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States after travel to an endemic area. Fungal abscesses are associated
with immunosuppression and carry the highest risk of mortality.
Treatment varies by category, but the general principles of therapy include antibiotics, percutaneous drainage (except in cases of
ALA), and rarely open drainage or liver resection in cases that fail to
respond to minimally invasive treatment.
PYOGENIC LIVER ABSCESS
The epidemiology of PLAs has evolved over the past several decades.
Although ascending portal venous infection originating from appendicitis or diverticulitis remains an important cause of PLAs, enteric
sources of infection are more promptly diagnosed and more effectively treated than they were in the first half of the twentieth century
and are less likely to progress to pylephlebitis. Instead, changes in diet
and exercise have led to an epidemic of obesity and associated biliary
disease: biliary obstruction with subsequent infection has become
the most frequent cause of PLAs.
Pathophysiology
As discussed earlier, PLAs may have several different sources,
including (1) biliary obstruction from cholelithiasis, malignancy, or
intrahepatic cholangiopathy in the setting of liver transplant with
subsequent infection, (2) portal vein pyemia from ascending enteric
infection, (3) blunt or penetrating trauma, (4) hematogenous seeding
from systemic circulation via the hepatic artery, and (5) unknown, or
“cryptogenic.”
The microbes implicated reflect the various sources of infection.
PLAs of biliary origin are frequently associated with Escherichia coli,
Klebsiella spp., and Enterococcus, whereas PLAs of enteric origin are
associated with Bacteroides fragilis and other anaerobes. Most infections are polymicrobial. Of note, while gram-negative organisms
appear to be the most common causative pathogens in Europe and
Asia, two large population-based studies of PLAs in the United States
identified Streptococcus spp. as the most common isolated pathogens.
PLAs occurring in the absence of biliary disease, enteric infection, or trauma, termed cryptogenic PLAs, are frequently associated
with Klebsiella pneumoniae infection. In contrast with the polymi-
crobial composition of PLAs originating from biliary and enteric
sources, cryptogenic PLAs are more often monomicrobial. Recent
studies have suggested that there may be an association between
cryptogenic PLAs and colon cancer. Based on these studies, some
advocate colonoscopy following diagnosis of cryptogenic PLA to rule
out occult malignancy.
Risk factors for the development of PLAs include age, diabetes,
biliary malignancy or instrumentation, immunosuppression, and
history of liver transplant. In addition, a case control study of over
1300 patients from Taiwan found proton pump inhibitor use as
an independent and potentially modifiable risk factor for PLAs.
Although the mechanism is unknown, loss of gastric acid may allow
overgrowth of bacteria in the stomach and duodenum, which may
subsequently colonize the biliary tree.
Diagnosis
Most patients present with fever (90%) and abdominal pain (60%),
but vague and nonspecific symptoms including malaise and weight
loss are also common. Physical examination may reveal jaundice
or right upper quadrant pain, although neither of these findings is
specific for liver abscess. Laboratory evaluation may demonstrate
leukocytosis (90%), elevation in alkaline phosphatase (80%), as well
as hyperbilirubinemia (50%) and transaminitis (50%).
Imaging is critical for diagnosis of PLA. Computed tomography
(CT) with intravenous contrast is most sensitive and can provide additional information about underlying etiology (Fig. 1). PLAs will appear
hypoattenuated and may have loculations and peripheral rim enhancement (uncommon though specific for liver abscess). Ultrasound is less
sensitive but is the preferred initial diagnostic test in pediatrics (Fig. 2).
Treatment
Antibiotics
Given the broad range of possible microbes, blood cultures (positive
in over one-half of PLAs) and abscess cultures are essential to guide
antibiotic therapy. Until culture results are available, empiric antibiotic
therapy should cover streptococci, gram-negative bacilli, and anaerobes,
and it should consider the possible source. Piperacillin/tazobactam
monotherapy or ceftriaxone plus metronidazole are reasonable empiric
regimens, but in patients with history of biliary instrumentation or
FIG. 1 CT images show liver abscess with rim enhancement.
