ENS 58219
ENS Event | |
|---|---|
19:11 Mar 25, 2026 | |
| Title | Medical Event |
| Event Description | The following information was provided by the Connecticut Department of Energy and Environmental Protection via phone and email:
On March 25, 2026, at 1511 EDT, a patient was planned for coronary brachytherapy for treatment to the proximal left circumflex coronary artery for an injury 30 millimeter (mm) in length and a target vessel mean luminal diameter of 3 mm. A proximal margin into the left main coronary artery and a distal margin further into the left circumflex vessel were also included. The planned treatment was to deliver 18.4 Gy at 2 mm depth using the 60 mm BetaCath source train. During catheter placement and wire test, the radiation oncologist (authorized user) noticed some friction in the catheter. Since the wire could still move through the catheter, the decision was made to attempt source deployment. Under fluoroscopy, it was observed that the 60 mm source did not fully deploy into the left circumflex but was stuck within the distal aspect in the left main coronary artery. This was likely due to an obstruction in the treatment catheter at the ostium of the left circumflex coronary artery where the left main coronary artery bifurcates at an acute angle in this patient. The radiation oncologist attempted to finish source deployment, which was unsuccessful. The source return to the transfer device was also unsuccessful. Emergency bailout was declared after approximately 16 seconds after sources arrived at the stuck location. After the device and treatment catheter were secured in the bailout box, the authorized medical physicist surveyed the patient, room, and bailout box and confirmed sources were located within the catheter in the bailout box. The decision was made to treat the patient with the 40 mm source, which was determined to provide adequate margin of the lesion, and a new treatment catheter was placed in the patient. After approval of the new treatment plan, and catheter wire test, the radiation oncologist attempted to deploy the 40 mm source, however this source also became stuck in the same location at the left circumflex ostium. The cardiologist pulled the treatment catheter back slightly to allow source return to the transfer device, which was successful. Dwell time at stuck position estimated at 16 seconds based on stopwatch time. The estimated dose was as follows: 40 mm: 0.058 Gy/sec x 16 sec = 0.928 Gy at 2 mm depth 60 mm: 0.059 Gy/sec x 16 sec = 0.944 Gy at 2 mm depth Total dose (assuming full overlap of source trains): 1.872 Gy at 2 mm depth. The target lesion did not receive the intended treatment dose (18.4 Gy at 2 mm depth). 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. |
| Where | |
|---|---|
| Yale New Haven Hospital New Haven, Connecticut (NRC Region 1) | |
| License number: | 06-00819-03 |
| Organization: | Ct Dept Of Environmental Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+41.92 h1.747 days <br />0.25 weeks <br />0.0574 months <br />) | |
| Opened: | Mike Firsick 13:06 Mar 27, 2026 |
| NRC Officer: | Karen Cotton |
| Last Updated: | Mar 27, 2026 |
| 58219 - NRC Website | |
Yale New Haven Hospital with Agreement State | |
WEEKMONTHYEARENS 582192026-03-25T19:11:00025 March 2026 19:11:00
[Table view]Agreement State Medical Event 2026-03-25T19:11:00 | |