Radioembolization and the Cystic Artery

Abstract

Based on a review of the literature about the topic and personal experience obtained in several years performing radioembolization, if I have to answer the question posed by Prince et al (1), I will arrive at a very similar conclusion as the authors: Yes, we need to take precautionary measures with RE, as we always do when performing an interventional procedure. However, there is no need for any sophisticated special or unusual precaution in regard to the particular issue concerning the gallbladder while performing an intraarterial procedure to treat a liver tumor. The article by Prince et al (1) raises several relevant topics; among them is the issue of “overembolization” of the extrahepatic vessels while “preparing” a patient for a safe RE procedure. It is now generally accepted that preventive, systematic occlusion of the gastroduodenal and right gastric arteries, among others, before any RE is not only needless but also dangerous and even harmful (2). It was initially stated that prophylactic preparation (ie, “skeletonization”) of the hepatic arteries was required before infusion of microparticles loaded with yttrium-90 (Y) to avoid gastrointestinal complications caused by the undesired deployment of microparticles (3,4). The reason for this action is that RE was initially understood as a therapeutic method applied mainly for salvage treatment in patients with diffuse primary or metastatic liver tumors, and the delivery device was placed consistently in a “proximal” artery for a unique “whole-liver” treatment (5,6). However, recent evidence has demonstrated that RE could also be administered as a first-line treatment (7), but also for segmentectomy (8), lobectomy (9), or downstaging of disease (10,11) in some liver tumors, thereby decreasing the rate of whole-liver treatment. Even in many bilobar treatments, the activity is now being independently administered in both liver lobes. Consequently, these technical modifications, with increased procedural “interaction” with the vascular peculiarities of the liver (12), indicate that the treatment