Japanese Journal of Clinical Oncology 32:68-70 (2002)
© 2002 Foundation for Promotion of Cancer Research
Occlusion of the Left Superficial Femoral Artery During Hepatic Arterial Infusion of Chemotherapy for Liver Metastases from Colon Cancer 18 Months After the Implantation of a Port System: a Case Report
1Department of Radiology and Radiation Oncology, Gunma University School of Medicine, Maebashi, Gunma and Departments of 2Radiology, 3Hepato-Gastroenterology, 4Cardiovascular Surgery and 5Surgery, Shizuoka General Hospital, Shizuoka, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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We report a case of complication of a catheter port system. A 67-year-old male who had undergone left hemicolorectomy and partial hepatectomy for liver metastases from colon cancer underwent hepatic arterial infusion (HAI) of chemotherapy by a percutaneously implanted catheter port system to prevent recurrence. Eighteen months after the implantation of a port system he complained of intermittent claudication. Intravenous digital subtraction angiography (IV-DSA) showed occlusion of the left superficial femoral artery. The catheter was removed and a femoro-popliteal bypass with an artificial graft was constructed. Thrombus was found around the indwelling catheter at the insertion site. After the operation his complaint disappeared and has been alive without recurrence for 6 years.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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Hepatic arterial infusion (HAI) of chemotherapy for liver metastases is gradually spreading as a therapeutic approach (1). This treatment increases the local drug concentration (1,2), it has a good response rate and it may prolong the survival of colorectal cancer patients (1–4).
The catheter port system is introduced by means of operation or angiography. Complications with these systems are many and various, including port-related, catheter-related, thrombosis, drug toxicity to the liver and infection (5–7). Recently, the frequency of device-related complications has decreased because the device system has been improved. A common type of thrombotic complication is occlusion of the catheter and the hepatic artery (6–10). Occlusion of the conduit artery is not a major problem in recent reports (2,6–10).
We report a rare case of occlusion of the left superficial femoral artery at the insertion site of an implanted catheter port system.
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CASE REPORT |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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A 67-year-old male underwent left hemicolorectomy and right lobectomy of the liver for colon cancer and liver metastases at the same time. He had been medicated for hypertension and brain infarction without anticoagulant agents. Slight left hemiplegia remained after the infarction attack. Eight months after the resection new metastases were found in the remnant liver and he was operated on again. To prevent recurrence of liver metastasis, a percutaneously implanted catheter port system was inserted. The catheters and port were commercially available and coated with anticoagulant. Under local anesthesia the left femoral artery was punctured by the Seldinger technique. In our hospital, puncture of the right femoral artery is generally avoided because if catheter problems arise, the technique of repair by the right femoral artery was easier than by the left. A lead catheter was introduced into the gastroduodenal artery (GDA). Passing over a guide wire, the indwelling catheter (5F-Anthron P-U catheter; Toray Medical, Tokyo, Japan) with a side hole 5 cm from the tip was placed in the GDA. Contrast medium was injected to confirm that the whole liver received its blood supply from the side hole. The tip was fixed and occluded with a few platinum coils by means of a coaxial catheter (Fig. 1). Branches to the stomach, duodenum and pancreas were occluded with platinum coils. A subcutaneous pocket where a reservoir port was inserted was formed on the surface over the groin. The catheter was cut off distally and connected to the port (Snap-Lock MacroPort Arterial Access System, Strato/Infusaid, Norwood MA, USA). No kinking of the catheter at the insertion site was found. HAI of chemotherapy was applied weekly. The chemotherapy regimen consisted of 5-FU (1000 mg/body/5 h). Seventeen months later the catheter tip was dislocated and flow to the splenic artery was revealed. The therapy was interrupted and the catheter remained in position. There were no radiographic signs or symptoms of kink in the catheter at that time. During the therapy no other problem with the port system was evident. Anticoagulant drugs were not administered after the end of the therapy.
