Retrograde embolization technique of the right gastric artery during the implantation of port-catheter system for hepatic arterial infusion chemotherapy

Abstract

Objective: This study aimed to introduce and evaluate a new embolization technique for the right gastric artery (RGA) during percutaneous implantation of a port-catheter system for hepatic arterial infusion chemotherapy (HAIC).

Methods: From January 2013 to January 2017, 159 patients with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In 86 of these patients (56 men; aged 28-88 years; mean: 60.6 ​± ​12.0 years), in whom the RGA was obvious on arteriography, embolization of RGA was attempted using microcoils to protect the gastric mucosa during HAIC. In the first phase (first three years), antegrade embolization of the RGA using a 2.7 Fr microcatheter was performed in 55 patients. In the second phase (next two years), embolization of the RGA was attempted by combining antegrade embolization and retrograde embolization through the left gastric artery (LGA) in 31 patients. The success rates and the incidence of acute gastroduodenal mucosal toxicity (AGMT) in these two groups were compared.

Results: The total success rate of the RGA embolization was 70.9%. The success rate was 83.9% in 31 patients who underwent combined antegrade and retrograde embolization, which was significantly higher than that of antegrade embolization alone (63.6%) performed in 55 patients (p ​= ​0.047). No complications related to embolization of RGA were documented. The incidence of AGMT was 29.1% (16/55) in patients in the first phase, which was significantly higher than that in the patients in the second phase (9.7%, 3/31) (p ​= ​0.037).

Conclusion: A combination of retrograde embolization via LGA could increase the success rates of RGA embolization and reduce the incidence of AGMT after HAIC.

Keywords: Acute gastroduodenal mucosal toxicity; Hepatic arterial infusion chemotherapy; Left gastric artery; Port-catheter system; Right gastric artery embolization.

Fig. 1

Antegrade embolization of RGA. 60-year-old man with perihilar cholangiocarcinoma. a. Celiac arteriogram obtained before implantation of port-catheter system showed the RGA (black arrow) arising from proximal the left hepatic artery (black dotted arrow). b. Right gastric arteriogram obtained through a coaxial microcatheter (white arrow) antegrade inserted into the RGA (white dotted arrow) showed its course. c. Left heptic arteriogram obtained after embolization of the proximal portion of the RGA with microcoils (black arrow) showed disappearance of blood flow into the RGA. d. Indwelling catheter tip (black arrow) was embolized in GDA (black dotted arrow) with the side hole (white arrow) at the proximal proper hepatic artery. Proper hepatic arteriogram obtained through side hole of port-catheter system (white dotted arrow) showed the whole hepatic artery tree, without blood flow into the RGA.

Fig. 2

Retrograde embolization of RGA. 44-year-old man with perihilar cholangiocarcinoma. a. Celiac arteriogram obtained before implantation of port-catheter system showing the RGA (black arrow) arising from the proper hepatic artery (white arrow). b. Arteriogram obtained via microcatheter (micro catheter tip, white arrow) coaxially advanced 5-French catheter placed in LGA (black dotted arrow) showed the anastomotic branch (black arrow) between left and right gastric arteries. c. Microcatheter (black dotted arrow) was advanced retrograde across the anastomotic branch into proximal RGA, angiogram showed RGA (black arrow) arising site of distal proper hepatic artery (white arrow). d. Retrograde released microcoils (white arrow) in the RGA. e. Arteriogram obtained after embolization of RGA through microcatheter (black arrow) via LGA (black dotted arrow) confirmed completely embolized RGA. f. Indwelling catheter tip (black dotted arrow) was fixed in GDA (white arrow) using microcoils, with the side hole (white dotted arrow)at the proximal proper hepatic artery. Proper hepatic arteriogram through the side hole of port-catheter system (black arrow) showed proper hepatic artery and its branches, without appearance of the RGA (white arrow head).