Hepatic arterial complications in liver transplant recipients treated with pretransplantation chemoembolization for hepatocellular carcinoma

Number of Local Regional Therapies for Hepatocellular Carcinoma and Peri-Operative Outcomes after Liver Transplantation

The wait times for patients with hepatocellular carcinoma (HCC) listed for liver transplant are longer than ever, which has led to an increased reliance on the use of pre-operative LRTs. The impact that multiple rounds of LRTs have on peri-operative outcomes following transplant is unknown. This was a retrospective single center analysis of 298 consecutive patients with HCC who underwent liver transplant (January 2017 to May 2021). The data was obtained from two institution-specific databases and the TransQIP database. Of the 298 patients, 27 (9.1%) underwent no LRTs, 156 (52.4%) underwent 1-2 LRTs, and 115 (38.6%) underwent ≥3 LRTs prior to LT. The patients with ≥3 LRTs had a significantly higher rate of bile leak compared to patients who received 1-2 LRTs (7.0 vs. 1.3%, p = 0.014). Unadjusted and adjusted regression analyses demonstrated a significant association between the total number of LRTs administered and bile leak, but not rates of overall biliary complications. The total number of LRTs was not significantly associated with any other peri-operative or post-operative outcome measure. These findings support the aggressive use of LRTs to control HCC in patients awaiting liver transplant, with further evaluation needed to confirm the biliary leak findings.

Intraarterial Therapies for the Management of Hepatocellular Carcinoma

Image-guided locoregional therapies play a crucial role in the management of patients with hepatocellular carcinoma (HCC). Transarterial therapies consist of a group of catheter-based treatments where embolic agents are delivered directly into the tumor via their supplying arteries. Some of the transarterial therapies available include bland embolization (TAE), transarterial chemoembolization (TACE), drug-eluting beads-transarterial chemoembolization (DEB-TACE), selective internal radioembolization therapy (SIRT), and hepatic artery infusion (HAI). This article provides a review of pre-procedural, intra-procedural, and post-procedural aspects of each therapy, along with a review of the literature. Newer embolotherapy options and future directions are also briefly discussed.

Transarterial chemoembolization of hepatocellular carcinoma before liver transplantation and risk of post-transplant vascular complications: a multicentre observational cohort and propensity score-matched analysis

BACKGROUND

Transarterial chemoembolization (TACE) in patients with hepatocellular cancer (HCC) on the waiting list for liver transplantation may be associated with an increased risk for hepatic artery complications. The present study aims to assess the risk for, primarily, intraoperative technical hepatic artery problems and, secondarily, postoperative hepatic artery complications encountered in patients who received TACE before liver transplantation.

METHODS

Available data from HCC liver transplantation recipients across six European centres from January 2007 to December 2018 were analysed in a 1 : 1 propensity score-matched cohort (TACE versus no TACE). Incidences of intraoperative hepatic artery interventions and postoperative hepatic artery complications were compared.

RESULTS

Data on postoperative hepatic artery complications were available in all 876 patients (425 patients with TACE and 451 patients without TACE). Fifty-eight (6.6 per cent) patients experienced postoperative hepatic artery complications. In total 253 patients who had undergone TACE could be matched to controls. In the matched cohort TACE was not associated with a composite of hepatic artery complications (OR 1.73, 95 per cent c.i. 0.82 to 3.63, P = 0.149). Data on intraoperative hepatic artery interventions were available in 825 patients (422 patients with TACE and 403 without TACE). Intraoperative hepatic artery interventions were necessary in 69 (8.4 per cent) patients. In the matched cohort TACE was not associated with an increased incidence of intraoperative hepatic artery interventions (OR 0.94, 95 per cent c.i. 0.49 to 1.83, P = 0.870).

CONCLUSION

In otherwise matched patients with HCC intended for liver transplantation, TACE treatment before transplantation was not associated with higher risk of technical vascular issues or hepatic artery complications.

Hepatobiliary Cancers, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Hepatobiliary Cancers focus on the screening, diagnosis, staging, treatment, and management of hepatocellular carcinoma (HCC), gallbladder cancer, and cancer of the bile ducts (intrahepatic and extrahepatic cholangiocarcinoma). Due to the multiple modalities that can be used to treat the disease and the complications that can arise from comorbid liver dysfunction, a multidisciplinary evaluation is essential for determining an optimal treatment strategy. A multidisciplinary team should include hepatologists, diagnostic radiologists, interventional radiologists, surgeons, medical oncologists, and pathologists with hepatobiliary cancer expertise. In addition to surgery, transplant, and intra-arterial therapies, there have been great advances in the systemic treatment of HCC. Until recently, sorafenib was the only systemic therapy option for patients with advanced HCC. In 2020, the combination of atezolizumab and bevacizumab became the first regimen to show superior survival to sorafenib, gaining it FDA approval as a new frontline standard regimen for unresectable or metastatic HCC. This article discusses the NCCN Guidelines recommendations for HCC.

