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120
N. M. Khilnani and R. J. Min
from about 6 cm below the knee to the ankle. The
GSV and its major named branches run superficial
to the deep and deep to the superficial fascia within
the saphenous space. The GSV has two important
and named tributaries above and below the knee:
the anterior and posterior circumflex veins of the
calf and thigh. In addition there are three smaller
tributaries at the groin which are important in that
they are often a source of recurrent varicose veins
following their surgical ligation along with the GSV
(high ligation). A common variant, the anterior
accessory GSV (AAGSV), runs more laterally than
the GSV within the saphenous space and often is
erroneously termed a duplication of this trunk. This
vein is frequently present and can be responsible for
varicose veins on the anterior aspect of the thigh.
An extrafascial tributary vein that communicates
with the GSV but runs parallel to the GSV course
and is relatively straight should be described as a
superficial accessory GSV.
The SSV begins on the lateral aspect of the foot,
ascends posterior to the lateral malleolus and then
up the midline of the calf, between the same fascial
planes as the GSV. The SSV runs adjacent to the
sural nerve (sensory) from just below the popliteal
crease to the foot. In about two thirds of cases, the
SSV drains into the popliteal vein at or just above
the popliteal crease. In about one third of cases it
has a cephalad extension with or without a saphe-
nopopliteal junction (SPJ) to ultimately drain into
a posterior thigh perforating vein, or into the pos-
terior circumflex vein of the thigh via the vein of
Giacomini (Fig. 9.1).
9.4
EVTA: Background
Treatment of SVI is indicated for symptoms unre-
lieved by conservative methods such as graduated
compression stockings (GCS), exercise, and avoid-
ing prolonged standing. It is also indicated for com-
plications from chronic venous hypertension such
as bleeding varices, superficial thrombophlebitis,
and skin injury. Treatment begins with elimina-
tion of any truncal incompetence. The treatment
modalities available to accomplish this include high
ligation, truncal vein stripping along with a high
ligation, endovenous thermal ablation (EVTA), and
duplex ultrasound (DUS)-guided sclerotherapy.
In the last 5 years, EVTA has developed into a
successful option for obliterating truncal incom-
petence. Its main advantages over surgery are that
there is no need for anesthesia or sedation and no
recovery or down time following the procedure. The
underlying mechanism of this procedure is to endo-
vascularly deliver sufficient thermal energy to the
wall of an incompetent vein segment to produce irre-
versible occlusion. The first modern report of EVTA
Fig. 9.1. Frontal and posterior diagrams
of the lower extremity demonstrating
the great and small saphenous veins and
their named tributaries. The two saphe-
nous systems can be connected via the
vein of Giacomini
Endovenous Thermal Ablation of Incompetent Truncal Veins in Patients with Superfi cial Venous Insuffi ciency 121
was made using laser-delivered energy to ablate the
saphenofemoral junction [6]. Since that time several
devices have been approved by the U.S. Food and
Drug Administration. The currently available tools
utilize radiofrequency or laser energy of a variety of
different wavelengths to deliver the required ther-
mal dose.
As mentioned, the goal of EVTA is to endove-
nously deliver sufficient thermal energy to the wall
of an incompetent vein to irreversibly occlude it. A
catheter inserted into the venous system either by
percutaneous access or by open venotomy delivers
the thermal energ y. The procedure can be performed
on an ambulatory basis with local anesthetic and
generally require little or no sedation. The patients
are generally fully ambulatory following treatment
and the recovery time is short.
The associated varicose tributary and reticular
veins and telangiectasias are treated separately with
adjunctive therapies such as compression sclero-
therapy or microphlebectomy. Some physicians will
perform microphlebectomy for varicose veins at
the same time as EVTA. Other physicians elect to
perform phlebectomy or compression sclerotherapy
of the varicose veins at a later time. Almost all phy-
sicians will defer therapy of spider veins to a later
time.
