Published on January 3, 2008
Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: Anatomic and Hemodynamic Considerations in the Hepatic Artery and Portal Vein: Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: Anatomic and Hemodynamic Considerations in the Hepatic Artery and Portal Vein Kwang-Hun Lee, MD, Kyu-Bo Sung, MD, Do-Yun Lee, MD, Sang Joon Park, MD, Ki Whang Kim, MD and Jeong-Sik Yu, MD 1 From the Department of Diagnostic Radiology and Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, South Korea (K.H.L., D.Y.L., S.J.P, K.W.K., J.S.Y.); and the Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul, South Korea (K.B.S.). ( Radiographics. 2002;22:1077-1091.) © RSNA, 2002 Introduction : Introduction Hepatocellular carcinoma (HCC) is the most common malignant tumor of the liver Treatment of HCC surgical resection : only 10-30% is operable radio-frequency thermal ablation (RFA) Percutaneous ethenol injection therapy (PEIT) Transcatheter arterial chemoembolization (TACE) Vessels in the portocaval space : Vessels in the portocaval space Variant RHA from SMA, GDA, celiac trunk, aorta, celiacomesenteric trunk, hepaticomesenteric trunk SPDA cavernous transformation Slide4: On a celiac angiogram, the RHA arises from the celiac axis CT scan shows that the RHA (arrows) branches early along the celiac axis and courses through the portocaval space Slide5: 1.replaced RHA (arrow) that arises from the aorta 2.both inferior phrenic arteries arise together from the aorta 3.tumors are supplied by replaced RHA CT scan shows the replaced RHA courses through the portocaval space (arrow) Vessels in the fissure for the ligamentum venosum: Vessels in the fissure for the ligamentum venosum Variant LHA from LGA PHA from LGA CHA from LGA Accessory LGA from LHA Accessory LGA from PHA Left IPA from LHA Aberrant LGV Slide7: 1.Rt post segmental HA from SMA 2.Intratumoral AP shunt 1.Rt ant. Segmental HA from CHA 2.Multiple small tumors 1.Replaced LHA from the LGA (LGA from aorta) 2.Multiple small tumors Slide8: 1.SMA arteriography showed stenosis of celiac trunk with regurgitation of arterial flow through PDA archade to opacify HA, LGA, and splenic artery 2.Replaced PHA from LGA 3.Tumors are supplied by RHA CT scan shows the replaced PHA as it courses along the fissure for the ligamentum venosum Non-tumorous AP shunt: Non-tumorous AP shunt CT or MRI wedge-shaped enhancement in arterial phase, and iso- in portal phase Nodular shape in cross section images (7-31%) Angiography branching or dotlike PV in arterial phase Then wedge-shaped parenchymal staining verified with iodized oil–enhanced CT Slide10: arterial-phase CT scan demonstrates nodular attenuation (arrow) equilibrium-phase CT scan, the nodule is isoattenuating hepatic angiograms show the typical branching portal vein in the central portion (arrow) triangular staining superselective subsegmental injection of iodized oil shows stippled accumulation of the oil in the portal branches Extrahepatic Collateral Routes : Extrahepatic Collateral Routes Rt & Lt int. mam. and sup. epigastric a. intercostal a. lumbar a. Rt & Lt inferior phrenic a.. Rt & Lt gastric a.. adrenal a. capsular branches of Rt renal a. periportal collaterals from GDA or PDA middle or Rt colic a. omental brr. of Rt & Lt gastroepiploic a.. (TACE is more effective if it continues until filling of omental vein) Slide12: Equilibrium-phase CT scan shows a single omental nodule (arrow) is surrounded by omental fat 1.CHA arteriogram shows only faint nodular staining(arrows) 2.A mildly hypertrophic omental Branch (arrowheads) is suspected to be the feeding vessel Single spot image obtained after TAE clearly depicts the draining omental vein (arrowheads) CT scan obtained 1 year later shows good uptake of the iodized oil Mechanisms of extrahepatic collaterals: Mechanisms of extrahepatic collaterals deprivation of the native hepatic artery repeated TACE or chemoinfusion dissection due to catheterization occlusion of hepatic artery due to surgical ligation or chemoport catheterization exophytic growth or subcapsular HCC Nontarget organ complications: Nontarget organ complications ischemic cholecystitis splenic infarction gastrointestinal mucosal lesions pancreatitis pulmonary embolism and infarction spinal cord injury ischemic skin lesions Nontarget arteries : Nontarget arteries cystic a. splenic a. gastroduodenal a. accessory LGA hepatic falciform a. Inf phrenic a. intercostal a. epigastric a. Considerations regarding nonhepatic arteries during TACE: Considerations regarding nonhepatic arteries during TACE Not acting as the feeding vessel superselective embolization to tumor a. embolized with a coil to non-target a. Acting as the feeding vessel superselective embolization to tumor a. alternative treatment other than TACE Gastric fundal staining supplied by accessory LGA vs. HCC tumor staining supplied by LHA : Gastric fundal staining supplied by accessory LGA vs. HCC tumor staining supplied by LHA Branching before the point at which the LHA kinks at the umbilical point Not parallel to dorsolateral and ventrolateral