The following was received from the state of
Illinois via email:
The Agency [Illinois Bureau of Radiation Safety] was notified at approximately 1530 CDT on 7/1/19, that a medical event had occurred at Alexian Brothers Medical Center, in Elk Grove Village. The circumstances are near identical to those in an event reported by the licensee in February of this year (EN53859). An attempted intravascular brachytherapy procedure utilizing a Novoste BetaCath 3.5F System was aborted when the source train could not successfully reach the intended treatment site after three attempts. The source train was retracted without complication and there were no indications of kinks in the delivery catheter. Aborting the procedure resulted in an underdose exceeding 20 percent of the prescribed dose (prescribed dose was 18.4 Gy of Y-90 and delivered dose was 0.0 Gy). The three attempts also resulted in an exposure exceeding 50 rem to tissue other than the treatment site (treatment site was in the circumflex artery). The source train stopped each of three times 10mm proximal to the treatment site in the junction between the left coronary artery and the circumflex artery. The inadvertently exposed region received approximately 0.98 Gy or a dose equivalent of approximately 100 rem.
A reactionary inspection was conducted by Agency staff on the morning of July 2, 2019. A written report was received by the licensee that same day in which tortuous patient anatomy was identified as the root cause. Agency inspectors will meet with the authorized user on the afternoon of July 3, 2019, to discuss each step of the intravascular brachytherapy procedure in an effort to further isolate the root cause. No adverse medical impact is expected to the patient as a result of this event, per the authorized user. Patient has been notified and referring physician was present. This report will be updated as additional information becomes available."
Illinois Item Number: IL190016
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.