398 MANAGEMENT OF HEPATIC ABSCESS
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FIG. 3 Radiographic images show drain in place.
liver transplantation, providers may consider carbapenems for empiric
extended-spectrum beta-lactamase (ESBL) coverage. The duration of
antibiotic treatment should be determined by clinical response and
resolution of abscess on follow-up imaging at 4 to 6 weeks.
Percutaneous Drainage
Drainage is the standard of care for PLAs, and most are managed
with minimally invasive percutaneous catheter drainage. Catheter
FIG. 2 Ultrasound images of liver abscess.
placement is recommended for any abscess >5 cm, as studies have
demonstrated superior outcomes when compared with needle aspiration alone. Percutaneous catheter drainage can also be safely employed
to manage very large abscesses >10 cm (though sometimes multiple
catheters are needed) and is therefore recommended as first-line
management of all PLAs (without evidence of abscess rupture or concurrent intraabdominal abscess) given lower morbidity as compared
with surgical drainage (Fig. 3). In cases in which the abscess is <3 cm
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and too small for catheter placement, aspiration should be attempted
(if technically feasible) to help guide antibiotic treatment (Fig. 4).
Drainage catheters should remain in place until output is low and
clear for several days. As drainage clears, providers should watch for
bile in the drains, which may indicate abscess communication with
the biliary tree. Suspicion for biliary tree communication should be
investigated with hepatobiliary iminodiacetic acid (HIDA) or magnetic resonance cholangiopancreatography (MRCP)/endoscopic retrograde cholangiopancreatography (ERCP). Abscess communication
with a large bile duct may mandate additional drainage procedures
such as sphincterotomy or percutaneous biliary drain placement.
Surgical Drainage or Resection
Antibiotics plus percutaneous drainage is an effective treatment
strategy for 80% to 90% of patients; however, in the rare cases that
fail a percutaneous treatment strategy—more often large, multiloculated abscesses or abscesses that communicate with the biliary
tree—surgery may be required. In general, minimally invasive surgery is preferred, although the recommended approach depends on
abscess location and etiology, as some situations, such as PLA with
simultaneous diverticulitis and intraabdominal abscesses, may be
best served by laparotomy.
Although some studies advocate partial hepatectomy of a diseased segment as the optimal definitive treatment strategy for large
and multiloculated abscesses that fail percutaneous drainage, there is
no evidence that this method is superior to standard surgical drainage with irrigation and drain placement. Moreover, manipulation of
diseased liver during resection may result in acute septic shock.
FIG. 4 MR images show decreased size of abscess cavity.
Outcomes
Outcomes have improved dramatically with expedited diagnosis,
antibiotics, and percutaneous catheter drainage. However, mortality remains high, between 4% and 10%. Retrospective studies have
found that diabetes mellitus, underlying malignancy, and cirrhosis
are associated with increased length of stay and increased mortality.
Studies have also shown that abscess size is an independent risk factor for prolonged hospitalization and mortality. This may be a function of higher bacterial load, more severe inflammatory syndrome,
and increased extrahepatic manifestations. In one series, more than
one-half of patients with abscesses >10 cm had an ipsilateral pleural
effusion and an increased risk of liver abscess rupture with subsequent purulent peritonitis.
AMEBIC LIVER ABSCESS
ALAs, caused by the protozoan E. histolytica, are a common source
of hepatic abscess worldwide and should be considered in the differential diagnosis among patients with suspected PLA. However, most
cases of ALA in the United States are seen in male patients (8:1 maleto-female predominance) with a history of travel to an endemic area.
Pathophysiology
ALA arises from colonic amebiasis, where ingestion of mature protozoan cysts or trophozoites through fecally contaminated food or
water leads to colitis with trophozoite invasion of intestinal mucosa.
In patients with ALA, trophozoites seed the liver through the portal
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system. This process typically occurs 2 to 4 months after symptoms
of colonic amebiasis. Abscesses contain necrotic hepatocytes and trophozoites in a thick, proteinaceous, brown fluid, classically described
as “anchovy paste.”
Diagnosis
As with PLA, patients with ALA present with fever (80%) and
right upper quadrant pain (60%). They often have leukocytosis and
elevations in alkaline phosphatase, bilirubin, and transaminases.
Although E. histolytica is a protozoan parasite, eosinophilia is not
commonly seen. ALA cannot be reliably differentiated from PLA on
imaging.
