Using a femoral approach for inserting an intra-arterial percutaneous catheter-port
device has recently been introduced for targeted treatment of hepatic tumors [[1]]. Unlike permanent devices that have to be implanted surgically under general anesthesia,
percutaneous catheter-ports may be installed under local anesthesia, a benefit for
the many cancer patients who have already undergone cancer surgery. The subclavian
route is also an option; however, there exists a risk of pneumothorax, reported to
be around 4%, and also other complications such as local hematoma and brain infarction
[[2],[3]]. Thus, many institutions have been compiling their experience with femoral access
and have reported relatively low complication rates [[1],[2]].
Unfortunately, as with any injection device, there is always the possibility of extravasation,
the leakage of injection material into tissue other than that targeted. Chemotherapeutic
agents are generally cytotoxic and may cause necrosis of the surrounding tissue in
the thigh and groin area; therefore, this medical emergency must never be underestimated.
A 29-year-old male patient was referred to the plastic surgery department for infection
signs in his right inguinal area ([Fig. 1]). A hepatitis B carrier through vertical transmission, he had been diagnosed with
hepatocellular carcinoma one month previously, and had received his first cycle of
chemotherapy by way of a percutaneous intra-arterial catheter port device via his
femoral artery.
While being started on his second cycle, he reported pain in the port area, and administration
of epirubicin was immediately stopped. An estimated 15 mL of epirubicin had been administered.
The port function was tested, and was found to be normal. Inflammation signs increased,
and the port device was removed three days later. He had developed erythema, induration,
and swelling of his right medial thigh with a necrotic skin defect measuring 3 cm
in diameter, and was thus referred to the plastic surgery department a week after
the incident. Computed tomography revealed diffuse swelling and inflammation of the
right femoral area, without any abnormal fluid collection.
Fig. 1 The lesion upon consultation. There is dry eschar, edema, and skin color change
in the right thigh of the patient.
The wound was dressed until demarcation, during which an area of erythematous induration
20×10 cm in size developed, with several points of skin necrosis. Excision of the
unhealthy skin was performed, and the necrotic soft tissue was debrided until healthy
pinpoint bleeding was found at the fascia level. Local flap coverage was performed
and negative pressure wound therapy was applied to aid flap approximation and circulation
([Fig. 2]).
Fig. 2 Intraoperative views. (A) Necrotic tissue including the skin, subcutaneous
layer, and part of the muscle fascia is debrided. (B) Local flap coverage is performed.
The flap took about 6 weeks to heal completely, with small areas of disruption that
were closed by secondary intention ([Fig. 3]). The patient's low levels of albumin ranging from 2.5 to 3.0 g/dL, anemia with
hemoglobin concentrations ranging from 8.2 to 11.0 g/dL, and cycles of chemotherapy
were all factors delaying the process of healing. His wound was otherwise uneventful
until he expired just over 6 months after diagnosis due to multiorgan failure. Hepatic
arterial infusion chemotherapy uses the hepatic artery catheter as a conduit to deliver
antineoplastic agents in high concentrations to liver tumors. Permanent intra-arterial
catheter systems have to be inserted surgically, either into the gastroduodenal artery
or the common hepatic artery. To facilitate long-term administration, percutaneous
implantable catheter-port devices have been developed. Herrmann reported on the use
of the femoral artery for percutaneous implantation in 2000, a readily accessible
method with which most radiologists are familiar [[1]]. The procedure may be performed under local anesthesia and provides a subcutaneous
port that is available for repeated chemotherapy or prolonged parenteral nutrition.
The success rate for implantation has been reported to be 90% to 100%, and the implantation
technique has been constantly refined to prevent such technical complications as catheter
dislocation or migration, catheter occlusion, or extrahepatic perfusion [[3]].
Fig. 3 The wound at 6 weeks' follow-up. The flap healed completely.
Chemotherapy ports, like all other injection devices, carry a risk of extravasation,
the leakage of an injection agent into untargeted surrounding tissue. The incidence
of implanted port extravasation has been reported to be 0.3% to 4.7% [[4]]. However, this is probably lower than the actual incidence, as most cases are not
reported in the literature. Femoral ports, with their many benefits, are unfortunately
located in an area where there is usually an abundance of soft tissue, unlike the
subclavian port, which is easily located visually. This increases the risk of missing
the target, and also necessitates use of a longer needle, which may be more easily
dislodged. This also increases the risk of delayed detection because a significant
amount of fluid may extravasate subcutaneously before tissue pressures increase.
Extravasation results in serious necrosis of the surrounding tissue and vasculature,
and may require extensive debridement and reconstruction, as in our case. Thus, the
authors suggest that several basic precautions be strictly adhered to when implanting
and injecting femoral catheter ports. If possible, the port should be located in a
more superficial layer so that it is visible externally. Blood withdrawal before injection
and saline injection preceding the agent to check for adequate needle placement is
mandatory. If in doubt, insertion of the injection needle under ultrasonographic guidance
is an option. Patient education and monitoring of the medical team are needed, given
the fact that thigh soft tissue is thick and therefore signs of extravasation may
be more muted in this area.
Oncology patients in general, not to mention hepatic tumor patients, are in a catabolic
state, and consequently have a delayed wound healing prognosis. Extravasation is a
devastating medical accident that is detrimental to the patient's quality of life
and physical health. The patient in our case spent two months of his remaining six
months of life recovering from this injury. The risk of extravasation should always
be kept in mind when manipulating femoral catheter ports.
