fig4

Figure 4. Angiographic images of the first percutaneous hepatic perfusion (PHP) performed in the patient. Please note, that after right hemihepatectomy, the anatomy of the upper abdomen has shifted due to the compensatory growths of the remaining liver tissue. After ultrasound-guided puncture of the left common femoral artery and insertion of a 5F sheath, a 4F diagnostic catheter is placed in the celiac trunk. (A)digital subtraction angiography (DSA) of the celiac trunk is performed. The left hepatic artery originates from the left gastric artery (orange arrow). The blue arrow marks an additional branch supplying the liver, which comes from the gastroduodenal artery; Both branches are selected as therapy positions and are successively probed using a microcatheter: (B) microcatheter-based probing of the left hepatic artery; (C) microcatheter-based probing of the additional branch coming from the gastroduodenal artery. Before administering the chemotherapy, the right common femoral vein is punctured using ultrasound-guidance. After insertion of a 18F sheath, a double balloon catheter in placed in the inferior vena cava (IVC); (D) the cranial balloon (blue) is inflated above the confluens of the liver veins and the caudal balloon (yellow) in inflated caudal the confluens. Using a dedicated side port of the double balloon catheter, a DSA of the IVC and liver veins is performed to rule out leakages alongside the balloons. Afterwards, subsequent chemotherapy infusion via the first and then second therapy position is performed. (Neither the extracorporeal circuit nor the venous return sheath placed in the internal jugular vein are depicted in this Figure. Please refer to the schematic overview in Figure 1.)