Given the similarity of presentation between PLA and ALA,
providers must be sure to ask about travel history and to ask about
history of remote antecedent diarrheal illness. All patients with
recent travel to an endemic area should undergo further diagnostic
testing with serology.
Amebic serologic testing (antibody or antigen) is highly sensitive
and is useful to rule out ALA. Antigen testing is more specific than
antibody serology, as one-third of patients with prior E. histolyt-
ica infection will have antibodies even if they do not have active
infection.
Treatment
Antibiotics
Treatment of ALA requires treatment of both the liver abscess and
its source: colonic amebiasis. Oral metronidazole (500–750 mg three
times daily for 7–10 days) is highly effective treatment for ALA, with
clinical improvement in over 90% of patients. However, an additional
antiparasite regimen is required to eliminate intestinal cysts and prevent recurrence, typically oral paromomycin (10 mg/kg three times
daily for 7 days) or oral diiodohydroxyquin (650 mg three times daily
for 20 days).
Whereas treatment duration for PLAs is guided by resolution
of abscess on imaging, ALA treatment duration is standardized as
appropriate antibiotic regimens will lead to quick clinical recovery
in most patients. Repeat imaging is still recommended, but abscess
resolution may take several months and is not necessary for antibiotic cessation.
Drainage
Another critical difference in management of ALAs as compared
with PLAs is that aspiration/drainage is only recommended when
there is no clinical response to antibiotic therapy alone. This is not
because there is increased risk with manipulation of ALA (routine
percutaneous aspiration of hydatid cysts caused by Echinococcus
granulosus is discouraged given the risk of anaphylaxis), but simply
because prospective studies have failed to demonstrate any benefit to
early drainage.
In cases that fail to respond to standard ALA therapy, clinicians
should broaden antibiotics to include coverage for PLA, as bacterial
secondary infections are not uncommon, and they should pursue
percutaneous catheter drainage.
FUNGAL HEPATIC ABSCESS
Invasive fungal infections involving the liver are almost exclusively
seen in immunocompromised patients. Those at highest risk include
patients who have undergone orthotopic liver transplantation (OLT)
or hematopoietic stem cell transplantation (HSCT), patients with
human immunodeficiency virus (HIV), and patients with hepatobiliary malignancy. As with PLAs, there are multiple possible sources
of infection. Patients undergoing OLT may develop hepatic artery
thrombosis, which can lead to intrahepatic cholangiopathy that
predisposes them to the development of fungal abscess; patients
undergoing HSCT may experience breakdown of the intestinal
mucosal barrier with translocation of candida from the gut into the
portal system; and patients with hepatic tumors who have undergone
ablation may be left with a fertile necrotic lesion that becomes superinfected with fungi.
These abscesses are associated with the highest risk of death, with
retrospective studies demonstrating that almost one-half of patients
with fungal hepatic abscesses succumb to disseminated infection.
Even with appropriate antifungal treatment, mortality remains
around 20%.
Treatment
Prompt recognition of mycotic infection is critical, and clinicians
must maintain a high index of suspicion for fungal infection in
at-risk patients. In transplantation, the risk of developing invasive
fungal infections is mitigated by routine antifungal prophylaxis,
and mortality in transplant patients with fungal hepatic abscess has
improved with early empiric antifungal coverage.
Fungal liver abscesses are managed according to the same treatment paradigm as PLAs: antimicrobials and percutaneous drainage.
As with PLAs, antifungal treatment should be guided by culture
data, and duration of treatment should be determined by resolution
of lesions on repeat imaging. Most fungal liver abscesses are caused
by Candida spp., and either amphotericin B or an echinocandin such
as caspofungin or micafungin would be appropriate empiric therapy.
S u g g e S t e d R e a d i n g S
Blessmann J, Binh HD, Hung DM, Tannich E, Burchard G. Treatment of
amoebic liver abscess with metronidazole alone or in combination with
ultrasound-guided needle aspiration: a comparative, prospective and ran-
domized study. Trop Med Int Health. 2003;8(11):1030–1034.
Hope WW, Vrochides DV, Newcomb WL, Mayo-Smith WW, Iannitti DA.
