Examination

Hepatic Arterial Chemoembolization

 

Clinical History

Hepatoma.

 

Operators:

Sarel Gaur MD

 

Medications:

Lidocaine 1%

IV Meds:

 

Contrast:

[ ] ml of iodinated contrast Intra-arterial

 

Fluoro time:

[ ] minutes

 

Access site(s):

[R] CFA

 

Device(s):

 

 

Complications:

None

 

Procedure:

1. Risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.

2. The patient was placed supine on the fluoroscopic table.

3. The R CFA was palpated and the pulse assessed.

4. A suitable access site was marked under fluoroscopy, then prepped and draped in sterile fashion.

5. Maximal sterile barrier technique was used,including cap, mask, sterile gown, gloves, large sterile sheet, hand hygiene, and 2% chlorhexidine for cutaneous antisepsis.

6. 1% lidocaine was used for local anesthesia.

7. The right common femoral artery was accessed percutaneously using standard micropuncture technique.

8. A 4F transitional sheath was advanced over the 018 microwire and upsized to a 035 [Bentson] wire which was manipulated into the upper abdominal aorta.

9. A 5F vascular sheath was advanced over the wire and into the right common femoral artery.  The side arm was aspirated, flushed, and connected to pressurized heparinized saline.

10. A 5F Contra-2 catheter was advanced over the wire and then manipulated into the celiac trunk under fluoroscopy.

11. Following a small test injection of contrast, digital subtraction angiography was performed in the [AP] projection.

12. A Progreat microcatheter and 70-degree angled Glidewire were placed coaxially and used to select the main left hepatic 
    artery. DSA was performed again in several projections.

13. The microcatheter was then manipulated over the wire more distally into a branch supplying segments 2 and 3.

14. From this location, one vial of 75-150 micron LC beads coated with 75 mg of doxorubicin was delivered, with intermittent fluoroscopy performed throughout. This was performed until near stasis was observed.

15. Completion angiography was performed through the Contra guiding catheter, which was then removed.

16. The pressurized saline infusion was disconnected, and following flushing of the sheath side arm, limited right common femoral arteriography was performed in the RAO projection.

17. A 5 French Mynx Grip vascular closure device was then advanced through the sheath and utilized to achieve hemostasis at the R CFA.

18. All instruments were removed and a sterile dressing placed.

19. Procedure was terminated.

 

Findings

Described in Technique section.

 

Impression

Successful Hepatic Chemoembolization.

 

Link to arterial anatomy:

 

 

Risks, benefits, and alternatives to mesenteric arteriography, branch
artery embolization, and hepatic arterial administration of
technetium 99m micro aggregated albumin as well as moderate IV
sedation were discussed with the patient and informed written consent
was obtained.  He was brought to fluoroscopy and placed supine.  The
right groin was identified under fluoroscopy and skin overlying its
lower margin was marked.  Moderate IV sedation was given and vital
signs were monitored continuously for 2 hr. 1 percent lidocaine was
given subcutaneously.  Access to the right common femoral artery was
obtained using micropuncture technique.  Micropuncture sheath was
exchanged for a 5 French vascular sheath over a Bentson wire. Bentson
wire and Sos catheter were manipulated into the superior mesenteric
artery. Superior mesenteric arteriogram was obtained and filmed
through portal venous phase. Sos was then manipulated into the celiac
axis.  Using road map images, a ProGreat micro catheter and wire were
manipulated into the gastroduodenal artery. Two 4 mm detachable coils
were deployed. Post embolization run of the gastroduodenal artery was
obtained.  Attention was now turned toward the hepatic arteries.
Micro catheter and wire were manipulated into the right hepatic
artery. Selective arteriogram was obtained. Technetium 99m MAA 3 mCi
was then injected into the right hepatic artery. Wire and catheter
were then manipulated into the left hepatic artery, selective
arteriogram was obtained. Technetium 99m MAA 3 mCi was then injected
into the left hepatic artery. Catheters were removed.  Vascular
sheath was exchanged for a Mynx Ace closure device sheath.  Mynx Ace
closure device was deployed.  Hemostasis was obtained using light
manual pressure.  The patient was then sent to nuclear medicine for
imaging, including SPECT CT and calculation of lung shunt. He
tolerated this procedure well. 

