Hemorrhage of Gastroepiploic Artery induced by Hepatic Artery Infusion Chemotherapy (HAIC) Catheter-Port System Implantation: five cases report

Transcription

1 中華放射醫誌 Chin J Radiol 009; 34: Hemorrhage of Gastroepiploic Artery induced by Hepatic Artery Infusion Chemotherapy (HAIC) Catheter-Port System Implantation: five cases report Jui-Lung Fang 1 Wen-Sheng Tzeng YenJen Wang 1 Reng-Hong Wu Shih-Chin Chang Department of Radiology 1, Chi Mei Medical Center, Liouying Department of Radiology, Chi Mei Medical Center, Yongkang Hepatic artery infusion chemotherapy (HAIC) is used primarily in patients with inoperable primary or metastatic hepatic tumors. During HAIC system implantation, the guide wire used to support the insertion of the catheter can damage the gastroepiploic artery resulting in intraperitoneal bleeding when percutaneous catheter placement and tip fixation method was used. Five cases complicated by gastroepiploic arterial hemorrhage are reported. Three were found to have active contrast extravasation during implantation. One had massive intraperitoneal hemorrhage several hours after implantation, and another had late-onset hemorrhage two months later. All hemorrhages were successfully controlled by transarterial embolization (TAE) from gastroepiploic artery. Reprint requests to: Dr. YenJen Wang Department of Radiology, Chi Mei Medical Center, Liouying. No. 01, Taikang Village, Liouying, Tainan 736, Taiwan, R.O.C. Massive intraperitoneal hemorrhage resulting from the gastroepiploic artery is rare but can be lethal if not properly managed. Most literature regarding bleeding from gastroepiploic ar ter y is mainly concerned with bleeding induced by gastroepiploic artery aneurysm rupture [1,, 3], penetrating stab wound [4], iatrogenic injury [5], or spontaneous rupture [6]. We report five cases of hemoperitoneum due to rupture of the gastroepiploic artery associated with HAIC catheter-port system implantation. They were successfully rescued by the intervention using TAE. MATERIALS and METHODS In this paper, all patient data were collected under approval of the Institutional Review Board ( I R B) i n ou r hospit al (reg ist r at ion nu mb e r: CLH-0048). From July 006 to December 007, 155 patients with unresectable hepatic tumors received a total of 165 HAIC catheter-port system implantations. Of the 165 implantations, 141 were performed with tip fixation method. Of these 141 implantations, five patients had subsequent intraperitoneal hemorrhage as shown in Table 1. In our tip fixation method, to prevent localized hematoma at puncture site after implantation of HAIC catheter-port system, we do not use sheath but use a 4-F RC1 catheter (Cordis. Super Torque; Europe, Roden, The Netherlands) as the guiding catheter for a.7-f micro-catheter (Progreat, Terumo Co., Tokyo, Japan) inserted coaxially to embolize all replaced and accessory hepatic arteries and identifiable extrahepatic tumor feeding arteries such as right and left inferior phrenic arteries, right adrenal arteries, right renal capsular arteries and omental arteries from gastroepiploic arteries to redistribute hepatic arterial inflow to single feeding artery from

2 14 Table 1. Patient Data and Treatment Outcome Patient number Age Sex Diagnosis Timing of bleeding Embolic agent used Outcome 1 74 F Multifocal HCC During procedure NBCA Successfully stopped bleeding and partial remission for 7 months. Still alive. 39 M Metastatic liver adenocarcinoma from unknown origin Several hours after procedure Gelfoam pledgets Successfully stopped bleeding and partial remission for 17 months. Still alive M Multifocal HCC with right portal vein thrombosis Two months after procedure with significantly prolonged prothrombin time Gelfoam pledgets Successfully stopped bleeding but expired after ten days due to liver failure 4 54 M Cholangiocarcinoma s/p modified hepatectomy with multiple recurrence within both lobes of liver 5 56 F Ascending colon carcinoma with multiple liver metastasis and extrahepatic portal veins thrombosis During procedure NBCA Successfully stopped bleeding and stationary disease for 10 months. Still alive. During procedure NBCA Successfully stopped bleeding and partial remission for 9 months. Still alive. HCC: hepatocellular carcinoma; NBCA: N-Butyl Cyanoacrylate 1a 1b Figure 1. A 74 year-old woman, with hepatocellular carcinoma in the right lobe and multiple tumors in both lobes, underwent implantation of the HAIC catheter-port system in August 007. HAIC catheter tip was placed in right gastroepiploic artery after passing through gastroduodenal artery. Active intraperitoneal contrast extravasation from left gastroepiploic artery (black arrow) was identified with contrast agent injected via a microcatheter passing coaxially through the HAIC catheter tip. After N-butyl cyanoacrylate (NBCA)-lipiodol mixture (1:) was infused into left gastroepiploic artery via microcatheter, contrast extravasation was no longer appreciated (black arrow).