In our practice, phlebectomy is generally recom-
mended at the same time as EVTA when varicose
tributaries are larger than 8–10 mm in diameter or
when EVTA will occlude their inflow and outflow.
If such veins are left untreated they may thrombose
in 5%–10% of cases and become painful, erythem-
atous, and possibly result in skin pigmentation.
Also, if they thrombose, their complete eradication
may be made more difficult and certainly will be
delayed. For smaller varicose veins and all reticular
and spider veins, we offer compression sclerother-
apy beginning 4 weeks after EVTA. By this point
the veins have substantially decompressed, making
their eradication with injections easier.
9.5
Evaluation Prior to EVTA
Treatment for patients with CVI begins with a care-
ful history and directed physical exam. All patients
with visible varicose veins or symptoms suggesting
venous insufficiency should be evaluated with DUS
[7, 8]. In patients with spider veins near the medial
ankle (corona phlebectasia) or along the medial
calf or thigh, a DUS of the GSV is recommended
to identify truncal ref lux. The goal of the DUS is to
determine which veins are normal and which veins
are incompetent to create a map of the pathways of
reflux in a given patient. Such a map is necessary to
define the best combination of treatments which are
available. In some cases, it may be possible to iden-
tify the abnormal vein segments by physical exam.
However, the different pathways of incompetence
overlap sufficiently such that reliance on physical
examination alone will lead to frequent diagnostic
errors.
Reflux in truncal veins must be treated prior to
addressing any visible abnormalities. EVTA is a
treatment option for endovenously eliminating such
reflux. The indications for ablation of incompetent
truncal veins are identical to those for surgical liga-
tion and stripping. Absolute contraindications have
yet to be identified for the laser procedure. For RF
ablation, a pacemaker or implantable defibrillator
is a contraindication. Relative contraindications for
EVTA include absent pedal pulses limiting GCS use,
liver abnormalities limiting local anesthesia use,
pregnancy, nursing, and uncorrectable coagulopa-
thies.
9.6
EVTA Technique
Once the pathways of incompetence are established,
EVTA can be utilized to treat incompetent truncal
veins and straight segments of their tributary veins.
In almost all cases venous access is directly into the
vein to be treated or directly into one of its principle
tributaries, if the tributary vein is straight. Gener-
ally the access is at or just below the lowest level of
reflux in the treated truncal vein as defined by DUS.
This is generally recognized as the level where the
diameter of the truncal vein decreases just periph-
eral to a large incompetent tributary. In many cases,
segmental great saphenous vein incompetence can
occur in two separate portions of this vein. The
reflux can completely spill out into a tributary vein
only to re-enter the GSV at a lower level. It is impor-
tant to determine if the intervening portion of the
GSV is hypoplastic or normal. Hypoplastic segments
occur commonly [9] and cannot be traversed by a
guidewire. In this circumstance, venous access will
be required into the most peripheral part of both
segments and the segments are subsequently ablated
sequentially. Normal intervening segments can be
122
N. M. Khilnani and R. J. Min
crossed and allow the operator to treat all incom-
petent segments of the GSV through one venous
access.
Prior to treatment, the treated veins are mapped
and the courses of the treated segments as well as
important landmarks such as junctions, venous
aneurysms and large perforator inflows are drawn
on the patient’s skin with a surgical marker. The
patient is then placed horizontal on the table allow-
ing full access to the treated segments. In general,
patients being treated for GSV reflux are placed
supine. Patients being treated for reflux in the SSV
are placed prone with their feet hanging off the end
of the table to relax the calf. Posterior medial tribu-
tary and Giacomini vein ablations may require more
challenging positions.
Ven ous access i s accom plishe d w ith ei ther a 19 - or
21-G needle using real-time US guidance and a one-
wall technique. The incompetent truncal vein can
become much smaller when the patient lies down.
Placing the patients in the reverse Trendelenburg
position and keeping the procedure room warm can
dilate the vein to make access easier. Also, when
the puncture is directed into a tributary vein or the
AAGSV, care must be taken to avoid venospasm,
which is much more common with missed punc-
tures of these veins.
