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For the past decade, Radioembolization with Yttrium-90(Y90) has revolutionized the treatment of liver tumors. Tran’s arterial methodologies for chemoembolization, Radioembolization, and bland embolization have reduced the need for formally invasive open procedures [1,2]. Prior to the procedure, a Computed Tomography (CT) scan is performed to stage the liver tumor and once the appropriate preoperative steps are completed, the procedure is performed via the Trans arterial access. The catheter tip is moved through the arterial system to deliver the Y90 microspheres to the tumor which will disrupt the tumor’s cellular replication integrity, destroying the tumor in effect [3,4]. Possible side effects secondary to this procedure include fatigue, nausea, vomiting, fever, abdominal pain, anorexia, and cachexia [5,6]. Severe side effects that warrant hospitalization include gastrointestinal ulceration caused by spread of microsphere [7]. Hepatobiliary toxicity may occur but it is difficult to conclude if the abnormal enzymes and metabolite levels are due to worsening hepatic cirrhosis or secondary to the procedure [7]. Due to the nature of the procedure, there is a low possibility of causing vascular injury and is mostly seen in patients who are taking systemic chemotherapy medication due to weakening of the vessel wall [7,8].

Innovations such using the radial artery instead of the traditional femoral artery access, has proven to be a practicable and safe technique that has reduced recovery time and pain, however extra steps must be taken [9-14]. If a transradial artery procedure is required, a Barbeau test and an ultrasound are often performed to determine if the diameter and circulatory flow are adequate to prevent ischemia to ulnopalmar arch [15-19]. The Barbeau test relies on the plethysmography waveform of the pulse oximetry and without adequate flow, waveforms cannot be viewed in extremities assessed [19,20]; Furthermore, the waveforms signal changes according to the hypervolemia or flow in a hemodynamic stable patients [21].

While CT scans are used to determine the extent of the liver tumor, the question arises as to whether the CT scan can also predict the radial artery size. Regardless of the inconvenience and expense of receiving an ultrasound, transradial artery Radioembolization seems to be on the trajectory for standard-of-practice, forgoing the Trans femoral arterybased procedure [15-18]. The purpose of this study is to assess if the CT scan can serve as an additional or primary method for predicting the radial artery’s feasibility for the procedure instead of requiring a preoperative ultrasound.

A retrospective analysis was conducted on 47 patients, each having Y90 Radioembolization performed at our institution from January 1, 2015 to December 31, 2019 (Table 1). Before data was reviewed from each patient, IRB was obtained and approved by the institution; patients were assigned an identification number to avoid any biases and to preserve confidentiality of personal information. All methods, experiments, and retrospective studies were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by Banner Health. Informed consents were waived by the Banner Health Institutional Review Board Ethics Committee.

Prior to each procedure, the patient underwent an ultrasound and Barbeau test. If the radial artery was 2.5 mm or greater in size and the patient had Barbeau A-C waveforms, the patient was deemed a candidate for radial artery access. If the vessel was smaller than 2.5 mm or Barbeau D, they underwent femoral arterial access. No other exclusions were made from statistical analysis if the patient met the prerequisites. Python-base module, Scipy (Version 1.6.0) was used to analyse the data.

The research team used a pre-operative CT abdomen/pelvis to measure the diameter of the femoral artery at the level of the femoral head. This value was recorded. Medical records were reviewed for demographic data. If no preoperative CT was performed, the patient was excluded. 47 patients were reviewed while 33 patients were included in the study. CT established diameters pertaining to presented study requirements. There were no other requirements to be included in the study. No other exclusion was made from statistical analysis if the patient met the prerequisites. There were no post-procedural complications recorded.

Procedural techniques

Data collection: For each respective Y90 liver tumor Radioembolization procedure performed, an accession number was assigned. The accession number adhered to Health Insurance Portability and Accountability Act (HIPAA) compliance coinciding with providing the patient appropriate anonymity during analysis. Only Y90 Radioembolization procedure information and patient demographics pertaining to gender, age, history of smoking, Avastin usage, and history of diabetic diagnosis were provided due to necessity for analysis. All other de-anonym zing information was withheld for patient anonymity and safety.

