Technical Solutions to Ensure Safe Yttrium-90 Radioembolization in Patients With Initial Extrahepatic Deposition of 99mTechnetium-Albumin Macroaggregates

Purpose To evaluate the incidence of extrahepatic deposition of technetium-99m-labeled albumin macroaggregates (Tc-99m-MAA) after pretreatment angiography, before yttrium-90 radioembolizaton (Y-90-RE), and to report on technical solutions that can be used to ensure safe delivery of Y-90-microspheres in patients with initial extrahepatic deposition. Materials and Methods A retrospective analysis of 26 patients with primary and secondary liver malignancies, who were scheduled for treatment with Y-90-RE in our institution in 2009, was performed. The angiograms and single-photon emission computed tomography images of all patients were reviewed by an interventional radiologist and a nuclear medicine physician, respectively, to identify and localize extrahepatic deposition of Tc-99m-MAA when present. Subsequently, the technical solutions were used to successfully perform Y-90-RE in these patients were evaluated and described. Results Extrahepatic deposition of Tc-99m-MAA was observed in 8 of 26 patients (31%). In 7 of 8 patients, a second pretreatment angiography was performed to detect the cause of extrahepatic deposition. The technical solutions to enable safe Y-90 microspheres delivery included more distal placement of the microcatheter in the proper/right hepatic artery in 4 of 7 (57%) patients; (super)selective catheterization of multiple segmental branches in 2 of 7 (29%); and additional coiling of a newly detected branch in the remaining patient (14%). This was confirmed by a second MAA procedure. Y-90-RE was eventually performed in 25 of 26 (96%) patients. No procedure-related complications (< 30 days) were observed. Conclusion Extrahepatic deposition of Tc-99m-MAA after pretreatment angiography did occur in 8 of 26 (31%) patients. The technical solutions as presented allowed safe Y-90-RE delivery in 25 of 26 (96%) patients.