Chemoembolization of the Left Inferior Phrenic Artery in Patients with Hepatocellular Carcinoma: Radiographic Findings and Clinical Outcome

Diaphragmatic perforation after transcatheter arterial chemoembolization of hepatocellular carcinoma via inferior phrenic artery: a case report

Background

Transcatheter arterial chemoembolization (TACE) via the inferior phrenic artery has been recognized to have its own therapeutic role without causing serious procedural complications. We report a case of diaphragmatic perforation after repeated TACE sessions conducted via the right inferior phrenic artery.

Case presentation

A 43-year-old man diagnosed with hepatocellular carcinoma was admitted to the hospital with a chief complaint of cough. The patient underwent TACE via the right inferior phrenic artery 3 months prior and was discharged without specific complications. Physical examination revealed decreased breathing sounds in the right lower lung zone. Chest radiograph demonstrated a small right pleural effusion. Chest CT scan revealed a small diaphragmatic perforation. The patient was unable to undergo surgical exploration, and a follow-up CT scan after 2 months revealed progression of the right diaphragmatic perforation with massive herniation of omental fat into the thoracic cavity.

Conclusions

Although TACE via the inferior phrenic artery is a relatively safe procedure, it can be associated with rare but serious complications after repeated procedures. This is a rare case report of diaphragmatic perforation after TACE via the right inferior phrenic artery. Early recognition and prompt surgical management are essential to prevent catastrophic outcomes.

Combined transarterial chemoembolization of the right inferior phrenic artery and radiofrequency ablation for small hepatocellular carcinoma near the diaphragm: its efficacy and safety

PURPOSE

The purpose of the study is to report the efficacy and safety of combined transarterial chemoembolization (TACE) of the right inferior phrenic artery (IPA) and radiofrequency ablation (RFA) for small hepatocellular carcinoma (HCC) near the diaphragm supplied by the right IPA.

METHODS

From July 2009 through April 2015, 11 patients with small (≤ 3 cm) HCC near the diaphragm, which was infeasible for ultrasound-guided RFA and supplied by the right IPA, received TACE of the right IPA and subsequent RFA in one session. The safety and therapeutic efficacy, including technique effectiveness and local tumor progression (LTP), were evaluated.

RESULTS

Technique effectiveness was achieved in all the 11 patients (100%). During average follow-up period of 39.2 months (range 13-89 months), LTP occurred in none of the 11 patients. There were twelve minor complications in eight patients, including right shoulder pain (n = 4), right pleural effusion (n = 2), diaphragmatic thickening (n = 2), transient lung change (n = 2), subsegmental intrahepatic bile duct stricture (n = 1), and subsegmental hepatic infarction (n = 1). No major complications were encountered CONCLUSION: Combined TACE of the right IPA and RFA can be a safe and effective treatment for small HCC near the diaphragm that is supplied by the right IPA.

Imaging findings and complications of transcatheter interventional treatments via the inferior phrenic arteries in patients with hepatocellular carcinoma

Objective

To evaluate imaging findings and complications from transcatheter interventional treatment of hepatocellular carcinoma via the inferior phrenic arteries.

Material & Methods

40 procedures in 25 patients (19 men; age range, 57-89 years) were retrospectively reviewed in this study. In all procedures, a micro-catheter was selectively inserted in the right inferior phrenic artery (n = 39) or left inferior phrenic artery (n = 1), and transcatheter arterial chemoembolization (n = 39) or transcatheter arterial embolization (n = 1) was performed. Imaging findings and patient charts were reviewed, and complications until time of discharge (median hospitalization period, 10.5 days; range, 3-21) were assessed.

Results

On angiography or computed tomography during angiography, collateral circulation from the right inferior phrenic artery to the pulmonary artery was seen in eight of 39 procedures (seven patients, 28%). In seven of these procedures, Lipiodol deposition was seen on the unenhanced computed tomography just after the procedure (post-procedure computed tomography) in the pulmonary arteries or pleura, and in six procedures, the deposited Lipiodol was noted to have spread into adjacent lung fields on the one week follow-up computed tomography. Branches of the right inferior phrenic artery were seen along the right margin of the heart in 18 procedures, and Lipiodol deposition was seen along the right margin of the heart on post-procedure computed tomography in four procedures. Complications occurred in 21 of 39 procedures of right inferior phrenic artery intervention (53%): shoulder pain in 18 (45%), pleural effusion in 14 (35%), basal atelectasis in 11 (28%), paroxysmal atrial fibrillation in two (5%) and hemoptysis in one (3%). In 14 procedures (35.9%), pleural effusion was seen on follow-up computed tomography examinations, and 11 (28.2%) of these procedures also showed basal atelectasis. However, only three procedures with pleural effusion showed Lipiodol deposition on the post-procedure computed tomography. In one patient who underwent transcatheter arterial chemoembolization twice via the right inferior phrenic artery, atrial fibrillation occurred after both procedures.