Optimal treatment of hepatic abscess. Am Surg. 2008;74(2):178–182.
Huang CJ, Pitt HA, Lipsett PA, et al. Pyogenic hepatic abscess. Changing
trends over 42 years. Ann Surg. 1996;223(5):600–609.
Lee CH, Jo HG, Cho EY, etal. Maximal diameter of liver abscess independently
predicts prolonged hospitalization and poor prognosis in patients with
pyogenic liver abscess. BMC Infect Dis. 2021;21(1):171.
Lin H-F, Liao K-F, Chang C-M, Lin C-L, Lai S-W. Correlation between proton
pump inhibitors and risk of pyogenic liver abscess. Eur J Clin Pharmacol.
2017;73(8):1019–1025.
Lipsett PA, Huang CJ, Lillemoe KD, Cameron JL, Pitt HA. Fungal hepatic
abscesses: Characterization and management. J Gastrointest Surg Off J Soc
Surg Aliment Tract. 1997;1(1):78–84.
Meddings L, Myers RP, Hubbard J, etal. A population-based study of pyogen-
ic liver abscesses in the United States: incidence, mortality, and temporal
trends. Am J Gastroenterol. 2010;105(1):117–124.
Mohan BP, Meyyur Aravamudan V, Khan SR, etal. Prevalence of colorectal
cancer in cryptogenic pyogenic liver abscess patients. Do they need
screening colonoscopy? A systematic review and meta-analysis. Dig Liver
Dis Off J Ital Soc Gastroenterol Ital Assoc Study Liver. 2019;51(12):1641–
1645.
Neill L, Edwards F, Collin SM, etal. Clinical characteristics and treatment
outcomes in a cohort of patients with pyogenic and amoebic liver abscess.
BMC Infect Dis. 2019;19(1):490.
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Transarterial Therapies
for Primary and
Metastatic Liver Tumors
Nariman Nezami, MD, and Clifford R. Weiss, MD
INTRODUCTION
Image-guided locoregional therapies play an important role in the
treatment of patients with primary or metastatic hepatic tumors.
Today, various intraarterial therapeutic modalities (Fig. 1) are available,
ranging from bland embolization (BE), transarterial chemoembolization (TACE), drug-eluting beads chemoembolization (DEB-TACE), to
selective internal radioembolization therapy (SIRT), or even hepatic
artery infusion (HAI). The rationale behind intraarterial therapies is
to reduce systemic toxicity while offering more effective local tumor
control. Extensive evidence has supported the benefit of image-guided
locoregional therapies, which eventually resulted in the addition of some
of procedures to the National Comprehensive Cancer Network treatment guidelines. This chapter reviews how intraarterial therapies (IATs)
could be incorporated into a multidisciplinary approach, with the goal of
treating cholangiocarcinoma and metastatic liver tumors to downstage
for resection, as a bridge to transplantation, or to provide palliation.
TRANSARTERIAL THERAPIES
The normal liver parenchyma has a dual blood supply; mainly, it is
supplied by the portal vein (70%–75%), which delivers deoxygenated
blood from the small intestine and contains nutrients, while 25%
FIG. 1 Transarterial embolization approaches. (A) BE. (B) cTACE. (C) DEB-TACE. (D) SIRT.
402 TRANSARTERIAL THERAPIES FOR PRIMARY AND METASTATIC LIVER TUMORS
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A
B
CD
FIG. 2 Bland embolization in a patient with numerous NET liver metastases. (A) Axial arterial enhanced MRI shows multifocal metastatic lesions in both
hepatic lobes, with the major burden in the right hepatic lobe. (B) Digital subtraction angiogram also reveals multifocal tumor blush in the right hepatic
lobe. (C) Digital subtraction angiogram shows selective angiogram and bland embolization of segment VI. (D) Axial arterial-enhanced MRI after 4 weeks
demonstrates multifocal tumor necrosis and partial response. (Courtesy Dr. Aran Chary, Emory University School of Medicine.)
to 30% is supplied by the hepatic artery, which delivers oxygenated
blood from the general circulation. The efficacy of TACE relies on
the fact that primary and secondary liver neoplasms are exclusively
fed by hepatic artery branches because of tumor-induced neoangiogenesis. Therefore, the intraarterial delivery of a tumoricidal drug
will primarily target tumor cells, while sparing the liver parenchyma.