The details of the laser and RF treatments vary at
this point but the ultimate treatment goals and tech-
niques are similar. With RF ablation, the RF cath-
eter is withdrawn only after its tines are exposed
to allow contact with the vein wall. The catheter is
withdrawn maintaining the vein wall temperature
at or above 85°C as measured by a thermocouple
embedded in its tip. For laser ablation the fiber is
withdrawn at a rate determined by the energy depo-
sition per length of vein treated. For the remainder
of this presentation on technique, the laser proce-
dure will be discussed. The details of the RF venous
ablation can be reviewed in the references cited in
the results section.
For laser EVTA, a 5F sheath is inserted through
the entire abnormal segment and into a more central
vein. A bare tipped laser fiber is inserted to the end
of the sheath, which is then withdrawn exposing the
tip of the fiber. The sheath and fiber are then with-
drawn to place the tip at the staring point of the abla-
tion. For the GSV this is usually about 1 cm below
the SFJ and for the SSV about 2 cm below the SPJ
where the SSV turns parallel to the skin just below
the popliteal fossa (Fig. 9.2). With the laser, confir-
mation of the position can be made with localization
of the light which comes from the red aiming beam
which can almost always be visualized through the
skin.
The most time consuming part of the procedure
is the US-guided delivery of perivenous tumescent
anesthesia (TA). TA is a form of local anesthesia
delivery which was popularized by plastic surgeons
which utilizes large volumes of dilute anesthetic
solutions which are infiltrated to anesthetize large
regions for treatment. TA can make EVTA pain-
less obviating the risks and additional monitoring
associated sedation or anesthesia. In fact, it can be
argued that sedation adds risk to EVTA by blunt-
ing the patients’ response to pain making them
potentially more susceptible to extravenous thermal
injury as well as delaying immediate ambulation
after the procedure.
TA is also necessary for safety and efficacy of
the procedure as well. Large volumes are utilized to
compress the truncal vein to maximize the transfer
of energy to the surrounding vein wall. Even though
venospasm f requently occu rs soon af ter sheath inse r-
tion, it is usually still necessary to empty the vein
further with TA to ensure adequate treatment. Also
important is that the large volume of fluid around
the vein is necessary to insulate the vein from the
surrounding structures. This part of the procedure
Fig. 9.2. Longitudinal view of the saphenofemoral junction
(SFJ) during positioning of a laser fi ber prior to EVTA. The
left of the image is toward the patient’s head. A thin arrow
points to the tip pf the laser fi ber approximately 5–10 mm
below the SFJ at the takeoff of the superfi cial epigastic vein.
The (*) identifi es the SFJ, FV the femoral vein, GSV the great
saphenous vein and SEG the superfi cial epigastric vein
Endovenous Thermal Ablation of Incompetent Truncal Veins in Patients with Superfi cial Venous Insuffi ciency 123
minimizes potential thermal injury to the skin or
adjacent nerves or arteries. In practice a 1-cm-diam-
eter cylinder of TA surrounding the treated vein and
1 cm separation of the treated vein from the skin is
adequate.
For EVTA, we generally use 100–200 ml of a 0.1%
lidocaine solution buffered with sodium bicarbon-
ate. Utilizing these volumes we can get close to the
4.5-mg lidocaine/kg dose without epinephrine and
7-mg/kg doses with epinephrine. In plastic surgery
these doses are routinely safely exceeded. The argu-
ment for this safety is that the large volumes of fluid
containing this drug are absorbed slowly avoid-
ing high systemic levels. However, in an outpatient
environment, it is best to avoid reaching these dose
thresholds. In our practice, we also avoid the use
of epinephrine to avoid any toxicity related to this
drug.