Conclusions

Transcatheter arterial chemoembolization or transcatheter arterial embolization via the inferior phrenic artery in patients with hepatocellular carcinoma was relatively safe. Shoulder pain was the most frequent complication, and required only conservative treatment. There was no clear connection between pleural effusion or basal atelectasis and collateral circulation from the right inferior phrenic artery to the pulmonary artery depicted on angiography, computed tomography during angiography or post-procedure computed tomography.

The vascular anatomy of the ligaments of the liver: gross anatomy, imaging and clinical applications

The vessels that communicate between the liver and adjacent structures require bridges between them. The bridges comprise the ligaments of the liver as follows: the falciform ligament, right and left coronary ligaments, lesser omentum including the hepatogastric ligament and hepatoduodenal ligament. Each ligament has specific communications between the intrahepatic and extrahapetic vessels. The venous communications called as the portosystemic shunt would become apparent in patients with portal hypertension, intrahepatic portal vein thrombosis and superior vena cava syndrome. The location of the venous communication is related to the pseudolesion or focal enhancement of the liver demonstrated on the CT scan. The arterial communications called collateral vascularization would become apparent in patients with hepatic artery occlusion, especially post-transhepatic arterial embolization, or in patients with the hepatic tumour abutting diaphragm. The knowledge of these collateral arteries is necessary to accomplish the effective transarterial embolization for the hepatic tumours. We reviewed the vessels in these ligaments using contrast-enhanced CT scans and angiography and discussed the clinical applications. Cadaver dissection photos were included as supplementary images for readers to recognize the actual spatial anatomy of the vessel in each ligament.

Hepatocellular carcinoma with blood supply from parasitized omental artery: angiographic appearance and chemoembolization

OBJECTIVE

To analyze angiographic appearance of hepatocellular carcinoma (HCC) with blood supply from parasitized omental artery (POA), and evaluate the technical feasibility, safety and therapeutic efficacy of chemo-embolization via the POAs.

METHODS

A total of 1,221 HCC patients who had undergone chemoembolization procedures were evaluated retrospectively. The evaluated indexes included the incidence rate of POAs, success rate of superselective catheterization, post-reaction after chemoembolization, and the cumulative survival rates.

RESULTS

Totally 1,221 HCC patients had undergone 3,639 chemoembolization procedures, and 32 patients with POAs were enrolled, with 97 POAs found in 76 angiography procedures, giving an incidence rate of 2.09%. POA was observed mostly at the right lobe and left medial lobe except the segment II, and 62 POAs underwent superselective catheterization with microcatheter, giving a success rate of 63.9%. The angiographic appearance was: (1) hypertrophic POAs participating in tumor staining (n=28); (2) stiff and distorted POA (n=11), displaced due to tumor's oppression (n=8); and (3) defective tumor staining close to either gastrocolic omentum distribution or liver capsule (n=7). In 19 patients, chemoembolization via POAs was performed successfully (A group), while the remaining 13 patients failed (B group). Except 1 acute edema pancreatitis case, no serious complication was recorded. The cumulative survival rates of 6-, 12-, 18- and 24-month were 78.9%, 47.4%, 31.6% and 21.1% respectively for A group; correspondingly, 61.5%, 30.8%, 15.4% and 7.7%% for B group, in which 2 patients died of ruptured HCC.

CONCLUSION

Chemoembolization with microcatheter via POAs is a relatively safe, feasible and valuable method.

Hepatocellular carcinomas smaller than 4 cm supplied by the intercostal artery: can we predict which intercostal artery supplies the tumor?

OBJECTIVE

To predict which intercostal artery supplies a tumor by examining the spatial relationship between hepatocellular carcinoma (HCC) and the intercostal artery feeding the tumor on transverse computed tomography (CT) images.

