A Rare Complication After Prophylactic Embolization of Right Gastric Artery

Abstract

The different treatment options for unresectable hepatocellular carcinoma (HCC) include: transarterial chemoembolization (TACE), radiofrequency ablation (RFA), sorafenib, and radioembolization using Yttrium 90 (Y-90) microspheres. Limited options are available for patients with tumor invasion of the portal vein. Radioembolization using intraarterial injection of Y-90 microspheres can be considered for treatment of advanced HCC with portal vein thrombosis. This report describes a 56 year old male who presents with hematemesis. He had a known history of multifocal hepatocellular carcinoma and portal vein tumor thrombosis due to Hepatitis C virus. Previous imaging had demonstrated multiple liver lesions consistent with HCC in both the right and left hepatic lobes along with portal vein invasion. He had well compensated liver disease with a MELD score of 9 and Child-Pugh Class B. His alpha-fetoprotein was greater than 200,000 ng/mL. Less than twenty-four hours prior to his presentation with hematemesis, he had undergone embolization of the right gastric and gastroduodenal arteries in preparation for Y-90 radioembolization. On endoscopy, as shown in Figure 1, he was found to have extensive gastric necrosis, extending from antrum to incisura, consistent with the embolization of these arteries.Figure 1Nonsurgical treatment options have been shown to result in a reduction of the tumor burden and an increased survival benefit in patients with unresectable HCC. Of these options, Y-90 has a good safety profile with minimal complications. Prophylactic embolization of the gastric arteries before treatment of HCC with Y-90 is performed to prevent gastroduodenal ulceration. In our case, the attempted prophylactic embolization of these gastric arteries prior to the Y-90 radioembolization paradoxically resulted in gastrointestinal hemorrhage due to severe gastric necrosis. To our knowledge, this type of extensive necrosis after prophylactic embolization has not been reported in the literature.