Chemoembolotherapy for recurrent hepatocellular carcinoma in the residual liver after hepatectomy.

The efficacy of transcatheter arterial chemoembolization using Lipiodol (TACE) to treat recurrent hepatocellular carcinoma (r-HCC) in the residual liver after radical hepatic resection was evaluated. During the last 8 years, TACE was performed in 68 patients with r-HCC for an aggregate total of 150 times. Of the 68 patients, 4 had a massive type r-HCC with tumor thrombus in the main portal vein (PVTT) at the time of the first TACE. Among the remaining 64 patients without PVTT, multiple r-HCCs were revealed in 46, and a single r-HCC in 18 by angiography and/or follow-up CT scans after the initial TACE. In 26 of the 68 patients (38.2%), at least one or more r-HCCs were fed not only by the hepatic arteries, but also by the extrahepatic collateral arteries, such as branches of the right inferior phrenic artery. The cumulative survival rates of these patients after hepatectomy and after the initial TACE for r-HCC were 98.6% and 87.1% for one year, 89.7% and 62.9% for 2 years, 74.0% and 34.3% for 3 years, 53.1% and 20.0% for 4 years and 40.3% and 0% for 5 years (mean survival duration: 1,647 days and 947 days), respectively. These results indicate that repeat TACE against r-HCC can help obtain long-term survival in patients with r-HCC. However, during TACE, we must give consideration to the newly developed collateral feeding artery to the r-HCC.

Chemoembolization for hepatocellular carcinoma via the inferior pancreaticoduodenal artery in patients with celiac artery stenosis.

Twenty-one patients with hepatocellular carcinoma (HCC) accompanied by extensive celiac artery stenosis or obstruction were treated by chemoembolization via the inferior pancreaticoduodenal artery (IPDA). The tip of the catheter was placed in the arteries in front of the confluence with the proper hepatic artery in 12 patients (group A: the proximal portion of the IPDA in 10, and common hepatic artery in 2), and in the proper hepatic artery or branches of it (group B) in 9 using a coaxial catheter system. Transient hyperamylasemia was observed in 10 of the 12 patients in group A and in 3 of the 9 patients in group B after chemoembolization. Splenic infarction developed in 8 patients in group A and in none in group B. Intrapancreatic fluid collection was present in 2 patients in group A following chemoembolization. No fatal complications were encountered. The 1-, 2-, and 3-year survival rates of the 10 patients in group A treated by only chemoembolization were 90, 57, and 23%, respectively (mean survival 780 days). The 1- and 2-year survival rates of 9 patients in group B were 85.8 and 85.8% (mean 879 days), respectively. Considering the severity of complications and the survival rates in groups A and B, chemoembolization by superselective catheterization into the hepatic artery via the IPDA is the treatment of choice. However, chemoembolization from the arteries in front of the confluence with the proper hepatic artery seems to be acceptable in cases of hypervascular HCC which fail to be superselectively catheterized.

Hepatocellular carcinoma: a multivariate analysis of prognostic features in patients treated with hepatic arterial embolization.

The prognosis after hepatic arterial chemoembolization was retrospectively analyzed in relation to therapeutic modalities, stage of tumor, and degree of liver cirrhosis in 150 patients with solitary tumors of hepatocellular carcinoma. The analyses of life-table methods revealed that adjunct hepatectomy, tumor size, bilirubin, albumin, globulin, and the 15-min retention rate of indocyanine green are statistically significant prognostic factors for hepatic arterial chemoembolization. Results of Cox's proportional hazard analyses disclosed that adjunct hepatectomy (p = 0.0001), serum albumin level (p = 0.0032), and stage of tumor (p = 0.0194) are statistically significant and independent prognostic factors. These findings suggest that the prognosis after hepatic arterial chemoembolization depends on the hepatic functional reserve and stage of tumor in patients with hepatocellular carcinoma, and adjunct hepatectomy improves the prognosis in these patients.

Emergent embolotherapy of small intestine hemorrhage.

