Temporary Balloon Occlusion of the Common Hepatic Artery for Yttrium-90 Glass Microspheres Administration in a Patient with Hepatocellular Cancer and Renal Insufficiency

The most severe complication of yttrium-90 therapy is gastrointestinal ulceration caused by extrahepatic dispersion of microspheres. Standard pretreatment planning requires extensive angiographic evaluation of the hepatic circulation and embolization of hepatoenteric collaterals; however, in patients with severe renal insufficiency, this evaluation may lead to acute renal failure. In order to minimize iodinated contrast utilization in a patient with preexisting severe renal insufficiency, the authors describe the use of a balloon catheter for temporary occlusion of the common hepatic artery to induce transient redirection of flow of the hepatoenteric arteries towards the liver, in lieu of conventional coil embolization. 1. Introduction The use of yttrium-90 radioembolotherapy of the liver has become increasingly more widespread. Indications include palliative therapy for unresectable metastatic liver disease and bridging therapy to liver transplant in patients with primary liver malignancy [1]. The conventional approach to yttrium-90 microsphere radioembolotherapy involves prior angiographic identification of the hepatoenteric arteries with subsequent prophylactic coil embolization of these vessels to prevent radiation-induced gastrointestinal ulceration, gastrointestinal bleeding, or pancreatitis [2]. This involves the additional administration of significant amounts (up to 150？mL) of iodinated contrast to monitor, modify, and confirm the occlusion process [3]. Unfortunately, patients with chronic kidney disease (CKD) may be excluded from this therapy given the risk of contrast-induced nephropathy (CIN). While ample pre- and postprocedural hydration remains the mainstay for prevention, the absolute volume of contrast that is administered has been shown as an independent predictor of CIN [4]. Temporary balloon occlusion of the common hepatic artery during yttrium-90 glass or resin microsphere therapy to induce transient hepatopetal flow in the hepatoenteric arteries has been described [5, 6]. This technique obviates the need for prophylactic coil embolization of the hepatoenteric arteries and may minimize additional iodinated contrast exposure. The experience of this technique in patients with compromised renal function has not been reported. We currently describe the safety and efficacy of temporary balloon occlusion for yttrium-90 radioembolotherapy in a patient with advanced chronic kidney disease. 2. Case Report HIPAA approval for a single patient report is waived by our institutional review board. A 68-year-old Caucasian male with history of