Clinical Diagnosis
63 year-old male with synchronous metastatic colon cancer to the liver who presented 6 years after resection of the primary tumor with slow progression in the liver in spite of multiple cycles of chemotherapy.

Anatomy
Preoperatively, there were multiple lesions located in segments 2, 3, 4, 5, 6, 7, and 8, the largest of which was a confluence of tumors in segments 4/5/8. The segment 4 region was supplied by the LHA and the segment 5/8 region was supplied by the RHA. The target arteries for infusion were the LHA (4 mm diameter), and RHA (6 mm diameter).

Infusion System Comparison
During angiographic planning, a traditional microcatheter was compared to a Surefire Infusion System prior to the radioembolization administration to determine tumor enhancement.

Treatment Plan
The treatment plan included Yttrium-90 radioembolization with two infusions of SIR-Spheres® microspheres, one to each lobe, separated by four weeks. During both infusions, a Surefire Sim1 Guiding Catheter was positioned at the origin of the celiac artery. For the left hepatic artery, a Surefire Infusion System mT was used to deliver the entire prescribed dose (1.13 GBq), and for the right hepatic artery, a Surefire Infusion System LT was used to deliver the entire prescribed dose of (0.48 GBq).

Why was the Surefire chosen for this procedure?
The Surefire Infusion System was used in this case primarily to prevent non-target embolization of the gastroduodenal artery and the right gastric artery, which arose from the common hepatic artery and proper hepatic artery, respectively. These vessels had not been prophylactically coil embolized prior to treatment. In addition, the mapping angiograms performed with the Surefire Infusion System demonstrated noticeably improved enhancement of the tumors with decreased enhancement of the normal liver parenchyma compared to an end-hole microcatheter. Although not yet confirmed with Yttrium-90 radioembolization[1], increased tumor enhancement on conventional angiography may be associated with improved imaging response and increased patient survival after either hepatic artery infusion chemotherapy or transarterial chemoembolization[2,3,4,5].

References
[1] Sato K, Omary R, Takehana C, Ibrahim S, Lewandowski R, Ryu R, Salem R. The role of tumor vascularity in predicting survival after Yttrium-90 radioembolization for liver metastases. J Vasc Interv Radiol. 2009 Dec;20(12):1564-69.
[2] Kim D, Watson R, Pahnke L, Fortner J. Tumor vascularity as a prognostic factor for hepatic tumors. Ann Surg. 1977 Jan;185(1):31-4.
[3] Kim J, Yoon H, Ko G, Gwon D, Jang C, Song H, Shin J, Sung K. Nonresectable combined hepatocellular carcinoma and cholangiocarcinoma: analysis of the response and prognostic factors after transarterial chemoembolization. Radiology. 2010 Apr;255(1):270-7.
[4] Kim J, Yoon H, Sung K, Ko G, Gwon D, Shin J, Song H. Transcatheter arterial chemoembolization or chemoinfusion for unresectable intrahepatic cholangiocarcinoma. Cancer. 2008 Oct;133(7):1614-22.
[5] Malagari K, Pomoni M, Moschouris H, Bouma E, Koskinas J, Stefaniotou A, Marinis A, Kelekis A, Alexopoulou E, Chatziioannou A, Chatzimichael K, Dourakis S, Kelekis N, Rizos S, Kelekis D. Chemoembolization with doxorubicin-eluting beads for unresectable hepatocellular carcinoma: five-year survival analysis. Cardiovasc Intervent Radiol. 2012 Oct;35(5):1119-28.