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Prophylactic Embolization of the Gastroduodenal and Right Gastric Arteries Is Not Routinely Necessary before Radioembolization with Glass Microspheres
Volume 24
’
Number 11
’
November
’
2013
1743
the utility of aggressive retrieval methods for technically complex cases. As the number of implanted optional IVC filters continues to increase, interventional radiologists will continue to see an increasing number of complex filter retrievals. In cases in which advanced techniques prove unsuccessful individually, combined approaches such as the sling and grasping forceps technique described herein may be the difference between successful filter retrieval and conversion of the filter into a permanent device.
REFERENCES 1. Angel LF, Tapson V, Galgon RE, Restrepo MI, Kaufman J. Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol 2011; 22:1522–1530. 2. Iliescu B, Haskal ZJ. Advanced techniques for removal of retrievable inferior vena cava filters. Cardiovasc Intervent Radiol 2012; 35:741–750. 3. Stavropoulos SW, Dixon RG, Burke CT, et al. Embedded inferior vena cava filter removal: use of endobronchial forceps. J Vasc Interv Radiol 2008; 19:1297–1301. 4. Kuo WT, Tong RT, Hwang GL, et al. High-risk retrieval of adherent and chronically implanted IVC filters: techniques for removal and management of thrombotic complications. J Vasc Interv Radiol 2009; 20:1548–1556.
with yttrium-90 (90Y) is one such intraarterial therapy. Y can be delivered to hepatic tumors in the form of an insoluble glass bead in which 90Y serves as an integral component, TheraSpheres (Nordion, Ottawa, Canada), or as a biocompatible resin-based microsphere impregnated with 90Y, SIR-Spheres (SIRTeX Medical Ltd, Lane Cove, Australia). Although both products use 90Y, TheraSpheres and SIR-Spheres are distinctly different from one another. These differences are reflected in the number and specific activity per microsphere implanted during a treatment session (Table 1). Radioembolization, an outpatient procedure, has an excellent safety profile. Compared with bland arterial embolization or chemoembolization, radioembolization is less often associated with symptoms after embolization, such as abdominal pain, fever, nausea, and vomiting. Additionally, radioembolization has been shown to result in a longer time to progression compared with chemoembolization in patients with hepatocellular carcinoma (1). However, radioembolization theoretically poses a greater risk for the development of gastrointestinal inflammation or ulcers secondary to the nontarget delivery of potent radiation therapy. This nontarget embolization is predominantly via the gastroduodenal artery (GDA) or right gastric artery (RGA) or both (2,3). The published incidence of gastroduodenal ulcer after radioembolization is 0.7%– 28.6% (4). To mitigate the risk of nontarget embolization, most standards guidelines have emphasized (i) identification
Prophylactic Embolization of the Gastroduodenal and Right Gastric Arteries Is Not Routinely Necessary before Radioembolization with Glass Microspheres
90
From: Nabeel Hamoui, MD Jeet Minocha, MD Khairuddin Memon, MD Kent Sato, MD Robert Ryu, MD Riad Salem, MD, MBA Robert J. Lewandowski, MD Department of Radiology (N.H., K.M., K.S., R.R., R.S., R.J.L.) Northwestern Memorial Hospital 251 East Huron Street, Suite 800 Chicago, IL 60611 Department of Radiology (J.M.) University of Illinois Hospital and Health Sciences System Chicago, Illinois
Editor: Transcatheter intraarterial liver-directed therapies are increasingly being used for treatment of unresectable primary and secondary hepatic malignancies. These therapies take advantage of the liver’s dual blood supply and the principle that hepatic tumors receive most of their blood supply via the hepatic arteries. Radioembolization Table 1 . Comparison of Available Yttrium-90 Radioembolic Devices TheraSphere
TheraSphere-EX
SIR-Spheres
Manufacturer
Nordion (Ottawa, Canada)
Nordion (Ottawa, Canada)
SIRTeX (Medical Ltd, Lane Cove, Australia)
Material
Glass
Glass
Resin
Size of particle Specific activity
25 m 2,500 Bq/sphere
25 m 250–300 Bq/sphere
35 m 50 Bq/sphere
3 GBq vial
1.2 million spheres
1.2 million spheres
40–80 million spheres
Spheres per treatment Embolic load
2–4 million Minimal
8–12 million Minimal-mild
13–40 million Moderate
From the SIR 2013 Annual Meeting. R.S. is a paid consultant for Nordion. R.J.L. served on an advisory board for Nordion. None of the other authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.07.011
1744
’
Letters to the Editor
Hamoui et al
Table 2 . Summary of Coil Embolization Procedures Performed No. Patients No coiling performed
92 (68.7%)
RGA coiling only GDA coiling only
28 (20.9%) 7 (5.2%)
Both RGA and GDA coiled Total
7 (5.2%) 134
GDA ¼ gastroduodenal artery, RGA ¼ right gastric artery.