branches of LHA characteristic tortuousness of the peripheral a. branches Draining veins are also tortuous Slide18: 1.CHA arteriogram shows diffuse tumor staining supplied by the LHA. 2.thread and streak sign of tumor thrombus in the LPV (arrowheads) 3.An accessory LGA arises proximal to the umbilical point of the LHA. 4.The distal branches of the accessory LGA Demonstrate the typical coiled appearance (arrows) 5TACE of the LHA was performed after coil embolization of the accessory LGA to prevent inadvertent damage to the gastric mucosa. CT scan, the coils are located at the fissure for the ligamentum venosum, through which the accessory LGA traverses (arrow). Hepatic falciform artery : Hepatic falciform artery small terminal br. of LHA or MHA runs through falciform lig. distributes around umbilicus communicates with sup. & inf epigastric a. coil embolization to prevent supraumbilical skin and fat necrosis is controversial Slide20: CHA arteriogram shows the thread and streak sign of tumor thrombus in the LPV with an AP shunt and parenchymal tumor staining supplied by the hypertrophic MHA and LHA. The RHA arises from the gastroduodenal artery. the hepatic falciform artery arises from the middle hepatic artery (arrows). Chemoinfusion was performed without prophylactic coil embolization of the hepatic falciform artery. The patient had no complications. Portogram of SMA, celiac, or splenic arteriography : Portogram of SMA, celiac, or splenic arteriography Laminar flow (common findings) layering of SMA flow on Rt side and splenic flow on Lt side of MPV Turbulent flow (rare) Filling defect in central portion of MPV can mimic thrombus Slide22: 1.SMA portogram shows central filling defects in MPV that mimic thrombus (arrows). 2.Portography of the celiac and splenic arteries showed central filling with contrast material. Equilibrium-phase CT shows full attenuation of the contrast material in the MPV. Arterial-phase CT shows low attenuation centrally in the MPV (arrowheads). Hepatofugal portal flow : Hepatofugal portal flow Functional hepatofugal portal flow advanced cirrhosis development of portosystemic collaterals decreased size of functionally blocked portal vein compensatory hypertrophy of the hepatic artery absence of cavernous transformation no "thread and streak" sign (indicating tumor thrombus) no change in hepatofugal flow even after control of HCC Hepatofugal flow caused by tumor thrombus Hepatofugal portal flow: Hepatofugal portal flow Categories segmental, lobar balanced, or total Diffuse multisegmental infiltrating HCC TACE is quite risky Nodular HCC superselective TACE is safe and effective If successful in tumor control, hepatofugal portal flow can be reversed Lobar hepatofugal portal flow: Lobar hepatofugal portal flow CHA arteriogram shows Rt lobar hepatofugal portal flow (arrow) due to right lobar portal H/T Unopacified laminar flow from splanchnic portal flow moving toward the LPV due to absence of left lobar portal H/T Slide26: 1.SMA portogram shows preserved hepatopetal portal flow but a decrease in the size of PV. 2.Marked development of a gastrorenal shunt. CHA arteriogram shows compensatory hypertrophic change in the hepatic arteries Sequential CHA arteriogram shows hepatofugal portal flow and gastrorenal shunts. Balanced hepatofugal portal flow Slide27: Total hepatofugal portal flow 1.SMA portogram shows absence of hepatopetal portal flow 2.Retroperitoneal varices: veins of Retzius (white arrows) with extension from the IMV (black arrow) to IVC (arrowheads). CHA arteriogram shows compensatory hypertrophic hepatic arteries and nodular tumor staining. nodular uptake of iodized oil in the tumor and surrounding PV after superselective chemoembolization Slide28: SMA portogram shows absence of Rt portal perfusion and poor Lt portal perfusion Replaced RHA angiogram shows extensive hypervascular tumor staining with a Transtumoral AP shunt and hepatofugal flow with coronary and paraumbilical varices. SMA portogram shows improved Hepatopetal portal flow after TAE x III Replaced RHA angiogram shows neither definitive tumor staining nor transtumoral AP shunt Portosystemic collaterals from LPV : Portosystemic collaterals from LPV Recanalized umbilical & paraumbilical v. located in and around falciform ligament Aberrant LGV derived from Lt omphalomesenteric v. or from subintestinal v. persistent LPV independent of RPV in lig. venosum fissure and directly connected to LPV br. Maybe drained by gastrorenal route Slide30: SMA portogram shows unusual hepatofugal flow from the LPV to an aberrant LGV and gastrorenal route (arrows). Equilibrium-phase CT shows the aberrant LGV (arrows) as it courses in the fissure for the ligamentum venosum. Arrowhead indicates the gastrorenal route. Aberrant LGV Significance of aberrant LGV: Significance of aberrant LGV potential source of bleeding during surgery gastric variceal bleeding in portal H/T hematogenous metastatic route in cases of hepatic malignancy the cause of a possible pseudolesion of focal fat sparing or deposition Slide33: Figure 7c. Slide34: Figure 5c.