3 15 a b c d Figure. A 39 year-old man with multiple hepatic metastases and unknown primary tumor origin. a. and b. Several hours after the placement of HAIC catheter-port system, emergent abdominal CT was performed due to hypotension and tachycardia. Massive intraperitoneal bleeding was detected (see arrow) High attenuation hematoma at the inferior aspect of the spleen was also found (see white arrow). Gastroepiploic arterial hemorrhage was suspected and angiography was immediately performed but failed to show any significant contrast extravasation. Based on the CT evidence, the patient was treated with gelfoam pledgets in the left gastroepiploic artery to stop the bleeding. proper hepatic artery with metallic micro-coils (MicroNester/Embolization Coil, Cook, Bjaeverskov, Denmark). We also embolize the right gastric artery and identifiable accessory left gastric artery from left hepatic artery to prevent gastric and duodenal mucosa injury after initiation of HAIC. Before the Anthron P-U catheter (5-F heparin-coated polyurethane catheter; PU5070SDST; Anthron P-U catheter; Toray Medical Industries, Tokyo, Japan) is indwelt, we insert a inch (Stiff type, Terumo, Tokyo, Japan) rather than a inch guide wire from the 4-F RC1 catheter through anterior division of gastroduodenal artery and right gastroepiploic artery to left gastroepiploic artery to support the placement of the Anthron P-U catheter. By using this technique we reach almost one hundred percent success rate for implantation of HAIC catheter-port system in patients without previous embolization of gastroduodenal artery and without previous gastrectomy. Patient 1: A 74 year-old woman had a 10 cm-diameter hepatocellular carcinoma in right lobe of the liver and multiple smaller tumors in both lobes. She had received transar terial chemoembolization (TACE) twice but the results were suboptimal. She subsequently underwent HAIC catheter-port system implantation. After implantation, contrast extravasation was noted from the left gastroepiploic artery during the procedure. A micro-catheter was then inserted through the Anthron P-U catheter to reach the location of the bleeding and N-butyl cyanoacrylate (NBCA) (Histoacryl, B.Braun, Aesculap AG, Tuttlingen/Germany)-lipiodol ( Lipiodol Ultra Fluide, Guerbet, Roissy, France) mixture (1:) was infused into left gastroepiploic artery to stop the bleeding (Fig. 1). The patient left the hospital one week later in stable condition. Patient : A 39 year-old man, with multiple hepatic metastases and unknown primary tumor origin, received systemic chemotherapy previously with poor response. Therefore, he underwent HAIC

4 16 catheter-port system implantation. However several hours after implantation, the patient complained of abdominal pain along with hypotension and tachycardia. Emergent CT showed massive intraperitoneal bleeding along the left upper quadrant of the abdomen near the spleen. The patient underwent angiography for suspected hemorrhage of the gastroepiploic artery and although the images did not show any significant contrast extravasation, based on the abdominal CT, the patient was treated with Gelfoam pledgets (Spongostan Film, Johnson & Johnson Medical, Gargrave, Skipton, U.K.) in the left gastroepiploic artery to stop the bleeding. The patient left the hospital several days later and follow-up CT showed his tumors had regressed (Fig. ). Patient 3: A 53 year-old man, with hepatic tumors and right portal vein thrombosis, underwent implantation of the HAIC catheter-port system. The patient underwent also coumadinization for suspected right popliteal vein partial thrombosis. Unfortunately, two months after implantation he returned to our hospital with complaints of constant abdominal pain and tarry stools. The patient had an abnormal prothrombin time of seconds, and an INR of 9.9. Considerable hemoperitoneum and contrast extravasation at the top of left abdomen were found on abdominal CT. Contrast extravasation from the branch of left gastroepiploic artery was also seen on angiography (Fig. 3), and Gelfoam pledgets were emergently injected into left gastroepiploic artery to stop the bleeding. Unfortunately, this patient died of liver failure 10 days later although the bleeding was controlled. Patients 4 and 5: A 54 year-old man with cholangiocarcinoma and multiple recurrences after resection of liver tumors and a 56 year-old woman with colon carcinoma complicated by multiple liver metastases and portal veins thrombosis, were both found to have active contrast extravasation from left gastroepiploic artery during implantation (same as Patient 1). After NBCA treatment, the bleeding was effectively stopped. DISCUSSION HAIC therapy is usually used for unresectable primary or metastatic hepatic tumors. It can also serve as adjuvant therapy for surgery [7,8], radiofrequency ablation [9,10], and transarterial chemoembolization. Whether combined with systemic chemotherapy, the local tumor response rate can reach higher than 57.1% for unresectable liver metastases from colorectal cancer [11,1]. Recent reports 3a 3b 3c Figure 3. A 53 year-old man with liver carcinoma complicated by right portal vein thrombosis received the implantation of HAIC catheter-port system in April 007. Unfortunately, he returned for continuous abdominal pain and tarry stool in June 007. The coagulation function test showed abnormal prothrombin time of sec and an INR of 9.9. a. and b. Hemoperitoneum, high density blood (white arrow) and contrast extravasation (hatched arrow) in the top left abdomen were found on abdominal CT. Contrast extravasation (arrow) from the branch of left gastroepiploic artery was detected during angiography. Gelfoam pledgets were injected into left gastroepiploic artery to efficiently stop bleeding. However, the patient died of liver failure 10 days later.

