The feasibility and safety of the brachial artery approach in the treatment of hepatic artery infusion chemotherapy: a retrospective study
Original Article

The feasibility and safety of the brachial artery approach in the treatment of hepatic artery infusion chemotherapy: a retrospective study

Jian Xiong1#, Yanyan Zhou1#, Kai Tan2#, Haofeng Liu3,4, Yunbao Cao1, Junde Liu1, Wenhao Wu1, Xilin Du2, Zhonghua Luo1

1Department of Interventional Radiology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China; 2Department of General Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China; 3SenseTime Joint Lab of Smart Health Care, Xidian University, Xi’an, China; 4School of Artificial Intelligence, Xidian University, Xi’an, China

Contributions: (I) Conception and design: J Xiong, Y Zhou, K Tan; (II) Administrative support: Z Luo, X Du; (III) Provision of study materials or patients: K Tan; (IV) Collection and assembly of data: J Xiong, Y Zhou; (V) Data analysis and interpretation: J Xiong; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

#These authors contributed equally to this work.

Correspondence to: Zhonghua Luo, MD. Department of Interventional Radiology, Tangdu Hospital, The Fourth Military Medical University, No. 1 Xinsi Road, Baqiao District, Xi’an 710038, China. Email: llhuaxian@163.com; Xilin Du, MD. Department of General Surgery, Tangdu Hospital, The Fourth Military Medical University, No. 1 Xinsi Road, Baqiao District, Xi’an 710038, China. Email: dxlin0705@163.com.

Background: Compared to hepatic artery infusion chemotherapy (HAIC) treatment through the femoral artery (TFA), the brachial artery (TBA) is more flexible and easier for patients to accept. However, the feasibility of TBA has not been studied yet. This study aims to evaluate the feasibility and safety of HAIC via the TBA.

Methods: We retrospectively reviewed the medical records of 63 patients with primary liver cancer who were treated with HAIC via TBA. In this study, a total of 163 HAIC procedures were performed via the left brachial artery pathway, and each patient underwent an average of 2.59 procedures. One patient received 5 treatments, 18 patients received 4 treatments, 15 patients received 3 treatments, 12 patients received 2 treatments, and 17 patients received 1 treatment. The main evaluation indicators were the technical success rate and complication rate.

Results: The main technical success rate was 99.4% (162/163). No patient required conversion to the femoral artery (TFA) access. All the complications were minor and occurred in 11 patients (6.75%). Subcutaneous ecchymosis occurred in 3 (1.84%) patients, arterial thrombosis in 2 patients (1.23%), and catheter displacement in 6 patients (3.68%). No serious complications occurred.

Conclusions: TBA pathway is feasible and safe for HAIC treatment of liver cancer patients. More research is needed in the future to confirm whether TBA is superior to other pathways.

Keywords: Brachial artery access; hepatic artery infusion chemotherapy (HAIC); safety; feasibility

Submitted Jun 25, 2023. Accepted for publication Aug 18, 2023. Published online Aug 30, 2023.

doi: 10.21037/jgo-23-523

Highlight box

Key findings

• The brachial artery (TBA) pathway is feasible and safe for HAIC treatment of liver cancer patients.

What is known and what is new?

• The commonly used regimen for HAIC treatment is administered via the femoral artery (TFA), which seriously affect the patients’ compliance and quality of life.

• In addition to the TFA, TBA pathway plays an important role in interventional surgery. Our study aims to evaluate the feasibility and safety of hepatic artery infusion chemotherapy (HAIC) via TBA.

What is the implication, and what should change now?

• Due to prolonged bed rest, patients are prone to complications such as urinary retention and lower limb vein thrombosis, which seriously affect the patients’ compliance and quality of life and limits the use of TFA in HAIC treatment of liver cancer.

Introduction

Hepatic artery infusion chemotherapy (HAIC), an important chemotherapy method for the treatment of liver cancer, allows direct infusion of chemotherapy drugs into the tumor blood supply artery (1-10). Specifically, HAIC can play an antitumor role by increasing the local drug concentration in liver tumors. In Asian countries such as China, Japan and South Korea, HAIC is recommended as one of the standard treatment regimens for liver cancer (11-13).

