Planning Arteriography for Yttrium-90 Microsphere Radioembolization

Yttrium-90 radioembolization ( 90 Y RE) is a contemporary transcatheter locoregional therapy for primary and secondary hepatic malignancies that is commonly utilized in modern Interventional Radiology (IR) practice.[ 1 ] Unlike other targeted endovascular therapies, such as transarterial chemoembolization (TACE) and transarterial embolization (TAE), the current standard of care protocol for 90 Y RE treatment of liver tumors involves a two-stage treatment process consisting of a planning arteriography procedure followed by the therapeutic 90 Y RE, typically performed 1 to 2 weeks later. The diagnostic planning procedure has threefold intent: (1) to delineate hepatic and tumor vascular anatomy relevant to 90 Y microsphere dosimetry and administration; (2) to identify and possibly embolize extrahepatic vessels at risk for nontarget microsphere deposition; and (3) to quantify the degree of hepatopulmonary shunting using technetium-99m macroaggregated albumin ( 99m Tc-MAA) scanning.[ 2 ] Given the multifactorial basis for performance of mapping arteriography, and despite some literature guidelines outlining procedure methodology,[ 3 ] [ 4 ] this procedure is often technically challenging, labor intensive, and time consuming. This article aims to present a simple overview of a single operator's technical approach to planning arteriography performed prior to 90 Y RE—including tips, tricks, and pitfalls—based on experience gained in having performed hundreds of hepatic arteriography procedures. Technical details of 90 Y RE dosimetry and microsphere administration are beyond the scope of the current topic, and will not be discussed.