Systematic Review and Meta-Analysis of Posttransplant Hepatic Artery and Biliary Complications in Patients Treated With Transarterial Chemoembolization Before Liver Transplantation

BACKGROUND

Hepatic artery complications are feared complications after liver transplantation and may compromise the biliary tract, graft, and patient survival. The objective of this systematic review and meta-analysis was to compare risk of hepatic artery and biliary complications after liver transplantation in patients who underwent neoadjuvant transarterial chemoembolization (TACE) versus no TACE.

METHODS

Comprehensive searches were performed in Embase, MEDLINE OvidSP, Web of Science, Google Scholar, and Cochrane databases to identify studies concerning hepatocellular cancer patients undergoing preliver transplantation TACE. Quality assessment of studies was done by the validated checklist of Downs and Black. Meta-analyses were performed to evaluate the incidence of all hepatic artery complications, hepatic artery thrombosis, and biliary tract complications, using binary random-effect models.

RESULTS

Fourteen retrospective studies, representing 1122 TACE patients, met the inclusion criteria. Postoperative hepatic artery complications consisted of hepatic artery thrombosis, stenosis, and (pseudo)-aneurysms. Preliver transplantation TACE was significantly associated with occurrence of posttransplant hepatic artery complications (odds ratio, 1.57; 95% confidence interval, 1.09-2.26; P = 0.02). No significant association between neoadjuvant TACE and hepatic artery thrombosis alone or biliary tract complications was found.

CONCLUSIONS

Patients treated with TACE before liver transplantation may be at increased risk for development of hepatic artery complications after liver transplantation.

Liver transplantation for hepatocellular carcinoma

Over the last several years, liver transplantation has evolved to become a widely used treatment for hepatocellular carcinoma (HCC). The criteria used were developed in order to have acceptable outcomes for transplant with survival similar to other indications for transplant. These criteria are discussed in detail along with alternate options, including surgical resection and downstaging of HCC in cirrhotics. Technical considerations of liver transplantation must be considered, and living donor liver transplant is a possibility for treatment.

Pretransplant Intra-arterial Liver-Directed Therapy Does Not Increase the Risk of Hepatic Arterial Complications in Liver Transplantation: A Single-Center 10-Year Experience

PURPOSE

To investigate the association between pretransplant intra-arterial liver-directed therapy (IAT) for hepatocellular carcinoma (HCC) and hepatic arterial complications (HAC) in orthotopic liver transplantation (OLT) [namely hepatic artery thrombosis (HAT) and/or the need for hepatic arterial conduit].

METHODS

A total of 175 HCC patients (mean age: 60 years) underwent IAT with either transarterial chemoembolization or yttrium-90 (90Y) transarterial radioembolization prior to OLT between 2003 and 2013. A matched control cohort of 159 HCC patients who underwent OLT without prior IAT was selected. Incidence of HAC in both cohorts was investigated. The categorical differences between both cohorts were calculated by chi-square test.

RESULTS

Among the 175 patients (chemoembolization, n = 82; radioembolization, n = 93), 8 (5%) required conduits due to HA disease (chemoembolization, n = 6; radioembolization, n = 2), 3 (2%) developed HAT (chemoembolization, n = 2; radioembolization, n = 1). Eleven of 175 patients (6.7%) had HAC. Of the 159 control patients, 6 (4%) needed conduits for HA disease and 3 (2%) developed HAT. Nine of 159 patients (5.7%) had HAC. Chi-square analysis between the IAT cohort and the control group yielded a p value of 0.810. When comparing chemoembolization to radioembolization, p = 0.076 (not significant at p < 0.05).

CONCLUSION

Although aggressive pretransplant radioembolization and chemoembolization are both utilized in most liver transplant centers, neither appears to increase the risk of peri-transplant hepatic arterial complications in HCC patients.