Comparison
CT abdomen and pelvis 

Findings
Portal vein is patent, flow shunted through TIPS stent. SMA and
celiac arteriogram show classic anatomy. Post coil embolization GDA
arteriogram shows good stasis. Arteriograms of right and left hepatic
arteries showed no branches leading to gastrointestinal structures.
Cystic artery not visualized. No reflux of contrast. 

Impression
Technically successful mesenteric arteriograms, selective right and
left hepatic arteriograms, prophylactic coil embolization of the
gastroduodenal artery. No immediate postprocedure complications.
Fluoroscopy time 15.8 min. 

Plan is to treat the left hepatic lobe first, it contains the
dominant mass. Planned treatment date is

Volume
left hepatic lobe 400 cc. Desire doses 

 

Medical Transcription Editor

 

Examination

Y-90 mapping procedure.

 

Clinical History

Multi focal hepatoma.  History of HCV

 

Technique

[]

Risks, benefits, and alternatives to mesenteric arteriography, branch artery embolization, and hepatic arterial administration of technetium 99m micro aggregated albumin as well as moderate IV sedation were discussed with the patient and informed written consent

was obtained. 

 

He was brought to fluoroscopy and placed supine.  The right groin was identified under fluoroscopy and skin overlying its lower margin was marked.  Moderate IV sedation was given and vital signs were monitored continuously for 2 hr. 1 percent lidocaine was given subcutaneously.  Access to the right common femoral artery was obtained using micropuncture technique.  Micropuncture sheath was exchangd for a 5 French vascular sheath over a Bentson wire. Bentson wire and Sos catheter were manipulated into the superior mesenteric artery. Superior mesenteric arteriogram was obtained and filmed through portal venous phase. Sos was then manipulated into the celiac axis.  Using road map images, a ProGreat micro catheter and wire were manipulated into the gastroduodenal artery. A single 4 mm and two 5 mm detachable coils were deployed. Post embolization run of the gastroduodenal artery was obtained. Of note the 4 mm coil embolized into the gastroepiploic artery, without evidence of immediate consequence.

 

Attention was now turned toward the hepatic arteries. Micro catheter and wire were manipulated into the right hepatic artery. Selective arteriogram was obtained. Technetium 99m MAA 3 mCi was then injected into the right hepatic artery. Wire and catheter were then manipulated into the left hepatic artery, selective arteriogram was obtained. Technetium 99m MAA 3 mCi was then injected into the left hepatic artery. Catheters were removed. 

 

sheath was exchanged for a Mynx Ace closure device sheath.  Mynx Ace closure device was deployed.  Hemostasis was obtained using light manual pressure.  The patient was then sent to nuclear medicine for imaging, including SPECT CT and calculation of lung shunt. He

tolerated this procedure well. 

 

Technologist Comments

16.4 MINUTES FLUORO

 

Comparison

[Outside hospital on MR abdomen dated 11/17/2015.

Findings

[]

Portal vein is patent.

There is large accessory right hepatic artery originating from the SMA.

Post coil embolization GDA arteriogram shows good stasis. Of note there is a distal embolization of the 4 mm coil into the gastroepiploic artery.

Arteriography of right hepatic artery does not show opacification of bowel. Retrospective review of the left hepatic artery arteriogram demonstrates questionable connection from the segment 2 and 3 branches with the left gastroepiploic artery.

Cystic artery not definitively visualized.

Impression

Technically successful mesenteric arteriograms, selective right and left hepatic arteriograms, prophylactic coil embolization of the gastroduodenal artery. No immediate postprocedure complications.

Plan is to treat the left hepatic lobe as it contains the dominant mass.

