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Supraumbilical Rash Caused by Nontarget Radioembolization to the Falciform Artery
Volume 25
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Number 3
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March
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2014
utility of an intravascular US catheter for creation of the transhepatic access into the portal vein further reduced the fluoroscopy time and radiation exposure. The role of the intravascular US catheter for creation of a TIPS has been evaluated and shown to be useful in difficult circumstances like portal vein thrombosis (8). The present case demonstrates the use of TIPS creation with intravascular US assistance in the preoperative setting to decompress enlarging caput medusae before Cesarean section, while limiting the radiation exposure compared with conventional TIPS creation.
REFERENCES 1. Russell MA, Craigo MD. Cirrhosis and portal hypertension in pregnancy. Semin Perinatol 1998; 22:156–165.
Supraumbilical Rash Caused by Nontarget Radioembolization to the Falciform Artery From: Ashwani K. Sharma, MD Thomas H. Foster, PhD Alan Katz, MD David E. Lee, MD David L. Waldman, MD, PhD Departments of Imaging Sciences (A.K.S., T.H.F., D.E.L., D.L.W.) and Radiation Oncology (A.K.) University of Rochester Medical Center 601 Elmwood Avenue Box 648 Rochester, NY 14642
Editor: We report a case of supraumbilical rash caused by yttrium-90 (90Y) delivered to the anterior abdominal wall via the falciform artery. Our institution does not require approval of the institutional review board to report retrospective case studies of this kind. A 63-year-old woman had a history of metastatic breast cancer. Following surgery and multiple courses of chemotherapy, she presented with progressive disease with development of liver lesions, as shown on positron emission tomography/computed tomography scan (Fig, a). Given the size of the lesion and the extent of prior chemotherapy, radioembolization with 90Y was deemed the most suitable option with regard to delivery of an effective therapeutic dose while minimizing risk of hepatotoxicity. Planning angiography showed the supply to the liver mass from both the right hepatic artery and the replaced left hepatic artery from the left gastric artery. The falciform artery (indicated by the arrow in Fig, b) was noted on retrospective analysis. 90Y SIR-Spheres (Sirtex None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.07.029
483
2. Westbrook RH, Yeoman AD, Kriese S, Heneghan MA. Outcomes of pregnancy in women with autoimmune hepatitis. J Autoimmun 2012; 38: 239–244. 3. Kim JJ, Dasika NL, Yu E, Fontana RJ. Cirrhotic patients with a transjugular intrahepatic portosystemic shunt undergoing major extrahepatic surgery. J Clin Gastroenterol 2009; 43:574–579. 4. Azoulay D, Buabse F, Damiano I, Small A, Ichai P, Dannaoui M. Neoadjuvant transjugular intrahepatic portosystemic shunt: a solution for extrahepatic abdominal operation in cirrhotic patients with severe portal hypertension. J Am Coll Surg 2001; 193:46–51. 5. Fitzgerald JB, Chalmers N, Abbott G, Lee SH. The use of TIPS to control bleeding caput medusae. Br J Radiol 1998; 71:558–560. 6. Assis DN, Pollack J, Schilsky ML, Emre S. Successful treatment of a bleeding umbilical varix by percutaneous umbilical vein embolization with sclerotherapy. J Clin Gastroenterol 2012; 46:115–118. 7. Savage C, Patel J, Rita Lepe M, Lazarre CH. Transjugular intrahepatic portosystemic shunt creation for recurrent gastrointestinal bleeding during pregnancy. J Vasc Interv Radiol 2007; 18:902–904. 8. Farsad K, Fuss C, Kolbeck KJ, et al. Transjugular intrahepatic portosystemic shunt creation using intravascular ultrasound guidance. J Vasc Interv Radiol 2012; 23:1594–1602.