After placing the patient in a Trendelenburg posi-
tion to further empty the vein of blood, the sheath
and fiber are withdrawn as a unit through the treated
vein segment as the laser is activated. With DUS, gas
bubbles can be seen to emanate from the tip of the
laser fiber which serves as additional confirmation
of the tip position at the appropriate location.
Suggested parameters vary slightly with the dif-
ferent laser devices but are under the control of the
operator. In our practice, using the 810-nm diode
laser (Diomed, Andover, MA) 14-watt continuous
mode is selected. The amount of energy necessary
to effec t re liable ve in ablation se ems to be an averag e
of 80 J/cm throughout the treated segment [10]. The
average pullback rate to accomplish this is about
2 mm/s. In practice for the GSV we generally pull
back at 1 mm/s for the first 10 cm or so f treatment
since failures, if they occur, will happen at this loca-
tion. We also pull back at this rate near the inflow
of incompetent perforators or pudendal veins or the
take of f of large incompetent tributaries to maximize
successful occlusion at these important locations.
When treating the GSV or a superficial accessory
saphenous vein when the vein is superficial, when
treating the SSV or the GSV below Boyd’s perforator,
we wit hdraw t he fiber at 3 mm/s to mini mize skin or
nerve injuries.
Following the procedure, patients should be
placed into a Class II (30–40 mmHg) graduated
compression stocking (GCS) usually for 2 weeks.
The purpose of this is to keep the variceal tributar-
ies as empty as possible in case they occlude to min-
imize the amount of resultant thrombus. The GCS
also increases the velocity of blood flow in the deep
veins decreasing the likelihood of deep vein throm-
bosis. Anticoagulation with low-molecular-weight
heparins is routinely used after EVTA in Europe but
not in the US.
After EVTA, most patients will develop an ecchy-
mosis over the entire treated segment. This gener-
ally develops the day after the procedure but fades
by about 2–3 weeks. Most patients will comment
about some mild discomfort over the treated vein
which begins hours after the procedure but resolves
within 24–48 h. The GCS helps minimize this dis-
comfort; some patients use acetaminophen with
good response. With laser ablation, patients will also
develop a discomfort over the vein about 7–10 days
after the procedure, which is generally described as
being similar to a pulled muscle. This is most likely
caused by transverse and longitudinal retraction of
the vein as the acute inflammation transitions to
cicatrization. This resolves with movement, occa-
sional NSAID use and continued use of the GCS. No
further treatment has been necessary in our experi-
ence.
Periodic follow-up DUS is suggested to monitor
for the response to therapy. In general, at about 4
weeks following EVTA, one will identify a smaller-
diameter, thick-walled truncal vein likely the result
of significant vein wall injury and its inflammatory
response. Little or no lumen or intraluminal throm-
bus is typically identified and no flow will be found
in the treated segment. By 6–12 months the vein will
continue to shrink in size so that in successfully
treated cases the vein can no longer be visualized
[11–13]. If the vein shrinks to this extent further
follow-up is probably not necessary.
Most patients will require adjunctive treatment of
the branch varicosities. Compression sclerotherapy
and micro-phlebectomy are the most commonly
used techniques to accomplish this. Occasionally,
deeper tributary veins may require DUS-guided
sclerotherapy, and rarely, large variceal clusters will
require conventional phlebectomy.
9.7
Clinical Data
The technical success of EVTA is defined as a pro-
cedure with successful access, crossing the segment
to be treated, delivery of tumescent anesthesia and
delivery of thermal energy to the entire incompe-
tent segment. Clinical success is defined as the per-
manent occlusion of the treated vein segments and
successful elimination of related varicose veins and
124
N. M. Khilnani and R. J. Min
an improvement in the clinical classification of the
patients by at least one grade at a certain time inter-
val after the procedure. As previously mentioned,
in practice most patients will also be treated with
either adjunctive micro-phlebectomy or compres-
sion sclerotherapy and as a result the clinical success
data for the different clinical reports can be con-
founded by the success of the adjunctive procedures
and by enthusiasm by which they are utilized by the
treating physician.