MATERIALS AND METHODS

Between January 2000 and September 2009, 46 intercostal arteries supplying HCCs smaller than 4 cm were noted in 44 patients, and CT scans and angiograms of these patients were retrospectively reviewed. The intercostal artery feeding the tumor was marked on the CT scan showing the center of the tumor. In addition, its spatial relationship with the tumor center was examined. The angle of the tumor location was measured on the transverse CT scan in the clockwise direction from the sagittal line on the virtual circle centered in the right hemithorax. Correlations between the angle of the tumor location and the level of the tumor-feeding intercostal artery were assessed with the Spearman rank coefficient.

RESULTS

Of 46 intercostal arteries feeding HCC, 39 (85%) were the first ones observed from the tumor center in a counterclockwise direction on the transverse CT image containing the tumor center. The level of the tumor-feeding intercostal artery was significantly correlated with the angle of the tumor, as the posteriorly located tumor tends to be supplied by lower intercostal arteries, while the laterally located tumor by upper intercostal arteries (Spearman coefficient = -0.537; p < 0.001).

CONCLUSION

We can predict the tumor feeder with an accuracy of 85% as the first intercostal artery encountered from the tumor center in a counterclockwise direction on a transverse CT image.

Hepatocellular carcinoma: prediction of blood supply from an intercostal artery with multidetector row computed tomography

PURPOSE

To evaluate the ability of multidetector row computed tomography (CT) to detect blood supply from the intercostal artery in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Between January 2003 and December 2007, angiography of the intercostal artery was performed in 93 patients (76 men and 17 women, mean age 58 years) with HCC who had also undergone multidetector row CT. CT scans and digital subtraction angiograms of these patients were retrospectively reviewed by two investigators in consensus to evaluate tumor feeding vessels. Multiple logistic regression analysis was used to identify factors that predict the presence of an HCC blood supply from an intercostal artery.

RESULTS

Tumor staining fed by an intercostal artery was noted in 65 patients (70%; 112 tumor feeding vessels) by intercostal angiography. Readers interpreted that tumor feeding vessels were evident by CT in 35 (54%) of these 65 patients with tumor staining supplied by an intercostal artery by angiography. Multiple logistic regression analysis showed that a visible tumor feeding vessel by CT (P = .003) and hepatic artery attenuation by angiography (P = .014) were significantly related to the presence of a blood supply from an intercostal artery.

CONCLUSIONS

Visualization of a tumor feeding vessel from the intercostal artery by multidetector row CT is an important sign of parasitic supply to an HCC.

Chemoembolization of the left inferior phrenic artery in patients with hepatocellular carcinoma: 9-year single-center experience

OBJECTIVE

The purpose of this study was to evaluate retrospectively the radiologic findings and imaging response of hepatocellular carcinoma supplied by the left inferior phrenic artery.

MATERIALS AND METHODS

From January 2000 through December 2008, chemoembolization of the left inferior phrenic artery was performed on 152 patients (123 men, 29 women; mean age, 55.8 years) with hepatocellular carcinoma. The CT scans and digital subtraction angiograms of these patients were retrospectively reviewed in consensus by two investigators, who evaluated tumor location, tumor-feeding vessels, origin of the left inferior phrenic artery, technical success of chemoembolization, complications, and tumor response. Tumor response was assessed on the basis of the criteria of the European Association for the Study of the Liver.

RESULTS

Tumors supplied by the left inferior phrenic artery were located in Couinaud segment 2/3 (n = 100), segment 4 (n = 45), and other segments (n = 7). The most common tumor-feeding vessel was the anteromedial limb of the left inferior phrenic artery (n = 82) followed by the lateral limb (n = 40) and the anterior limb (n = 30). Selective chemoembolization via the left inferior phrenic artery was achieved in 58 of the patients (38%). Complete or partial response as detected on first follow-up CT images (mean follow-up time, 2.5 months) was achieved by 30 patients. In 33 patients in whom the tumor was supplied exclusively by the left inferior phrenic artery, the tumor response was more favorable in patients who underwent selective than in those who underwent nonselective chemoembolization via the left inferior phrenic artery (p = 0.028).

CONCLUSION

Selective chemoembolization via the left inferior phrenic artery is possible and results in good response of tumors supplied exclusively by the left inferior phrenic artery.

Left inferior phrenic artery feeding hepatocellular carcinoma: angiographic anatomy using C-arm CT

OBJECTIVE

The left inferior phrenic artery (LIPA) is one of the common extrahepatic collateral arteries that supply hepatocellular carcinomas (HCCs). The purpose of this study is to describe the anatomy of the LIPA that supplies HCCs using C-arm CT in 23 patients.