Currently, there are four different intraarterial therapeutic options
for treating patients using a catheter-based approach. Multiple
studies have failed to show whether the efficacy of any of these
approaches is superior to the others. Thus, the choice of a transarterial approach is operator/institution-dependent and sometimes
depends on the patient’s arterial anatomy (multiple blood supply to a
tumor or an existing significant shunt).
Bland Embolization
The rationale for the use of BE for hypervascular tumors is that the
majority of tumors are perfused by the hepatic artery. BE results in
antitumor effects solely by blocking blood supply and inducing ischemia and infarction of tumor tissue. During BE, embolic particles are
used to achieve complete stasis in the hepatic artery branches that
supply the target tumor (Fig. 2). TAE could be nearly as effective as
TACE. Therefore, the patient could still benefit from embolization if
chemotherapy is contraindicated (e.g., maximum amount of lifetime
doxorubicin is reached or the patient is allergic).
Conventional Transarterial Chemoembolization
Conventional transarterial chemoembolization (cTACE) is referred
to as Lipiodol-based TACE. This is the originally described conventional TACE method. It involves the transcatheter delivery of a
mixture of chemotherapy and lipiodol into the target tumor, followed
by particle embolization (Fig. 3). The chemotherapy mixture consists
of any combination of cisplatin (100 mg), doxorubicin (50 mg), and
mitomycin C (10 mg). This is mixed with lipiodol (Ethiodol) in a 1:1
or a 2:1 (chemotherapy:lipiodol) volume ratio depending on flow
characteristics. The aqueous-to-lipid phase ratio affects the emulsion
stability and the drug release rate. A 1:1 ratio is more viscous and is
used for high-flow states, whereas the 2:1 ratio is less viscous and is
used in low-flow states.
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A
C
B
D
FIG. 3 cTACE in a 70-year-old woman with intrahepatic cholangiocarcinoma. (A) Axial arterial enhancement MRI shows a large intrahepatic cholangiocar-
cinoma in the right hepatic lobe. (B) Digital subtraction angiogram reveals tumor blush in the right hepatic lobe and blood supply from the right hepatic
artery. (C) Immediate postembolization axial noncontrast CT shows dense lipiodol deposition within the tumor. (D) Axial arterial enhancement MRI after
4 weeks shows extensive tumor necrosis.
Drug-Eluting Beads Transarterial
Chemoembolization
One of the latest developments is the introduction of spongelike
particles that can be preloaded with chemotherapeutics. These particles are used to embolize the target tumor similar to conventional
TACE without the addition of lipiodol. Over a period of time, these
particles elute chemotherapy drugs, maintaining a high intratumoral
dose and a low plasma concentration. DEBs allow only one chemotherapy drug to be loaded, which is most commonly doxorubicin or,
recently, irinotecan.
Selective Internal Radiation Therapy
SIRT is the intravascular administration of microspheres that contain
a radioisotope, which allows delivery of a higher dose of radiation
directly to the tumor than traditional radiation with an external
beam, while exposing healthy liver tissue to only a small dose. SIRT
has been proven to be safe and effective, and is recommended for
patients with unresectable tumors who are refractory to systemic
therapy and have liver-only or liver-dominant disease. The injected
microspheres embolize the microvasculature surrounding the tumor
and emit high-energy beta-radiation. The normal liver parenchyma
is largely spared since healthy liver tissue is mainly supplied by the
portal vein.
Microspheres (∼30 m) are loaded with radioactive isotopes, such
as yttrium-90 (
a microcatheter in the hepatic artery.
90
Y) or holmium-166 (
166
Ho), and delivered through
90
Y-resin microspheres (SIRSpheres, Sirtex) are Food and Drug Administration (FDA)-approved
and CE-marked for treatment of metastatic colorectal can-
90
cer.
Y -glass microspheres (TheraSphere, BTG/Boston Scientific)
166
and
Ho microspheres (QuiremSpheres, Quirem) are CE-approved
for this indication but are not FDA-approved.
