Chemoembolization with Drug-Eluting Beads - Supported by syngo DynaCT
A 63-year-old female with liver dominant metastases from breast cancer.
Treatment-refractory liver metastases from breast cancer. History of radioembolization (SIRT) of the right liver lobe. Due to the complex arterial anatomy of the left liver lobe (figure 1), SIRT of the left liver lobe was abandoned.
A planar angiogram revealed a separate origin of the gastro-hepatic trunk together with the right inferior phrenic artery from the aorta (figure 1). Short gastric branches (arrow) arising from the left hepatic artery are detected. A microcatheter is positioned superselectively in the left hepatic artery distal to the origin of the gastric branches and a power-injection angiographic run is performed (figure 2). A falciform artery is visualized immediately (figure 2, red arrow). To confirm that no vessels other than the falciform artery are at risk for an ectopic embolization of the drugeluting beads in non-target territories, a syngo DynaCT was performed 8sDR; 5 s X-ray delay; 15 cc of volume (50 % contrast (300 mg iodine/cc) / 50 % of saline) at 1.5 cc per second followed by saline with the same injection parameters). Instant multiplanar reformats (MPR) demonstrate nicely the contrast uptake of the segments 2 and 3 of the left liver lobe (figure 3) with no contrast enhancement of the gastric wall (arrow). Reviewing all MPRs (figures 4 and 5) in addition to the falciform artery, contrast enhancement of the distal esophagus (arrows) is revealed, which was not recognized initially when looking at the planar angiogram only (inferior esophageal artery, figure 2, blue arrows). The color-coded volume rendered dataset (figure 6) as well as the curved MPR (image 7) nicely illustrate the course of the falciform artery (yellow arrows). Before delivering the drug-eluting beads the falciform artery was coil-embolized (figure 8) and the treatment was performed safely and uneventfully with special attention to the inferior esophageal arteries (carefully avoiding reflux).
The patient neither described any symptoms during the treatment nor side-effects during follow-up. PET-CT performed 2 months after EBTACE revealed photopenic defects in the former area of the liver metastases, indicating a favorable response to treatment.
Complex arterial anatomy of the left liver lobe with gastric branches (arrows) arising from the left hepatic artery.
Power injection angiography run: A falciform artery is visualized immediately (red arrow) by inserting a microcatheter in the left hepatic artery distal to the origin of the gastric branches. Suspicious arteries crossing the diaphragm are detected (blue arrows).
Instant multiplanar reformats (MPR) to demonstrate the contrast uptake of segments 2 and 3 of the left liver lobe without contrast enhancement of the gastric wall (arrow).
Figure 4 + 5
Furthermore, MPR visualizations (figures 4 and 5) reveal contrast enhancement of the distal esophagus (arrows), indicating that the suspicous arteries in figure 2 (blue arrows) are inferior esophageal arteries that should not be embolized with drug-eluting beads.
Figure 6 + 7
Color-coded, volume-rendered dataset (figure 6) together with curved MPR (image 7) show the morphology of the falciform artery (yellow arrows).
Coil embolization of the falciform artery to prepare treatment with drug-eluting beads.