In China, the commonly used regimen for HAIC treatment is oxaliplatin plus fluorouracil (FOLFOX), most of which is administered via the femoral artery (TFA) (11). The infusion typically lasts for more than 48 hours. Hemostasis is usually achieved after 6–8 hours of compression, strict bed rest is needed, and hips must not be flexed for more than 50 hours (7,14-16). Due to prolonged bed rest, patients are prone to complications such as urinary retention and lower limb vein thrombosis, which seriously affect the patients’ compliance and quality of life and limits the use of TFA in HAIC treatment of liver cancer (17).

In addition to the TFA, the brachial artery (TBA) pathway plays an important role in interventional surgery. In previous studies, the incidence of TBA complications was as high as 11% (18-20). The purpose of this study was to analyze the technical success and complication rates of HAIC treatment in patients with liver cancer and evaluate the feasibility and safety of HAIC via the TBA. We present this article in accordance with the STROBE reporting checklist (available at https://jgo.amegroups.com/article/view/10.21037/jgo-23-523/rc).

Methods

Patients

Hepatic artery catheterization was performed 163 times through TBA pathway in 63 patients. The baseline characteristics and complications of the patients are shown in Table 1. Inclusion criteria: (I) pathological diagnosis of primary liver cancer in patients aged 18–75 years; (II) CHILD PUGH stage A or B; (III) Eastern Cooperative Oncology Group (ECOG) PS score of 0/1. Exclusion criteria: (I) severe dysfunction of the heart, liver, kidney and lung; (II) malignant tumors in other parts; (III) iodine allergy; (IV) coagulation dysfunction.

Table 1

Baseline patient characteristics and comorbidities

Characteristic Value
Gender
   Male 49
   Female 14
Age (years) 55.4±11.2
Smoking 42 (66.67)
Drinking 21 (33.33)
Comorbidities
   Diabetes 9 (14.29)
   Hypertension 14 (22.22)
   Cerebrovascular disease 5 (7.94)
   Coronary artery disease 8 (12.70)
Tumor distribution
   Left lobe 12 (19.05)
   Right lobe 44 (69.84)
   Caudate lobes 3 (4.76)
   Multi-lobular 4 (6.35)
ECOG (PS score)
   0 42 (66.67)
   1 21 (33.33)

Continuous data are expressed as mean ± standard deviation; categorical data are expressed as count (%). EOCG, Eastern Cooperative Oncology Group; PS, performance status.

Study methods

This retrospective study was approved by the Ethics Committee of Tangdu Hospital (No. K202108-43). The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013), and individual consent for this retrospective analysis was waived. Patients with primary liver cancer were treated with HAIC via TBA at the Intervention Center of Tangdu Hospital of The Fourth Military Medical University from January 1, 2020, to April 30, 2022. There was no embolic disease in the left brachial artery, axillary artery or subclavian artery detected by B-ultrasound before the operation. The puncture site was at the place where TBA pulsation of the left elbow joint was most obvious, 2% lidocaine was used for local infiltration anesthesia, and an 18-G puncture needle was used for blood vessel puncture.

After successful vascular puncture by using the Seldinger technique, a 5-F (Terumo, Tokyo, Japan) was placed into the celiac trunk, and a 5-F H1 catheter (Cook, Bloomington, USA) was guided into the celiac trunk for arteriography with a 0.035-inch loach guide wire (Terumo). Then, a 0.018-inch micro guide wire (ASAHI, Tokyo, Japan) was used to guide a 2.7-F micro catheter (ASAHI, Tokyo, Japan) into the tumor feeding artery. If the tumor received blood supply from both the celiac trunk and the superior mesenteric artery, the microcatheter was placed in the largest tumor blood supply artery. The peripheral end of the microcatheter was anticoagulated with heparin to prevent the catheter from clotting. The part of the catheter that was exposed outside the body was covered with sterile gauze and then fixed on the skin of the left arm with medical tape. Finally, the patient was transferred to the ward remained in bed for more than 54 hours. Chemotherapy was administered according to the FOLFOX4 protocol (the first day: oxaliplatin 85 mg/m2 intra-arterial injection for 2 hours, calcium folinate 200 mg/m2 intra-arterial injection for 2 hours, fluorouracil 400 mg/m2 intra-arterial injection for 2 hours, fluorouracil 600 mg/m2 intra-arterial injection for 22 hours; the second day: calcium folinate 200 mg/m2 intra-arterial injection for 2 hours, fluorouracil 400 mg/m2 intra-arterial injection for 2 hours, fluorouracil 600 mg/m2 intra-arterial injection for 22 hours, once every 3 weeks). The vessel sheath was sealed with 10 mL of normal saline and 0.0625 million U of heparin sodium once every 4 hours. After chemotherapy, fluoroscopy was performed under DSA to determine if the catheter was displaced. The puncture point should be locally sterilized, the puncture point should be covered with sterile dressing, the vascular sheath and catheter should be removed, the left upper arm should be pressure bandaged with the bandage loosely wound so that the radial artery pulse can be taken and the puncture point will not bleed.