The CT scan images for each procedure were reviewed for analysis. Measurements of the femoral artery diameter were performed by leveraging the radiologic imaging software, Synapse^® by Fujifilm Global. We validated the measurements by repeating the measuring step, blinded to the initial results, and reporting the mean femoral artery diameter between the two measurements steps if a difference was present. The final results of the femoral artery diameter were reported in millimetres.

From the records, total percentage of Y90 administration relative to the prescribed dose and procedure access site (femoral or radial artery) were recorded.

Analysis

Results of each procedure, (access site, total percentage uptake, femoral artery size, smoking history, diabetes, Avastin, age, and gender) were reported in Table 1. Figure 1 compares procedure access site to femoral artery dimension. Statistical analysis was performed on the collected data via the open-source computer language, Python (Version 3.9.1) [22], and the open-source, web-based interactive computational environment, Jupyter Notebook (Version 7.19.0) [23]. Using the statistics, Python-base module, Scipy (Version 1.6.0), characteristics of the transradial artery procedure group and Tran’s femoral artery procedure group were revealed and compared [24]. Characteristics such as minimum femoral artery diameter within the transradial artery group, femoral artery diameter variability when compared to age and an unpaired t-test of the mean Y90 tumor uptake between the radial artery procedure group and femoral artery procedure group were performed. All statistical results and methodology were reported [22,23].

Of the 47 patients recorded in Table 1, 14 were excluded due to unreliable data collection, lack of pre-operative CT availability, or loss to follow up. The 33 analysed procedures contained 19 men and 14 women. The mean age of the patients was 63 years old (range 45-82 years old). It was found that 9 patients had a history of smoking, of which 5 were active smokers. 4 patients were found to have a diagnosis of diabetes and 2 patients received Avastin. The group was subdivided into patients who received Radioembolization via transradial artery or Tran’s femoral artery procedure. 20 patients (12 males, 8 females) received transradial artery Radioembolization, while 13 patients (7 males, 6 females) received Tran’s femoral artery Radioembolization.

Table 1: Patient dataset from Y90 liver tumor radio embolization procedure.

The transradial artery procedure group was found to have a mean Tran’s femoral artery diameter of 10 mm. The Trans femoral artery procedure group was found to have a mean femoral artery diameter of 10 mm. The minimum femoral artery diameter for the transradial artery procedure group was found to be 6 mm.

Comparative analysis of Y90 liver tumor uptake was performed via unpaired t-test. It was revealed that there was no statistical difference between the transradial artery procedure group and Trans femoral artery procedure group when comparing mean Y90 uptake (p>0.81229).

Further analyses were performed via stratification of patient groups based on diabetes history, smoking history, and procedural access point, either transradial or Trans femoral. Figures 1 and 2 illustrate the differences in mean femoral artery diameter based on prior diagnosis of diabetes and prior smoking history, respectively. Figure 1 illustrates the mean femoral artery diameter for patients with a prior diagnosis of diabetes was reported to be 9.8 mm with a standard deviation of 1.6 mm, while the mean femoral artery diameter for patients without a prior diagnosis of diabetes was reported to be 10.3 mm with a standard deviation of 1.9 mm. Figure 2 illustrates the mean femoral artery diameter for patients with a smoking history was reported to be 9.8 mm with a standard deviation of 1.8 mm, while the mean femoral artery diameter for patients without a smoking history was reported to be 10.4 mm with a standard deviation of 1.9 mm.

Figure 1: Comparison of mean femoral artery diameter with no respect to patient smoking diabetes diagnosis history.

Figure 2: Comparison of mean femoral artery diameter with no respect to patient diabetes diagnosis history.

Figure 3 illustrates the comparison of mean femoral diameter between patients that successfully received Tran’s femoral artery Radioembolization and transradial artery Radioembolization. It was found that the mean femoral artery diameter for the Trans femoral artery Radioembolization group was 9.9 mm with a standard deviation of 1.8 mm, while the mean for the transradial artery Radioembolization group was 10.4 mm with a standard deviation of 1.9 mm.

Figure 3: Comparison of mean femoral artery diameter with no respect to radioembolization access site.