of extrahepatic perfusion on planning angiography and (ii) prophylactic embolization of the GDA and RGA before all radioembolization procedures (5). This technique effectively skeletonizes the hepatic arteries, similar in concept to the technique previously employed by surgeons placing hepatic artery infusion ports (6). Over the course of performing 4 2,000 radioembolization procedures, we have changed our practice, and we no longer routinely perform embolization of the GDA or RGA before radioembolization with glass microspheres. In our experience, this technology is minimally embolic, without the risk of inadvertent reflux to proximal vessels. This concept was confirmed more recently using cone-beam computed tomography imaging (7). With this background, we performed a retrospective review of 134 consecutive patients with unresectable primary or secondary hepatic malignancy undergoing radioembolization with glass 90Y microspheres. Conservatively, we included only patients treated with extended shelf-life glass microspheres. These are vials of glass 90Y microspheres decayed to the allowable second week of their shelf life. Each microsphere is of lower specific activity at the time of delivery. A higher number of microspheres is required to achieve the same desired dose. In our series, the mean number of microspheres was 7.78 million, and mean dose was 123 mGy. The rationale behind the development and use of extended-glass microspheres is predicated on the increased embolic load and decreased activity per microsphere, theoretically resulting in better tumor coverage and improved response rates (8). In 68.7% (92 of 134) of patients, neither the GDA nor the RGA underwent coil embolization. In these patients, the microcatheter was placed distal to the GDA or RGA or both during infusion of the microspheres. Both the GDA and the RGA underwent coil embolization in only 5.2% (7 of 134) of patients. The RGA was the only vessel that underwent coil embolization in 20.9% (28 of 134) of patients, and the GDA was the only vessel that underwent coil embolization in 5.2% (7 of 134) of patients (Table 2). Two patients (1%) in the group who did not undergo prophylactic embolization of either the RGA or the GDA developed gastrointestinal ulcers, both of which healed with conservative therapy. In one case, retrospective analysis of the angiogram demonstrated a small gastric vessel that was overlooked during planning angiography and radioembolization. The microcatheter was placed proximal to the RGA at the time of treatment, resulting in nontarget delivery of radioactive microspheres.
’
JVIR
Endoscopic biopsy revealed glass microspheres in the gastric wall of this patient. The other patient had a history of peptic ulcer disease and developed an ulcer 6 weeks after radioembolization. This patient was found to have melena by routine screening; he was asymptomatic. Endoscopic biopsy did not reveal glass microspheres. The ulcer healed with conservative measures. The potential theoretical advantage of prophylactic GDA or RGA coil embolization includes a reduction in the risk of nontarget embolization. Our cohort suggests that this potential advantage becomes less clinically necessary with glass microsphere radioembolization as the user gains experience. We now routinely perform prophylactic coil embolization of the GDA or RGA only when there is poor hepatic antegrade flow, most commonly observed in patients who have been receiving bevacizumab (Avastin; Genentech, San Francisco, California). In a series of 247 patients, Lam et al (9) reported that stasis of flow during 90Y administration was the strongest independent risk factor for developing nontarget embolization and subsequent gastroduodenal ulceration. These investigators noted that patients receiving bevacizumab were at highest risk for developing stasis of flow. An ancillary advantage of prophylactic coil embolization is increased reimbursement owing to the separate procedural codes for coil embolization during the mapping angiogram. The “advantage” of increased reimbursement may become negated with the increased tendency toward bundling of fees for procedures. Routine prophylactic coil embolization of the GDA and RGA has numerous disadvantages, including increased procedure complexity, increased radiation dose to the patient and the interventional radiologist because of increased procedure time, inadvertent vessel injury or coil deployment, and development of new hepatic-enteric collaterals (10). Many of these disadvantages may ultimately affect the ability to deliver intraarterial therapy safely. Because of these disadvantages, some authors have advocated the use of antireflux techniques and catheters (11). Although these devices potentially prevent nontarget embolization via reflux of microspheres, they may cause vessel injury or spasm secondary to the device size and inflexibility. In our practice, we have found that using standard microcatheters in conjunction with meticulous technique and proper catheter positioning is sufficient in allowing one to perform radioembolization safely with an extremely low incidence of nontarget embolization. Our observations, coupled with the challenges and risks of GDA and RGA coil embolization, lend further support to the need to reconsider routine, prophylactic coil embolization of the GDA and RGA before radioembolization procedures, specifically with regard to using glass microspheres. Even with the most embolic formulation of this device, second-week shelf-life microspheres, the risk of vascular stasis or reflux and gastrointestinal ulcer appears to be acceptably low in patients who do not undergo prophylactic GDA or RGA coil embolization.