Transarterial chemoembolization prior to liver transplantation for patients with hepatocellular carcinoma: A meta-analysis

BACKGROUND AND AIM

A debate exists over whether using preoperative transarterial chemoembolization for patients with hepatocellular carcinoma before liver transplantation. Numerous studies have been investigating on this, but there is still no unanimous conclusion about the effect of preoperative transarterial chemoembolization. We conducted the meta-analysis of all available studies to systematically evaluate the influence of preoperative transarterial chemoembolization on liver transplant.

METHODS

A systematic search was performed by two authors (Si TF. and Guan RY.) through PubMed, Embase, Cochrane, and Science Citation Index Expanded, combined with Manual Retrieval and Cited Reference Search. The searching cut-off date was 2016/07/31, and all the data obtained were statistically analyzed using Review Manager version 5.1 software (Copenhagen, The Nordic Cochrane Center, The Cochrane Collaboration, 2011) recommended by Cochrane Collaboration.

RESULTS

The study showed that there was no difference between the experimental group and the control group on perioperative mortality (RR = 1.10, 95% confidence interval (CI) = [0.49-2.48], P = 0.82) or biliary complications (RR = 0.96, 95%CI = [0.66-1.39], P = 0.83). Preoperative transarterial chemoembolization had no obvious effect on improving overall survival (HR = 1.05, 95%CI = [0.65-1.72], P = 0. 83) but would result in a higher rate of vascular complications (RR = 2.01, 95%CI = [1.23-3.27], P = 0.005) and a reduction of disease free survival (HR = 1.66, 95%CI = [1.02-2.70], P = 0.04). Subgroup analysis also revealed that patients from transarterial chemoembolization group in Asia had a much lower overall survival rate (HR = 2.65, 95%CI = [1.49-4.71], P = 0.0009) compared with the control group.

CONCLUSIONS

Considering the possible adverse impacts on liver transplantation and the variation in sensitivity to transarterial chemoembolization, clinicians should be more cautious when considering transarterial chemoembolization as the bridging therapy for patients in the waiting list.

Bridging locoregional therapy: Longitudinal trends and outcomes in patients with hepatocellular carcinoma

The purpose of this article is to analyze longitudinal trends in locoregional therapy (LRT) use and review locoregional therapy's role in the management of hepatocellular carcinoma prior to orthotropic liver transplantation Porrett et al. (2006) . LRT has a role in both bridge to transplantation and downstaging of patients not initially meeting Milan or UCSF Criteria. Due to the lack of randomized controlled trials, no specific bridging LRT modality is recommended over another for treating patients on the waiting list, however each modality has unique and patient-specific advantages. Pre-transplant LRT use in the United States has increased dramatically over the last two decades with more than 50% of the currently listed patients receiving LRT Freeman et al. (2008) . Despite these national trends, significant differences in LRT utilization, referral patterns, recurrence rates and survival have been observed among UNOS regions, socioeconomic levels and races. The use of LRT as a biologic selection tool based on response to treatment has shown promising results in its ability to predict successful post-transplant outcomes.

Preoperative transarterial chemoembolization does not increase hepatic artery complications after liver transplantation: A single center 12-year experience

BACKGROUND

As a bridge to liver transplantation or downstaging therapy for hepatocellular carcinoma (HCC) patients, preoperative transarterial chemoembolization (TACE) has potential risks in causing damage to hepatic artery (HA), resulting in severe postoperative complications.

AIM

To evaluate the impact of pre-TACE on postoperative hepatic artery complications (HAC) for HCC patients in a single liver transplant center.

MATERIALS AND METHODS

Clinical data of 450 HCC patients undergoing orthotopic liver transplantation (OLT) from January 2001 to December 2013 were retrospectively analyzed. Patients were divided into Group 1 (with pre-TACE) and Group 2 (without pre-TACE). Preoperative characteristics and postoperative HAC were compared.

RESULTS

One hundred and eleven patients (69 men; median age, 37±9.9 years) in Group 1 were compared with 339 patients (244 men; median age, 38.8±8.0 years) in Group 2. Patients were comparable in donor/recipients characteristics between groups. Histological review for native liver samples showed that Edema was the most often seen complication following pre-OLT TACE (troncluar: 87 vs 9; segmental: 91 vs 10; liver parenchyma: 93 vs 8; P=0.000). Fibrosis, thrombosis and aneurysm were only seen in Group 1. There were no significant difference in postoperative HAC (5/111 (4.5%) vs 5/339 (1.5%), P=0.131) between groups.

CONCLUSION

Our single institution experience showed that it might be safe to perform pre-TACE in HCC patients before OLT. It would not increase postoperative HAC risk.