Duplex ultrasound is essential to document the
permanent occlusion of truncal veins treated with
EVTA [11–13]. A successful procedure will result in
non-thrombotic circumferential vein wall injury
from the highest level of the incompetent segment
and through its treated course on early evaluation.
On late follow-up the vein segment will ideally be
obliterated and impossible to find or at least will
be significantly smaller in cross section than prior
to treatment and will have no f low throughout the
treated segment.
RF ablation was the first approved device for
EVTA. Several single-center reviews have been pub-
lished and are presented in Table 9.1. These stud-
ies have consistently demonstrated a high degree
of success in occluding the target vein. Complica-
tion rates have been low, with paresthesias and skin
burns being the most common and vexing problem
with RF ablation. DVT is an uncommon problem
in these series [19]. The imaging follow-up of these
patients (median 25 months) has demonstrated
truncal occlusion of the GSV in 90% with persistent
patency without reflux of the SFJ in the overwhelm-
ing majority of cases [12].
An industry-sponsored registry is being accu-
mulated with published 2-year follow-up data [17].
The patients in this trial were selected to have GSV
d12mm and without significant tortuosity. In this
review 142 limbs were followed up at 2 years with
DUS. Reflux was demonstrated absent in 90% with
significant reductions in pain, fatigue and edema
and 94.6% improvement in symptoms overall. There
were no cases of neovascularization. Complications
were minor, with DVT in 0.7%, PE in 0.3%, skin
burns in 4.2% of the early cases and 0% after the use
of TA, and paresthesias persistent at 2 years in 5.6%
of patients (Table 9.1).
A single-center pilot randomized trial was per-
formed early in the RF experience comparing pro-
cedure related success and complications of ligation
and stripping to RF EVTA of the GSV [20]. Fifteen
patients were randomized to RF and 13 to surgery
and all patients were followed for a mean of 50 days.
The technical and clinical success and complica-
tion rates were similar. The RF technique was per-
formed without tumescent anesthesia and many of
the described complication would likely have been
avoided with its utilization. Using a visual ana-
logue pain scale, clear advantages were noted for
EVTA most marked from days 5–14 following treat-
ment. Less analgesics and days off from work were
required by the EVTA group. Health related quality
of life assessments ultimately improved to a similar
extent but the EVTA group reached maximum ben-
efit earlier.
Another small multi-center randomized trial
comparing RF ablation to surgical stripping of the
GSV with high ligation has been performed [21]. The
data collected at a mean of 4-month follow-up and
demonstrated that the recovery following RF abla-
tion was shorter than following surgery with a sig-
nificantly higher fraction of patients back to their
usual level of activity at one day following the abla-
tions. Of note was that the recovery was significantly
quicker in those patients treated with RF ablation
using only TA than in those treated with TA along
with any other form of anesthesia. QOL as assessed
using a standardized instrument was found to be
significantly better immediately after RFA than
after surgery, although by 4 months this difference
was becoming significantly smaller.
Endovenous laser ablation of the great saphenous
vein, short saphenous vein and other saphenous-
related trunks has been approved by the FDA. The
Table 9.1. Clinical data evaluating the use of RF ablation of the GSV
Author Limbs Follow-up Success
(occluded vein/partly open, no reflux)
Parasthesias DVT Burns Ref #
We is s
140 6 wks–2
years
96% 8% / 1% @ 6 mos. 0 0 14
Kistner
300 1 year 97% NR 0.7% 0.3% 15
Goldman
41 6–24 mos. 68%/22% 0 0 NR 16
Merchant
(VNUS registry)
232@12 mos./
142@24 mos.