Volume 24
’
Number 11
’
November
’
2013
Coil embolization should be considered when antegrade arterial flow is diminished, such as in patients receiving bevacizumab. Our results have three important limitations. First, our data were gathered from procedures performed at a tertiary care center with extensive radioembolization experience and as such may make our observations less generalizable. Second, our analysis focused on glass microspheres and cannot be extrapolated to the more moderately embolic resin spheres. Further studies are needed before any further recommendations for resin spheres can be made. Third, this is a letter to the editor and not a formal scientific article. More studies, including one with a larger series powered to achieve statistical significance, are needed before these observations can be generalized.
REFERENCES 1. Salem R, Lewandowski RJ, Kulik L, et al. Radioembolization results in longer time-to-progression and reduced toxicity compared with chemoembolization in patients with hepatocellular carcinoma. Gastroenterology 2011;140: 497.e2–507.e2. 2. Riaz A, Lewandowski RJ, Kulik LM, et al. Complications following radioembolization with yttrium-90 microspheres: a comprehensive literature review. J Vasc Interv Radiol 2009; 20:1121–1130; quiz 1131.
Unexpected Ischemic Complication after Proximal Coil Embolization of a Replaced Left Hepatic Artery before Yttrium-90 Radioembolization From: Geert Maleux, MD, PhD Pascal Wolter, MD Ragna Vanslembrouck, MD Christophe Deroose, MD, PhD Departments of Radiology and Imaging & Pathology (G.M., R.V.), Medical Oncology (P.W.), and Nuclear Medicine (C.D.) University Hospitals Leuven KU Leuven Herestraat 49 B-3000 Leuven, Belgium
Editor: Proximal coil embolization of variant hepatic arteries is a safe and effective method to simplify yttrium-90 (90Y) radioembolization by reducing the number of sites of 90 Y administration necessary to treat all targeted tumors and by facilitating treatment of tumors in territories supplied by a hepatic artery with a variant anatomy. Consolidation of arterial inflow into the liver segments that have received embolization is still possible via intrahepatic collateral channels, and the tumoricidal effect seems to be unaffected by proximal coil occlusion None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.04.026
1745
3. Cosin O, Bilbao JI, Alvarez S, de Luis E, Alonso A, Martinez-Cuesta A. Right gastric artery embolization prior to treatment with yttrium-90 microspheres. Cardiovasc Intervent Radiol 2007; 30:98–103. 4. Naymagon S, Warner RR, Patel K, et al. Gastroduodenal ulceration associated with radioembolization for the treatment of hepatic tumors: an institutional experience and review of the literature. Dig Dis Sci 2010; 55:2450–2458. 5. Lewandowski RJ, Sato KT, Atassi B, et al. Radioembolization with 90Y microspheres: angiographic and technical considerations. Cardiovasc Intervent Radiol 2007; 30:571–592. 6. Salem R, Lewandowski RJ, Sato KT, et al. Technical aspects of radioembolization with 90Y microspheres. Tech Vasc Interv Radiol 2007; 10: 12–29. 7. Pellerin O, Lin M, Bhagat N, Shao W, Geschwind JF. Can C-arm cone-beam CT detect a micro-embolic effect after TheraSphere radioembolization of neuroendocrine and carcinoid liver metastasis? Cancer Biother Radiopharm In press; available online March 13, 2013. 8. Lewandowski RJ, Riaz A, Ryu RK, et al. Optimization of radioembolic effect with extended-shelf-life yttrium-90 microspheres: results from a pilot study. J Vasc Interv Radiol 2009; 20: 1557–1563. 9. Lam MG, Banerjee S, Louie JD, et al. Root cause analysis of gastroduodenal ulceration after yttrium-90 radioembolization. Cardiovasc Intervent Radiol In press; available online February 22, 2013. 10. Abdelmaksoud MH, Hwang GL, Louie JD, et al. Development of new hepaticoenteric collateral pathways after hepatic arterial skeletonization in preparation for yttrium-90 radioembolization. J Vasc Interv Radiol 2010; 21:1385–1395. 11. Arepally A, Chomas J, Kraitchman D, Hong K. Quantification and reduction of reflux during embolotherapy using an antireflux catheter and tantalum microspheres: ex vivo analysis. J Vasc Interv Radiol 2013; 24:575–580.
