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Review
. 2015 Dec;32(4):428-38.
doi: 10.1055/s-0035-1564708.

Planning Arteriography for Yttrium-90 Microsphere Radioembolization

Ron C Gaba  1
Affiliations
Review

Planning Arteriography for Yttrium-90 Microsphere Radioembolization

Ron C Gaba. Semin Intervent Radiol. 2015 Dec.
No abstract available

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest None.

Figures

Fig. 1
Fig. 1
Hepatic arteriograms in same patient performed using microcatheter (a) and 4F catheter (b) demonstrate improved vessel filling with greater contrast injection capability of larger caliber catheter, with hypervascular tumor visualization (arrowheads).
Fig. 2
Fig. 2
Selection of catheter position for 90Y RE. Coronal reformatted contrast-enhanced CT scan (a) shows two hepatocellular carcinoma nodules (arrowheads) within right hepatic lobe. Arteriogram (b) displays suitable microcatheter position for lobar 90Y RE, with tip (arrow) in right hepatic artery in vascular distribution of both tumors (arrowheads), but sufficiently proximal to branching to allow homogeneous microsphere dispersal.
Fig. 3
Fig. 3
Incomplete treatment due to extrahepatic tumor blood supply. Axial contrast-enhanced CT scan (a) demonstrates segment 7 hepatocellular carcinoma (arrowheads). Arteriogram (b) shows hypervascular tumor (arrows). However, note absent perfusion along posteromedial margin (arrowheads), which was unnoticed prior to 90Y RE. Posttreatment axial contrast-enhanced CT scan (c) displays partial tumor response, with persistent viable tumor enhancement (asterisk). Arteriogram performed during retreatment (d) reveals tumor blood supply (arrowheads) via inferior phrenic artery, which was treated with transarterial chemoembolization.
Fig. 4
Fig. 4
Arterioportal shunting. Axial contrast-enhanced CT scan (a) shows large primary liver tumor (arrowheads). Arteriogram (b) performed during 90Y RE planning demonstrates extensive arterioportal shunting, with early portal vein visualization (black arrowheads) during late arterial phase of imaging (black arrows delineate common hepatic artery). Shunt subsequently closed with large particles.
Fig. 5
Fig. 5
Chemoembolic shunt reduction to allow 90Y RE. Axial contrast-enhanced CT scan (a) demonstrates left hepatic lobe infiltrative tumor with portal vein invasion. 99mTc-MAA scan (b) shows high lung shunt fraction measuring 30%. Axial contrast-enhanced CT scan (c) performed after transarterial chemoembolization shows high attenuation chemoembolic material (arrowheads) in left hepatic lobe tumor. Repeat 99mTc-MAA scan (d) obtained following chemoembolization reveals lung shunt fraction reduced to 22%. 90Y RE to left liver lobe subsequently performed at later date.
Fig. 6
Fig. 6
Arteriogram performed for 90Y RE planning illustrates typical falciform artery (arrowheads) arising from segment 4 branch of left hepatic artery.
Fig. 7
Fig. 7
Accessory gastric artery. Left hepatic arteriogram (a) shows branch vessel (arrowheads) supplying hypervascular “tuft” (arrows) in abdominal left upper quadrant. Arterial (b) and venous (c) phase angiograms performed after microcatheter interrogation reveal gastric fundal enhancement (arrowheads) with venous drainage via left gastric vein (arrowheads), confirming vessel to be accessory gastric artery.
Fig. 8
Fig. 8
Anchor technique shown on postembolization arteriogram after gastroduodenal artery (GDA) embolization. Note proximal coil (black arrowheads) anchored into GDA side branch (arrow) to ensure coil positional stability, as well as base catheter tip (white arrowhead) advanced to near GDA origin for extra support.
Fig. 9
Fig. 9
Plug embolization. Postembolization common hepatic arteriogram shows plug device (arrowheads) accurately positioned at the origin of gastroduodenal artery.
Fig. 10
Fig. 10
Magnified common hepatic arteriogram nicely delineates right gastric artery origin (arrowheads) from right lateral wall of proper hepatic artery.
Fig. 11
Fig. 11
Retrograde right gastric artery (RGA) embolization for patient depicted in Fig. 10. Left gastric arteriogram (a) portrays complete arcade (arrowheads) with RGA along lesser curvature of stomach. Fluoroscopic images (b) and (c) display sequential microcatheterization across arcade, with successful coil embolization (arrowheads) illustrated in fluoroscopic image (d).
Fig. 12
Fig. 12
Coil malposition. Common hepatic arteriogram (a) demonstrates herniation of gastroduodenal artery (GDA) coil (arrows) into parent artery, which could limit later 90Y RE; second coil (white arrowhead) located in right gastric artery. GDA coil retrieved by snaring free end (black arrowhead), and GDA then embolized again with better result, shown in arteriogram (b).
Fig. 13
Fig. 13
Coil migration. Celiac arteriogram (a) shows right hepatic lobe hypervascular liver tumor (arrowheads). Arteriogram (b) performed after inadvertent right hepatic artery coil migration (arrowhead) during gastroduodenal artery embolization displays poor tumor perfusion. Coil could not be retrieved. Nonetheless, arteriogram (c) performed during 90Y RE ∼2 weeks later demonstrates tumor perfusion through coil pack and via collateral vessels; 90Y RE successfully performed.
Fig. 14
Fig. 14
Coil migration resolved with intrahepatic vascular flow redistribution (case courtesy of Brandon K. Martinez, MD, Corvasc MDs PC, Indianapolis, IN). Axial contrast-enhanced CT scan (a) shows right hepatic dome hepatocellular carcinoma (arrowhead), for which 90Y RE therapy planned. Arteriogram (b) reveals unintentional coil migration (arrowhead) into right hepatic artery from attempted gastroduodenal artery embolization. As coil could not be retrieved, right hepatic artery intentionally further coil embolized (arrowheads in image c) to induce left-to-right intrahepatic arterial collateralization (arrowheads in image d). Right hepatic lobe 90Y RE then successfully performed via left hepatic artery segment 4 branch, as depicted on Bremsstrahlung scan (e).
Fig. 15
Fig. 15
Gastrohepatic trunk. Axial contrast-enhanced CT scan (a) shows typical location of anomalous left gastric artery (black arrowhead) within fissure for ligamentum venosum; left hepatic lobe exophytic hepatocellular carcinoma also present (white arrowhead). Left gastrohepatic trunk arteriogram (b) depicts numerous gastric branches (arrowheads) at risk for nontarget 90Y microsphere deposition during hypervascular tumor (arrows) therapy.
Fig. 16
Fig. 16
Left hepatic arteriogram reveals anomalous origin of left interior phrenic artery (arrowheads) from left hepatic artery. Embolization of this vessel would be required prior to left hepatic lobe 90Y therapy.
See this image and copyright information in PMC

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