Radial artery access and pre y90 embolization of the right gastric artery technique and dictation

PROCEDURE: 

1. Left radial artery angiogram.
2. Superior mesenteric artery angiogram 
3. Celiac axis angiogram
4. Common hepatic artery angiogram.
5. Right gastric artery angiogram.
6. Coil embolization of the right gastric artery.
7. Postembolization angiogram of the right gastric artery.
8. Left hepatic artery angiogram.
9. Sheath removal and arteriotomy compression with a TR band

INDICATION: __-year-old __ with multifocal hepatocellular carcinoma HCV cirrhosis status post numerous prior chemotherapy embolizations. Recent MRI  shows disease progression predominantly in the left hepatic lobe. Here for Y-90 shunt study for radio embolization evaluation.

MEDICATIONS: Versed 2 mg IV, Fentanyl 100 mcg IV, 50 mg Benadryl IV, 1 g Ancef IV, 2.5 mg verapamil IA, 3000 units heparin IA, 600 units nitroglycerin IA.

OPERATORS: , MD (Attending)/ , MD (Fellow)

CONTRAST: 50 ml of nonionic contrast

FLUOROSCOPY TIME: 16.6 minutes

ACCESS SITE: Left radial artery

TECHNIQUE: The risks, benefits, and alternatives to the procedure and sedation were explained to the patient, and written informed consent obtained. A timeout was performed.  After interrogating the left radial artery with ultrasound to determine an appropriate arterial size and collateral flow via the ulnar artery, the left wrist was prepped and draped in usual sterile fashion. Lidocaine was infiltrated into the subcutaneous soft tissues for local anesthesia. Under ultrasound guidance, a 22-gauge needle was used to access the left renal artery. A 0.021″ wire was advanced through the needle under fluoroscopy. The needle was then exchanged for a 6 French Glidesheath Slender. The inner dilator and introducer wire were removed. The sheath was aspirated and flushed. A cocktail of 200 mcg nitroglycerin, 2.5 mg verapamil, and 3000 units heparin were administered intra-arterially through the sheath. DSA was performed through the sheath. The sheath was then aspirated and flushed.

A 5 French Jackey catheter and J-tipped Glidewire were advanced coaxially through the sheath under fluoroscopy into the abdominal aorta. The catheter was then used to select the superior mesenteric artery. Digital subtraction angiography was performed.  

The catheter was then used to select the celiac axis. Digital subtraction angiography was performed. A 2.8 French Progreat catheter and 0.014″ Transend guidewire were advanced coaxially through the Jackey catheter and used to select the right gastric artery.  Digital subtraction angiography was performed. The right gastric artery was then embolized using Azur 2 mm x 2 cm (two) and 3 mm x 2 cm detachable coils. DSA was repeated.

The microcatheter was then repositioned into the left hepatic artery. Once the catheter was adequately positioned distal to the origin of the gastroduodenal artery, approximately 4.3 mCi of technetium MAA were infused into the left hepatic artery. The catheter was then flushed and removed.  

The catheter was removed over a Glidewire. The sheath was then aspirated and flushed. An additional 200 mcg of nitroglycerin were through the sheath. An angiogram of the left forearm was repeated through the sheath. The transradial TR band was applied around the wrist in the sheath removed. The patient tolerated the procedure well, and was brought to Nuclear Medicine for the shunt study. 

FINDINGS: 

1. Left forearm angiogram demonstrates patent radial, ulnar, and interosseous arteries with collateralized flow distal to the sheath within the radial artery.
2. No replaced or accessory right hepatic artery off the superior mesenteric artery. 
3. Celiac axis angiogram demonstrates conventional anatomy.  There is tumor blush arising from both hepatic lobes; however, there is tumor vascularity and blush more significant in the left hepatic lobe. Corresponds with the MRI findings. Splenomegaly is also noted.
4. Common hepatic artery angiogram demonstrates a prominent right gastric artery arising from the hepatic bifurcation. Segment IV is supplied from the right hepatic artery.
5. Right gastric artery angiogram demonstrates patent flow and tip position distal to the hepatic arteries adequate for embolization.
6. Successful coil embolization of the right gastric artery.
7. Post embolization angiogram of the right gastric artery demonstrates minimal flow with adequate stasis.
8. Left hepatic artery angiogram demonstrates significant flow to the tumor vascularity and blush throughout the left hepatic lobe.
9. Successful administration of radiotracer for Y 90 evaluation.
10. Left forearm angiogram at the end of the procedure demonstrates patency of the radial, interosseous, and ulnar arteries with minimal spasm from the mid radial artery adjacent to the catheter tip.

IMPRESSION: 

Successful pre-Y90 evaluation with embolization of the right gastric artery and injection of MAA into the left hepatic artery as described above.