and flow redistribution of variant hepatic arteries (1). We report an ischemic complication as a result of proximal coil embolization of a replaced left hepatic artery before 90Y radioembolization. A 47-year-old woman presented with abdominal pain related to diffuse metastatic liver involvement as detected by ultrasound. Computed tomography (CT) confirmed the presence of a diffuse spread of multiple, nearly isodense metastases over both liver lobes. The portal venous system was completely patent without any tumor encasement. Liver biopsy revealed metastases from malignant melanoma. However, no primary or other extrahepatic focus could be identified. Initial treatment consisted of dacarbazine monotherapy. However, owing to poor tolerance and intrahepatic progression of disease (Fig 1), it was decided to treat the patient by selective internal radiation therapy using resin microspheres (SIR-Spheres; Sirtex Medical Inc, Woburn, Massachusetts, USA). The angiographic work-up revealed (i) a replaced left hepatic artery, originating from the left gastric artery; (ii) a middle hepatic artery supplying segment 4; and (iii) a replaced right hepatic artery originating from the superior mesenteric artery (Fig 2a, b). Because several small gastric end branches were close to the origin of the replaced left hepatic artery, we decided to perform a proximal coil occlusion (Micro-Tornado; Cook Medical, Bjaeverskov, Denmark) of the replaced left hepatic artery. After additional proximal coil occlusion of the gastroduodenal artery, technetium-99m-labeled macroaggregated albumin was selectively injected into the
’
Number 11
’
November
’
2013
1743
the utility of aggressive retrieval methods for technically complex cases. As the number of implanted optional IVC filters continues to increase, interventional radiologists will continue to see an increasing number of complex filter retrievals. In cases in which advanced techniques prove unsuccessful individually, combined approaches such as the sling and grasping forceps technique described herein may be the difference between successful filter retrieval and conversion of the filter into a permanent device.
REFERENCES 1. Angel LF, Tapson V, Galgon RE, Restrepo MI, Kaufman J. Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol 2011; 22:1522–1530. 2. Iliescu B, Haskal ZJ. Advanced techniques for removal of retrievable inferior vena cava filters. Cardiovasc Intervent Radiol 2012; 35:741–750. 3. Stavropoulos SW, Dixon RG, Burke CT, et al. Embedded inferior vena cava filter removal: use of endobronchial forceps. J Vasc Interv Radiol 2008; 19:1297–1301. 4. Kuo WT, Tong RT, Hwang GL, et al. High-risk retrieval of adherent and chronically implanted IVC filters: techniques for removal and management of thrombotic complications. J Vasc Interv Radiol 2009; 20:1548–1556.