The efficacy of emergent embolotherapy was evaluated in six patients suffering hemorrhage from the small intestine. Hemorrhage was from the jejunum in four patients, from the ileum in one, and from Meckel's diverticulum in one. Superselective embolization of the arcade of the small intestine artery branch was performed in all patients with a coaxial catheter. Embolic materials used were Gelfoam particles alone or Gelfoam particles plus coils in earlier cases and microcoils in recent cases. Complete hemostasis was immediately achieved in all patients, but one patient died of disseminated intravascular coagulation. After stabilization of the patient's condition by hemostasis, elective surgery was performed on three patients suffering small intestine ulcer. Histopathologically, no bowel infarction was noted but mild mucosal inflammation with submucosal edema was found in the jejunum of two patients. We recommend embolization for life-threatening small intestine hemorrhage, preferentially in situations where the blood vessel involved can be super-selectively occluded at the nearest level of the arcade of the vasa recta, lest the vasa recta should be occluded.

Emergent embolization for control of massive hemorrhage from a splanchnic artery with a new coaxial catheter system.

Emergent superselective embolization with a 3.0 F (1 mm) coaxial catheter and a steerable guidewire was performed in 27 patients with massive hemorrhage from a small-caliber splanchnic artery. Eight patients had intraperitoneal hemorrhage, 3 had hemobilia, 9 had gastric hemorrhage, and 7 had intestinal hemorrhage. Out of 27 patients, 7 had hemorrhage from a splanchnic artery pseudoaneurysm. Complete cessation of bleeding was obtained in all patients initially, but in 3 patients gastric hemorrhage recurred later. Otherwise, there was no rebleeding nor any major complication such as marked infarction of tissue or misplacement of embolic materials. This coaxial catheter system was highly reliable for achieving superselective catheterization in small-caliber arteries, minimizing the volume of infarcted tissue and allowing maximal preservation of splanchnic organic function. We conclude that this system represents a major advance in interventional radiology.

Embolotherapy of massive duodenal hemorrhage.

Eleven patients with massive duodenal hemorrhage were treated by emergent embolization. Bleeding originated from duodenal ulcer in three patients, from duodenal tumor in one, from ruptured pancreaticoduodenal artery pseudoaneurysm in three, and from ruptured gastroduodenal artery pseudoaneurysm in four. Complete hemostasis was obtained immediately after embolotherapy in all cases. Three of these patients died during the hospitalization period, one of whom from duodenal infarction and pancreas necrosis induced by embolization. In three patients with duodenal ulcer, complete hemostasis was obtained only by the gastroduodenal artery embolization with Gelfoam particles. Seven patients with pseudoaneurysms of the gastroduodenal artery or its branches required not only blockage of blood flow from the celiac artery but also the superior mesenteric artery for complete hemostasis. Therefore, in patients presenting with duodenal hemorrhage, the possibility of dual blood supply to the duodenum should be considered. Emergent embolization represents a useful alternative to surgery for massive duodenal hemorrhage, but it carries a risk of complications in patients with previous gastroduodenal surgery or significant visceral atherosclerosis.

Intraperitoneal hemorrhage from hepatocellular carcinoma: emergency chemoembolization or embolization.

From 1982 to 1990, 38 patients with intraperitoneal hemorrhage from hepatocellular carcinoma (HCC) underwent treatment with emergency embolization with or without anticancer drug and iodized oil. Before emergency embolization, 24 patients had a serum total bilirubin value of 3.0 mg/dL or less (group A) and 14 patients had hyperbilirubinemia, with a serum bilirubin level greater than 3.0 mg/dL (group B). Successful hemostasis was achieved in all patients. The mean length of survival was 165 days in group A and 13 days in group B. A significant correlation (P less than .00003) between serum bilirubin level and prognosis was obtained. While tumor thrombus in the portal vein made the prognosis poor, there was no significant difference in prognosis between groups with and without tumor thrombus (P = .145). Emergency embolization is an effective treatment in patients with intraperitoneal hemorrhage from HCC. The prognosis for patients with HCC depends on the serum bilirubin level before embolization.

Percutaneous embolization of ruptured splanchnic artery pseudoaneurysms.

The usefulness of emergent embolotherapy was evaluated in 17 patients with life-threatening hemorrhage from 18 ruptured splanchnic artery pseudoaneurysms. Complete hemostasis was obtained in 16 out of 17 patients by embolotherapy. Of the 12 initial embolization procedures with permanent embolic materials including stainless steel coils, microcoils, and Ivalon, complete cessation of bleeding was obtained in 11. On the other hand, 6 out of 9 initial embolization procedures with Gelfoam particles failed to halt bleeding, and additional embolization with permanent embolic materials was required. Emergent embolization with permanent embolic materials using superselective catheterization should be considered the initial treatment of choice for ruptured splanchnic artery pseudoaneurysms.

