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Soonchunhyang Med Sci > Volume 28(2); 2022 > Article
Shim: Extrusion of Port Catheter Fixation Coil into Gastrointestinal Tract Lumen for Intra-arterial Chemotherapy: A Case Report

ABSTRACT

For patients with hepatocellular carcinoma, intra-arterial chemotherapy can be applied as an alternative treatment if there is concern about the occurrence of hepatic failure during transcatheter arterial chemoembolization (TACE) due to main portal vein thrombosis or if the patient does not respond to TACE. Various complications due to the port system for intra-arterial chemotherapy have been reported so far, but no case has been reported in which a coil for port catheter fixation was extruded into the gastrointestinal tract lumen. We report a case of a patient who developed persistent gastrointestinal bleeding after a coil for port catheter fixation was extruded into the gastrointestinal tract lumen.

INTRODUCTION

Compared to transvenous systemic chemotherapy, intra-arterial chemotherapy, which administers chemo-agents directly to the target artery where the tumor is located, can reduce systemic toxicity and increase local therapeutic effects because the drug concentration in the target organ is high even when a small dose is administered [1].
One of the most commonly used treatments for hepatocellular carcinoma patients is transcatheter arterial chemoembolization (TACE). However, the risk of hepatic failure increases when TACE is performed on hepatocellular carcinoma patients with main portal vein thrombosis. Therefore, intraarterial chemotherapy is widely applied to hepatocellular carcinoma patients with portal vein thrombosis, which is difficult to operate. In addition, intra-arterial chemotherapy can be applied as an alternative treatment for hepatocellular carcinoma unresponsive to TACE [2,3].
In general, intra-arterial chemotherapy for hepatocellular carcinoma is performed through a port system and a port catheter for intra-arterial drug administration is placed in the gastroduodenal artery or right gastroepiploic artery and then fixed around the catheter using coils to prevent migration of the catheter [4]. However, to the knowledge of the author, there was no report of a case in which the fixation coil was extruded into the gastrointestinal lumen.
Herein, we report a case of a patient with persistent gastrointestinal bleeding due to the extrusion of a fixation coil into the duodenum lumen during intra-arterial chemotherapy.

CASE REPORT

A 66-year-old male patient visited Soonchunhyang University Bucheon Hospital for treatment of hepatocellular carcinoma found in an outside hospital. A computed tomography (CT) scan performed at an outside hospital showed diffuse infiltrative-type hepatocellular carcinoma in the right lobe of the liver and thrombus due to tumor invasion in the right posterior portal vein (Fig. 1).
The patient underwent TACE, but there was no response, so intra-arterial port system implantation was performed for intra-arterial chemotherapy (Fig. 2A–C). After intra-arterial port system implantation, the patient received periodic intra-arterial chemotherapy and follow-up observation.
One year later, the patient was admitted to the hospital for intra-arterial chemotherapy. However, the day after admission, the patient began hematemesis. At this time, the patient’s blood pressure was measured to be 80/70 mm Hg. And the hemoglobin level was measured to be decreased to 7.2 g/dL.
The patient underwent emergency angiography, but no bleeding focus was found on the angiography. However, deformation and displacement of the fixation coil of the port catheter in the gastroduodenal artery were observed on fluoroscopy (Fig. 3).
Afterward, the patient underwent an endoscopy. On the endoscopy, ulceration and bleeding were observed in the second portion of the duodenum, and coil extrusion was observed through the ulceration site (Fig. 4). Epinephrine was injected through the endoscope into the duodenal ulceration where the coil was extruded.
However, bleeding persisted even after endoscopic hemostasis, and surgical gastroduodenal artery resection and primary repair of the duodenal ulceration site were performed as an emergency. After that, the bleeding stopped and the patient recovered well.
The patient provided written informed consent for the publication of clinical details and images.

DISCUSSION

In 1997, Strecker et al. [5] devised and introduced a port system in a form that can be installed by percutaneous procedure, and Wacker et al. [6] introduced a method of installing a port catheter into the artery using a percutaneous transcatheter angiography technique.
In general, the common femoral artery is used as the access route to the hepatic artery. The port system installation method for intra-arterial chemotherapy of hepatocellular carcinoma is as follows [4].
  1. A 5F catheter is inserted under local anesthesia into the common femoral artery and is advanced to the celiac trunk.

