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Poster 7
Retrospective review of falciform artery radiotracer uptake prior to Y90 treatment: consequences of non-reporting, potential need for intervention and risk of complications

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Background:

Potential complications of falciform artery (FA) nontarget embolization following transarterial hepatic chemoradiation therapies have been described including supraumbilical skin rash, epigastric pain and skin necrosis with delivery of embolic agents into the terminal capillaries of the FA. Injection of technetium-99m macroaggregated albumin (MAA) during pretreatment planning studies allows for identification of potential variant anatomy, otherwise unseen on standard angiography, that may place a patient at risk for nontarget radioembolization prior to yttrium-90 (Y90) therapy.

Objectives:

The purpose of this study is to identify all cases at our institution of FA radiotracer uptake during MAA pretreatment planning prior to Y90 administration utilizing SPECT/CT. Our goal is to describe the clinical consequences of reporting or failing to report FA uptake and the need for possible intervention prior to Y90 in order to avoid potential complications.

Methods:

A retrospective review was performed for all MAA injections from 2014-2017 (n= 116). Of these cases, 103 patients underwent SPECT/CT at the time of MAA injection, which were reviewed for potential FA radiotracer uptake. The patient record was then reviewed for all cases of positive FA uptake to determine if intervention was performed at the time of the procedure and if there were postprocedure adverse effects. This study was performed under IRB approval.

Results:

Of 103 patients reviewed, 10 showed FA uptake (9.7%) on initial MAA injection for pretreatment planning. Of these, the FA was visualized on 1/10 angiographic exams prior to treatment. Prospectively only 4/10 nuclear medicine MAA reports mentioned uptake in the FA. An ice pack was placed at the umbilicus to minimize symptoms in all 4/10 patients. Coil embolization of the FA prior to Y90 was performed in 1/10 cases. No immediate or latent postprocedure complications were directly related to Y90.

Discussion:

•The falciform artery (FA) runs with the falciform ligament dividing the medial and lateral segments of the left liver lobe to the anterior abdominal wall. FA supplies the skin around the navel.
•While the FA is recognized in 69% of postmortem cadavers, it is only seen in 2-52% of hepatic angiography examinations. Major origins include the left hepatic and middle hepatic arteries.
•There is limited knowledge regarding the implications of nontarget embolization of the FA after Y90 or the need for pretreatment intervention compared to other at risk vessels.
•This retrospective review shows that FA uptake was underreported on MAA nuclear medicine studies and is often unseen even on retrospective angiography.
•Treatment/intervention at our institution is variable (ice pack, embolization or nothing at all). Based on the lack of symptoms in cases without preprocedure FA intervention, small amounts of radiotracer uptake in the FA likely remain asymptomatic.
•Postprocedure physical examination and symptom documentation were often limited and lacking in detail, making it difficult to determine whether reported symptoms were directly related to nontarget embolization versus other etiology.
•Identification of FA uptake and documentation of symptoms will likely be more thorough and intentional as interventional radiology moves toward a clinical specialty with routine follow up of our patients.
 
Conclusions:

There is limited knowledge regarding the implications of nontarget radioembolization of the FA after Y90 or the need for preprocedure intervention. While MAA pretreatment planning is instrumental in identifying uptake in the FA, it is often underreported. Greater attention must be paid to this anatomic variant to limit complications such as peri-umbilical rash and necrosis. However, small amounts of radiotracer uptake in the FA are unlikely to result in such complications.

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