​

ZB Y90 Planning / Mapping Study

 

PROCEDURES:

Y90 Planning Arteriography including Embolization 

 

DATE OF PROCEDURE:

7/8/2016

 

INDICATION:

Liver tumors.

 

MEDICATIONS:

250 mcg IV fentanyl

2 mg IV Versed

50 mg IV Benadryl

2.5 mg verapamil, 3000 units heparin, 400 mcg nitroglycerin (AKA cocktail).

Predetermined dose of intra-arterial technetium 99 labeled macroaggregated albumin

 

OPERATORS:

Sarel Gaur MD, Fellow

 

CONTRAST:

( ) mls of Omnipaque 350

 

FLUOROSCOPY TIME:

( ) minutes

 

ACCESS SITE:

Left radial artery.

 

COMPLICATIONS:

None.

 

PROCEDURE:

​

1. The risks, benefits, and alternatives to the procedure and sedation were explained to the patient, and written informed consent obtained.

2. Constant physiologic monitoring was performed by personnel from radiology nursing.

3. A timeout / call to order was performed in adherence to departmental protocol.

4. The left radial artery was evaluated with ultrasound and found to be within appropriate size limits.

5. There was a patent palmar arch as demonstrated by the Barbeau test.

6. The patient was noted to have a suitable waveform for radial access.

7. The left wrist was prepped and draped with maximal sterile barrier.

8. The skin and subcutaneous tissue overlying the left radial artery were infiltrated with 2% lidocaine for local anesthetic.

9. The left radial artery was accessed with a micropuncture needle (Images of the needle entering the vessel were saved and sent to PACS).

10. A 0.021" Nitinol wire was advanced through the needle into the artery.

11. The needle was exchanged for a 5F (4,5) French Glidesheath Slender.

12. The wire and inner dilator were removed.

13. The sheath was aspirated and flushed.

14. Intra-arterial nitroglycerin, verapamil, and heparin (vasodilatory cocktail) were administered.

15. A 5 French Cera Radial Catheter was advanced over 0.035 Bentson wire up the arm and into the descending thoracic aorta.

16. The catheter and wire further advanced into the abdominal aorta. Vessels catheterized are noted in detail below. Digital subtraction angiography was performed in each vessel, with further details as below.

17. A 2.48 French Progreat microcatheter was advanced over a 0.016" guidewire into the following hepatic arteries as described below. Corresponding arteriograms were obtained.

18. Vessel embolization was performed. Post angiogram was performed.

19. A predetermined dose of technetium 99 MAA was administered within the right, left, and middle hepatic artery.

20. All wires and catheters were removed.

21. The sheath was removed and patent hemostasis achieved with a TR band.

22. The patient tolerated the procedure well and left the angiography suite in stable condition.

 

FINDINGS:

 

Superior mesenteric artery catheterized: Yes

Findings: The superior mesenteric artery is patent. The portal vein is patent.

 

Celiac artery catheterized: Yes

Findings: The celiac artery is patent.

 

Left hepatic artery catheterized: Yes

Findings: Artery is patent.

 

Right hepatic artery catheterized: Yes

Findings: Artery is patent.

 

Left gastric artery catheterized: Yes

Findings: The left gastric artery is patent and branches off just proximal to the gastroduodenal artery.

Embolized: Yes

Coils used: 2 mm x 2 cm Azur coils (x2)

Post embolization angiography demonstrates no significant residual flow within the left gastric artery.

 

Of note, Dyna CT capabilities were utilized in order to visualize extrahepatic arterial flow. This was performed on a separate workstation.

 

Additional arteries catheterized:

Findings: N/A

 

IMPRESSION:

1. Successful coil embolization of a left gastric artery.

2. Successful administration of technetium 99 MAA as described. The patient will subsequently be dosed for a Y 90 therapy based on the findings of the subsequent nuclear medicine study.

 

The attending radiologist, ( ) , was present for the procedure and interpreted the images.