Percutaneous implantation of intra-arterial port system for regional drug infusion: Results and complications in 110 cases

PURPOSE: To investigate the feasibility and complications of a percutaneously implantable port system for regional drug infusion. MATERIALS AND METHODS: For intra-arterial drug infusion, a 5.8 or 5-F pediatric venous port system was implanted in 110 patients with hepatocelluar carcinoma (n = 79), liver metastasis (n = 16), gallbladder cancer (n = 4), stomach cancer (n = 3), pancreatic cancer (n = 3), Burger's disease (n = 2), diabetes mellitus (n = 2), or lymphoma (n = 1). All intra-arterial port implantations were performed percutaneously in an angiographic ward through the common femoral artery (n = 98), left subclavian artery (n = 10), or left superficial femoral artery (n = 2). Complications were evaluated during the follow-up period, which ranged from 21 to 530 (mean, 163) RESULTS: The technical success rate for percutaneous implantation of the system was 97.3% (107 of 110 patients). The tips of the port catheter were located in the common hepatic artery (n = 34), proper hepatic artery (n = 49), right hepatic artery (n = 8), left hepatic artery (n = 1), descending aorta at T9 level (n = 10), left popliteal artery (n = 2), right external iliac artery (n = 1), left external iliac artery (n = 1), or left deep femoral artery (n = 1). Complications were encountered in 24 patients(22.4%), namely chamber site infection (n = 7), catheter dislodgement (n = 7), catheter occlusion (n = 3), migration of coil (n = 2), disconnection between chamber and catheter (n = 1), kinking of catheter (n = 1), arterial occlusion (n = 1), necrosis of overlying skin (n = 1), and leakage around port chamber (n = 1). Outcomes of complications included removal of port systems or cessation of therapy in 12 cases (11.2%), correction of catheter location using a guide wire in five (4.7%), thrombolysis with urokinase in three (2.8%), and straightening using a snare in one (0.9%). In three patients, the port system was used without reintervention. CONCLUSION: Percutaneous implantation of an intra-arterial port system showed a high technical success rate and a low rate of serious complications. The method may be useful for regional drug infusion in various

Evaluation of Results and Radiologic Follow-up in Detachable Balloon Occlusion Thera py of the Internal CarotidArtery Aneurysms

PURPOSE: The author has studied the clinical results of CT and MR findings of proximal carotid artery occlusion using detachable balloons in the treatement of unclippable internal carotid (IC) aneurysms. MATERIALS AND METHODS: From 1987 to 1995, twenty-eight patients with IC aneurysms were treated by proximal arteryocclusion with detachable balloons. Of these patients, 4 had aneurysms arising from the supraclinoid portion ofthe IC artery, 23 had aneuryms arising from cavernous portion of the IC artery, and one had aneurysm arising fromcervical portion of the IC artery. Of the 28 patients, 7 patients without CT or MR examinations were excluded inthis study. The mean follow-up period was 18.6 months. The causes of aneurysm formation were spontaneous in 17cases and traumatic in 4 cases. RESULTS: Of 20 patients with aneurysms arising from supraclinoid and cavernousportion of the IC artery, 16 patients (80%) had cranial nerve symptoms by mass effect. Five patients had epistaxis(3 patient), carotid cavernous fistula (1 patient) or subarachnoid hemorrhage (1 patient) due to aneurysmrupture. Two patients, each with aneuryms arising from supraclinoid and cervical portion of carotid artery had 9thand 12th cranial nerve symptom. There were three instances of complication after permanent occlusion; two patientshad subarachnoid and intracerebral hemorrhage by aneurysm rupture and expired. One patient had ischemia ofposterior cerebral artery teritorry after one day. Delayed ischemic event did not occur during the follow-upperiod. All aneurysms of the carotid artery below the level of ophthalmic artery presented radiographic proof ofcomplete thrombosis within two months. However, complete thrombosis of aneurysm was considerably delayed in twoaneurysms arising from the supraclinoid portion of the carotid artery. In long-term follow-up study, complete-lythrombosed aneurysms decreased in size slowly. But incompletely thrombosed aneurysms did not decrease in size fora long time and began to contract after formation of complete thrombosis. All three traumatic pseudoaneurymscharacteristically decreased in size rapidly, comparing with spontaneous aneurysms. CONCLUSION: In conclusion,proximal IC balloon occlusion for unclippable IC aneurysms is a convenient, safe, and effective way of producinganeurysm obliteration. Longer-term follow-up study is needed for incompletely thrombosed aneuryms after balloonocclusion of the proximal IC artery.

