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Abstract
Introduction Intra-arterial chemotherapy (IAC) for children with retinoblastoma represents a new treatment strategy with increasing safety and effectiveness. However, proper technique is vital as complications can lead to stroke and blindness, and accurate drug delivery is critical to treatment success. As the arterial supply to the eye is often a hemodynamic balance between the ophthalmic artery (OA) and external carotid artery branches, it is often necessary to perform exploratory superselective angiography prior to initiating IAC (Klufas, Gobin, et al ., 2012). Additionally, some have described the use of an occlusion balloon distal to the OA to deliver IAC without the need to select the OA itself (Yamane, Kaneko, and Mohri, 2004).
Materials and methods Our protocol for initiation of IAC for retinoblastoma begins with internal carotid artery angiography. If the OA is visualized, then an attempt is made to select it with a 1.3 or 1.5 French microcatheter. If no antegrade flow is seen in the OA (Figure 1A), then external carotid artery (ECA) branches are explored to identify supply to the eye. If no ECA supply is identified or if the OA could not be selected, then a HyperForm 4 mm × 7 mm balloon is advanced through a 4.3 French DAC, and inflated just distal to the OA. Angiography is then used to confirm antegrade flow in the OA before delivering IAC (Figure 1B).
Results We have observed two cases that displayed no antegrade flow in the OA with carotid arteriography. In both cases, ECA branch exploration was undertaken. One patient exhibited robust ocular supply via the anterior deep temporal artery, which was used for IAC. However on subsequent angiography the anterior deep temporal supply was diminished and an alternative delivery route was needed. The other patient did not have significant ocular supply from ECA branches. Both patients were subsequently treated with the balloon technique and displayed antegrade OA opacification with a robust choroidal blush after balloon inflation (Figure 1). Treatments were successful and without complication.
Conclusion IAC is a powerful new tool in the treatment of retinoblastoma, but relies on the technical ability to infuse chemotherapy into the OA. In cases when no antegrade OA flow is identified with carotid angiography, balloon occlusion distal to the OA may induce hemodynamic change allowing treatment via the carotid and OA.
Disclosures M. Froehler: None.