Ambulatory Same-Day Map-and-Treat Angiography for Selective Internal Radiation Therapy Using a Transradial Approach

Abstract

Historically, selective internal radiation therapy (SIRT) with yttrium-90 (Y-90) requires a two-week interval between workup and treatment (map and treat). The intervening gap between workup and treatment is used to plan for the dose required and obtain delivery of the radioactive Y-90. During the coronavirus disease 2019 pandemic, the delivery of a robust SIRT service was challenging due to unprecedented demands on all hospital services. Emergent practice changes were required to ensure this service could still be delivered to patients while retaining sufficient inpatient hospital beds and services for acutely unwell patients. In response to this, the interventional radiology team proposed the retention of a full SIRT service by removing the historical two-week interval between map and treat, delivering both components of the SIRT procedure on the same day. A traditional approach using femoral access would require a prolonged period of immobility and potentially an overnight stay. By adopting a transradial approach without sedo-analgesia, an ambulatory day-case map and treat SIRT with no post-procedure immobilisation was performed. This case report demonstrates the technical feasibility of same-day 'map-and-treat' SIRT, highlighting a paradigm shift from the conventional femoral access method and immobilisation to an 'ambulatory' approach with immediate mobilisation post-procedure.

Keywords: day-case procedures; liver cancer-directed therapies; liver metastases; radial artery access; selective internal radiation therapy (sirt).

Figure 1. Portal-phase CT of the abdomen prior to SIRT therapy.

(A) Segment 6 liver metastasis (red arrow) with an absence of the left kidney in the left renal bed (blue circle) after left adrenalectomy and nephrectomy. (B) Segment 2 and segment 7 liver metastases (red arrows). A haematoma of the resection bed (yellow arrow) was present. This was deemed stable with subsequent imaging. CT: computed tomography; SIRT: selective internal radiation therapy

Figure 2. Outpatient PET-CT (pre-SIRT).

PET-CT performed pre-SIRT showing solid FDG avid tumour (black arrow) with an SUVmax of 18.6. PET-CT: positron emission tomography-computed tomography; SIRT: selective internal radiation therapy; FDG: fluorine-18-labelled fluorodeoxyglucose; SUVmax: maximum standardized uptake value

Figure 3. Fluoroscopic image (digital subtraction angiography) showing contrast injection through the arterial catheter.

(A) Mesenteric angiogram demonstrating the catheter (red arrow) selecting the superior mesenteric artery (blue arrow) via a caudal approach from the radial artery, with no accessory branch or replaced supply to the liver. (B) Coeliac artery angiogram showing left (blue arrow) and right (red arrow) hepatic arteries. Segments 4 and 1 of the liver are being supplied from a right hepatic artery branch (yellow arrow).

Figure 4. SPECT scan planar images following 99mTc MAA injection.

SPECT scan showing no extrahepatic uptake of ^99mTc MAA, allowing same-day SIRT treatment to proceed. SPECT: single photon emission computed tomography; 99mTc MAA: technetium-99 macro-aggregated albumin; SIRT: selective internal radiation therapy

Figure 5. Outpatient PET-CT (post-SIRT).

PET-CT three months post-SIRT treatment showing a reduction in the size of the segment 6 metastatic deposit from 5.5 cm to 3.5 cm. There was a reduction in the maximal FDG avidity to 8.4, with central necrosis present (black arrow). PET-CT: positron emission tomography-computed tomography; SIRT: selective internal radiation therapy