12–24 mos. 84%/6%@12 mos., 85%/4%@24 mos. 15%/6%@24 mos. 1% 2.1% 17
Wa g n e r
24 3–12 mos. 21/21@3 mos. And 3/3 @ 12 mos. 0 1/24 0 18
Endovenous Thermal Ablation of Incompetent Truncal Veins in Patients with Superfi cial Venous Insuffi ciency 125
reported success rates reported in several single-
center series laser ablation for GSV are presented in
Table 9.2. In these series there were no restrictions
to vein size or degree of tortuosity. These data have
consistently shown successful nonthrombotic occlu-
sion of the target truncal vein in >90% of cases with
very rare recanalizations of previously occluded
vein segments. Clinical improvement was noted in
almost all of the cases with successful truncal vein
occlusion. The incidence of DVT, paresthesias and
skin burns was almost 0% in these series. Most
patients have bruising over the region treated prob-
ably related to the needle injections for tumescent
anesthesia. Many also describe a pulling sensation
about 1 week after the procedure which is thought
to be secondary to the evolution of the inf lamma-
tory response from vein wall injury maturing into
a cicatrization phase. Superficial phlebitis was
reported in 5–12% of patients after laser treatment
noted primarily in cohorts of patients treated with
delayed compression sclerotherapy rather than in
those treated with immediate ambulatory phlebec-
tomy of the larger tributary varicosities.
Optimization of the laser technique has prompted
an evaluation of outcomes related to treatment
parameters. Zimmett has suggested a lower rate of
bruising and discomfort associate with continu-
ous as opposed to pulsed laser energy delivery [27].
Timperman [10] has shown that the success of laser
EVTA is unity when energy delivery is maintained
on average as greater than 80 J/cm of vein treated.
Further optimization is likely to inf luence the out-
come and side effects somewhat. However, given the
high degree of success comparisons of large num-
bers of patients will likely be necessary to establish
any expected subtle difference.
Although speculation exits regarding differences
between laser and RF EVTA success and side effects,
there is no significant published experience com-
paring these two technologies. The important thing
to recognize is that both of these technologies rep-
resent exciting, minimally invasive, low-risk, quick-
recovery options for patients with symptoms or
complications of superficial venous insufficiency.
Re-canalization of a treated vein presenting within
the first few months after EVTA likely results from
insufficient thermal energy delivery. This is either
because of excessively rapid pull back of the thermal
device or inadequate TA resulting in poor transfer of
thermal energy to the wall. Vein diameter probably
has no bearing on the success assuming adequate TA
is applied, regardless of whether RFA or laser is the
source of this energy. Late recurrences can be related
to re-canalization of a previously occluded vein but
are more likely related to development of incompe-
tence in previously untreated vein segments.
9.8
Summary
EVTA should be considered a scientifically accept-
able option to eliminate truncal reflux. The pro-
cedures can be performed without sedation in an
ambulatory setting and are very effective, safe and
associated with virtually immediate recovery. EVTA
appears to be associated with a lower rate of recur-
rent SVI due to a virtual absence of the high rate
of groin neovascularity seen with high ligation and
stripping of the GSV. EVTA procedures have already
begun to supplant traditional surgery for truncal
incompetence.
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Table 9.2. Data evaluating the use of laser ablation of the GSV
Author Limbs Follow-up Success Parasthesias DVT SVT Burns Ref #
Min
121 24 mos. 93% 0 0 NR 0 22
Proebstle (GSV)
104 12 mos. 90% 0 0 10% 0 23
Sadick
030 24 mos. 97% 0 00024
To dd
291 12 mos. 96% NR NR NR NR 25
Roizental
150 12 mos. 99% NR NR NR NR 26
126
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Chemo-Embolization for Liver 127
Embolotherapy Applications in Oncology
Chemo-Embolization for Liver 129
10 Chemo-Embolization for Liver
Christos S. Georgiades and Jean-Francois Geschwind
C. S. Georgiades MD, PhD
Assistant Professor of Radiology and Surgery, Johns Hopkins
Medical Institutions, Blalock 545, 600 N. Wolfe Street, Balti-
more, MD 21287, USA
J.-F. Geschwind, MD
Associate Professor of Radiology, Surgery and Oncology, Johns
Hopkins Medical Institutions, Blalock 545, 600 N. Wolfe Street,
Baltimore, MD 21287, USA
in the incidence of Hepatitis C(three-fold from 1993
to 1998) and alcoholic cirrhosis [1]. Epidemiologic
analyses project increasing incidence in cirrhosis
and HCC in the USA for the foreseeable future [2,3]
and the trend is expected to eclipse the 70% increase
in incidence of HCC over the last twenty years [1].