Influence of hepatitis B virus infection and age on mode of growth of hepatocellular carcinoma.

According to the extent of hepatic involvement of the tumor and that of portal vein invasion at the time of initial diagnosis, patients with hepatocellular carcinoma (HCC) were grouped into three or four groups. Correlations among the extent of hepatic involvement, extent of portal vein invasion, and prevalence of hepatitis B surface antigen (HBsAg) and age distribution were examined. The extent of hepatic involvement of the tumor and that of portal vein invasion were significantly greater in patients with positive HBsAg compared with findings in the negative patients (P less than 0.001). For cases of both positive and negative HBsAg, patients with a more extensive HCC were significantly younger. Results of the multivariate logistic regression analysis showed that hepatitis B antigenemia and younger age were statistically significant and independent positive predictors of extensive HCC. These results strongly suggest that hepatitis B surface antigenemia and age play an important role in the growth mode and the kinetics of HCC in Japanese patients.

Angiographic management of massive hemobilia due to iatrogenic trauma.

Ten patients with massive hemobilia in shock or preshock status were treated with angiography. The hemobilia had been induced by iatrogenic trauma: biliary drainage in seven patients, and surgery, liver biopsy, and angiography in one patient each. Angiography was performed on all patients. Embolization was performed in nine, and in the one remaining patient, spasm of the right anterior hepatic artery and catheter manipulation injured the intima and obliterated the artery. In seven patients with hepatic artery pseudoaneurysm, gelfoam particles were injected in five, however, extravasation could not be prevented in four of these patients. Permanent embolic materials were added and complete hemostatis was obtained. Hemobilia never recurred in any patient. Emergency embolization should be considered as the initial treatment of choice for hemobilia and when pseudoaneurysms are discovered, they should be obliterated by permanent embolic materials. Moreover, tumor thrombus in the portal vein is not a contraindication for this procedure.

[Transcatheter left gastric arterial embolization (TAE) in the management of massive gastric bleeding from gastric ulcer].

Emergency TAE was employed in 17 patients with massive hemorrhage from gastric ulcer. All patients were considered unacceptable or extremely high risk candidates for emergency surgical control of hemorrhage. In 12 patients, hemorrhage was completely controlled and their prognosis has been fair. Partial control in 4 patients were related to underlying severe coagulopathy and arterio-sclerosis. 1 case with ulcer which received a dual blood supply from left gastric artery (LGA) and small LGA originated from the splenic artery failed to stop bleeding. No major complication was noted after these procedures. Emergency TAE should be the initial treatment of choice in patients with massive gastric bleeding.

[A long surviving case (1 year 9 months) with stage IV ruptured HCC treated by emergency embolization].

The spontaneous rupture of hepatocellular carcinoma (HCC) constitutes usually critical and life threatening condition because of hypovolemic shock due to massive hemorrhage, underlying liver cirrhosis and extensive tumor growth. Recently, transcatheter arterial embolization (TAE) has been used for controlling arterial bleeding of spontaneous rupture of HCC. We report a long surviving case (1 year 9 months) with stage IV ruptured HCC treated by emergency TAE.

[Emergency hepatic arterial embolization in the management of hemobilia].

We present 5 patients with hemobilia treated successfully by emergency transcatheter hepatic artery embolization (TAE). All patients had severe associated illnesses and were very poor candidates for operative treatment. In 3 patients, hemorrhage was completely controlled by TAE using sponge alone, however in 2 patients with hepatic artery pseudoaneurysm, additional TAE using coil was necessary for hemostasis. No major complication was encountered after TAE. Since angiography can offer both diagnostic and therapeutic benefits, we feel that angiography should be considered for exact localization of hemobilia and possible transcatheter therapeutic embolization for control.

[Transcatheter arterial embolization in the management of duodenal bleeding].

Emergency transcatheter arterial embolization was performed in 6 patients with massive duodenal bleeding. Three out of 6 patients were bleeding from duodenal ulcer and erosion, 2 from aneurysm of the gastroduodenal artery (GDA) and 1 from duodenal tumor. In 4 cases, complete and permanent cessation of bleeding was obtained by GDA embolization alone and additional pancreatico-duodenal artery embolization were necessary for hemostasis in 2 patients with GDA pseudoaneurysm. One patient maintained by hemodialysis had complication of duodenal infarction and pancreas necrosis following this procedure. Emergency embolization represents a useful alternative to the operative management of massive duodenal bleeding and should be the initial treatment of choice in those patients.