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Angiographic Anatomy and Relevance of 3 and 9 O’clock Arteries During Radioembolization

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Abstract

Purpose

3 and 9 o’clock arteries (3&9As) which supply the common hepatic duct connect hepatic with duodenal/pancreatic territories. The study purpose is to describe the angiographic anatomy of 3&9As and discuss their relevance when performing radioembolization (RE) of liver malignancies.

Materials and Methods

The anatomy of the 3&9As was systematically investigated by a retrospective analysis of angiograms, technetium Tc-99 m-macroaggregated albumin (MAA) scintigrams, yttrium-90 (Y90) Bremsstrahlung-SPECT/CT datasets, and clinical data of 153 patients who underwent RE between 2010 and 2013.

Results

Analysis of preprocedural angiograms identified 3&9As in 36 (24%) of the 153 patients. Following embolization of the gastroduodenal artery, 3&9As were seen in 53 cases (35%). The three most common origins of the 3&9As were the right hepatic artery (n = 14), the cystic artery (n = 11), and S5 and S6 segmental arteries (n = 5 each). Extrahepatic Tc-99 m-MAA deposition in the territory of the 3&9As was significantly more frequent when 3&9As were detectable on preprocedural angiograms (28%visible vs. 11%not visible; p = 0.001) and especially when the 3&9As were not embolized or bridged prior to RE (50%not occluded/bridged vs. 19%occupied/bridged; p = 0.043). The presence of extrahepatic Y90 Bremsstrahlung after RE (n = 17) was attributable to microsphere diversion via the 3&9A territory in four patients and possible diversion via this territory in nine patients. Five of these 13 patients presented with epigastric pain, nausea, or vomiting (CTCAE severity grade ≤ 3) (p = 0.014).

Conclusion

3&9As are commonly detectable during evaluation angiography prior to RE, have a variable angioanatomic origin, and should be prophylactically occluded to prevent complications.

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References

  1. Mahnken AH. Current status of transarterial radioembolization. World J Radiol. 2016;8:449.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Tong AKT, Kao YH, Too CW, Chin KFW, Ng DCE, Chow PKH. Yttrium-90 hepatic radioembolization: clinical review and current techniques in interventional radiology and personalized dosimetry. Br J Radiol. 2016;89:20150943.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Lewandowski RJ, Sato KT, Atassi B, Ryu RK, Nemcek AA, Kulik L, et al. Radioembolization with 90Y microspheres: angiographic and technical considerations. Cardiovasc Intervent Radiol. 2007;30:571–92.

    Article  PubMed  Google Scholar 

  4. Vesselle G, Petit I, Boucebci S, Rocher T, Velasco S, Tasu J-P. Radioembolization with yttrium-90 microspheres work up: practical approach and literature review. Diagn Interv Imaging. 2015;96:547–62.

    Article  CAS  PubMed  Google Scholar 

  5. Jia Z, Sella DM, Wang W. Regarding, “radioembolization: Is prophylactic embolization of hepaticoenteric arteries necessary? A systematic review”. Cardiovasc Intervent Radiol. 2016;39:1365–6.

    Article  PubMed  Google Scholar 

  6. Powerski MJ, Scheurig-Munkler C, Banzer J, Schnapauff D, Hamm B, Gebauer B. Clinical practice in radioembolization of hepatic malignancies: a survey among interventional centers in Europe. Eur J Radiol. 2012;81:804–11.

    Article  Google Scholar 

  7. Gunji H, Cho A, Tohma T, Okazumi S, Makino H, Shuto K, et al. The blood supply of the hilar bile duct and its relationship to the communicating arcade located between the right and left hepatic arteries. Am J Surg. 2006;192:276–80.

    Article  PubMed  Google Scholar 

  8. Chen WJ, Ying DJ, Liu ZJ, He ZP. Analysis of the arterial supply of the extrahepatic bile ducts and its clinical significance. Clin Anat. 1999;12:245–9.

    Article  CAS  PubMed  Google Scholar 

  9. Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB. 2011;13:1–14.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Stapleton GN, Hickman R, Terblanche J. Blood supply of the right and left hepatic ducts. Br J Surg. 1998;85:202–7.

    Article  CAS  PubMed  Google Scholar 

  11. Schelhorn J, Theysohn J, Ertle J, Schlaak JF, Mueller S, Bockisch A, et al. Selective internal radiation therapy of hepatic tumours: Is coiling of the gastroduodenal artery always beneficial? Clin Radiol. 2014;69:e216–22.