Though less frequent, the incidence of cholangio-
cellular carcinoma (CCC) in the USA is also on the
increase with approximately 4,000 new cases per
year. HCC and CCC comprise the overwhelming
majority of primary malignant hepatic neoplasms.
Secondary or metastatic hepatic neoplasms are espe-
cially common ow ing to the blood filtration fu nction
of the liver. With prolonged life expectancy, more
people develop cancer and with improved cancer
treatments patients live longer and thus have a
greater chance of developing liver metastases. These
factors have contributed to the ever-increasing inci-
dence of patients with secondary hepatic neoplasms,
especially in the Western World. Whether primary
(HCC, CCC) or secondary however, hepatic malig-
nancies carry a dismal prognosis with overall long-
term survival percentage rates in the single digits.
Both HCC and CCC are slow-growing tumors and
even when the presence of risk factors initiates
some sort of surveillance (cross-sectional imaging
or tumor markers such as alpha-feto protein (AFP))
the majority of patients are unresectable at presen-
tation. Of the 10%–20% of patients with HCC who
are deemed resectable most will recur even with
optimum treatment either due to residual tumor or
metachronous lesions that eventually will develop in
a cirrhotic liver. Liver involvement with metastatic
disease from solid tumor imparts an equally dismal
prognosis. A patient with resectable liver metasta-
ses and controlled primary disease who can benefit
f rom s uc h a gg re ss iv e t re at ment is th e r ar e e xc ept ion.
Median survival for patients with unresectable liver
cancer is disappointingly short irrespective of his-
tology. Survival ranges from a short two months for
patients with adenocarcinoma of unknown primary
to a maximum median survival of 15 months for
colon metastases. Carcinoid patients in particular,
CONTENTS
10.1 Introduction 129
10.2 Clinical Considerations 130
10.2.1 Patient Selection and Preparation 130
10.2.2 Pathophysiology and Anatomical
Considerations 132
10.3 Technique 132
10.3.1 Procedure 132
10.3.2 Recovery 135
10.3.3 Follow-up 137
10.4 Results 138
10.5 Conclusion 139
References 140
10.1
Introduction
Chemoembolization is being used with increasing
frequency in the treatment of solid hepatic tumors.
Continued refinements of the technique and better
designed studies have confirmed the survival bene-
fit imparted by chemoembolization on patients with
unresectable liver cancer, though still being consid-
ered a palliative option. While no conclusive data
exist as to a survival benefit for patients with hepatic
tumors other than hepatocellular carcinoma (HCC),
this procedure is rapidly gaining favor over other
nonsurgical alternatives (see below). HCC is the
most common solid, nonskin cancer in the world,
with an especially high prevalence in Southeast
Asia and Sub-Saharan Africa. The main predispos-
ing factor in these geographic regions is Hepatitis B
(the strongest risk factor associated with developing
HCC), whereas in Europe and the USA the increasing
incidence is attributable to a concomitant increase
130
C. S. Georgiades and J.-F. Geschwind
have very slow disease progression and despite the
presence of liver metastases may survive for years.
Survival for unresectable disease from hepatocellu-
lar carcinoma, cholangiocarcinoma, and metastases
from pancreatic, breast cancer, and melanoma are
between 4 and 9 months [3–9].
These disappointing results coupled with the
poor response of HCC to traditional chemotherapy
have provided the impetus for the development of a
variety of nonsurgical techniques for the treatment
of hepatic neoplasms (Table 10.1). Such techniques
are generally divided into transarterial interven-
tions versus percutaneous ones. The latter group is
further subdivided into thermal ablation techniques
versus chemical ablation techniques.
