BackgroundTo assess the technical and clinical outcome of percutaneous insertion of tunneled peritoneal catheters in the palliative treatment of refractory malignant ascites and to determine the safety and feasibility of intraperitoneal administration of cytotoxic drugs through the tunneled catheter.Materials and methodsConsecutive patients palliatively treated with a tunneled peritoneal catheter to drain the malignant ascites were identified. Patients’ medical history, procedural and clinical follow-up data, including complications and estimated survival, were reviewed. Additionally, a sub analysis of the patients with widespread ovarian cancer and refractory ascites treated with or without intraperitoneal administration of cytotoxic drugs was made.ResultsIn all 94 patients it was technically feasible to insert the peritoneal drainage catheter and to drain a median of 3260 cc (range 100 cc – 8500 cc) of malignant ascitic fluid. Post procedural complications included catheter infection (n = 2; 2%), fluid leakage around the entry site (n = 4; 4%), catheter occlusion (n = 2; 2%), sleeve formation around the catheter tip (n = 1; 1%) and accidental loss of the catheter (n = 1; 1%). There was no increase in catheter infection rate in patients treated with or without intraperitoneal administration of cytotoxic drugs. Median overall survival after catheter insertion is 1.7 months.ConclusionsPercutaneous insertion of a tunneled Tenckhoff catheter for the palliative drainage of malignant ascites and intraperitoneal infusion of cytotoxic drugs is feasible and associated with a very low complication rate, including catheter infection. These tunneled peritoneal lines are beneficial for symptomatic palliative treatment of refractory ascites and allow safe intraperitoneal chemotherapy.

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A 56-year-old man presented with fatigue and intermittent, occult lower gastrointestinal bleeding since a percutaneous transluminal coronary angioplasty with bare metal stent implantation was performed for critical stenosis of the left anterior descending. Associated medical treatment was aspirin 80 mg and clopidogrel 75 mg daily. One episode of massive lower gastrointestinal bleeding (hemoglobin 5.0 g/dL) occurred 1 day after endoscopic polypectomy, which was treated with 6 units of packed cells.Endoscopic work-up included a negative gastroscopy and colonoscopy. A double-balloon enteroscopy revealed pulsatile waves in the distal ileal mucosa.Contrast-enhanced computed tomography scan revealed a hypertrophied ileocolic artery (arrowheads) feeding a preterminal ileal small bowel loop presenting with a hyperdense contrast enhancement (small arrows); early filling of a hypertrophied ileal draining vein (large arrow) is also seen ( Figure A). A catheter-directed selective angiogram showed a hypertrophied ileocolic artery (small arrows) and end-branches (arrowheads) and an early draining hypertrophied ileal vein (large arrow) ( Figure B), suggesting an ileal high-flow arterioportal vascular malformation. Because of the large intestinal territory the high-flow malformation was extended, it was decided to resect the affected small bowel segment.Pathologic analysis of the resected specimen (hematoxylin-eosin; original magnification, Â25) revealed a submucosal high-flow arteriovenous malformation with very large, thick-walled vessels in the submucosa (yellow arrows); the muscularis propria is indicated by a yellow star ( Figure C). Clinical follow-up after surgery was uneventful.High-flow arterioportal vascular malformations are extremely rare and are mostly seen as spontaneously formed vascular lesions within a hepatocellular carcinoma 1 ; extrahepatic arterioportal fistulas are extremely rare and can be isolated or associated with a visceral aneurysm, eroding into the portal circulation. 2 Intestinal angiodysplasia is characterized by the presence of thin, ectatic vessels with little or no smooth muscle but without early draining veins. 2 Clinically these lesions tend to bleed intermittently, especially in patients on antiplatelet or anticoagulation drug regimens. 2 In the present case, there was radiologic, macroscopic, and microscopic pathologic evidence of a highflow arterioportal vascular malformation located in the preterminal ileum. Because of the intermittent bleeding episodes and the potential for progression to symptomatic portal hypertension and liver cirrhosis, surgical resection seemed to be justified.These are our main findings. A small bowel highflow arterioportal vascular malformation may cause