US-guided Left-sided Percutaneous Biliary Drainage: Analysis of the Technical Factors Related to Procedure

PURPOSE: To evaluate the factors affecting procedure related technical difficulties of US-guided left sidedPTBD and the complications involved in the use of this method. MATERIAL AND METHODS: We prospectively evaluatedUS-guided left PTBD in 26 patients with malignant biliary obstructions. The causes of underlying malignancy werebile duct carcinoma(n=10), adenocarcinoma of the pancreas(n=8), GB carcinoma(n=4), metastasis to the portahepatis(n=2), duodenal carcinoma(n=1), hepatocellular carcinoma(n=1). We divided the procedure into four steps forthe evaluation of technical difficulties, and we measured procedure time and fluoroscopic exposure time. And weevaluated the incidence of procedure related complications. RESULTS: US-guided left PTBD was successful in allattempted cases. The average procedure time and fluoroscopic exposure time involved were 14.2 min. and 5.5 min.,respectively. From the first step to the fourth step, the average time required was 4.4 min, 2.3 min., 1.9 min.,5.6 min., respectively. One major complication involved sepsis(3.8%), and ten minor complications including fivetransient hemobilia(19.2%), three tube malfunction(11.5%), and two fever(7.6%). CONCLUSION: US-guided left PTBDwas easy to perform and a relatively safe method. The total procedure time was short, and as the radiologistbecomes more experienced, this could be further reduced.

Placement of an Implantable Central Venous Access Device

PURPOSE: To evaluate the efficacy and safety of placement of a central venous catheter with infusion portinto the superior vena cava MATERIALS & METHODS: Central venous catheters with a infusion port were implanted in21 patients (M:F=4:17, age range:15-63, mean age:41) diagnosed as suffering from breast cancer(n=9),lymphoma(n=7), thymoma(n=2) rhabdomyosarcoma(n=2) and rectal cancer(n=1). The peripheral portion of the subclaveanvein was punctured under fluoroscopic guidance during injection of contrast media at the site of the ipsilateralperipheral vein (20 cases) and under ultrasonographic guidance (1 case). 9.6F central venous catheters placed inthe superior vena cava via the subclavian vein and the connected infusion ports were implanted in the subcutaneouspocket near the puncture site of the right anterosuperior chest wall. RESULTS: Catheter insertion in the superiorvena cava and port implantation in the subcutaneous pocket were successful in all patients. Mean procedure timewas 23 minutes and there were no early complications. Because the incision site had not healed, one patientunderwent resuturing 3 weeks after the procedure. In one case, thrombotic occlusion of the catheter occurred, butsuccessful recanalization, involving urokinase infusion, was performed. At the end of the chemotherapy schedule,at 180, 157 and 139 days after the procedure, three central venous catheters with a infusion port were removed inthe radiologic suite. Catheter days are 5 days-180 days(mean, 119) from now (1997. 7. 1). CONCLUSIONS: Radiologicplacement under fluoroscopic guidance of a central venous catheter with a infusion port is easy, safe and usefulfor patients requring long-term venous access.

Correction of Malfunctioning peritoneal Dialysis Catheter with Guidewire and Stiffener Under fluoroscopic Guidance

PURPOSE: To determine the efficacy of correction of a malfunctioning peritoneal dialysis catheter with guidewire and stiffener under fluoroscopic guidance. MATERIALS AND METHODS: Between November 1994 and March 1997, we performed 15 manipulations in 12 patients in whom a dual-cuff, straight Tenckhoff peritoneal dialysis catheter had been implanted due to chronic renal failure. The causes of catheter malfunctioning were inadequate drainage of the dialysate (n=14) and painful dialysis (n=1). Under fluoroscopic guidance, adhesiolysis and repositioning of the malfunctioning catheter were performed with an Amplatz Super Stiff guidewire and the stiffener from a biliary drainage catheter. The results of procedures were categorized as either immediate or durable success, this latter being defined as adequate catheter function for at least one month after the procedure. RESULTS: Immediate success was achieved in 14 of 15 procedures (93%), and durable success in 7 of 15 (47%). The mean duration of catheter function was 157 (range, 30 to 578) days. After manipulation, abdominal pain developed in eight patients and peritonitis in two, but with conservative treatment, these symptoms improved. CONCLUSION: The correction of a malfunctioning peritoneal dialysis catheter with guidewire and stiffener under fluoroscopic guidance is an effective means of restoring catheter function and may be an effective alternative to surgical reimplantation of the catheter, or hemodialysis.

Placement of Central Venous Access via Subclavian Vein under Fluoroscopic Guidance with Intravenous Contrast Injection

PURPOSE: To evaluate the safety and efficacy of Hickman catheter placement via the subclavian vein under fluoroscopic guidance with intravenous contrast injection. MATERIALS AND METHODS: During an eleven-month period, 187 Hickman catheters were percutaneously placed in 167 consecutive patients in an interventional radiology suite. Subclavian venous puncture was made with injection of contrast medium into the peripheral venous line. After subclavian venous access had been obtained, a subcutaneous tunnel was created using a peel-away sheath or a tunneler. The Hickman catheters were inserted through a peel-away sheath, the distal tip of which was at the junction of the right atrium and the superior vena cava. RESULTS: One hundred and eighty-six Hickman catheters were successfully placed; the one failure was due to an atomical tortuosity of the vein(0.53%). Complications included one case of subclavian vein occlusion (0.53%); three of line occlusion by thrombus (1.6%); one of oozing at the suture site (0.53%); six of infection or inflammation (3.2%); eight of natural removal (4.2%); one case of air embolism (0.53%) and two of malposition (0.1%). Major complications such as pneumothorax or arterial puncture leading to mediastinal hemorrhage did not, however, occur. CONCLUSION: The authors concluded that radiologic Hickman catheter placement offers advantages over traditional approaches in terms of safety, convenience, and time and cost savings.