Medical Limited, Woburn, Massachusetts) were injected into the left hepatic artery. Stasis was noted before the complete dose was administered. A repeat angiogram after 15 minutes showed tumor blush with opening of the vessel. We subsequently injected the remaining dose over 30 minutes. Within 2 hours, the patient complained of abdominal pain. Examination revealed a tender indurated supraumbilical skin rash with geographic margins (Fig, c). We initiated oral oxycodone 5 mg every 4–6 hours. The patient responded to the initial administration and was discharged 6 hours after 90Y injection. Although the pain symptoms responded well to the opioid, the patient reported that the rash and the underlying induration continued to increase for approximately 1 week. We proposed a second radioembolization administered via the right hepatic artery, to which the patient agreed. At the time of this second procedure, 30 days after the initial left hepatic artery injection, we noted continued improvement of the rash (Fig, d). The rash disappeared completely after 2 months with no direct treatment, and there were no adverse reactions to the right hepatic artery radioembolization. The identification of the falciform artery on angiography varies, and the artery is reportedly found in approximately 25% of cases. The high degree of variation in identification may be a result of several factors, including the need for prolonged digital subtraction angiography runs to allow for opacification of the vessel, adequate superselective catheterization of the left hepatic artery, and competing blood flow in the anastomotic network between the left hepatic artery via the falciform and superior epigastric arteries. It is well known that during transarterial chemoembolization, influx of chemoembolic agents into the hepatic falciform artery from the hepatic artery can cause supraumbilical skin rash, epigastric pain, and skin necrosis (1). The significance of a patent falciform artery in patients undergoing radioembolization is unclear (1). Stasis during radioembolization causes retrograde efflux and gastric or esophageal complications. Falciform artery filling occurs during antegrade injection. One anticipates that the radiospheres would
484
’
Letters to the Editor
Magabe and Bloom
’
JVIR
Figure. (a) Positron emission tomography scan of the liver shows hypermetabolic liver metastasis (arrow). (b) Angiography of the left hepatic artery shows falciform artery (arrow). (c) Supraumbilical rash that appeared 2 hours after the initial radioembolization. (d) Marked resolution of the rash 30 days after the initial radioembolization. (Available in color online at www.jvir.org.)
be present there before stasis is noted during the procedure. The dosing of radiospheres depends on the tumor burden to the liver and is not modified if the falciform artery is observed. The literature suggests that supraumbilical skin changes, which are common with chemoembolization, are rarely seen with radioembolization, although the reported incidence of falciform artery patency is the same (2). To avoid potential adverse risks related to inadvertent nontarget administration of 90Y, embolization of the falciform artery should be performed whenever the artery is seen (3). Although we did not use this approach, Wang et al (4) have suggested prophylactic use of topically applied ice as a means to prevent cutaneous complications of nontarget chemoembolization and radio-
Sudden Death from Carcinoid Crisis during Image-Guided Biopsy of a Lung Mass From: Peter Chacha Magabe, MBChB, MMed Allan L. Bloom, MD
Neither of the authors has identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.10.054
embolization when embolization of the falciform artery cannot be achieved.
REFERENCES 1. Leong QM, Lai HK, Lo RG, Teo TK, Goh A, Chow PK. Radiation dermatitis following radioembolization for hepatocellular carcinoma: a case for prophylactic embolization of a patent falciform artery. J Vasc Interv Radiol 2009; 20:833–836. 2. Liu DM, Salem R, Bui JT, et al. Angiographic considerations in patients undergoing liver-directed therapy. J Vasc Interv Radiol 2005; 16:911–935. 3. Bhalani SM, Lewandowski RJ. Radioembolization complicated by nontarget embolization to the falciform artery. Semin Intervent Radiol 2011; 28:234–239. 4. Wang DS, Louie JD, Kothary N, Shah RP, Sze DY. Prophylactic topically applied ice to prevent cutaneous complications of nontarget chemoembolization and radioembolization. J Vasc Interv Radiol 2013; 24: 596–600.