5 17 show that metastatic colorectal cancer treated with HAIC improved liver function and served as a bridge for surgery [13]. Percutaneous placement is a common method for the implantation of the catheter-port system [14,15]. Most researchers currently use a side-hole catheter and fix the catheter tip in the gastroduodenal artery rather than direct placement of the catheter in the hepatic artery. This reduces the occurrence of catheter dislodgement and improves the long-term patency rate. During the catheter placement with our tip fixation method, the inch guide wire is placed in the gastroepiploic artery as a support for catheter placement. In our experience, without the use of sheath the Anthron P-U catheter is difficult to be indwelt percutaneously with a inch guide wire and a inch guide wire will make the procedure more smoothly due to its higher rigidity and trackability. But during advancement of the Anthron P-U catheter through the arteries punctured, the guide wire in the gastroepiploic artery could suddenly advance and the gastroepiploic artery or its branches could be damaged or even be perforated if we did not hold the guide wire firmly and keep an eye on the tip of the guide wire. Otherwise, active and probably lethal bleeding could happen if neglected. In our patient 1, 4 and 5, the active contrast extravasations from gastroepiploic artery were noted during the procedures immediately after the Anthron P-U catheter implantation because sudden advance of the tips of guide wires were appreciated. Gastroepiploic arteriographies were checked and the bleeders were successfully embolized with diluted NBCA via a micro-catheter inserted through the Anthron P-U catheter. In our patient, we probably neglected the injury of gastroepiploic artery during the implantation of HAIC catheter-port system and massive hemoperitoneum happened. Due to rapid clinical downhill occurring in the ward, the patient was then successfully treated with TAE. In our patient 3, the massive hemoperitoneum with active bleeding from left gastroepiploic artery was noted two months later closely related to inappropriate anticoagulation. We suggested the gastroepiplic artery could have been damaged during HAIC catheter implantation and then damaged artery bled due to bleeding tendency as a result of poor monitoring of anticoagulation. Most hemoperitoneum from gastroepiploic artery reported in the literature are secondary to gastroepiploic artery aneurysm rupture, penetrating stab wound, or spontaneous rupture. A few cases are due to iatrogenic injury. The management options include expectant management, vessel ligation, vascular resection and TAE. According to the current literature, which is primarily in the form of case reports, most interventions involve surgical vascular ligations or resections [1, 6]. Until now, there is no report of HAIC catheter-port system implantation induced gastroepiploic arterial bleeding. We repor t f ive pat ie nt s receiv i ng H A IC catheter-port system implantation complicated by hemorrhage that was successfully treated by TAE in left gastroepiploic artery. Gastroepiploic arterial bleeding should be monitored during the implantation. If hemoperitoneum is suspected, arteriography of gastroepiploic artery should be checked during the procedure from Anthron P-U catheter and the splenic artery should be checked for possible contrast extravasation from left gastroepiploic artery if gastroduodenal arteries were emoblized. Under suitable conditions, we suggest using NBCA for superselective embolization as it can efficiently stop bleeding. Even if contrast extravasation from the gastroepiploic artery is not detected at angiography, we suggest empirical use of gelfoam pledgets to stop bleeding. CONCLUSIONS HAIC therapy is commonly used for unresectable primary or metastatic hepatic carcinoma. If a stiff guide wire is placed in gastroepiploic artery via the gastroduodenal artery to support the pathway of catheter placement, gastroepiploic artery might be damaged by sudden inadvertent advance of guide wire with resultant intraperitoneal bleeding. The bleeding may occur during implantation, or several hours later, or may even be induced by inappropriate anticoagulation several months later. If we are aware of the possibility of gastroepiploic arterial bleeding, this complication can be identified earlier and treated appropriately to avoid a catastrophic outcome. According to our experience with TAE, embolization by using NBCA or gelfoam pledgets can efficiently stop the bleeding and prevent further complications.