CONCLUSION

The anteromedial limb of the ascending branch was present in 14 patients and accessory gastric branches were noted in 11 patients. The use of angiography and C-arm CT of the LIPA showed 26 tumor feeders in 23 patients. The feeders were seen in the anteromedial limb (n = 12), lateral limb (n = 9), anterior limb (n = 3), and descending branch (n = 2). The anteromedial limb of the ascending branch is a common tumor feeder of the LIPA and can supply HCCs located in the right liver dome. Gastric staining is also frequently depicted on LIPA angiography and should not be confused with tumor staining.

The march of extrahepatic collaterals: analysis of blood supply to hepatocellular carcinoma located in the bare area of the liver after chemoembolization

The purpose of this study was to evaluate changes in vascular supply to hepatocellular carcinoma (HCC) located in the bare area of the liver in patients who were mainly treated with chemoembolization. Twenty-six patients with HCC showing a mean diameter of 3.1 +/- 1.4 cm (mean +/- standard deviation) were mainly treated with chemoembolization. All patients underwent 2.7 +/- 2.3 chemoembolization sessions over 40.1 +/- 25.2 months. Tumor feeding branches demonstrated in each chemoembolization session were retrospectively evaluated. Initially, 18 tumors (59.2%) were supplied by the hepatic artery (H) and 8 (30.8%) by both the hepatic and the extrahepatic arteries (H + C). Fourteen tumors (53.8%) recurred at the posterior aspect of the tumor and were supplied by H (n = 4), H + C (n = 5), and extrahepatic collaterals (C) (n = 5). Several tumors recurred despite repeated chemoembolization, and these were supplied by H (n = 1), H + C (n = 7), and C (n = 2) at the second recurrence, by H (n = 1), H + C (n = 2), and C (n = 3) at the third, by H + C (n = 2) and C (n = 2) at the fourth, by H + C (n = 2) and C (n = 2) at the fifth, and by H (n = 1) and C (n = 1) at the sixth. One tumor was supplied by H at the seventh and by H + C at the eighth recurrence. As the number of local recurrences increased, the feeding vessel shifted from H to C. Especially, the right inferior phrenic artery (IPA) and renal capsular artery (RCA) supplied the tumor early, while the small right RCAs, adrenal arteries, and intercostal and lumbar artery supplied late recurrences in turns. In conclusion, HCCs located in the bare area are frequently supplied by extrahepatic vessels initially, while recurrence after chemoembolization is mainly due to extrahepatic blood supply. The right IPA and RCA are common feeding vessels demonstrated early, while other extrahepatic collateral supply from the retroperitoneal circulation occurs in turns during the later course.

The right inferior phrenic artery: origin and proximal anatomy on digital subtraction angiography and thin-section helical computed tomography

PURPOSE

To investigate the origin sites of the right inferior phrenic artery (RIPA) and its proximal anatomy with use of digital subtraction angiography (DSA) and thin-section computed tomography (CT).

MATERIALS AND METHODS

Among 2,593 patients, selective RIPA arteriography was attempted in 591 (507 men; mean age, 54 years) who underwent chemoembolization and thin-section liver CT. CT and DSA images were reviewed.

RESULTS

The origin sites of the RIPA and its proximal segment were analyzed on DSA and CT in 580 patients after 11 were excluded because of a completely occluded or unidentifiable RIPA. The RIPA originated directly from the aorta in 336 patients (57.9%) and from the major visceral aortic branches in 244 (42.1%). In RIPAs of aortic origin, the most common level was the supraceliac aorta (n = 119; 35.4%), and the mean angular orientation slightly deviated to the left side of the aorta (12.1 degrees ). As the level of origin became lower (from "juxtaceliac" to suprarenal), there were two groups in whom the RIPAs arose around an oblique path from the supraceliac aorta to the right renal artery (n = 199; 59.2%) or left renal artery (n = 18; 5.4%). When the RIPA origin was draped by the diaphragm (n = 197; 58.6%), its proximal segment showed a downward and/or leftward impression or an acute rightward turn depending on its level of origin and angular orientation. Unusually, three RIPAs under the right hemidiaphragm exhibited a transdiaphragmatic course.

CONCLUSIONS

RIPAs had diverse proximal anatomy relative to their origin level and overhanging diaphragmatic crus, which could be evaluated with thin-section helical CT.