Transradial approach is becoming the preferred method of treatment for Y90 liver tumor Radioembolization. From a clinical standpoint, studies have shown that transradial artery Radioembolization has similar clinical outcomes when compared to Tran’s femoral artery Radio embolization [25]. In addition, patients have shorter recovery times when using the transradial approach. As discussed by Liu, transradial artery procedures were associated with signifcantly lower pain scores overall during the procedure, at the access site during the procedure, and in the recovery room compared with trans femoral artery procedures [12].

Our study attempts to improve the ease of pre-procedure planning for transradial Radioembolization by providing an alternative means of assessing radial artery capacity for procedure without needing additional tests. Traditionally, ultrasound, as well as, the Barbeau test followed by radial artery ultrasound is used for radial artery assessment. This study reports successful assessment of the radial artery by sole reliance on femoral artery measurements via CT scan.

Out of 47 patients that have undergone Y90 Radioembolization, 33 patients’ femoral arteries were measured and recorded regardless of access point of procedure. 20 patients underwent the transradial approach with a mean femoral artery diameter of 10 mm. No adverse effects or diminished outcomes were found when using either artery. Thus we conclude that a femoral artery diameter of 10 mm or greater is predictive of adequate radial artery diameter for catheter access. Moreover, statistical analysis didn’t reveal a significant difference between radioisotope uptake between the different access points for the procedure (p>0.81229). It is acknowledged that due to limited sample size, more investigation should be performed on the variable that could influence radial artery size.

Other studies have attempted to capture contributing factors to radial artery size variability. For example, it is understood that differences in sex may also include anatomic differences, such as vasculature diameters and lengths, can have an effect on procedure times, rates of vessel spasm, and radiation exposures. However, multiple studies have found that sex is insignificant when attempting to predict radial artery size based on characteristics such as Body Mass Index (BMI), lifestyle, etc. [12,26,27] Other methods have been used to assess radial artery size differences. In Aykan it was found that radial artery diameter was correlated with wrist circumference (r=0.539, p<0.001), height (r=0.258, p<0.001), weight (r=0.237, p<0.001), body mass index (r=0.167, p=0.013), shoe size (r=0.559, p<0.001), and pulse pressure (r=-0.161, p=0.016). The right radial artery was larger in men than in women (2.73 ± 0.39 mm vs. 2.15 ± 0.35 mm, p<0.001), and smaller in patients with sedentary office work than in physically active outdoor workers (2.42 ± 0.45 mm vs. 2.81 ± 0.37 mm, p<0.001) [28].

Further investigation of radial artery size was performed by Kis. Using ultrasound guidance for vascular access, their study performed successful transradial artery Y90 Radioembolization procedures. Though the study size was only 27 patients, Kis found that radial arteries with a diameter of greater than 1.7 mm were indicative of transradial feasibility [29].

Regardless of procedure success, the transradial artery Radioembolization is not without its drawbacks. It was found by Kis. that the procedure required greater technical acuity and skill. Traditionally, Tran’s femoral artery procedures are routine for interventional radiologists [29]. Thus, expenses for continuing education must be taken into account when deciding between the two methods of Radioembolization [12,30].

These concerns have subsided due to improvements in technology and imaging modalities. In addition, more training programs are exposing their trainees to the transradial approach earlier in their careers. Physicians continue to become more precise and healthcare costs conscious which improves patient care. What may seem now as a more difficult procedure, transradial artery procedures show greater promise over Tran’s femoral artery procedures in a multitude of medical fields, from interventional oncology to cardiology. Since medical infrastructure has been adapting from the traditional femoral artery approach to the newer transradial approach, our research hopes to further this advancement by providing an improved method to assess radial artery size based off of the pre-procedure CT.

This study acknowledges the limited retrospective cohort size with regards to the findings. Moreover, this study would benefit from measurement of the radial artery per each patient, which would provide a direct comparative analysis between the femoral and radial artery.

No conflicts of interest reported.

No financial gain or funding was provided in conducting the study.

Banner Health- Project # 05-18-0038, iRIS Reference # 020561, FWA #00002630

IORG #0004299

This study was supported by Banner Desert Medical.

NA

Retrospective study: For this type of study formal consent is not required per Banner Health Institutional Review Board.

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