6 18 REFERENCES 1. B o r i o n i R, G a r of a l o M, I n n o c e n t i P, e t a l. Hemoperitoneum due to spontaneous rupture of an aneurysm of the left gastroepiploic artery. J Cardiovasc Surg (Torino) 1999; 40: Yamaguchi M, Kumada K, Sugiyama H, et al. Hemoperitoneum due to a ruptured gastroepiploic artery aneurysm in systemic lupus erythematosus. A case report and literature review. J Clin Gastroenterol 1990; 1: Rohatgi A, Cherian T. Spontaneous rupture of a left gastroepiploic artery aneurysm. J Postgrad Med 00; 48: Schindel Y, Stein M. Right gastroepiploic artery stab wound presenting as massive hemothorax: a diagnostic dilemma. Isr Med Assoc J 003; 5: Risher WH, Smith JW. Intraperitoneal hemorrhage from injury to the gastroepiploic artery: a complication of endoscopic retrograde sphincterotomy. Gastrointest Endosc 1990; 36: Jadav M, Ducheine Y, Brief D, et al. Abdominal apoplexy: a case study of the spontaneous rupture of the gastroepiploic artery. Curr Surg 004; 61: Yamagami T, Kato T, Iida S, et al. Adjuvant hepatic arterial infusion chemotherapy after curative resection for Dukes C colorectal cancer: a pilot study. Hepatogastroenterology 004; 51: Asahara T, Itamoto T, Katayama K, et al. Adjuvant hepatic arterial infusion chemotherapy after radical hepatectomy for hepatocellular carcinoma--results of long-term follow-up. Hepatogastroenterology 1999; 46: Yamagami T, Kato T, Tanaka O, et al. Radiofrequency ablation therapy of remnant colorectal liver metastases after a course of hepatic arterial infusion chemotherapy. J Vasc Interv Radiol 005; 16: Ya makado K, Na k at su k a A, Ta k a k i H, et al. Prospective study of arterial infusion chemotherapy followed by radiofrequency ablation for the treatment of liver metastasis of gastric cancer. J Vasc Interv Radiol 005; 16: Sameshima S, Horikoshi H, Motegi K, et al. Outcomes of hepatic artery infusion therapy for hepatic metastases from colorectal carcinoma after radiological placement of infusion catheters. Eur J Surg Oncol 007; 33: Kemeny N, Jarnagin W, Paty P,et al. Phase I trial of systemic oxaliplatin combination chemotherapy with hepatic arterial infusion in patients with unresectable liver metastases from colorectal cancer. J Clin Oncol 005; 3: Iguchi T, Arai Y, Inaba Y, et al. Hepatic arterial infusion chemotherapy through a port-catheter system as preoperative initial therapy in patients with advanced liver dysfunction due to synchronous and unresectable liver metastases from colorectal cancer. Cardiovasc Intervent Radiol. 008; 31: Seki H, Kimura M, Yoshimura N, et al. Hepatic arterial infusion chemotherapy using percutaneous catheter placement with an implantable port: assessment of factors affecting patency of the hepatic artery. Clin Radiol 1999; 54: Tanaka T, Arai Y, Inaba Y, et al. Radiologic placement of side-hole catheter with tip fixation for hepatic arterial infusion chemotherapy. J Vasc Interv Radiol 003; 14: 63-68

7 19 肝動脈化療導管暨注射基座系統植入術導致胃大網膜動脈出血 : 五病例報告 方瑞隆 1 曾文盛 王彥人 1 吳仁宏 張世欽 奇美醫學中心柳營院區影像醫學部 1 奇美醫學中心永康院區影像醫學部 肝動脈化療經常是用在無法開刀的原發性或轉移性惡性肝腫瘤的治療方法, 而在肝動脈化療導管暨注射基座系統植入時經常將導線置於胃大網膜動脈來做為支撐導管置入的路徑, 所以在肝動脈化療導管暨注射基座系統植入過程中胃大網膜動脈可能會受到損害而有可能導致腹內之出血 若能早期發現出血, 並適當止血就能避免更大的併發症產生 在此報告五例因肝動脈化療導管暨注射基座系統植入術造成胃大網膜動脈出血個案, 包含三例於術中當場發現胃大網膜動脈明顯顯影劑外漏現象, 一例於術後數小時發現腹內大量出血, 以及一例於術後兩個月後可能因右腳靜脈血栓使用抗凝血藥物 (Coumadin) 而導致的遲發性出血 在經過血管攝影檢查於胃大網膜動脈適當血管栓塞止血後均能達成有效止血