Intratumoral pseudoaneurysms in hepatocellular carcinoma: do they occur de novo without any prior intervention? A tertiary care center experience of 6 years

BACKGROUND

Intratumoural pseudoaneurysms (ITPA) within hepatocellular carcinomas (HCC) usually arise as postprocedural complications of endovascular therapies or surgical procedures. Their de novo presence in HCC without any prior interventions has not been adequately described in medical literature.

PURPOSE

To evaluate and quantify the presence of intratumoural pseudoaneurysms (ITPA) within hepatocellular carcinomas (HCC) prior to any intervention.

MATERIAL AND METHODS

Retrospective cross-sectional review of 519 patients with HCC at a tertiary care university hospital with the purpose to evaluate and quantify the presence of ITPA present prior to any therapy. Patients' baseline data along with viral marker status, alpha fetoprotein (AFP) levels, imaging findings, and any prior treatment provided were recorded. Multi-detector computed tomography (MDCT) scans of selected patients were reviewed for presence of any ITPA and their incidence was calculated.

RESULTS

ITPAs without any prior therapy were found in 5% (25/519) of patients with HCC. Seventeen of 25 (68%) patients had liver cirrhosis while eight of 25 (32%) patients were non-cirrhotic on imaging. Multiple ITPAs were seen in 44% (11/25) of patients. Eight percent (2/25) of patients had pseudoaneurysm-associated hemorrhage, 20% (5/25) had lung metastasis, 12% (3/25) had portal vein thrombosis, 8% (2/25) had hepatic vein thrombosis, and 16% (4/25) had peritumoral hematoma. The incidence of de novo ITPAs occurring in patients with HCC without any prior therapy or intervention was 0.24%.

CONCLUSION

These cases provide a unique insight into an additional feature of HCC and usefulness of recognizing the ITPAs on imaging studies. Although de novo ITPAs in HCC are uncommon, occurring with an incidence rate of 0.24%, their presence in hypervascular hepatic lesion may point towards the diagnosis of HCC. Additionally, they should be accounted for in management planning as they can lead to complications of rupture and hemorrhage.

Evaluation of arterial impairment after experimental gelatin sponge embolization in a rabbit renal model

OBJECTIVE

Arterial stenosis is a major obstacle for subsequent interventional procedures. We hypothesized that the stenosis is caused by gelatin sponge embolization and performed an experimental study in a rabbit renal model.

MATERIALS AND METHODS

A total of 24 rabbits were embolized with porcine gelatin sponge particles injected into the renal arteries. Four rabbits were sacrificed on 1 day, 4 days, 1 week, 2 weeks, 3 weeks, and 4 weeks after embolization. Microscopic evaluations were performed on hematoxylin-eosin and smooth muscle actin immunohistochemical stained sections.

RESULTS

Gelatin sponge particles were mainly observed in the segmental and interlobar arteries. Transmural inflammation of the embolized arterial wall and mild thickening of the media were observed 1 week after embolization. Resorption of the gelatin sponge and organization of thrombus accompanied by foreign body reactions, were observed from 2 to 4 weeks after embolization. Microscopic images of the 3 weeks group showed vessel lumens filled mostly with organized thrombi, resulting in severe stenosis. Additionally, vessels showed a thickened intima that contained migrating smooth muscle cells and accompanying interruption of the internal elastic lamina. The migrating smooth muscle cells were distributed around the recanalized arterial lumen.

CONCLUSION

Gelatin sponge embolization may induce arterial stenosis by causing organized thrombus and intimal hyperplasia, which consists of migrating smooth muscle cells and intimal collagen deposits.

Hepatic artery and biliary complications in liver transplant recipients undergoing pretransplant transarterial chemoembolization

