Intra arterial ports: complex, demanding but rewarding

Transcription

1 Intra arterial ports: complex, demanding but rewarding Gregory Amouyal, MD. Marc sapoval, MD. PhD. Olivier Pellerin, MD. MsC. Interventional Radiology Department, hospital European Georges Pompidou, Paris, France.

2 No disclosures Clinical results of 25 patients after PAE

3 3 different clinical presentations in a daily practice. Hepatic Arterial Infusion chemotherapy (HAIC) for Colo-rectal cancer liver metastasis (CRCLM): Non resectable patients. Potentially resectable patients. Resectable patients.

4 Resectable patients: high risk of hepatic recurrence Concerns 10 to 15% of cases of patients with CRCLM. Neo and adjuvant chemotherapy (AI VS IV): HAI VS FOLFOX/IRI 3 months before + 3 months after surgery/ablation. (HAI) Increase of Progression Free Survival at 3 years to 8% But OS looks similar Is there room for intra arterial treatment in term of Intensification? Need of clinical evidence (Trials are ongoing) Nordlinger B et al, Lancet 2007 Goere D et al, Ann Surg 20013

5 *Am J. Pathol 1954

6 Investigative Radiology 2004 Colorectal liver metastases: contrast enhanced-us

7 Rationale for HAI chemotherapy Liver mcrc 2,5 mm in diameter become arterially supplied E. Bugyik, Chin J Cancer. 2016

8 Rationale for HAIchemotherapy Hepatic Arterial Infusion Chemotherapy Increase of therapeutic index (Ammori Sem oncol 2010) Increase intra-tumoral concentration of chemo (accurate cytotoxicity ( 3 to 20 / iv). Use of drugs with high liver extraction Increase biodisponibility, Reduce systemic passage and sideffects.

9 Rationale for HAI chemotherapy Response rate >> surgical resection (Folprecht G. et al Ann Oncol 2005)

10 Material Endovascular approach: right femoral. 4/5 Fr femoral sheath (or no sheath). Cobra / Shepherd catheter, glide guidewire. Microcatheter 2.7 Fr Progreat Fathom micro wire useful (R. gastric) A good look at pre-therapeutic AngioCT helps for arterial mapping +++

11 Step by step 1. Mesenteric artery angiography + Celiac axis artery angiography - Hepatic feeders - modal anatomy or not 2. Embolization of left or middle hepatic artery ( monopediclz ) 3. Embolization of the right gastric 4. Implantation of port + embo GDA

12 3 2 Modal anatomy Stomac Common Hépatic A 2- Left Gastric 3 - Right Gastric 4 Gastro-duodenal A 5- Gastro-epiploic A 6 Splenic A

13 Anatomic variation Left hepatic A Right hepatic A

14 How it s done

15 direct undirect

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20 Case 1 Anatomical variations

21 Anatomical variations Case 1

22 Case 2 Anatomical variations

23 Cath into PHA When too much tortuosity Anatomical variations

24 Acute angle of Origin of celiac axis (arcuate ligt +++) Technical failures.

25 Acute angle of Origin of celiac axis (arcuate ligt +++) Technical failures.

26 Technical failures. Acute angle of Origin of celiac axis (arcuate ligt +++)

27 Results Technical Success: 92 et 100 % Patency rate at 6,12 and 24 months are respectively: 91 %, 81, and 58 %. Complications: Gastro duodenal ulcerations (reflux of chemo): prevented by embo of right gastric and GDA or duodenal branches Cholecystitis: rare event no need to embolize, the cystic artery. Hepatic artery thrombosis/chemical arteritis related to artery size Infection rate: 2%. Secondary side hole catheter dislodgement Ischemic cholangititis. Deschamps et al. CVIR 2011 Farouil et al. Surg Oncol 2013

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29 Cost / Feasability Advantage bile duct dilatation (possible) hepatico-jejunal anastomosis (possible) combined with systemic therapy recommended Disadvantages systemic toxicity of oxaliplatin every second week Expert center only available in very limited number of center worldwide Interventional radiology Port/catheter/ pump implanation Mediacal oncology Perfusion in IA port sepcific premedication Cost: efficacy port implantation : 1 to 4 hours in IR suite 6 coils 1 port Oxaliplatinium every second week Port control every second course Port/cathter re-intervention: embolization, exchange, thombolysis (36,5%)

30 Magnitude / Deepness of response 49 unresectable mcrc HAIC FUDR, IV Oxaliplatin + Irinotecan 35 unresectable mcrc HAIC Oxaliplatin, IV 5FU/Cetuximab 92% OR (8% CR 84% PR) 47% (n=23) converted to surgery 86% OR 55% resection rate Kemeny N. J Clin Oncol 2009 Malka D, ASCO 2001 abst % OR after first line IV CT (Boige V Ann Surg Oncol 2008)

31 Magnitude / Deepness of response Kemeny N. J Clin Oncol 2009 Malka D, ASCO 2001 abst 3558

32 Conclusions IAH-c is the most powerful chemo in term of response rate: # 90% as 1st line 60% as 2nd line Allows downstaging and secondary hepatic surgery. Long lasting liver control. But need for skilled IR for insertion