Past, Present and Future of Long-Term Hepatic Arterial Accesses with Implantable Ports

Abstract

Intra-Arterial Hepatic Chemotherapy (IAHC) with floxuridine (FUdR) is an effective treatment for unresectable hepatic metastases from colorectal cancer, providing higher response rates than systemic treatments (1,2). The administration of IAHC requires a long-term vascular access to the hepatic arterial stream. Following a few anecdotal reports, in 1970 Watkins (3) published an extensive and detailed description of the surgical technique for implanting an indwelling catheter into the hepatic artery via the gastroduodenal artery for the administration of regional chemotherapy in patients affected by liver metastases from colorectal cancer. The original technique described the implantation of an external catheter with the tip placed into the lumen of the hepatic artery. However, a high incidence of device-related complications was reported, including catheter occlusion and vascular thrombosis. During the 80s, subcutaneous totally implantable reservoirs or infusion pumps were connected to a silicone catheter provided with a suture bead (4); the technique was modified by placing the tip of the catheter at the confluence between the gastroduodenal artery and the hepatic artery without causing any resistance to the regular arterial flow towards the liver. These changes in both the device and the surgical technique decreased the incidence of catheter occlusion, vascular thrombosis and infections, thus allowing an improvement in the results of locoregional hepatic treatments. Since then, partially or totally implantable devices with an indwelling catheter placed into the hepatic arterial stream have been extensively used for different purposes, including palliative treatment of unresectable lesions (5), adjuvant therapy after liver resection (6,7), and neoadjuvant therapy for tumor downstaging prior to surgery (8). However, the ever increasing experience in the field of surgically placed, long-term arterial accesses has been leading surgeons and oncologists to face up to the complications and limits of this approach. Complications secondary to surgically implanted arterial devices include mostly catheter occlusion and displacement (8.4% among infusion pumps and 21.6% among subcutaneous reservoirs) (9), hepatic artery thrombosis (1.4-8.1%) (9-12), device infection (1.1-4.4%) (9-12), decubitus of the catheter (11, 13), and other rare adverse events (i.e. hepatic artery-biliary fistula) (14). Furthermore, the traditional surgical technique requires a laparotomy and includes a meticolous dissection of the hepatic hilum with exposure of the hepatic arterial axis from the origin of the gastroduodenal artery up to the biforcation of the common hepatic artery and the so-called gastroduodenal de-vascularization. This approach of implanting the catheter into the hepatic artery has so far represented a significant limiting factor in an extensive application of IAHC in patients with metachronous metastatic liver disease. In such cases, indeed, an extensive surgical procedure whose only purpose is the implantation of a device may be...