Liver transplantation (LT) is the treatment of choice for patients with cirrhosis and hepatocellular carcinoma (HCC) not amenable to resection. Locoregional therapies for HCC are often used to reduce tumor burden, bridge patients to LT, and down-stage HCC so that patients are eligible for LT. We hypothesized that prior endovascular antitumor therapy may increase the risk of hepatic artery (HA) and biliary complications after LT. The aim of this study was to compare HA and biliary complications in LT recipients with HCC who received transarterial chemoembolization (TACE) before LT with complications in LT recipients with HCC who did not receive TACE before LT. This was a retrospective cohort study of HCC patients at two transplant centers. The prevalence of HA complications (HA thrombosis, stenosis, or pseudoaneurysm) and biliary complications (nonanastomotic stricture, bile leak, and diffuse injury) were compared between patients treated with or without TACE. There were 456 HCC patients with a median age of 61 years (77% were male, and 63% had hepatitis C virus), and 328 (72%) received TACE before LT. The overall prevalence of HA complications was 4.7% in the no-TACE group and 7.9% in the TACE group (P = 0.22). All HA stenosis complications (n = 14) occurred in the TACE group (P = 0.018 versus the no-TACE group). An older donor age and a lower albumin level significantly increased the odds of HA complications. There was a nonstatistically significant increased odds of HA complications in the TACE group versus the no-TACE group according to an adjusted analysis (odds ratio = 2.02, 95% confidence interval = 0.79-5.16, P = 0.14). The overall prevalence of biliary complications was 16.4% in the no-TACE group and 19.8% in the TACE group (P = 0.40). In conclusion, a lower pre-LT albumin level and an older donor age were significantly associated with higher odds of HA complications after LT. TACE was not associated with higher odds of overall HA complications but was associated with a higher prevalence of HA stenosis. Further studies are warranted to confirm the HA stenosis findings and elucidate the pathogenesis.

Hepatic artery pseudoaneurysms arising from within a hepatocellular carcinoma

We report a case of a 70-year-old man with a large hepatocellular carcinoma (HCC) containing two pseudoaneurysms measuring up to 2 cm in diameter. The pseudoaneurysms and part of the HCC were supplied by branches from the middle colic artery, which arises from the superior mesenteric artery. This complex arterial vasculature was visualised on CT and confirmed with conventional angiography.

Imaging of the transplant liver

As the number of patients with liver transplants continues to increase, radiologists need to be aware of the normal post-operative appearance of the different liver transplants currently performed along with the wide variety of complications encountered. The complications commonly affect the biliar and vascular systems and can include anastomotic bile leakage and biliary stenosis along with stenosis or obstruction of the hepatic artery, portal or hepatic veins and IVC. Other complications include parenchymal abnormalities such as hepatic infarction, organ rejection, localized collections and post transplant lymphoproliferative disorder. This article reviews and illustrates the role of imaging for pediatric transplantation including the role of interventional radiology.

TACE versus TAE as therapy for hepatocellular carcinoma

Transarterial chemoembolization (TACE) improves survival in cirrhotic patients with hepatocellular carcinoma (HCC). The optimal schedule, best anticancer agent and best technique are still unclear. TACE may not be better than transarterial embolization (TAE). HCC is very chemoresistant, thus embolization may be more important than chemotherapy. Lipiodol cannot be considered as an embolic agent and there are no data to show that it can release chemotherapeutic agents slowly. It can mask residual vascularity on CT imaging and its use is not recommended. Both TACE and TAE result in hypoxia, which stimulates angiogenesis, promoting tumor growth; thus combination of TACE with antiangiogenic agents may improve current results. To date, there is no evidence that TACE pre-liver transplantation or resection helps to expand current selection criteria for patients with HCC, nor results in less recurrence after surgery. Combination with other techniques, such as radiofrequency ablation and drugs, may enhance the effect of TACE. New trials are being conducted to clarify these issues.

Transarterial chemoembolization as a bridge to liver transplantation for hepatocellular carcinoma: an evidence-based analysis

The aim of this review was to assess the impact of transarterial chemoembolization (TACE) as a neoadjuvant therapy prior to orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC). An electronic search on the Medline database (1990-2005) was used to identify relevant articles. The studies were reviewed and ranked according to their quality of evidence using the grading system proposed by the Oxford Centre for Evidence-based Medicine. As a bridge to OLT, pretransplant TACE does not improve long-term survival (grade C). There is currently no convincing evidence that TACE allows to expand the current selection criteria for OLT, nor that TACE decreases dropout rates on the waiting list (grade C). However, TACE does not increase the risk for postoperative complications (grade C). There is insufficient evidence that TACE offers any benefit when used prior to OLT, neither for early nor for advanced HCC. Well-designed randomized controlled trials are needed to define the role of TACE in OLT patients.

Treatment outcomes for hepatocellular carcinoma using chemoembolization in combination with other therapies

BACKGROUND

Although transarterial chemoembolization (TACE) improves survival in patients with hepatocellular carcinoma (HCC), it is not known if TACE combined with other treatments is beneficial.

AIM

To evaluate the evidence for improved outcomes in HCC with a multimodal treatment approach involving TACE.

