Percutaneous Hepatic Perfusion (PHP) with Melphalan as a Treatment for Unresectable Metastases Confined to the Liver

The overall goal of this procedure is to carry out Percutaneous Hepatic Perfusion to treat unresectable metastases confined to the liver. The main advantage of this technique is that it allows delivery of a high dose of chemotherapeutic agents to the liver with limited systemic exposure. It is minimally invasive, and therefore associated with low mobility and mortality rates.

And finally, an advantage is that it can be repeated. Demonstrating the procedure will be Christian Martini, the anesthesiologist, and Fred Tijl, the perfusionist. In preparation for the PHP procedure, perform a pre-procedural angiography several days prior to PHP, according to the text protocol.

On the day of the PHP procedure, have the extracorporeal profusionist, or ECP, collect the chemo saturation tubing pack, chemo filters, and the centrifugal pump as provided by the manufacturer. With carbon dioxide gas, flush the complete extracorporeal circuit. Then, use 0.9%sodium chloride and heparin to prime the circuit, including the filters.

Allow six liters of heparinized 0.9%sodium chloride to rinse the extracorporeal system initially through the force of gravity. Then after the carbon filters are fully hydrated, use the centrifugal pump to apply more pressure to the filter to remove the remaining gas bubbles. After the anesthesiologist prepares the patient according to the text protocol, have the interventional radiologist or IR, use ultrasound to place a 7.5F triple lumen, 27 centimeter intravenous catheter in the left internal jugular vein, or IJV.

Next, place a 10F venous return catheter in the right IJV, and insert a 5F sheathe into the left common femoral artery, or CFA. Using eight to 10F and 12 to 14F dilaters, perform a serial dilation of the right common femoral vein, or CFV, using the dilaters to adjust the insertion opening to the correct size. Then insert an 18F sheathe that will be used to introduce the double balloon catheter.

Check the blood pressure of the patient. Following the administration of heparin and after starting norepinephrine and phenylephrine according to the text protocol, through the 5F sheathe in the left CFA, introduce the 2.7F micro catheter coaxially, and with angiography monitoring, insert it into the proper hepatic artery or lobar arteries. Attach filters and pump to the sheathe in the jugular vein BIJECP.

Through the 18F sheathe and the right CFV, introduce the 16F double balloon catheter or isolation aspiration catheter, and via the angiography monitor, place it with the tip in the right atrium. Attach the extracorporeal filter system to the balloon catheter. Fill the extracorporeal system with the patient's blood.

Next, start the centrifugal pump per the manufacturer's instructions. And after intravenous infusion of 0.5 liters of colloid solution, use a 50%saline, 50%contrast medium mixture to inflate the cranial balloon. Monitor the blood pressure by anesthesiologist and radiologist, for a decrease in blood pressure is likely after inflation of the cranial balloon.

Then with the coddled balloon still deflated, slowly retract the double balloon catheter until the cranial balloon is at the junction of the right atrium and the inferior caval vein or ICV, just above the right hepatic vein. The balloon will now be wedge shaped. Using a solution of 90%saline and 10%contrast medium, inflate the coddled balloon until the lateral edges start to become effaced by the ICV.

To use phonography to check the position of the balloons and to check for leaks, by hand, inject 20 milliliters of contrast through the fenestration port of the venous double balloon catheter. Check the position of the balloons by retrograde injection of contrasts through the fenetrated double balloon catheter. When sufficient flows and pressures have been reached according to the text protocol, open the filters one by one.

Then, when a systolic blood pressure between 140 and 160 milliliters of mercury has been reached, close the bypass line. Attach the melphalan into the injector and load the pump. Be aware of a drop in blood pressure.

After performing another venography to check positioning of the double balloon, perform an angiogram by injecting contrast through the micro catheter in the hepatic artery to rule out arterial spasm. When a steady flow rate is established, no leakage is present, and the patient's blood pressure is stable, use an auto-injector to administer 100 milliliters of three milligrams per kilogram of melphalan into the proper hepatic artery or sequentially into both lobar arteries at a rate of 0.4 ccs per second. Following the 30 minutes of chemotherapeutic infusion, continue hemofiltration for an additional 30 minute washout period.

After complete infusion, a 30 minute washout time follows. After the washout period, slowly deflate the double cava balloons. Then empty the extracorporeal circuit as much as possible before stopping the extracorporeal perfusion.

Remove the double balloon catheter and the infusion micro catheter, but leave the access sheathes in place until coagulation is normalized. Place a vascular closure device in the common femoral artery if desired, to achieve hemostasis. Finally, close and remove the bypass circuit, stabilize the patient, and carry out post-operative care according to the text protocol.

Shown here is an overview of small case one and two trials, and a case series for PHP. The first manuscript was published in 1994 and 5-FU and doxorubin were used. Published overall response rates varied between 30 and 90%and survival data were not reported.

A recent phase three trial comparing PHP to best alternative care, or BAC, for patients with hepatic metastases of uveal melanoma reports significant improved hepatic progression-free survival of seven months, compared to 1.6 months for the group that received BAC. Once mastered, this procedure can be performed in three to four hours if performed properly. When attempting percutaneous hepatic perfusion, patient selection is very important.

Patients should be fit to undergo treatment and they should have liver-dominant or liver-only disease. Patients that are most likely to be the best candidates for percutaneous hepatic perfusion are patients with metastases from ocular melanoma. After watching this video, you should be able to understand how percutaneous hepatic perfusion is performed in a patient with liver tumors.

Bare in mind that the procedure is best performed by a well trained and dedicated team of interventional radiologists, anesthesiologists, perfusionists, and technicians. Don't forget that significant hemodynamic perturbations may occur during the procedure and may require administration of high doses of sympathomimetics. Bone marrow depression is not uncommon and may be anticipated by administration of granulocyte colony-stimulating factor one to two days after the procedure.