  2. Hepatic arteriography is performed to determine the anatomical structure of the hepatic artery.

  3. If the chemo-agent enters the right gastric artery, a gastric ulcer can occur. Therefore, if the right gastric artery is located in the chemo-agent inflow path, the right gastric artery is embolized with a coil using a microcatheter system.

  4. Make an incision in the skin 3–4 cm below the common femoral artery puncture site and exfoliate the subcutaneous fat to make a pocket for the port installation.

  5. Make a side hole at the proximal part of the port catheter 5–6 cm away from the port catheter tip.

  6. After inserting the guide wire into the distal portion more than the portion where the port catheter tip will be located, the 5F catheter is removed and a port catheter is inserted into the artery along the guide wire.

  7. The port catheter tip was placed in the gastroduodenal artery or right gastroepiploic artery, and the side hole of the port catheter prepared in advance was placed at the proper hepatic artery branching site.

  8. Insert the microcatheter into the port catheter and manipulate it so that the microcatheter comes out of the port catheter through the side hole of the port catheter. Then, to prevent migration of the port catheter, coils are used to fix the port catheter inside the gastroduodenal artery.

  9. Make a subcutaneous tunnel between the subcutaneous pocket and the common femoral artery puncture site, then pass the port catheter through the subcutaneous tunnel, and connect the port catheter to the port.

  10. The port connected to the catheter is placed in the subcutaneous pocket and seals the skin incision site.

Chemo-agents used for intra-arterial chemotherapy for hepatocellular carcinoma are diverse, and the response rate to treatment also varies depending on the type of patient and drug. In a study by He et al. [7], the response rate to intra-arterial chemotherapy for hepatocellular carcinoma was reported to be 54%.
Among the various complications of intra-arterial chemotherapy, there is the occurrence of peptic ulcers. Although the exact mechanism is not known, it is estimated that it is a change due to ischemia due to the embolization effect of an artery by the port catheter itself or coil for port catheter fixation or toxicity caused by the inflow of chemo-agent into a non-target vessel [8,9]. In our case, it is presumed that the duodenal ulcer was caused by one or both of these factors. And we speculate that the extrusion coil through the fragile luminal wall of the ulcer interfered with the healing of the ulcer so that bleeding continued.
Intra-arterial chemotherapy through the port system can be applied as a substitute for standard treatment in hepatocellular carcinoma patients with portal vein invasion. However, it should be recognized that serious complications such as our case may occur.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

Fig. 1
Computed tomography scan demonstrates low-density right posterior portal vein thrombosis (arrow).
sms-28-2-121f1.jpg
Fig. 2
(A) Port is implanted in the subcutaneous pocket beneath the right common femoral artery puncture site and connected with the port catheter. (B) The port catheter is located in the gastroduodenal artery and coils for catheter fixation are observed around it. (C) Hepatic angiography performed through the port catheter show that the pre-created side hole of the port catheter was well located at the proper hepatic artery branching site.
sms-28-2-121f2.jpg
Fig. 3
The fluoroscopy image shows that one strand of the coils for fixing the port catheter is displaced (arrow).
sms-28-2-121f3.jpg
Fig. 4
Endoscopy shows the ulcer in the second portion of the duodenum, bleeding at that site, and extrusion of the coil through the site and into the lumen.
sms-28-2-121f4.jpg

REFERENCES

1. Watkins E Jr, Khazei AM, Nahra KS. Surgical basis for arterial infusion chemotherapy of disseminated carcinoma of the liver. Surg Gynecol Obstet 1970;130: 581-605.

2. Toyoda H, Nakano S, Kumada T, Takeda I, Sugiyama K, Osada T, et al. The efficacy of continuous local arterial infusion of 5-fluorouracil and cisplatin through an implanted reservoir for severe advanced hepatocellular carcinoma. Oncology 1995;52: 295-9.
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7. He MK, Le Y, Li QJ, Yu ZS, Li SH, Wei W, et al. Hepatic artery infusion chemotherapy using mFOLFOX versus transarterial chemoembolization for massive unresectable hepatocellular carcinoma: a prospective non-randomized study. Chin J Cancer 2017;36: 83.
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9. Sundqvist K, Hafstrom L, Jonsson PE, Lunderquist A, Nowak E. Upper G-I bleeding following intraarterial chemotherapy infusion. Ann Chir Gynaecol 1983;72: 183-6.
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