166
Ho microspheres are
the most recently developed agents that emit high-energy β particles
while also producing γ radiation, which allows for quantitative, single-photon emission computed tomography (SPECT) imaging. Interestingly,
166
Ho microspheres are paramagnetic, enabling monitoring
with magnetic resonance imaging (MRI).
Two approaches have been described for SIRT: lobar or sublobar
(Fig. 4) versus segmentectomy (Fig. 5). A lobar or sublobar approach
404 TRANSARTERIAL THERAPIES FOR PRIMARY AND METASTATIC LIVER TUMORS
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A
B
C
FIG. 4 Lobar SIRT in 65-year-old man with colorectal liver metastases. (A) Axial PET CT scan shows extensive FDG avidity in the right hepatic lobe. (B)
Digital subtraction angiogram reveals tumor blush in the right hepatic lobe and blood supply from the right hepatic artery. (C) Intraprocedural cone-beam
CT scan confirms corresponding perfusion. (D) Nuclear medicine SPECT CT immediately post-MAA mapping/shunt study shows MAA deposition within
the tumor region. (E). Nuclear medicine SPECT CT demonstrates dense resin-based 90Y retention within the right hepatic lobe. (F) Axial PET CT scan
shows partial response in the right hepatic lobe tumor. (Courtesy Dr. Aran Chary, Emory University School of Medicine.)
D
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B
A
C
FIG. 5 SIRT, segmentectomy in a 58-year-old woman with a surgical history of colectomy, cholecystectomy, right hepatectomy, on multiple lines of
chemotherapy and SIRT with a single colorectal liver metastasis. (A) Axial arterial enhanced CT scan shows a single metastasis in the right hepatic lobe.
(B) Digital subtraction angiogram reveals tumor blush with corresponding blood supply from segment VII of the hepatic artery. (C) Intraprocedural cone-
beam CT confirms the corresponding perfusion from segment VII of the right hepatic artery branch. (D) Nuclear medicine SPECT CT demonstrates dense
glass-based 90Y retention within the tumor. Immediate post-SIRT SPECT CT shows dense 90Y glass deposition within the tumor. (E) Follow-up axial arterial
enhanced MRI after 6 weeks shows extensive necrosis and complete response of the metastatic lesion in segment VII. (F) Follow-up axial arterial enhanced
CT scan shows no change in the complete response of the metastatic lesion in segment VII. (Courtesy Dr. Aran Chary, Emory University School of Medicine.)
D
406 TRANSARTERIAL THERAPIES FOR PRIMARY AND METASTATIC LIVER TUMORS
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is chosen when there is multifocal disease, while segmentectomy is
offered to those patients with a solitary tumor ≤5 cm and liver-only
disease when the tumor can be isolated angiographically.
Hepatic Artery Infusion
HAI chemotherapy is administered in the proper hepatic artery by a
surgically implanted pump, a hepatic arterial port, or through a percutaneously placed catheter connected to an external pump (Fig. 6).
Certain drugs with a high first-pass extraction can be delivered into
the arterial circulation with the goal of increased local concentration
of the agent, which increases the therapeutic response with decreased
systemic exposure and toxicity.
