Chemoembolization of Hepatocellular Carcinoma with Extrahepatic Collateral Blood Supply: Anatomic and Technical Considerations

Abstract

Transarterial chemoembolization (TACE) is considered a standard local-regional treatment for intermediate-stage hepatocellular carcinoma (HCC) and the most common bridging therapy. This treatment is offered to more than 70% of patients who are on the waiting list for liver transplantation in the United States. HCC typically receives its blood supply from the hepatic artery; however, it can recruit a parasitic supply from extrahepatic collateral (EHC) arteries. The development of an EHC arterial blood supply can interfere with the therapeutic efficacy of TACE and result in treatment failure and poor outcome. Cross-sectional imaging-specifically computed tomography and magnetic resonance imaging-has some limitations in depicting the presence or absence of an EHC arterial supply during the pre-TACE evaluation. Catheterization and angiography of every possible EHC artery during a routine TACE procedure would be time consuming and technically challenging and would not always be feasible. Therefore, the prediction of a potential EHC arterial supply on the basis of tumor location before, during, and after TACE is fundamental to achieving optimal therapeutic efficacy. To perform TACE through EHC arteries, special considerations are necessary to avoid potentially serious complications. The authors review the factors influencing the development of an EHC arterial blood supply to HCC and describe a systematic approach to enhance the ability to predict the presence of EHC arteries. They also describe the proper technique for TACE of each EHC artery and how to avoid potential technique-related complications. RSNA, 2017.

Conventional Chemoembolization for Hepatocellular Carcinoma: Role of Cone-Beam Computed Tomography Guidance

“…A B C of parasitic supply through extrahepatic collateral arteries is essential to achieve a successful outcome after chemoembolization. 41,42 It is not easy to detect the extrahepatic collateral supply to…”

Right inferior phrenic artery; Don't miss on MDCT before chemoembolization of hepatic dome HCC

“…Familiarity with variations in the hepatic arterial anatomy is essential to accomplish embolization. In some patients, in addition to anatomic variations of the hepatic arteries, various extrahepatic collateral (EHC) arteries that may provide a partial or total vascular supply to HCC in certain conditions can obtain TACE technically challenging [6].…”

Conventional Transarterial Chemoembolization (TACE) of a Hepatocellular Carcinoma with Aberrant Extrahepatic Blood Supply using Balloon Microcatheter for Flow Redirection

“…Hepatic arteries are the primary feeders in 80% of liver malignancies [4]. In patients with tumor sizes >5cm, prior TACEs or surgeries, exophytic tumors, extrahepatic tumor infiltration, and/or tumor location at the bare area of the liver, extrahepatic collateral (EHC) arteries from nearby vasculature may provide additional supply in addition to a patent hepatic artery [5]. The right inferior phrenic artery contributes an additional blood supply to 70-83% of HCCs [5].…”

“…In patients with tumor sizes >5cm, prior TACEs or surgeries, exophytic tumors, extrahepatic tumor infiltration, and/or tumor location at the bare area of the liver, extrahepatic collateral (EHC) arteries from nearby vasculature may provide additional supply in addition to a patent hepatic artery [5]. The right inferior phrenic artery contributes an additional blood supply to 70-83% of HCCs [5]. In rare cases, hepatic tumors in segments V and VI that are close to the duodenum can have EHC from the gastroduodenal artery (GDA) and its branches [5].…”

“…The right inferior phrenic artery contributes an additional blood supply to 70-83% of HCCs [5]. In rare cases, hepatic tumors in segments V and VI that are close to the duodenum can have EHC from the gastroduodenal artery (GDA) and its branches [5]. However, no known cases have been reported where the GDA is the primary and sole blood supply to the HCC.…”