METHOD

PubMed search for all cohort and randomized trials (n=84) evaluating TACE combined with other therapies; meta-analysis performed where appropriate.

RESULTS

A meta-analysis involving 4 RCTs showed a significant decrease in mortality favouring combination treatment (TACE plus percutaneous ablation) compared to monotherapy in patients with either small (<3cm) or large HCC nodules (>3cm) (OR, 0.534; 95% CI, 0.288-0.990; p=0.046). TACE combined with local radiotherapy improved survival in patients with tumour thrombosis of the portal vein in 7 non-randomized studies. Two RCTs and 13 non-randomized studies showed that TACE prior to hepatic resection does not improve survival nor tumour recurrence. Conversely, 2 RCTs and 5 comparative studies showed that transarterial injection of chemotherapeutic drugs mixed with lipiodol (TOCE) following hepatectomy confers survival benefit and less tumour recurrence. TACE before liver transplantation is safe and reduces drop-out rate from the waiting list, but there is no current evidence of improvement in subsequent survival or recurrence rate.

CONCLUSIONS

A combined approach involving TACE and percutaneous ablation improves survival. Adjuvant TOCE improves outcome after hepatectomy. TACE is useful to control tumours burden while on the waiting list for OLT. Multimodal treatment seems to be the best way to optimize TACE outcomes in HCC.

Hepatocellular carcinoma: interventional bridging to liver transplantation

Hepatocellular carcinoma (HCC) is one of the most common solid cancers worldwide with surgery being considered the treatment of choice. However, it is limited in view of the hepatic dysfunction and high recurrence rates associated with the disease. Liver transplantation offers the advantage of both, eradicating the tumor and treating the underlying liver disease and is the only chance for cure in patients suffering from HCC. Survival is known to reach 70% after 5 years and recurrent tumor can be found in less than 20% provided transplantation is restricted to patients with single tumors < or =5 cm or three nodules <3 cm (Milan criteria). However, donor organs are limited and the time on the transplant waiting list is up to 6 or 12 months in Europe and the United States with up to 30-40% dropouts per year. It has been demonstrated that patients with untreated HCC while on the waiting list longer than 6-10 months do not have any benefit in survival after liver transplantation. Interventional treatment options such as transarterial chemoembolization and percutaneous ablation techniques documented promising results concerning the reduction of dropouts from the waiting list and the potential risk for recurrent tumor. Mortality and morbidity were considerably low when radiological interventions had been considered as bridging therapies for liver transplantation. Percutaneous therapies come along with tumoral seeding of 0.1% to 0.6%. Adjuvant treatment with TACE, PEI, and/ or RFA in T1- and T2-staged HCC resulted in tumor-free survival after transplantation of 95.2% after 4 years and intention-to-treat survival of 94%, 85%, and 79% at 1, 2, and 3 years, respectively. Aggressive ablation therapy with a short transplant waiting time has the potential to optimize the use of liver transplantation for curative intent in selected cirrhotic HCC patients. Especially combined treatments seemed to play a key role in achieving complete tumor necrosis associated with improved disease-free survival after liver transplantation. In conclusion, no evidence based data exist in the literature supporting the efficacy of adjuvant interventional treatment modalities for HCC in patients awaiting liver transplantation. However, it has been shown that adjuvant (multimodal) interventional treatments seem a promising option for safe and effective bridging.

Chemoembolization and bland embolization: a critical appraisal

Hepatocellular carcinoma is a major cause of cancer-related mortality worldwide, and most patients are not candidates for potentially curative treatment. Bland and chemoembolization are palliative options for hepatocellular carcinoma (HCC) that have been evaluated in controlled trials. Chemoembolization and perhaps bland embolization used as primary treatment for HCC in selected patients are effective at prolonging survival. The role of these therapies before surgical resection, liver transplantation, or in combination with local ablative therapy is controversial and yet unproven.

Interventional Radiology in Liver Transplantation

Radiology is a key specialty within a liver transplant program. Interventional techniques not only contribute to graft and recipient survival but also allow appropriate patient selection and ensure that recipients with severe liver decompensation, hepatocellular carcinoma or portal hypertension are transplanted with the best chance of prolonged survival. Equally inappropriate selection for these techniques may adversely affect survival. Liver transplantation is a dynamic field of innovative surgical techniques with a requirement for interventional radiology to parallel these developments. This paper reviews the current practice within a major European center for adult and pediatric transplantation.

Does variant hepatic artery anatomy in a liver transplant recipient increase the risk of hepatic artery complications after transplantation?

