Radial artery access TACE technique and dictation

PROCEDURE: 

1. Left radial artery angiogram
2. Celiac axis angiogram
3. Right posterior division hepatic artery angiogram
4. Drug-eluting bead chemoembolization of the right posterior division hepatic artery
5. Repeat left radial artery angiography and arteriotomy closure using a TR band

DATE: 

CLINICAL INDICATION: __-year-old female with hepatocellular carcinoma referred for locoregional therapy. 

OPERATING PHYSICIANS: , MD (Attending)/, MD (Resident)

MEDICATIONS: Verapamil 2.5 mg IA, nitroglycerin 600 mcg IA, heparin 3000 units IA, Versed 4 mg IV, fentanyl 250 mcg IV, Ancef 1 g IV, Zofran 4 mg IV, Flagyl 500 mg IV 

ACCESS: Left radial artery with ultrasound guidance

CONTRAST: Approximately 60 mL of Omnipaque 350

FLUOROSCOPY TIME: 16.9 minutes

COMPLICATIONS: None

PROCEDURE: After written and informed consent was obtained, the patient was placed supine on the procedure table. A timeout was performed. Constant physiologic monitoring and conscious sedation were performed by personnel from radiology nursing.

The left wrist was prepped and draped in standard sterile fashion. Scout images were obtained. Under direct ultrasound visualization, the left radial artery was punctured retrograde with a 21-gauge needle. A 0.021-in. wire was advanced through the needle into the artery. The needle was exchanged for a 6 French glide sheath slender. The wire and inner dilator were removed. Once intravascular positioning was confirmed with aspiration, the verapamil, 200 mcg of the nitroglycerin, and the heparin were infused through the sheath. Following this digital subtraction angiography of the radial artery was performed.

A 5 French 110 cm Sarah catheter preloaded with a 0.035-in. 1.5 mm J-tip Glidewire were advanced without difficulty up the arm to the origin of the left subclavian artery. The wire and catheter were advanced more distally into the descending thoracic aorta and into the abdominal aorta.

Using the catheter the celiac axis was selected. Digital subtraction angiography was performed.

A 2.8 French 150 cm Progreat microcatheter were advanced through the base catheter and used to select the posterior division right hepatic artery. Digital subtraction angiography was performed. 200 mcg of nitroglycerin were given intra-arterially due to vasospasm. From this location, the tumor was subsequently embolized with 2 vials of 100-300 micron LC beads, followed by three quarters of a vial of 300-500 micron embospheres. The microcatheter was flushed and removed. The sterile catheter was disengaged from the celiac axis and removed slowly over a wire without difficulty.

The sheath at the wrist was aspirated. An additional 200 mcg of nitroglycerin were given through the sheath. Repeat left radial artery angiography was performed.

The TR vein was placed at the wrist with the marker positioned over the puncture site. The balloon was inflated with 15 mL of air. The sheath was removed.  Bleeding occurred following deflation x 2 mL, so the balloon was reinflated to a total volume of 15 mL. There is patent hemostasis on the pulse oximeter.

The patient tolerated the procedure well and there were no immediate complications.

FINDINGS: 

1. Left radial artery angiogram demonstrates conventional anatomy and a patent ulnar loop with filling of the radial artery distal to the puncture site.
2. Celiac axis angiogram demonstrates conventional anatomy. There are coils in the gastroduodenal artery from prior embolization. There is a large hypervascular mass in the posterior aspect of the liver, which is predominantly supplied by the posterior division of the right hepatic artery. There is a smaller portion of the tumor more superiorly located in the liver that is supplied by the anterior division.
3. Posterior division right hepatic artery angiogram confirms vascular supply to the bulk of the tumor. This warrants treatment with chemoembolization.
4. Left radial artery angiogram at the conclusion of the case again demonstrates conventional anatomy and no evidence of vasospasm. Persistent filling of the distal radial artery is noted.

IMPRESSION:  Successful drug-eluting bead chemoembolization of a hepatocellular carcinoma in the right liver via a transradial approach.