Observational Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Radiol. Jul 28, 2019; 11(7): 102-109
Published online Jul 28, 2019. doi: 10.4329/wjr.v11.i7.102
Y90-radioembolization via variant hepatic arteries: Is there a relevant risk for non-target embolization?
Markus Zimmermann, Maximilian Schulze-Hagen, Federico Pedersoli, Peter Isfort, Alexander Heinzel, Christiane Kuhl, Philipp Bruners
Markus Zimmermann, Maximilian Schulze-Hagen, Federico Pedersoli, Peter Isfort, Christiane Kuhl, Philipp Bruners, Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen 52074, Germany
Alexander Heinzel, Department of Nuclear Medicine, RWTH Aachen University Hospital, Pauwelsstrasse 30, Aachen 52074, Germany
Author contributions: Zimmermann M, Schulze-Hagen M, Isfort P, Kuhl C and Bruners P contributed to study conception and design; Zimmermann M, Pedersoli F and Heinzel A contributed to data acquisition, data analysis and interpretation, and writing of article; Zimmermann M, Schulze-Hagen M, Pedersoli F, Heinzel A, Isfort P, Kuhl C and Bruners P contributed to editing, reviewing and final approval of article.
Institutional review board statement: Approval for this retrospective study was granted by the institutional review board, internal reference number: EK 308/18.
Informed consent statement: The need for informed consent was waived by the institutional review board due to the retrospective study design and use of fully anonymized patient data.
Conflict-of-interest statement: On behalf of all authors, the corresponding author states that there is no conflict of interest.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Markus Zimmermann, MD, Attending Doctor, Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstr 30, Aachen 52074, Germany. mzimmermann@ukaachen.de
Telephone: +49-241-8037443 Fax: +49-241-8082411
Received: May 8, 2019
Peer-review started: May 10, 2019
First decision: June 6, 2019
Revised: July 3, 2019
Accepted: July 25, 2019
Article in press: July 25, 2019
Published online: July 28, 2019
Processing time: 80 Days and 20.9 Hours
ARTICLE HIGHLIGHTS
Research Background

Radioembolization with Yttrium-90 (90Y) microspheres is commonly used for treatment of primary or secondary liver tumors. It is generally a well-tolerated treatment with few side effects, however non-target embolization of 90Y microspheres to the gastrointestinal tract is a severe potential complication. The risk for non-target embolization is very low in patients with a normal hepatic arterial anatomy. However, around 45% of patients have some form of variant hepatic arterial anatomy and patients with aberrant hepatic arteries might have a higher risk for reflux and non-target embolization of 90Y microspheres due to the close proximity between hepatic and enteric vessel branches.

Research motivation

So far, no study has specifically evaluated the safety of 90Y-Radioembolization in patients with a variant hepatic arterial anatomy. Therefore, this study aimed to evaluate whether there is an increased risk for non-target embolization during 90Y Radioembolization in this specific patient population.

Research objectives

To evaluate the safety of 90Y Radioembolization with resin microspheres in patients with one of the two most common hepatic arterial variants: A right hepatic artery (RHA) originating from the superior mesenteric artery (SMA) or a left hepatic artery (LHA) originating from the left gastric artery (LGA).

Research methods

For this study, electronic medical records and imaging studies of 24 patients who had been treated with Radioembolization via an aberrant hepatic artery were retrospectively reviewed regarding clinical and imaging evidence of non-target embolization of 90Y-resin microspheres to the GI tract. 11 patients who underwent 90Y Radioembolization via an LHA originating from the LGA and 13 patients who underwent 90Y Radioembolization via an RHA originating from the SMA were included. Positioning of the tip of the microcatheter in relationship to the last hepatoenteric side branch was retrospectively analyzed using angiographic images, cone-beam CT and pre-interventional CT-angiograms.

Research results

None of the 24 patients developed clinical symptoms indicating a potential non-target embolization to the GI tract within the first month after 90Y-RE and there was no imaging evidence of non-target embolization on the postinterventional 90Y-bremsstrahlung images and/or 90Y-PETs in any of the patients. The distance between the tip of the microcatheter and the last enteric side branch was substantially shorter in patients with an aberrant LHA originating from a LGA (mean distance of 3.2 cm (range: 1.9-5 cm) than in those patients with an aberrant RHA originating from the SMA (mean distance of 5.2 cm (range: 2.9-7.7 cm). However even a minimum distance of 1.9 cm was sufficient to avoid reflux and non-target embolization of 90Y microspheres.

Research conclusions

This study suggests that 90Y Radioembolization may be safely performed in patients with aberrant hepatic arteries. A minimum distance of 1.9 cm between the tip of the microcatheter and the last enteric side branch in combination with slow, manual infusion of the 90Y microspheres was sufficient to avoid reflux of microspheres and non-target embolization in this study.

Research perspectives

Although this study provides clinical evidence that patients with aberrant hepatic arteries can generally be safely treated with 90Y Radioembolization, further studies with standardized infusion rates and catheter positions would be desirable to systematically determine exact cut-off values at which reflux and non-target embolization of 90Y microspheres occurs.