title: Root cause analysis of gastroduodenal ulceration after yttrium-90 radioembolization.
abstract: BACKGROUND
  A root cause analysis was performed on the occurrence of gastroduodenal ulceration after hepatic radioembolization (RE). We aimed to identify the risk factors in the treated population and to determine the specific mechanism of nontarget RE in individual cases.
  
  
  METHODS
  The records of 247 consecutive patients treated with yttrium-90 RE for primary (n = 90) or metastatic (n = 157) liver cancer using either resin (n = 181) or glass (n = 66) microspheres were reviewed. All patients who developed a biopsy-proven microsphere-induced gastroduodenal ulcer were identified. Univariate and multivariate analyses were performed on baseline parameters and procedural data to determine possible risk factors in the total population. Individual cases were analyzed to ascertain the specific cause, including identification of the culprit vessel(s) leading to extrahepatic deposition of the microspheres.
  
  
  RESULTS
  Eight patients (3.2 %) developed a gastroduodenal ulcer. Stasis during injection was the strongest independent risk factor (p = 0.004), followed by distal origin of the gastroduodenal artery (p = 0.004), young age (p = 0.040), and proximal injection of the microspheres (p = 0.043). Prolonged administrations, pain during administration, whole liver treatment, and use of resin microspheres also showed interrelated trends in multivariate analysis. Retrospective review of intraprocedural and postprocedural imaging showed a probable or possible culprit vessel, each a tiny complex collateral vessel, in seven patients.
  
  
  CONCLUSIONS
  Proximal administrations and those resulting in stasis of flow presented increased risk for gastroduodenal ulceration. Patients who had undergone bevacizumab therapy were at high risk for developing stasis.
authors: Division of Interventional Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.|Department of Radiology and Nuclear Medicine, UMC Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
authors: Marnix G E H
authors: MGEH
authors: Lam
authors: Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
authors: Subhas
authors: S
authors: Banerjee
authors: Division of Interventional Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
authors: John D
authors: JD
authors: Louie
authors: Division of Interventional Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
authors: Mohamed H K
authors: MHK
authors: Abdelmaksoud
authors: Division of Nuclear Medicine and Molecular Imaging, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
authors: Andrei H
authors: AH
authors: Iagaru
authors: Division of Interventional Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
authors: Rebecca E
authors: RE
authors: Ennen
authors: Division of Interventional Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA. dansze@stanford.edu.
authors: Daniel Y
authors: DY
authors: Sze
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D004621:Embolization, Therapeutic / Q000009:adverse effects* / Q000379:methods*; D005260:Female; D018589:Gastroparesis / Q000150:complications; D006801:Humans; D008113:Liver Neoplasms / Q000150:complications / Q000532:radiotherapy*; D008297:Male; D008863:Microspheres; D008875:Middle Aged; D010437:Peptic Ulcer / Q000150:complications / Q000209:etiology*; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D060891:Root Cause Analysis / Q000379:methods*; D055815:Young Adult; D015021:Yttrium Radioisotopes / Q000009:adverse effects / Q000627:therapeutic use*
chemical_list: D015021:Yttrium Radioisotopes