with yttrium-90 (90Y) is one such intraarterial therapy. Y can be delivered to hepatic tumors in the form of an insoluble glass bead in which 90Y serves as an integral component, TheraSpheres (Nordion, Ottawa, Canada), or as a biocompatible resin-based microsphere impregnated with 90Y, SIR-Spheres (SIRTeX Medical Ltd, Lane Cove, Australia). Although both products use 90Y, TheraSpheres and SIR-Spheres are distinctly different from one another. These differences are reflected in the number and specific activity per microsphere implanted during a treatment session (Table 1). Radioembolization, an outpatient procedure, has an excellent safety profile. Compared with bland arterial embolization or chemoembolization, radioembolization is less often associated with symptoms after embolization, such as abdominal pain, fever, nausea, and vomiting. Additionally, radioembolization has been shown to result in a longer time to progression compared with chemoembolization in patients with hepatocellular carcinoma (1). However, radioembolization theoretically poses a greater risk for the development of gastrointestinal inflammation or ulcers secondary to the nontarget delivery of potent radiation therapy. This nontarget embolization is predominantly via the gastroduodenal artery (GDA) or right gastric artery (RGA) or both (2,3). The published incidence of gastroduodenal ulcer after radioembolization is 0.7%– 28.6% (4). To mitigate the risk of nontarget embolization, most standards guidelines have emphasized (i) identification
Prophylactic Embolization of the Gastroduodenal and Right Gastric Arteries Is Not Routinely Necessary before Radioembolization with Glass Microspheres
90
From: Nabeel Hamoui, MD Jeet Minocha, MD Khairuddin Memon, MD Kent Sato, MD Robert Ryu, MD Riad Salem, MD, MBA Robert J. Lewandowski, MD Department of Radiology (N.H., K.M., K.S., R.R., R.S., R.J.L.) Northwestern Memorial Hospital 251 East Huron Street, Suite 800 Chicago, IL 60611 Department of Radiology (J.M.) University of Illinois Hospital and Health Sciences System Chicago, Illinois
Editor: Transcatheter intraarterial liver-directed therapies are increasingly being used for treatment of unresectable primary and secondary hepatic malignancies. These therapies take advantage of the liver’s dual blood supply and the principle that hepatic tumors receive most of their blood supply via the hepatic arteries. Radioembolization Table 1 . Comparison of Available Yttrium-90 Radioembolic Devices TheraSphere
TheraSphere-EX
SIR-Spheres
Manufacturer
Nordion (Ottawa, Canada)
Nordion (Ottawa, Canada)
SIRTeX (Medical Ltd, Lane Cove, Australia)
Material
Glass
Glass
Resin
Size of particle Specific activity
25 m 2,500 Bq/sphere
25 m 250–300 Bq/sphere
35 m 50 Bq/sphere
3 GBq vial
1.2 million spheres
1.2 million spheres
40–80 million spheres
Spheres per treatment Embolic load
2–4 million Minimal
8–12 million Minimal-mild
13–40 million Moderate
From the SIR 2013 Annual Meeting. R.S. is a paid consultant for Nordion. R.J.L. served on an advisory board for Nordion. None of the other authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.07.011
1744
’
Letters to the Editor
Hamoui et al
Table 2 . Summary of Coil Embolization Procedures Performed No. Patients No coiling performed
92 (68.7%)
RGA coiling only GDA coiling only
28 (20.9%) 7 (5.2%)
Both RGA and GDA coiled Total
7 (5.2%) 134
GDA ¼ gastroduodenal artery, RGA ¼ right gastric artery.
of extrahepatic perfusion on planning angiography and (ii) prophylactic embolization of the GDA and RGA before all radioembolization procedures (5). This technique effectively skeletonizes the hepatic arteries, similar in concept to the technique previously employed by surgeons placing hepatic artery infusion ports (6). Over the course of performing 4 2,000 radioembolization procedures, we have changed our practice, and we no longer routinely perform embolization of the GDA or RGA before radioembolization with glass microspheres. In our experience, this technology is minimally embolic, without the risk of inadvertent reflux to proximal vessels. This concept was confirmed more recently using cone-beam computed tomography imaging (7). With this background, we performed a retrospective review of 134 consecutive patients with unresectable primary or secondary hepatic malignancy undergoing radioembolization with glass 90Y microspheres. Conservatively, we included only patients treated with extended shelf-life glass microspheres. These are vials of glass 90Y microspheres decayed to the allowable second week of their shelf life. Each microsphere is of lower specific activity at the time of delivery. A higher number of microspheres is required to achieve the same desired dose. In our series, the mean number of microspheres was 7.78 million, and mean dose was 123 mGy. The rationale behind the development and use of extended-glass microspheres is predicated on the increased embolic load and decreased activity per microsphere, theoretically resulting in better tumor coverage and improved response rates (8). In 68.7% (92 of 134) of patients, neither the GDA nor the RGA underwent coil embolization. In these patients, the microcatheter was placed distal to the GDA or RGA or both during infusion of the microspheres. Both the GDA and the RGA underwent coil embolization in only 5.2% (7 of 134) of patients. The RGA was the only vessel that underwent coil embolization in 20.9% (28 of 134) of patients, and the GDA was the only vessel that underwent coil embolization in 5.2% (7 of 134) of patients (Table 2). Two patients (1%) in the group who did not undergo prophylactic embolization of either the RGA or the GDA developed gastrointestinal ulcers, both of which healed with conservative therapy. In one case, retrospective analysis of the angiogram demonstrated a small gastric vessel that was overlooked during planning angiography and radioembolization. The microcatheter was placed proximal to the RGA at the time of treatment, resulting in nontarget delivery of radioactive microspheres.