    Article  CAS  PubMed  Google Scholar 

  12. Northover JM, Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical implications. Br J Surg. 1979;66:379–84.

    Article  CAS  PubMed  Google Scholar 

  13. SIRTEX Sirspheres [Internet]. http://www.radmed.com.tr/usr_img/sir_spheres/pdf/package_insert_sirtex.pdf.

  14. CTCAE v4.03 [Internet]. https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf.

  15. Vellar ID. The blood supply of the biliary ductal system and its relevance to vasculobiliary injuries following cholecystectomy. Aust N Z J Surg. 1999;69:816–20.

    Article  CAS  PubMed  Google Scholar 

  16. Li N, Wu X-F, Yang C, Liu G-Z, Song Y-Z, Wu H-H, et al. Study of relationship between the blood supply of the extrahepatic bile duct and duct supply branches from gastroduodenal artery on imaging and anatomy. Chin Med J. 2015;128:322.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Ahmadzadehfar H, Sabet A, Biermann K, Muckle M, Brockmann H, Kuhl C, et al. The significance of 99mTc-MAA SPECT/CT liver perfusion imaging in treatment planning for 90Y-microsphere selective internal radiation treatment. J Nucl Med. 2010;51:1206–12.

    Article  PubMed  Google Scholar 

  18. Ahmadzadehfar H, Duan H, Haug AR, Walrand S, Hoffmann M. The role of SPECT/CT in radioembolization of liver tumours. Eur J Nucl Med Mol Imaging. 2014;41(Suppl 1):S115–24.

    Article  PubMed  Google Scholar 

  19. Dudeck O, Wilhelmsen S, Ulrich G, Lowenthal D, Pech M, Amthauer H, et al. Effectiveness of repeat angiographic assessment in patients designated for radioembolization using yttrium-90 microspheres with initial extrahepatic accumulation of technitium-99m macroaggregated albumin: a single center’s experience. Cardiovasc Intervent Radiol. 2012;35:1083–93.

    Article  PubMed  Google Scholar 

  20. Ahmadzadehfar H, Muckle M, Sabet A, Wilhelm K, Kuhl C, Biermann K, et al. The significance of bremsstrahlung SPECT/CT after yttrium-90 radioembolization treatment in the prediction of extrahepatic side effects. Eur J Nucl Med Mol Imaging. 2012;39:309–15.

    Article  CAS  PubMed  Google Scholar 

  21. Kim YC, Kim YH, Um SH, Seo YS, Park EK, Oh SY, et al. Usefulness of bremsstrahlung images after intra-arterial Y-90 resin microphere radioembolization for hepatic tumors. Nucl Med Mol Imaging. 2011;45:59–67.

    Article  PubMed  Google Scholar 

  22. Veloso N, Brandão C, Gonçalves B, Costa L, Coimbra N, Jacome M, et al. Gastroduodenal ulceration following liver radioembolization with yttrium-90. Endoscopy. 2013;45(Suppl 2 UCTN):E108–9.

    PubMed  Google Scholar 

  23. Yim SY, Kim JD, Jung JY, Kim CH, Seo YS, Yim HJ, et al. Gastrectomy for the treatment of refractory gastric ulceration after radioembolization with 90Y microspheres. Clin Mol Hepatol. 2014;20:300.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Sabet A, Ahmadzadehfar H, Schäfer N, Wilhelm K, Schüller H, Ezziddin S. Survival after accidental extrahepatic distribution of Y90 microspheres to the mesentery during a radioembolization procedure. Cardiovasc Intervent Radiol. 2012;35:954–7.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Radiology and Nuclear Medicine, Otto-von-Guericke University, Leipziger Strasse 44, 39120, Magdeburg, Germany

    Maciej Powerski, Jazan Omari, Shahen El-Sanosy, Oliver S. Grosser, Frank Fischbach & Maciej Pech

  2. 2nd Department of Radiology, Medical University of Gdansk, Mariana Smoluchowskiego 17, 80-214, Gdańsk, Poland

    Bartosz Bascik & Maciej Pech

  3. Klinik und Poliklinik für Radiologie, Klinikum der Universität München, 81377, Munich, Germany

    Max Seidensticker

Authors
  1. Maciej Powerski
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  2. Bartosz Bascik
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  3. Jazan Omari
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  4. Shahen El-Sanosy
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  8. Maciej Pech
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Correspondence to Maciej Powerski.

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Conflict of interest

Author M. Pech is Proctors for Sirtex Medical and received funding for congress and scientific meetings. Author M. Powerski, O. Grosser and M. Seidensticker declares that he has received research grant and/or honoraria by Sirtex Medical. The other authors declare no conflict of interest.

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Powerski, M., Bascik, B., Omari, J. et al. Angiographic Anatomy and Relevance of 3 and 9 O’clock Arteries During Radioembolization. Cardiovasc Intervent Radiol 41, 890–897 (2018). https://doi.org/10.1007/s00270-017-1873-0

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  • DOI: https://doi.org/10.1007/s00270-017-1873-0

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