Authors: Kozarek K L et al.
A & A Practice, 20(3):e02163, March 2026
This article reviews anesthetic management for percutaneous hepatic perfusion (PHP), a relatively new, minimally invasive technique used to treat hepatic metastases from uveal melanoma.
PHP is designed to deliver high-dose chemotherapy (melphalan) directly to the liver while limiting systemic exposure. The procedure involves isolating hepatic venous outflow with a double-balloon catheter and using an extracorporeal hemofiltration circuit to remove chemotherapy before blood returns to systemic circulation. While less invasive than open isolated hepatic perfusion, PHP introduces significant anesthetic complexity.
The most important intraoperative challenge is profound and predictable hemodynamic instability. The authors identify three distinct phases of hypotension. The first occurs with balloon inflation due to reduced preload as hepatic venous return is isolated. The second—and most severe—occurs when blood is exposed to carbon filters in the extracorporeal circuit, likely due to cytokine release, vasodilation, and removal of endogenous catecholamines. The third occurs when the bypass line is clamped, forcing full flow through the filters and worsening vasodilation.
Management requires aggressive preparation. Patients are preloaded with both crystalloid and albumin, and vasopressors are initiated preemptively before each high-risk phase. High-dose norepinephrine and vasopressin infusions are often required, with transient systolic blood pressures dropping into the 70–80 mm Hg range despite maximal support. The authors emphasize timing and coordination with the interventional radiology and perfusion teams to blunt these hemodynamic swings.
Coagulopathy is another major issue. Patients receive full heparinization (ACT >450 seconds) for extracorporeal circulation, followed by protamine reversal. Postoperatively, hypofibrinogenemia, thrombocytopenia, and elevated INR are common due to filtration effects. The authors favor viscoelastic testing to guide transfusion rather than empiric blood product administration.
Metabolic derangements are frequent after the procedure, including metabolic acidosis, hypocalcemia, and hyperglycemia, all of which require correction. Despite the intensity of the procedure, most patients can be extubated immediately and monitored in the ICU.
Cardiovascular stress is significant, with frequent postoperative troponin elevations consistent with type 2 myocardial injury. These are thought to result from repeated episodes of hypotension, hypertension, tachycardia, and high-dose vasopressor use. However, these elevations are typically transient and not associated with major adverse cardiac events.
The article highlights the importance of multidisciplinary coordination. Successful PHP programs rely on tight collaboration between anesthesia, interventional radiology, oncology, and perfusion teams. Standardized protocols, careful patient selection, and experienced providers are essential to safely manage this high-risk but increasingly utilized therapy.
Key Points
- PHP allows high-dose liver-directed chemotherapy with extracorporeal filtration
- Three predictable phases of severe hypotension occur during the procedure
- Requires aggressive volume loading and high-dose vasopressor support
- Significant coagulopathy develops due to hemofiltration and anticoagulation
- Postoperative troponin elevation is common but usually clinically insignificant
- Multidisciplinary coordination is critical for safe execution
What You Should Know
This is not a routine IR case—it behaves more like cardiopulmonary bypass physiology in an interventional suite. If you are covering PHP, expect extreme hemodynamic swings, high vasopressor requirements, and complex coagulation management. The key to success is anticipation: preload early, start pressors before instability occurs, and maintain constant communication with the procedural team. As PHP expands, anesthesia providers will need to approach this as a high-acuity, protocol-driven procedure rather than a typical radiology case.
We want to thank A & A Practice for allowing us to summarize and share this important work with the anesthesia community.