Indications and Patient Selection
1. Colon cancer
a. If surgery or ablation is not an option and there are no sys-
temic options
b. To maintain tumor size if planned surgery is significantly
delayed
2. Intrahepatic cholangiocarcinoma (ICC)
a. If systemic chemotherapy fails or in conjunction with systemic
chemotherapy
b. To target a portion of the tumor along a precarious resection
margin, thus aiding surgery
3. Neuroendocrine cancer
a. If symptomatic
b. There are clinically significant laboratory abnormalities, such
as hypoglycemia from metastatic insulinoma, or hyperglyce-
mia from metastatic glucagonoma
c. Rapid growth
d. High Ki-67 index
4. Other (pancreatic, breast, melanoma)
a. TACE for such neoplasms is less well studied and should be
tailored to each individual patient
5. Developing indications
Three novel indications are:
a. The use of preimmunotherapy TACE to bolster immune
response
b. Preoperative TACE to address micrometastasis or microvas-
cular components
c. Combined with ablation/systematic therapies for improved
outcome
Contraindications to Transarterial Chemoembolization
Major Contraindications
1. ECOG 3
2. Decompensated or borderline liver function
3. Severely reduced portal vein blood flow (acute and chronic portal
vein tumor thrombosis)
4. Extensive tumor involving the entirety of both liver lobes
5. Untreatable arteriovenous fistula
6. Renal insufficiency, including creatinine ≥2 mg/dL or creatinine
clearance <30 mL/min
7. Total bilirubin >4 or rapidly rising total bilirubin
8. Active bacterial infection
Relative Contraindications
1. Severe comorbidities (acute cardiovascular or lung disease)
a. Bilioenteric anastomosis or biliary stents, bile duct occlusion
2. Life expectancy <6 months
Contraindications to SIRT Application (FDA
Recommendation):
1. Prior liver irradiation
2. Coexistence of ascites and/or liver failure
3. The presence of liver dysfunction
4. The presence of metastases to organs other than the liver
5. A Capecitabine treatment in the last two months before the
surgery
6. Portal vein thrombosis
7. Pregnancy
8. Abnormal test results: WBC <2.5 thousand, Neu <1.5 thousand,
PLT <60 thousand, AST/ALT >5 × normal, bilirubin >2 mg/dL,
albumin < 3 g/dL, creatinine >2.5 mg/dL
9. Irregularities in the anatomical structure of the venous system in
the liver
Patient Preparation
1. Preprocedural fasting for 6 to 8 hours in preparation for conscious sedation or general anesthesia
2. Premedication:
a. Dexamethasone (20 mg intravenously), which reduces the
extent of postembolization syndrome
b. Proton pump inhibitors, which reduce the risk of gastri-
tis/duodenitis and mitigate the significance of nontarget
embolization
c. Hydration, which reduces fatigue, nausea
d. Antibiotics. Prophylaxis administration is necessary if the
integrity of the biliary system has been compromised by prior
biliary intubation or post-Whipple. The recommended regi-
men is moxifloxacin 400 mg by mouth daily beginning 3 days
before and continuing for 7 days postembolization.
e. Somatostatin analogs. For neuroendocrine tumors (NETs)
with a carcinoid origin. These patients are at risk of develop-
ing a carcinoid crisis during or immediately after intervention.
The ideal scheme and dosing of octreotide to prevent the
development of a carcinoid crisis have not been clearly estab-
lished and are mostly operator-dependent.
Techniques: Angiogram and Embolization Technique
1. Vascular access. Transarterial embolization can be performed
either via common femoral arterial (CFA) or radial arterial (TRA)
access. In both approaches, a 5-6 Fr vascular sheath is used. If
the radial approach is chosen, a Barbeau’s test is first performed
to minimize the risk of hand ischemia. Upon TRA access, a
cocktail of heparin and one or more vasodilators (nitroglycerin,
verapamil, or nicardipine) is administered. Administration of this
cocktail is not necessary for CFA access.
2. Diagnostic arteriograms. An angiogram is performed to:
a. Delineate the vascular anatomy related to the tumor and
assess the best treatment delivery route.
b. Map any nontarget and collateral vessels at risk for inadver-
tent chemoembolization and plan an approach to minimize
the risk. A superior mesenteric arteriogram is performed
first. This excludes replaced/collateral vascular anatomy to
the liver and shows whether the portal vein is patent or not.
Then, a celiac arteriogram is performed. This shows the target
(hepatic artery branches) and nontarget arteries (i.e., left and
right gastric artery, supraduodenal artery, cystic artery, and
umbilical artery).
3. Treatment.
a. TACE. Once the target arteries are chosen, a microcatheter is
used to obtain super-selective access. The ideal location for
the tip of the catheter is one in which an infusion from that
point would cover the entire tumor and, at the same time,
spare as much of the normal liver parenchyma as possible.
Once the catheter is in the optimum position, the treatment
mixture is delivered. Whether cTACE or DEB-TACE, this
is done under continuous fluoroscopic observation. As the
cocktail is administered, target arterioles embolize and flow
dynamics may change. cTACE is continued until stasis is
achieved and the peribiliary venous plexus is seen, while DEBTACE is stopped once substasis (slow blood flow) is noticed
on the angiogram. Overaggressive embolization may result in
antegrade reflux around the catheter and inadvertently reach
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