Vascular Complications of Hepatic Artery After Transcatheter Arterial Chemoembolization in Patients With Hepatocellular Carcinoma

Transcription

1 Vascular and Interventional Radiology Pictorial Essay Sueyoshi et al. TE in Hepatocellular arcinoma Downloaded from by on 02/04/18 from IP address opyright RRS. For personal use only; all rights reserved Vascular and Interventional Radiology Pictorial Essay Eijun Sueyoshi 1 Takeshi Hayashida Ichiro Sakamoto Masataka Uetani Sueyoshi E, Hayashida T, Sakamoto I, Uetani M Keywords: angiography, complication, hepatocellular carcinoma, transcatheter arterial chemoembolization (TE) DOI: /JR Received December 23, 2008; accepted after revision December 17, ll authors: Department of Radiology, Nagasaki University School of Medicine, Sakamoto, Nagasaki , Japan. ddress correspondence to E. Sueyoshi (eijunsueyoshi@aol.com). JR 2010; 195: X/10/ merican Roentgen Ray Society Vascular omplications of Hepatic rtery fter Transcatheter rterial hemoembolization in Patients With Hepatocellular arcinoma OJETIVE. The purpose of this article is to review the angiographic changes, development of collaterals, and possible complications after transcatheter arterial chemoembolization (TE) in hepatocellular carcinoma (H). ONLUSION. Extrahepatic collateral arteries can supply the tumor after repeated TE. Knowledge of hepatic artery changes can help in repeated TE procedures and reduce TE time. ppreciation of the complications and collaterals may improve the outcome of patients with H. H epatocellular carcinoma (H) is uncommon in North merica, but worldwide it is estimated to be the sixth most common cancer after cancers of lung, breast, colon, stomach, and prostate [1]. Treatment selection for H is variable, such as surgery, percutaneous ethanol injection, radiofrequency ablation, and systemic chemotherapy, compared with that for other cancers because patient prognosis depends on not only the tumor extent but also hepatic function reserve [2 4]. Transcatheter arterial chemoembolization (TE) is the mainstay of symptomatic palliation for unresectable H without distant metastasis [3, 4]. Patients with H often require repeated TE for residual viable tumor or local recurrence; however, hepatic artery damage associated with TE may interfere with catheterization in the next session, compromising the treatment success and clinical outcome. Knowledge of the changes in the hepatic artery can help repeated TE and reduce TE time. The purpose of this article is to provide a pictorial review of changes of the arterial anatomy of the hepatic artery and the formation of collateral vessels after TE in patients with H. Vascular omplications of the Hepatic rtery fter TE TE may cause injury to the hepatic artery, which leads to hepatic artery spasm and inflammatory constriction, and severe cases may lead to occlusion, dissection, intrahepatic and extrahepatic collateralization, and an- eurysm formation in the hepatic artery [5 7] (Figs. 1 4). Dissection is a form of vessel injury caused by the guidewire, and spasm is transient. Hepatic artery stenosis, occlusion, and aneurysmal change are caused by irritation from chemotherapeutic drugs and stagnated blood flow caused by gelatin sponge particles. neurysmal change also can be caused by catheter or guidewire injury of the vessel wall. Hepatic artery spasm is usually reversible, but hepatic artery attenuation, stenosis, occlusion, and aneurysmal change are not reversible. Hepatic artery injury caused by dissection frequently may be resolved without significant residual stenosis, but some cases show irreversible stenosis or occlusion after dissection [5 7] (Fig. 1). direct result of irreversible occlusion is difficulty in selecting the artery in the next TE procedure (Fig. 2). Maeda et al. [5] reported the incidence, degree, and predictors of hepatic artery damage after TE for H. Damage was evaluated in each subsegment of the hepatic artery using a 3-point grading scale (1, no or slight wall irregularity; 2, overt stenosis; 3, occlusion). TE is more likely to induce hepatic artery damage in cirrhotic patients with impaired liver function and when a high dose of the chemotherapeutic agent is used (Fig. 3). The authors reported that the incidence of significant hepatic artery damage was 16% per artery and 48% per patient [5]. Pseudoaneurysm formation can be caused by mechanical stimulation of the guidewire JR:195, July