Department of Radiology (P.C.M.) Kenyatta National Hospital University of Nairobi P.O. Box 19676–00202 Nairobi, Kenya; and Department of Vascular and Interventional Radiology (A.L.B.) Hadassah University Hospital Jerusalem, Israel
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Number 3
’
March
’
2014
utility of an intravascular US catheter for creation of the transhepatic access into the portal vein further reduced the fluoroscopy time and radiation exposure. The role of the intravascular US catheter for creation of a TIPS has been evaluated and shown to be useful in difficult circumstances like portal vein thrombosis (8). The present case demonstrates the use of TIPS creation with intravascular US assistance in the preoperative setting to decompress enlarging caput medusae before Cesarean section, while limiting the radiation exposure compared with conventional TIPS creation.
REFERENCES 1. Russell MA, Craigo MD. Cirrhosis and portal hypertension in pregnancy. Semin Perinatol 1998; 22:156–165.
Supraumbilical Rash Caused by Nontarget Radioembolization to the Falciform Artery From: Ashwani K. Sharma, MD Thomas H. Foster, PhD Alan Katz, MD David E. Lee, MD David L. Waldman, MD, PhD Departments of Imaging Sciences (A.K.S., T.H.F., D.E.L., D.L.W.) and Radiation Oncology (A.K.) University of Rochester Medical Center 601 Elmwood Avenue Box 648 Rochester, NY 14642
Editor: We report a case of supraumbilical rash caused by yttrium-90 (90Y) delivered to the anterior abdominal wall via the falciform artery. Our institution does not require approval of the institutional review board to report retrospective case studies of this kind. A 63-year-old woman had a history of metastatic breast cancer. Following surgery and multiple courses of chemotherapy, she presented with progressive disease with development of liver lesions, as shown on positron emission tomography/computed tomography scan (Fig, a). Given the size of the lesion and the extent of prior chemotherapy, radioembolization with 90Y was deemed the most suitable option with regard to delivery of an effective therapeutic dose while minimizing risk of hepatotoxicity. Planning angiography showed the supply to the liver mass from both the right hepatic artery and the replaced left hepatic artery from the left gastric artery. The falciform artery (indicated by the arrow in Fig, b) was noted on retrospective analysis. 90Y SIR-Spheres (Sirtex None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.07.029
483
2. Westbrook RH, Yeoman AD, Kriese S, Heneghan MA. Outcomes of pregnancy in women with autoimmune hepatitis. J Autoimmun 2012; 38: 239–244. 3. Kim JJ, Dasika NL, Yu E, Fontana RJ. Cirrhotic patients with a transjugular intrahepatic portosystemic shunt undergoing major extrahepatic surgery. J Clin Gastroenterol 2009; 43:574–579. 4. Azoulay D, Buabse F, Damiano I, Small A, Ichai P, Dannaoui M. Neoadjuvant transjugular intrahepatic portosystemic shunt: a solution for extrahepatic abdominal operation in cirrhotic patients with severe portal hypertension. J Am Coll Surg 2001; 193:46–51. 5. Fitzgerald JB, Chalmers N, Abbott G, Lee SH. The use of TIPS to control bleeding caput medusae. Br J Radiol 1998; 71:558–560. 6. Assis DN, Pollack J, Schilsky ML, Emre S. Successful treatment of a bleeding umbilical varix by percutaneous umbilical vein embolization with sclerotherapy. J Clin Gastroenterol 2012; 46:115–118. 7. Savage C, Patel J, Rita Lepe M, Lazarre CH. Transjugular intrahepatic portosystemic shunt creation for recurrent gastrointestinal bleeding during pregnancy. J Vasc Interv Radiol 2007; 18:902–904. 8. Farsad K, Fuss C, Kolbeck KJ, et al. Transjugular intrahepatic portosystemic shunt creation using intravascular ultrasound guidance. J Vasc Interv Radiol 2012; 23:1594–1602.