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Eighteen months after the beginning of the treatment he complained of intermittent claudication and pain in his left leg. His left popliteal and dorsalis pedis arteries were not palpable. His laboratory findings on coagulation were almost in the normal range. He was immediately admitted to our hospital again and underwent IV-DSA. The left superficial femoral artery was occluded at the insertion site (Figs 2 and 3). Collateral vessels developed around it. The left popliteal artery appeared by contrast medium through collateral vessels from the left profundus femoral artery. Under lumbar anesthesia the catheter was removed and a femoro-popliteal bypass with an artificial graft was constructed. There was old thrombus around the catheter at the insertion site and the superficial left femoral artery was occluded from the orifice by the thrombus. The catheter had not migrated and was not kinked in the subcutaneous tissue and/or at the insertion site. Immediately after the operation his complaint disappeared. He received anticoagulant therapy. There has been no recurrence of the remnant liver after 6 years.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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Major thrombotic complications of HAI of chemotherapy are occlusion of the catheter and visceral arteries (5–7,9). The occlusion of the artery at the insertion site of the catheter is a rare case. In this case the catheter had not migrated and was not kinked in the subcutaneous tissue and/or at the insertion site. We speculate that one of the causes of this complication is the duration of the therapy. The catheter remained in position for 18 months. The overall rate of thrombotic complications was 0.06 per 100 days, of infectious complications 0.03 per 100 days and of catheter-related complications 0.14 per 100 days (11). We suppose that the longer the catheter remains, the more complications are likely to occur. Furthermore, we left the disused catheter after the interruption of HAI. In some reports the catheter was removed after therapy (6,7,11). However, it has been reported that a cerebellar embolism occurred just after removal of a catheter from the thoracoacromial artery (12). Removal of a catheter requires discretion. It might be necessary to administer anticoagulant agents during insertion of a catheter or before removal.
As other causes of this complication, it is speculated that this case had potentially high coagulation activity related to the past history of hypertension and brain infarction. It seems that mechanical stimulation to the intima with the catheter caused hypercoagulation. In addition, this case had a slight left hemiplegia which might have affected the circulation of the blood in the left leg. In most patients with cancer, abnormalities of the coagulation system have been reported. Activation of the coagulation system is commonly found (13). It has been reported that arterial thrombosis was observed around the indwelling catheter in a patient with Buerger disease (11). It seems better that these patients receive anticoagulant therapy during HAI.
HAI of chemotherapy for metastatic liver tumor to avoid complications is most important, because now it is almost palliative treatment for patients with limited survival. The complications adversely affect their quality of life.
HAI of chemotherapy has been achieved via the gastroduodenal artery by laparotomy and via a branch of the femoral artery or the left subclavian artery by percutaneous incision (1,6,7). Surgery has commonly been used. However, compared with surgery, angiographic implantation is a quick and simple procedure that does not require general anesthesia and can be performed in the outpatient department (6). The method protects the strength of a patient better than operation and causes fewer complications than laparotomy (6). Approach via a branch of the femoral artery is safe and easy. The superficial femoral artery allows easy palpation and puncture, even in obese patients. Insertion of the catheter needs no guidance. Placement of a catheter port system on the anterior surface of the thigh below the groin seems to be well accepted, even in very active patients (6). In this case the port was placed over the groin and the patient had no complaint about the placement. Additionally in such cases of thrombi at the insertion site as in this case, this approach minimizes fatal vascular complications. There has been a report of five cases concerning cerebral and/or cerebellar embolism after insertion of a heparin-coated catheter from the left thoracoacromial artery for liver metastases (12). In this case the visceral artery was not occluded. To put the catheter tip in the GDA is better than in other places with regard to patency of the hepatic artery. Interruption of therapy caused by dislocation of the catheter occurs less than with other methods (14). We suggest that percutaneous implantation of a catheter port system via the femoral artery is well accepted from the point of view of safety, feasibility and tolerance of patients and that to fix the catheter tip in the GDA is the best method with regard to patency of the hepatic artery.
There have been some studies regarding the benefit of HAI of chemotherapy for liver metastases from colorectal cancer (1–4). Also, there are various results of studies on prophylactic HAI plus systemic chemotherapy after resection of liver metastases (1,4,15). This case showed no recurrence during 6 years without systemic chemotherapy. To establish HAI of chemotherapy for colorectal cancer requires further studies.
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FOOTNOTES |
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+ For reprints and all correspondence: Reiko Imai, Department of Radiology and Radiation Oncology, Gunma University School of Medicine, 3–39–22 Showa-Machi, Maebashi, Gunma 371-8511, Japan. E-mail: r_imai@nirs.go.jp
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REFERENCES |
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Received May 22, 2001; accepted November 5, 2001.
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