2 Sueyoshi et al. Downloaded from by on 02/04/18 from IP address opyright RRS. For personal use only; all rights reserved or catheter (Fig. 4). lso, intrahepatic aneurysm can appear during the follow-up period. lthough the mechanism of intrahepatic aneurysm formation after TE is controversial, the arterial wall may become fragile after TE because of inflammatory and reparative changes and pressure from blood flow during recanalization or turbulent flow due to an organized thrombus resulting in the formation of an aneurysm [7]. Formation of Extrahepatic ollateral rteries fter TE The main cause of extrahepatic collateral vessel development has been believed to be hepatic artery occlusion by surgical ligation, a procedure that is no longer performed. Some authors advocate that hepatic artery interruption by repeated TE or arterial dissection is the primary cause; however, only about 4% of patients had proximal hepatic artery occlusion, and most patients with a collateral supply had a widely patent hepatic artery [2, 8, 9]. Extrahepatic ollateral Vessels That Supply H Kim et al. [2], in a study of 9,618 TE sessions performed in 3,179 patients, observed 2,104 extrahepatic collateral routes in 1,622 sessions in 860 patients (27%) and performed TE via 1,556 extrahepatic collateral vessels (74%) in 732 patients (1,281 sessions). onsidering the broad contact between the liver and the diaphragm, it may be expected that diaphragmatic blood supplies, including the inferior phrenic, internal mammary, and intercostal arteries, are the major sources of collateral circulation [2] (Figs. 5 8). Exophytic growth and extracapsular H infiltration can cause omental adhesion. Direct contact or invasion into other organs, including the stomach, colon, adrenal gland, and kidney, may create a blood supply to the tumor from these organs (Fig. 9). previous abdominal operation may predispose a patient to early formation of collateral vessels to a tumor because of postoperative omental or peritoneal adhesion. In cases of recurrent tumor at the resection margin, collateral supply from omental arteries should be considered. Peripheral hepatic infarction after TE sometimes induces omental or peritoneal adhesion, and extrahepatic collateral vessels can develop through the adhesion. TE of ollateral Vessels When collateral vessels are chemoembolized, there is a risk of embolizing branches indicating nontarget tissue or organ embolization, which can lead to a variety of complications, depending on the location. utaneous problems, such as itching, erythema, and necrosis, may arise when the internal mammary, intercostal, or lumbar artery is embolized [2, 9 13]. Gastrointestinal erosion, ulceration, or perforation can be caused by gastric, omental, and colic branch artery embolization. Paraplegia may result from the inadvertent embolization of spinal branches arising from intercostal or lumbar collateral vessels, and embolization of the cystic artery may cause cholecystitis or gallbladder infarction. hemoembolization of the inferior phrenic artery may result in shoulder pain, pleural effusion, or basal atelectasis [2, 8]. To avoid these complications, selective catheterization should be achieved by placing the catheter tip as close as possible to the specific branch or branches supplying a neoplasm (Fig. 10). Embolic materials should be infused incrementally to prevent them from refluxing into a nontarget branch [2]. oils and gelatin sponge particles may be used to occlude and protect the territory of the normal distal branches before chemoembolization (Fig. 11). If an extrahepatic collateral vessel is proximally embolized or is complicated by an arterial spasm during catheterization or if there is local recurrence after chemoembolization of an extrahepatic collateral vessel, adjacent vessels can take over its territory [2]. onclusion fter TE, anatomic changes and complications of the hepatic artery can occur. Extrahepatic collateral arteries can supply the tumor after repeated TE. Knowledge of the changes in the hepatic artery can help repeated TE and reduce TE time. This knowledge may be useful to improve the outcome of patients with H. References 1. Ferlay J, ray F, Pisani P, Parkin DM. GLOO- N 2002: cancer incidence, mortality and prevalence worldwide IR ancer ase No. 5, version 2.0. Lyon, France: International gency for Research on ancer Press, Kim H, hung JW, Lee W, Jae HJ, Park JH. Recognizing extrahepatic collateral vessels that supply hepatocellular carcinoma to avoid complications of transcatheter arterial chemoembolization. RadioGraphics 2005; 25[suppl 1]:S25 S39 3. Takayasu K, rii S, Ikai I, et al.; Liver ancer Study Group of Japan. Prospective cohort study of transarterial chemoembolization for unresectable hepatocellular carcinoma in 8510 patients. Gastroenterology 2006; 131: Llovet JM, ruix J. Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival. Hepatology 2003; 37: Maeda N, Osuga K, Mikami K, et al. ngiographic evaluation of hepatic arterial damage after trans arterial chemoembolization for hepatocellular carcinoma. Radiat Med 2008; 26: elli L, Magistretti G, Puricelli GP, Damiani G, olombo E, ornalba GP. rteritis following intra-arterial chemotherapy for liver tumors. Eur Radiol 1997; 7: Sakamoto I, so N, Nagaoki K, et al. omplications associated with transcatheter arterial embolization for hepatic tumors. RadloGraphlcs 1998; 18: hung JW, Park JH, Han JK, hoi I, Kim TK, Han M. Transcatheter oily chemoembolization of the inferior phrenic artery in hepatocellular carcinoma: the safety and potential therapeutic role. J Vasc Interv Radiol 1998; 9: Wang YL, Li MH, heng YS, Shi H, Fan HL. Influential factors and formation of extrahepatic collateral artery in unresectable hepatocellular carcinoma. World J Gastroenterol 2005; 11: Miyayama S, Matsui O, Taki K, et al. Extrahepatic blood supply to hepatocellular carcinoma: angiographic demonstration and transcatheter arterial chemoembolization. ardiovasc Intervent Radiol 2006; 29: Kim H, hung JW, hoi SH, et al. Hepatocellular carcinoma with internal mammary artery supply: feasibility and efficacy of transarterial chemoembolization and factors affecting patient prognosis. J Vasc Interv Radiol 2007; 18: Kim H, hung JW, hoi SH, et al. Internal mammary arteries supplying hepatocellular carcinoma: vascular anatomy at digital subtraction angiography in 97 patients. Radiology 2007; 242: hung JW, Kim H, Yoon JH, et al. Transcatheter arterial chemoembolization of hepatocellular carcinoma: prevalence and causative factors of extrahepatic collateral arteries in 479 patients. Korean J Radiol 2006; 7: JR:195, July 2010