’
JVIR
Endoscopic biopsy revealed glass microspheres in the gastric wall of this patient. The other patient had a history of peptic ulcer disease and developed an ulcer 6 weeks after radioembolization. This patient was found to have melena by routine screening; he was asymptomatic. Endoscopic biopsy did not reveal glass microspheres. The ulcer healed with conservative measures. The potential theoretical advantage of prophylactic GDA or RGA coil embolization includes a reduction in the risk of nontarget embolization. Our cohort suggests that this potential advantage becomes less clinically necessary with glass microsphere radioembolization as the user gains experience. We now routinely perform prophylactic coil embolization of the GDA or RGA only when there is poor hepatic antegrade flow, most commonly observed in patients who have been receiving bevacizumab (Avastin; Genentech, San Francisco, California). In a series of 247 patients, Lam et al (9) reported that stasis of flow during 90Y administration was the strongest independent risk factor for developing nontarget embolization and subsequent gastroduodenal ulceration. These investigators noted that patients receiving bevacizumab were at highest risk for developing stasis of flow. An ancillary advantage of prophylactic coil embolization is increased reimbursement owing to the separate procedural codes for coil embolization during the mapping angiogram. The “advantage” of increased reimbursement may become negated with the increased tendency toward bundling of fees for procedures. Routine prophylactic coil embolization of the GDA and RGA has numerous disadvantages, including increased procedure complexity, increased radiation dose to the patient and the interventional radiologist because of increased procedure time, inadvertent vessel injury or coil deployment, and development of new hepatic-enteric collaterals (10). Many of these disadvantages may ultimately affect the ability to deliver intraarterial therapy safely. Because of these disadvantages, some authors have advocated the use of antireflux techniques and catheters (11). Although these devices potentially prevent nontarget embolization via reflux of microspheres, they may cause vessel injury or spasm secondary to the device size and inflexibility. In our practice, we have found that using standard microcatheters in conjunction with meticulous technique and proper catheter positioning is sufficient in allowing one to perform radioembolization safely with an extremely low incidence of nontarget embolization. Our observations, coupled with the challenges and risks of GDA and RGA coil embolization, lend further support to the need to reconsider routine, prophylactic coil embolization of the GDA and RGA before radioembolization procedures, specifically with regard to using glass microspheres. Even with the most embolic formulation of this device, second-week shelf-life microspheres, the risk of vascular stasis or reflux and gastrointestinal ulcer appears to be acceptably low in patients who do not undergo prophylactic GDA or RGA coil embolization.
Volume 24
’
Number 11
’
November
’
2013
Coil embolization should be considered when antegrade arterial flow is diminished, such as in patients receiving bevacizumab. Our results have three important limitations. First, our data were gathered from procedures performed at a tertiary care center with extensive radioembolization experience and as such may make our observations less generalizable. Second, our analysis focused on glass microspheres and cannot be extrapolated to the more moderately embolic resin spheres. Further studies are needed before any further recommendations for resin spheres can be made. Third, this is a letter to the editor and not a formal scientific article. More studies, including one with a larger series powered to achieve statistical significance, are needed before these observations can be generalized.
REFERENCES 1. Salem R, Lewandowski RJ, Kulik L, et al. Radioembolization results in longer time-to-progression and reduced toxicity compared with chemoembolization in patients with hepatocellular carcinoma. Gastroenterology 2011;140: 497.e2–507.e2. 2. Riaz A, Lewandowski RJ, Kulik LM, et al. Complications following radioembolization with yttrium-90 microspheres: a comprehensive literature review. J Vasc Interv Radiol 2009; 20:1121–1130; quiz 1131.