OBJECTIVE

Our aim was to determine whether variant hepatic artery anatomy in a liver transplant recipient increases the risk of hepatic artery complications after liver transplantation.

MATERIALS AND METHODS

The study group consisted of 84 patients who underwent gadolinium-enhanced 3D MR angiography before orthotopic liver transplantation in which a branch patch arterial anastomosis at the gastroduodenal takeoff was used. MR angiography studies were retrospectively reviewed and assessed for the presence and type of variant hepatic artery anatomy. The diameter of the distal common hepatic artery was measured. The incidence of posttransplantation hepatic artery stenosis or thrombosis was assessed.

RESULTS

Seven (8.3%) of the 84 patients developed hepatic artery complications after transplantation. Of the 24 patients with variant hepatic artery anatomy, five (20.8%) had posttransplantation/ hepatic artery complications. In contrast, only two (3.3%) of the 60 patients with classic hepatic artery anatomy had complications. The higher complication rate in patients with variant hepatic artery anatomy was statistically significant (p < 0.05). The odds ratio was 7.6 (95% confidence interval, 1.4-42.6). The diameter of the distal common hepatic artery was smaller in patients with variant hepatic artery anatomy compared with those with classic hepatic artery anatomy (range, 4.3-7.1 mm [mean, 5.8 mm] vs 4.0-8.9 mm [mean 6.3 mm], p < 0.05), and it was also smaller in patients who had posttransplantation hepatic artery complications compared with those who had no complications (range, 4.2-6.3 mm [mean, 5.2 mm] vs 4.0-8.9 mm, [mean, 6.2 mm], p < 0.01).

CONCLUSION

Variant hepatic artery anatomy in a liver transplant recipient increased the risk of hepatic artery complications after transplantation. The smaller caliber of the native common hepatic artery may contribute to the higher risk.

Treatment of hepatic artery thrombosis after orthotopic liver transplantation

OBJECTIVES

This study evaluated conservative treatment for delayed hepatic artery thrombosis after orthotopic liver transplantation (OLT).

METHODS

Whole-graft OLTs (n=108) and live donor liver transplants (LDLTs; n=140) were performed in 237 patients between October 1991 and July 2002. Seven episodes of hepatic artery thrombosis were identified in six patients. Among the six patients, three had received whole-graft OLT and three had received right-lobe LDLT. Treatment included retransplantation, thrombectomy plus thrombolysis, and conservative treatment of hepatic and biliary complications.

RESULTS

Five patients survived after treatment. Among the three LDLT recipients who received conservative treatment, two had subsequent collateral formation and one had spontaneous recanalization of arterial inflow. Of the three recipients of whole-graft OLT, the first died because of hepatic failure and technically difficult retransplantation, the second had thrombectomy plus thrombolysis but had recurrence of thrombosis that spontaneously recannulated during conservative treatment, and the third patient had successful retransplantation for graft failure.

CONCLUSION

In the absence of hepatic failure, conservative treatment appears to be effective for patients with hepatic artery thrombosis. Collateralization is more likely to develop after LDLT than after whole-graft OLT.

Hepatic artery chemoembolization for hepatocellular carcinoma in patients listed for liver transplantation

We retrospectively analyzed all listed patients having hepatic artery chemoembolization (HACE) for hepatocellular carcinoma (HCC) stage T2 or less. Outcomes were transplantation, waiting list removal, death, and HCC recurrence. Twenty patients (mean age 55.7 years; 15 males) were identified. Twelve (60%) were transplanted, seven (35%) were removed from the list and one (5%) remains listed. Fourteen (70%) are alive. All 12 transplanted patients are alive (mean 2.94 years); one of seven removed from the list is alive (mean 1.45 years). Survival was significantly higher for those transplanted or listed vs. removed from the list (100% vs. 14.3%, p = 0.0002). No HCC's recurred. Three patients (15%) were removed from the list after prolonged waiting times before MELD. Hepatic artery chemoembolization induced deterioration and removal from the list of one (5%) patient. Survival for those transplanted was excellent(100%), but overall survival was significantly lower (61.3%) at a mean 5.48 years. Hepatic artery chemoembolization for listed patients with <or=euro T2 stage HCC is beneficial, but must be weighed against decreased waiting times and risk of HACE-induced deterioration. This balance is influenced greatly by the MELD system's determination of waiting times for HCC patients.