3 TE in Hepatocellular arcinoma Downloaded from by on 02/04/18 from IP address opyright RRS. For personal use only; all rights reserved Fig year-old man with liver cirrhosis caused by hepatitis virus., ngiogram of left hepatic artery shows spasm caused by mechanical stimulation from guidewire (arrow). Tumor stains were not found at this time., t next procedure, angiogram of celiac trunk shows disappearance of hepatic artery spasm (arrow). Tumor stain was seen (arrowheads). Transcatheter arterial chemoembolization was performed via left hepatic artery. Fig year-old woman with liver cirrhosis caused by hepatitis virus., ngiogram of right hepatic artery shows arterial injury (dissection) caused by guidewire manipulation before transcatheter arterial chemoembolization (TE) (arrow)., Several minutes after, angiogram shows occlusion of right hepatic artery (arrow). One month later, right hepatic artery was patent, and TE could be performed (not shown). Fig year-old man with liver cirrhosis caused by hepatitis virus., fter first transcatheter arterial chemoembolization (TE), angiogram of left hepatic artery shows no abnormalities, considered grade 1 hepatic arterial damage (no or slight wall irregularity)., fter second TE, angiogram of left hepatic artery shows irregularity and stenosis (arrows), findings considered grade 2 hepatic arterial damage (overt stenosis)., fter fourth TE, angiogram of left hepatic artery shows irregularity, stenosis, and occlusion, findings considered grade 3 hepatic arterial damage (occlusion). ollateral vessels are also seen (arrows). JR:195, July