End point and definition

The main outcome measures were the success and complication rates of catheterization. Successful catheterization was defined as successful catheterization via puncture of the left brachial artery, and complications were mainly defined as access- and puncture-related complications. An auxiliary femoral artery puncture was considered a failure of catheterization. Minor complications are those that do not require treatment or have no adverse consequences. Serious complications refer to those that require prolonged hospitalization, special treatment or reoperation.

Results

A total of 163 HAIC treatments were performed via the left brachial artery pathway (see Table 2), and each patient underwent an average of 1.65 treatments via this access point. One patient received 5 treatments, 18 patients received 4 treatments, 15 patients received 3 treatments, 12 patients received 2 treatments, and 17 patients received 1 treatment. In 1 patient, the puncture failed but was later successful under ultrasound guidance. The main technical success rate was 99.4% (162/163). No patient required conversion to TFA access. All the complications were minor (see Table 3) and occurred in 11 patients (6.75%). Subcutaneous ecchymosis occurred in 3 (1.84%) patients, arterial thrombosis in 2 (1.23%) patients, and catheter displacement in 6 (3.68%) patients. No serious complications occurred.

Table 2

Surgical details

Statistical Items N=163 (%)
Number of punctures (times)
   1 78 (47.9)
   2 56 (34.4)
   3 29 (17.8)
Puncture time (min) 10.3±2.9
Tube placement time (min) 9.9±1.8
Catheter head end position
   Left hepatic artery 24 (14.7)
   Right hepatic artery 102 (62.6)
   Intrinsic hepatic artery 34 (20.9)
   Superior mesenteric artery 3 (1.8)
Treatment modality
   HAIC 118 (72.4)
   HAIC + embolism 45 (27.6)
Number of tube placement
   1 17 (10.4)
   2 12 (7.4)
   3 15 (9.2)
   4 18 (11.0)
   5 1 (0.6)

Continuous data are expressed as mean ± standard deviation; categorical data are expressed as count (%). HAIC, hepatic artery infusion chemotherapy.

Table 3

Incidence of complications

Complications Patients, n (%)
Slight
   Subcutaneous ecchymosis 3 (1.84)
   Local hematoma 0 (0.00)
   Pseudoaneurysm 0 (0.00)
   Arterial thrombosis 2 (1.23)
   Arterial dissection 0 (0.00)
   Hemorrhage 0 (0.00)
   Catheter abscission 0 (0.00)
   Catheter displacement 6 (3.68)
   Catheter block 0 (0.00)
Serious
   Vascular occlusion 0 (0.00)
   Hematoma 0 (0.00)
   Pseudoaneurysm 0 (0.00)
   Median nerve injury 0 (0.00)
Total 11 (6.75)

Discussion

TBA access has been increasingly used in endovascular therapy for peripheral vascular disease, aortic disease, and cardiac disease (21-23). In a part of the study, the brachial access was considered to be a complement to the femoral access, and the brachial access was chosen only when the femoral access failed. In this study, we chose the brachial access in all the patients and then chose the femoral access if the first puncture attempt was unsuccessful.

TBA is better than TFA due its superficial anatomical location and large diameter (3.93±0.49 mm) (24), which allows for an extremely high technical success rate (95–100%) and excellent access for vascular interventions (25). In an analysis of 265 procedures performed through the brachial access, Franz et al. showed a high technical success rate of 98.9% (26). The technical success rate in this study was approximately 100%, with only one case of difficult puncture of TBA, which was ultimately successful under ultrasound guidance. The brachial access is the preferred access for HAIC.

