolization, but patients appear to remain at increased risk for gastrointestinal complications.