4 Sueyoshi et al. Downloaded from by on 02/04/18 from IP address opyright RRS. For personal use only; all rights reserved Fig year-old man with liver cirrhosis caused by hepatitis virus; 2 years before first transcatheter arterial chemoembolization (TE), right lobectomy was performed for hepatocellular carcinoma., t first TE, angiogram of left hepatic artery shows pseudoaneurysm (arrow) with extravasation (arrowhead) caused by guidewire manipulation., oil embolization was performed, and lesion was successfully treated. Fig year-old man with liver cirrhosis caused by hepatitis virus., ngiogram obtained at time of fifth transcatheter arterial chemoembolization (TE) shows multiple occlusions of segmental branches of hepatic artery. Tumor stain is not seen., ngiogram of right internal mammary artery shows multiple tumor stains (new tumors) supplied via branches of right internal mammary artery (arrows)., ngiogram of right inferior phrenic artery shows multiple tumor stains (new tumors) supplied via right inferior phrenic artery (arrows). TE was performed via right internal mammary artery and right inferior phrenic artery. Fig year-old man with liver cirrhosis caused by hepatitis virus; 4 years before first transcatheter arterial chemoembolization, right lobectomy was performed for hepatocellular carcinoma (H)., T image shows recurrent H (contrast enhancement) (arrow). and, ngiograms show tumor stain (arrow, ) supplied via intercostal artery. 248 JR:195, July 2010

5 TE in Hepatocellular arcinoma Downloaded from by on 02/04/18 from IP address opyright RRS. For personal use only; all rights reserved Fig year-old man with liver cirrhosis caused by hepatitis virus., T image shows recurrent hepatocellular carcinoma (H) (contrast enhancement) adjacent to gallbladder (arrow)., ngiogram shows tumor stain (arrow) supplied via cystic artery (arrowheads)., T image shows recurrent H (arrow) in subcapsular region of posterior segment of liver. D and E, ngiograms of right renal artery show exophytic H (arrows) was supplied via right inferior adrenal artery (arrowheads, D). D Fig year-old woman with liver cirrhosis caused by hepatitis virus. fter third transcatheter arterial chemoembolization, angiogram shows tumor stain (arrows) supplied via right middle adrenal artery (arrowheads). E JR:195, July

6 Sueyoshi et al. Downloaded from by on 02/04/18 from IP address opyright RRS. For personal use only; all rights reserved D Fig year-old man with liver cirrhosis caused by hepatitis virus., T image shows enhancing mass adjacent to ascending colon (arrow). and, fter fourth transcatheter arterial chemoembolization (TE), angiograms of superior mesenteric artery show tumor stain (arrow, ) supplied via branch of right colic artery (arrowheads, ). D, Selective angiogram of right colic artery shows tumor stain (arrow). TE was not performed to avoid complications. Fig year-old man with liver cirrhosis caused by hepatitis virus., ngiogram shows tumor stain supplied via right internal mammary artery (cardiophrenic artery) (arrow)., Selective catheterization was achieved by placing catheter tip into cardiophrenic artery, and transcatheter arterial chemoembolization was performed. 250 JR:195, July 2010

7 TE in Hepatocellular arcinoma Downloaded from by on 02/04/18 from IP address opyright RRS. For personal use only; all rights reserved Fig year-old woman with liver cirrhosis caused by hepatitis virus., fter sixth transcatheter arterial chemoembolization (TE), angiogram shows tumor stain supplied via omental branches of gastroepiploic artery (arrows)., atheterization of omental branch was unfeasible. Initially, coil embolization of distal portion of gastroepiploic artery was performed (arrow). Subsequently, TE was performed via omental branch of gastroepiploic artery (arrowheads). JR:195, July