Hepatocellular Carcinoma with Internal Mammary Artery Supply: Feasibility and Efficacy of Transarterial Chemoembolization and Factors Affecting Patient Prognosis

PURPOSE

To determine technical feasibility, therapeutic efficacies, and identify prognostic factors in patients with hepatocellular carcinoma (HCC) treated by transarterial chemoembolization via the internal mammary artery.

MATERIALS AND METHODS

From August 1996 to July 2005, the authors identified the internal mammary arteries supplying HCCs in 97 (2.2%) of 4,438 HCC patients. Computed tomography scans and digital subtraction angiography images of these 97 patients were retrospectively reviewed by consensus between two of the authors regarding technical success and clinical outcome. The technical success of internal mammary artery chemoembolization was defined as achievement of catheterization into feeding vessels, delivery of drugs via those vessels, and no residual tumor staining fed by the internal mammary artery. Multivariate Cox proportional hazard regression analysis was performed to enable evaluation of prognostic factors for survival.

RESULTS

Technical success by selective chemoembolization via internal mammary artery was achieved in 53 (55%) of the 97 patients. The clinical responses of the 97 patients were complete remission (n=3), partial remission (n=19), no response (n=65), and no available follow-up image (n=10). Overall cumulative survival rates, calculated from times of internal mammary artery chemoembolization, were 55.9% (at 6 months), 32.5% (at 1 year), 15.4% (at 2 years), and 8.2% (at 3 years). Multivariate analysis showed that tumor multiplicity (single vs multiple nodular or diffuse; P=.013), portal vein thrombosis (P=.004), and the technical success of internal mammary artery chemoembolization (P=.02) each significantly affected survival.

CONCLUSIONS

Although patients with HCC supplied by the internal mammary artery had poor prognosis because of their advanced stage of disease, chemoembolization via the internal mammary artery is possible and worth performing in selective situations.

Inferior Phrenic Artery: Anatomy, Variations, Pathologic Conditions, and Interventional Management

The inferior phrenic artery (IPA) is the most common source of extra-hepatic collateral blood supply for hepatocellular carcinoma (HCC) and frequently supplies HCCs located in the bare area of the liver. Other pathologic conditions including hemoptysis, diaphragmatic or hepatic bleeding due to trauma or surgery, and bleeding caused by gastroesophageal problems (eg, Mallory-Weiss tear or gastroesophageal cancer) may be related to the IPA. Over a 4-year period, the authors performed 383 interventional procedures related to the IPA. The right and left IPAs originate with almost equal frequency from the aorta and celiac axis and with lesser frequency from the renal arteries. Various other sites of origin-such as the left gastric, hepatic, superior mesenteric, spermatic, and adrenal arteries-are also seen. Radiologists must be familiar with the normal spectrum of IPA anatomy so that detection and adequate interventional management can be achieved when pathologic conditions related to the IPA are present.

Internal Mammary Arteries Supplying Hepatocellular Carcinoma: Vascular Anatomy at Digital Subtraction Angiography in 97 Patients

PURPOSE

To retrospectively evaluate the vascular anatomy of the internal mammary arteries that supply hepatocellular carcinomas (HCCs), with an emphasis on number of tumor feeders.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board; informed consent was waived. Between August 1996 and July 2005, internal mammary arteries that supply HCCs were found in 97 (2.2%) of 4438 patients (76 men, 21 women; mean age, 55 years +/- 10.5 [standard deviation]; range, 19-79 years). Computed tomographic scans and digital subtraction angiograms in these 97 patients were retrospectively reviewed in consensus by two interventional radiologists. Tumor size, number of tumor feeders, and tumor location were recorded. The t test and analysis of variance were used to correlate tumor size with number of tumor feeders, tumor feeder laterality, and transcatheter arterial chemoembolization (TACE) time.

RESULTS

The following 125 tumor feeders were identified in 97 patients: phrenic branch (n = 59), musculophrenic artery (n = 40), superior epigastric artery (n = 15), anterior intercostal artery (n = 6), ensiform artery (n = 4), and pericardiacophrenic artery (n = 1). In two patients, tumors were in dorsal hepatic areas directly beneath the diaphragm. Half of the tumors located in liver segments II or III were supplied by the right internal mammary artery. In three patients, the tumor feeders from the left internal mammary artery crossed the midline. Tumor size was not statistically associated with number of tumor feeders (P = .076), tumor feeder laterality (P = .141), and TACE time (P = .729).

CONCLUSION

The common tumor feeders of the internal mammary artery are the phrenic branch and the musculophrenic artery. Moreover, the internal mammary artery can supply a tumor even in the dorsal hepatic area.