TBA is the most prominent artery in the forearm, and serious consequences can occur if TBA is occluded. Therefore, it has been suggested that although the complication rate of accessing TBA is low, complications are often serious and even require surgery or rehospitalization for intervention (25). More than 30 years ago, a study of 225 brachial artery access placement in 157 patients who underwent perfusion chemotherapy was performed, and the median placement time was 68 days, 52 (23%) root catheters were removed due to complications, and the rate of placement complications was high (27). In the present study, the complication rate was 6.75%, all of which were minor complications, and no cases required surgery or an extended hospital stay. This is strongly related to the advances in materials and the puncture placement technique and the shortening of the placement time.

There is a strong relationship between the size of the vascular sheath and the complication rate (21). In a review of 157 transbrachial procedures, Madden et al. (28) found that the complication rates were 5.4% (2/37), 12.4% (11/89), and 12.5% (2/16) for vascular sheaths that were size 5, 6, and 7 F, respectively. A 5-F vascular sheath was chosen for most of the placements in this study, which may be one of the reasons for the low complication rate.

TBA is close to the median nerve, so interventions via TBA may cause a hematoma or pseudoaneurysm to compress the median nerve, resulting in patient discomfort or disability. Median nerve injuries were observed in the studies by Stavroulakis et al. (29) and Treitl et al. (21). A nerve ultrasound is important in the diagnosis of these patients (30). To avoid causing injury to the median nerve, some vascular surgeons prefer brachial artery dissection (31-33). In the present study, no median nerve injury or compression symptoms were observed, which may have been related to the fact that we tried to perform the puncture operation at a more distant pulsation point of TBA. The exact method of achieving hemostasis with compression also plays a great role.

A stroke or transient ischemic attack used to be a serious complication of the transbrachial access, thus limiting the use of the brachial access in interventional procedures (26,27,32). Hamon et al. (34) used MRI to observe the occurrence of cerebral microthrombosis after transradial coronary cannulation. Cerebral complications may be related to the manipulation of the guidewire or catheter as it passes through the aortic arch. In this study, there were no encephalitic complications, and we tried to avoid manipulation of the aortic arch to reduce the risk of microthrombosis during treatment.

Catheter displacement is a noteworthy problem that occurs during HAIC and may affect the outcome. Catheter displacement was observed in 3.68% of patients in this study. This was closely related to the patients’ substantial shoulder joint movement. Extensive joint movement may cause the microcatheter to exit the target vessel. To reduce the risk of catheter displacement, the left upper arm can be attached to the chest wall and secured with a bandage to limit substantial shoulder joint motion.

A preliminary exploration of how many HAIC procedures can be tolerated via TBA access was performed. In this study, one patient underwent five HAIC procedures, 18 patients underwent four HAIC procedures, and 15 patients underwent more than three HAIC procedures without serious complications. It is probably safe to perform 3 to 4 HAIC treatments via TBA access.

Perfusion chemotherapy via the hepatic artery access is worth noting. In one patient, the chemotherapy drugs that were infused via the vascular sheath entered the circulation via TBA, causing temporary vascular irritation in the left upper arm and contracture of the left arm and resulting in the inability to straighten it. After rehabilitation exercises, the left arm function was largely restored to normal after 1 month. The team performing HAIC requires specialized training to avoid such events and reduce the incidence of adverse events.

This study was retrospective and may have led to reporting bias. Patients were routinely screened via preoperative ultrasound, which may have resulted in a higher success rate. A randomized controlled trial is needed to further analyze whether TBA is superior to other access points.

Conclusions

In conclusion, brachial artery access is feasible and safe in HAIC for patients with hepatocellular carcinoma. More studies are needed in the future to confirm whether TBA is superior to other accesses.

Acknowledgments

Funding: This study was supported by Scientific Innovation and Development Project of Tangdu Hospital (Grant No. 2021TYJC-004) and is partially supported by the SenseTime Joint Lab of Smart Health Care, Xidian University (Grant No. A202201).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-23-523/rc

Data Sharing Statement: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-23-523/dss

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-23-523/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-23-523/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This retrospective study was approved by the Ethics Committee of Tangdu Hospital (No. K202108-43). The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013), and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Xiong J, Zhou Y, Tan K, Liu H, Cao Y, Liu J, Wu W, Du X, Luo Z. The feasibility and safety of the brachial artery approach in the treatment of hepatic artery infusion chemotherapy: a retrospective study. J Gastrointest Oncol 2023;14(4):1830-1836. doi: 10.21037/jgo-23-523

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