Review article: liver transplantation for HCC. Treatment options on the waiting list

The most widely adopted criteria to admit and maintain patients with HCC and cirrhosis in the waiting list for liver transplantation are the Milano criteria, consisting in the presence of a single tumour <or=5 cm in diameter or up to three tumours, none exceeding 3 cm in diameter. Since the average time to transplantation has become longer than 10-12 months in most European and American Centers, the exclusion from the list during the waiting period due to increase of the neoplasm over the established criteria is not uncommon at present. It is mandatory, therefore, to seek an effective therapeutic strategy for patients with HCC waiting for transplantation. Surgical resection and eventual subsequent salvage transplantation seems a cost-effective strategy in resectable HCC. In unresectable neoplasms both transarterial chemoembolization and percutaneous ablation techniques are currently used and one or the other are chosen according to individual applicability, limitations and specific risks. However, although positive trends were reported, no definitive evidence has been produced so far about their efficacy in increasing patient's survival and decreasing tumour recurrence rates after transplantation. Adult-to-adult living donor liver transplantation is one possible way to shorten the waiting list, but this strategy involves important ethical implications. At present it appears justified to take it into consideration only if the waiting time for cadaveric OLT is expected to exceed 7 months. A more general and definitive attempt to overcome problems related to long waiting times for patients with HCC and relatively preserved hepatic function has been introduced in the USA very recently and consists in prioritizing patients with HCC. However, the overall efficacy of this approach will be established only in some years.

Liver transplantation for hepatocellular carcinoma: an Asian perspective

Liver transplantation is an established treatment modality for patients with hepatocellular carcinoma (HCC), creating a potential for disease-free, long-term survival. In Asia, due to a severe shortage of donors, resection remains the treatment of choice for patients with HCC and good liver functional reserve. The use of marginal donors, split liver grafts and grafts from living donors are potential solutions that are best performed in experienced liver transplant centres to ensure an optimal outcome. Ethical issues relating to living donor liver transplantation have yet to be fully addressed. The roles of therapies to limit tumour progression during the waiting period, such as transarterial chemoembolization, need to be further investigated in the setting of a prospective trial and their benefits better defined.

Chemoembolization of hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) is the mainstay of treatment for patients with unresectable hepatocellular carcinoma (HCC). Chemoembolization involves delivery of some type of chemotherapy combined with some type of arterial embolization to destroy tumor cells. Whereas diffuse tumors may require lobar embolization, smaller tumors may be treated selectively. The goal of TACE is to cause tumor necrosis and control tumor growth while preserving as much functional liver tissue as possible. The ultimate purpose, however, is to prolong life. Several different TACE protocols have been developed, with no consensus as to the most effective techniques. The effect of TACE on patient survival remains unclear. Several nonrandomized studies have demonstrated a beneficial effect of TACE on survival. This result has not been confirmed with randomized trials. It is clear, however, that TACE is a palliative procedure that has been unable to provide a cure for HCC. When combined with other procedures such as percutaneous ethanol injection, TACE has been more successful at achieving survival rates matching those obtained after surgical resection in similar patient populations. Finally, TACE may also be useful as a neoadjuvant therapy by improving the outcomes of potentially curative therapies and as a bridge to liver transplantation.

Use of arterial conduit as an alternative technique in arterial revascularization during orthotopic liver transplantation

BACKGROUND

The risk of hepatic artery thrombosis after orthotopic liver transplantation is higher in cases of poor hepatic arterial inflow, small or anomalous recipient hepatic arteries, unsafe native hepatic arteries.

AIMS

To assess the use of arterial conduits as alternative technique for graft revascularization.

PATIENTS

At the Liver Transplant Center of the "S. Giovanni Battista" Hospital in Torino, a review has been made of 600 consecutive orthotopic liver transplantations in 545 adult patients from 1990 to 1999.

METHODS

In 95 orthotopic liver transplantations (15.8%) in 88 patients, the graft was supplied by infrarenal conduit, while in 505 orthotopic liver transplantations (84.2%) in 457 patients, a direct anastomosis was used.

RESULTS AND CONCLUSIONS

The overall incidence of hepatic artery thrombosis in our series was 3.5% (21/600): 5.3% (5/91) for conduits and 3.2% (16/505) for standard technique (p=ns, chi2 test). The actuarial 5-year graft survival was 67.7% for conduits and 68.6% for the standard technique; p (log rank): ns. The iliac prosthesis torsion was the only complication related to the use of infrarenal iliac conduit. The arterial conduit, performed with donor iliac artery, is an effective and safe revascularization technique in patients at high risk of arterial thrombosis.