Transarterial chemoembolization (TACE) has
become the most popular locoregional technique
for the treatment of unresectable HCC. Llovet et al.
[10.] showed for the first time that TACE imparts a
survival benefit to patients with unresectable HCC.
It should be mentioned that some institutions do not
routinely use chemotherapy during embolization
for primary or secondary unresectable liver can-
cers. Though data show such patients who receive
TACE have a longer survival and/or better response
than those receiving blunt transarterial emboliza-
tion (TAE) only with Lipiodol (Savage Laboratories,
Melville, NY), Gelfoam (Pharmacia and Upjohn,
Kalamazoo, Michigan) or particles (PVA by Boston
Scientific or Embospheres by Biosphere Medical
Corp., Boston, MA), the difference is not statistically
significant [10–13]. The reason that the differences
in patient survival between chemoembolization and
blunt embolization are not significant is probably
the small number of patients in the relevant studies.
Chemoembolization should reasonably be expected
to effect greater response not only pathophysiologi-
cally; studies (despite lack of statistical significance)
always show greater survival for patients treated
with TACE versus TAE.
10. 2
Clinical Considerations
10. 2.1
Patient Selection and Preparation
In addition to improved survival for patients who
undergo TACE for unresectable disease, there have
been reports of patients whose tumor has shrunk
enough to permit resection or liver transplanta-
tion and provide a chance for cure. Despite these
benefits, TACE is considered a palliative treatment
option. Surgical resection is the only procedure that
can be performed with curative intention, therefore,
TACE should be reserved for patients who are not
surgical candidates. This is the only absolute con-
traindication to TACE. Table 10.2 summarizes a list
of relative contraindications.
Prior to TACE all patients should undergo a
gadolinium-enhanced [Omniscan, GE Healthcare,
Princeton, NJ] MRI of the liver, preferably with per-
fusion/diffusion sequences (Fig. 10.1). CT, without
and even with contrast cannot adequately delineate
viable tumor and differentiate it from necrosis, scar,
or inflammatory tissue. CT can follow the tumor
response as far as size goes, but we believe this is
inadequate, whereas enhancement on MRI perfu-
sion imaging provides more accurate information
on which part of the tumor is viable and which is
dead.
Dual phase, contrast-enhanced MRI with perfu-
sion sequence will not only delineate the extent and
viability of tumor but also serve as a baseline study
to plan future treatment. A simple dual-phase MRI
or CT is acceptable as well but inferior to MRI per-
fusion in quantifying viable tumor. In addition to
information rega rding tumor v iability and morphol-
ogy, cross-sectional provides information regarding
the tumor’s vascular supply and anatomy. For exam-
ple, knowing the presence of portal vein thrombosis
Table 10.1. Nonsurgical treatment options for unresectable hepatic malignancies
Nonsurgical treatment options for mass-forming hepatic neoplasms
Percutaneous Intra-arterial
Thermal ablation Chemical ablation TACE TARE
MCT RFA LIPC Cryo PEI PAAI PCI
All of the percutaneous techniques are limited by the size and number of the lesions (up to three lesions each measuring up to
4 cm) as well as their location. Subdiaphragmatic lesions may be percutaneously inaccessible, and lesions close to large vascular
structures respond poorly to thermal ablation techniques (RFA, MCT, Cryo, and LIPC). On the contrary, intra-arterial techniques
are not limited by the number, size, or location of the lesions; rather by the hepatic function reserve, as shown in Table 10.2.
TAC E , trans-arterial chemo-embolization; TARE, trans-arterial radio-embolization; MCT, microwave coagulation therapy; RFA,
radio frequency ablation; LIPC, laser interstitial photocoagulation; Cryo, cryo-ablation; PEI, percutaneous ethanol injection;
PAAI, percutaneous acetic acid injection; PCI, percutaneous chemotherapy injection
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