Medical Limited, Woburn, Massachusetts) were injected into the left hepatic artery. Stasis was noted before the complete dose was administered. A repeat angiogram after 15 minutes showed tumor blush with opening of the vessel. We subsequently injected the remaining dose over 30 minutes. Within 2 hours, the patient complained of abdominal pain. Examination revealed a tender indurated supraumbilical skin rash with geographic margins (Fig, c). We initiated oral oxycodone 5 mg every 4–6 hours. The patient responded to the initial administration and was discharged 6 hours after 90Y injection. Although the pain symptoms responded well to the opioid, the patient reported that the rash and the underlying induration continued to increase for approximately 1 week. We proposed a second radioembolization administered via the right hepatic artery, to which the patient agreed. At the time of this second procedure, 30 days after the initial left hepatic artery injection, we noted continued improvement of the rash (Fig, d). The rash disappeared completely after 2 months with no direct treatment, and there were no adverse reactions to the right hepatic artery radioembolization. The identification of the falciform artery on angiography varies, and the artery is reportedly found in approximately 25% of cases. The high degree of variation in identification may be a result of several factors, including the need for prolonged digital subtraction angiography runs to allow for opacification of the vessel, adequate superselective catheterization of the left hepatic artery, and competing blood flow in the anastomotic network between the left hepatic artery via the falciform and superior epigastric arteries. It is well known that during transarterial chemoembolization, influx of chemoembolic agents into the hepatic falciform artery from the hepatic artery can cause supraumbilical skin rash, epigastric pain, and skin necrosis (1). The significance of a patent falciform artery in patients undergoing radioembolization is unclear (1). Stasis during radioembolization causes retrograde efflux and gastric or esophageal complications. Falciform artery filling occurs during antegrade injection. One anticipates that the radiospheres would
484
’
Letters to the Editor
Magabe and Bloom
’
JVIR
Figure. (a) Positron emission tomography scan of the liver shows hypermetabolic liver metastasis (arrow). (b) Angiography of the left hepatic artery shows falciform artery (arrow). (c) Supraumbilical rash that appeared 2 hours after the initial radioembolization. (d) Marked resolution of the rash 30 days after the initial radioembolization. (Available in color online at www.jvir.org.)
be present there before stasis is noted during the procedure. The dosing of radiospheres depends on the tumor burden to the liver and is not modified if the falciform artery is observed. The literature suggests that supraumbilical skin changes, which are common with chemoembolization, are rarely seen with radioembolization, although the reported incidence of falciform artery patency is the same (2). To avoid potential adverse risks related to inadvertent nontarget administration of 90Y, embolization of the falciform artery should be performed whenever the artery is seen (3). Although we did not use this approach, Wang et al (4) have suggested prophylactic use of topically applied ice as a means to prevent cutaneous complications of nontarget chemoembolization and radio-
Sudden Death from Carcinoid Crisis during Image-Guided Biopsy of a Lung Mass From: Peter Chacha Magabe, MBChB, MMed Allan L. Bloom, MD
Neither of the authors has identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.10.054
embolization when embolization of the falciform artery cannot be achieved.
REFERENCES 1. Leong QM, Lai HK, Lo RG, Teo TK, Goh A, Chow PK. Radiation dermatitis following radioembolization for hepatocellular carcinoma: a case for prophylactic embolization of a patent falciform artery. J Vasc Interv Radiol 2009; 20:833–836. 2. Liu DM, Salem R, Bui JT, et al. Angiographic considerations in patients undergoing liver-directed therapy. J Vasc Interv Radiol 2005; 16:911–935. 3. Bhalani SM, Lewandowski RJ. Radioembolization complicated by nontarget embolization to the falciform artery. Semin Intervent Radiol 2011; 28:234–239. 4. Wang DS, Louie JD, Kothary N, Shah RP, Sze DY. Prophylactic topically applied ice to prevent cutaneous complications of nontarget chemoembolization and radioembolization. J Vasc Interv Radiol 2013; 24: 596–600.
Department of Radiology (P.C.M.) Kenyatta National Hospital University of Nairobi P.O. Box 19676–00202 Nairobi, Kenya; and Department of Vascular and Interventional Radiology (A.L.B.) Hadassah University Hospital Jerusalem, Israel