Unexpected Ischemic Complication after Proximal Coil Embolization of a Replaced Left Hepatic Artery before Yttrium-90 Radioembolization From: Geert Maleux, MD, PhD Pascal Wolter, MD Ragna Vanslembrouck, MD Christophe Deroose, MD, PhD Departments of Radiology and Imaging & Pathology (G.M., R.V.), Medical Oncology (P.W.), and Nuclear Medicine (C.D.) University Hospitals Leuven KU Leuven Herestraat 49 B-3000 Leuven, Belgium
Editor: Proximal coil embolization of variant hepatic arteries is a safe and effective method to simplify yttrium-90 (90Y) radioembolization by reducing the number of sites of 90 Y administration necessary to treat all targeted tumors and by facilitating treatment of tumors in territories supplied by a hepatic artery with a variant anatomy. Consolidation of arterial inflow into the liver segments that have received embolization is still possible via intrahepatic collateral channels, and the tumoricidal effect seems to be unaffected by proximal coil occlusion None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.04.026
1745
3. Cosin O, Bilbao JI, Alvarez S, de Luis E, Alonso A, Martinez-Cuesta A. Right gastric artery embolization prior to treatment with yttrium-90 microspheres. Cardiovasc Intervent Radiol 2007; 30:98–103. 4. Naymagon S, Warner RR, Patel K, et al. Gastroduodenal ulceration associated with radioembolization for the treatment of hepatic tumors: an institutional experience and review of the literature. Dig Dis Sci 2010; 55:2450–2458. 5. Lewandowski RJ, Sato KT, Atassi B, et al. Radioembolization with 90Y microspheres: angiographic and technical considerations. Cardiovasc Intervent Radiol 2007; 30:571–592. 6. Salem R, Lewandowski RJ, Sato KT, et al. Technical aspects of radioembolization with 90Y microspheres. Tech Vasc Interv Radiol 2007; 10: 12–29. 7. Pellerin O, Lin M, Bhagat N, Shao W, Geschwind JF. Can C-arm cone-beam CT detect a micro-embolic effect after TheraSphere radioembolization of neuroendocrine and carcinoid liver metastasis? Cancer Biother Radiopharm In press; available online March 13, 2013. 8. Lewandowski RJ, Riaz A, Ryu RK, et al. Optimization of radioembolic effect with extended-shelf-life yttrium-90 microspheres: results from a pilot study. J Vasc Interv Radiol 2009; 20: 1557–1563. 9. Lam MG, Banerjee S, Louie JD, et al. Root cause analysis of gastroduodenal ulceration after yttrium-90 radioembolization. Cardiovasc Intervent Radiol In press; available online February 22, 2013. 10. Abdelmaksoud MH, Hwang GL, Louie JD, et al. Development of new hepaticoenteric collateral pathways after hepatic arterial skeletonization in preparation for yttrium-90 radioembolization. J Vasc Interv Radiol 2010; 21:1385–1395. 11. Arepally A, Chomas J, Kraitchman D, Hong K. Quantification and reduction of reflux during embolotherapy using an antireflux catheter and tantalum microspheres: ex vivo analysis. J Vasc Interv Radiol 2013; 24:575–580.
and flow redistribution of variant hepatic arteries (1). We report an ischemic complication as a result of proximal coil embolization of a replaced left hepatic artery before 90Y radioembolization. A 47-year-old woman presented with abdominal pain related to diffuse metastatic liver involvement as detected by ultrasound. Computed tomography (CT) confirmed the presence of a diffuse spread of multiple, nearly isodense metastases over both liver lobes. The portal venous system was completely patent without any tumor encasement. Liver biopsy revealed metastases from malignant melanoma. However, no primary or other extrahepatic focus could be identified. Initial treatment consisted of dacarbazine monotherapy. However, owing to poor tolerance and intrahepatic progression of disease (Fig 1), it was decided to treat the patient by selective internal radiation therapy using resin microspheres (SIR-Spheres; Sirtex Medical Inc, Woburn, Massachusetts, USA). The angiographic work-up revealed (i) a replaced left hepatic artery, originating from the left gastric artery; (ii) a middle hepatic artery supplying segment 4; and (iii) a replaced right hepatic artery originating from the superior mesenteric artery (Fig 2a, b). Because several small gastric end branches were close to the origin of the replaced left hepatic artery, we decided to perform a proximal coil occlusion (Micro-Tornado; Cook Medical, Bjaeverskov, Denmark) of the replaced left hepatic artery. After additional proximal coil occlusion of the gastroduodenal artery, technetium-99m-labeled macroaggregated albumin was selectively injected into the