Biliary-Caval Fistula following Y90 Radioembolization

Abstract

The safety of radioembolization with yttrium-90 ( ⁹⁰ Y) is well documented and major complications are rare. Previous studies have demonstrated that biliary complications following ⁹⁰ Y, including bile duct injury and hepatic abscess formation, occur at an increased rate in patients who have had prior biliary surgery and interventions. This article reviews a case of a patient who developed recurrent cholangitis and sepsis as well as a biliary-caval fistula following radioembolization. Additionally, we review current data regarding biliary complications following radioembolization in patients with prior biliary intervention.

Keywords: 90 Y; biliary infection; cholangitis; interventional radiology; liver-directed therapy; radioembolization.

Fig. 1

Initial presentation. Single axial contrast-enhanced CT image demonstrating a 7-cm mass in the head of the pancreas abutting the portal vein (arrow).

Fig. 2

Progression of liver metastases. Single axial contrast-enhanced MR image demonstrating a central metastasis (circle) that was progressing despite systemic therapy.

Fig. 3

Radioembolization. Digital subtraction angiographic image from ⁹⁰ Y treatment demonstrating avid tumor enhancement (circle) ( a ). Axial image from a contrast-enhanced CT obtained 2 months after ⁹⁰ Y demonstrates a complete response (circle). Mild biliary dilatation is noted (arrow) ( b ).

Fig. 4

Percutaneous biliary drainage. Radiograph obtained after percutaneous cholangiogram/percutaneous biliary drainage demonstrates a communication between the biliary tree (black arrow) and the necrotic tumor (white arrow).

Fig. 5

Intraoperative imaging. Radiograph acquired during the open surgical rendezvous demonstrates the wire in the inferior vena cava (arrow) ( a ). Completion radiograph after the wire was successfully captured and directed into the small bowel and an internal/external biliary drain (arrow) was placed ( b ).

Fig. 6

Caval stenting. Digital subtraction angiographic image demonstrating thrombus in the inferior vena cava (arrow) ( a ). A stent graft was placed to exclude the biliary-caval fistula, which was thought to be the cause of the patient's recurrent cholangitis ( b ).