Balloon-occluded arterial stump pressure before balloon-occluded transarterial chemoembolization

Double-Balloon Catheter-Mediated Transarterial Chemotherapy Delivery in a Swine Model: A Mechanism Recruiting the Vasa Vasorum for Localized Therapies

PURPOSE

Treatment of hypovascular tumors, such as pancreatic adenocarcinoma, is challenging owing to inefficient drug delivery. This report examines the potential mechanism of localized drug delivery via transarterial microperfusion (TAMP) using a proprietary adjustable double-balloon occlusion catheter in a porcine model.

MATERIALS AND METHODS

Adult Yorkshire swine (N = 21) were used in the Institutional Animal Care & Use Committee-approved protocols. The RC-120 catheter (RenovoRx, Los Altos, California) was positioned into visceral, femoral, and pulmonary arteries with infusion of methylene blue dye, gemcitabine, or gold nanoparticles. Transmural delivery was compared under double-balloon occlusion with and without side-branch exclusion, single-balloon occlusion, and intravenous delivery. Intra-arterial pressure and vascular histologic changes were assessed.

RESULTS

Infusion with double-balloon occlusion and side-branch exclusion provided increased intra-arterial pressure in the isolated segment and enhanced perivascular infusate penetration with minimal vascular injury. Infusates were predominantly found in the vasa vasorum by electron microscopy.

CONCLUSIONS

TAMP enhanced transmural passage mediated by localized increase in arterial pressure via vasa vasorum.

Microballoon Interventions for Liver Tumors: Review of Literature and Future Perspectives

Background: Microballoon interventions (MBIs) have been proposed as useful tools to improve the efficacy of locoregional liver treatments. The aim of this systematic review was to summarize the existing evidence on procedural characteristics, safety, and efficacy of MBIs. Methods: PubMed and Cochrane Central Register of Controlled Trials were queried for original research articles evaluating MBIs in patients with liver malignancies from 2012 to August 2022. Search terms employed were liver malignancies, hepatocellular carcinoma, cholangiocarcinoma, liver metastases, microballoon transarterial chemoembolization, balloon-occluded trans-arterial chemoembolization, balloon-occluded selective internal radiation therapies, balloon-occluded TACE and ablation, and safety or oncological results or efficacy. Merely technical studies and animal studies were excluded. Results: Thirty-four original research studies and one abstract involving 744 patients treated with MBIs were included; 76% of the studies were retrospective, with low risk of bias and moderate-to-poor levels of evidence. Heterogeneity precluded meta-analysis. All studies proved MBI safety, which was not inferior to non-occlusive procedures. Balloon employment ameliorates oncological results, improving time to recurrence, objective response rate, and lowers need for retreatment. Conclusions: MBIs appear to be potential game changers in the treatment of liver malignancies. Multicentric, prospective and randomized studies are necessary to confirm these findings.

In Vitro Model for Simulating Drug Delivery during Balloon-Occluded Transarterial Chemoembolization

Background: Balloon-occluded transarterial chemoembolization (B-TACE) has emerged as a safe and effective procedure for patients with liver cancer, which is one of the deadliest types of cancer worldwide. B-TACE consist of the transcatheter intraarterial infusion of chemotherapeutic agents, followed by embolizing particles, and it is performed with a microballoon catheter that temporarily occludes a hepatic artery. B-TACE relies on the blood flow redistribution promoted by the balloon-occlusion. However, flow redistribution phenomenon is not yet well understood. Methods: This study aims to present a simple in vitro model (IVM) where B-TACE can be simulated. Results: By visually analyzing the results of various clinically-realistic experiments, the IVM allows for the understanding of balloon-occlusion-related hemodynamic changes and the importance of the occlusion site. Conclusion: The IVM can be used as an educational tool to help clinicians better understand B-TACE treatments. This IVM could also serve as a base for a more sophisticated IVM to be used as a research tool.

Transcatheter arterial embolization for unruptured renal angiomyolipoma using a 1.8-Fr tip microballoon catheter with a mixture of ethanol and Lipiodol

Background

To evaluate the efficacy and safety of transcatheter arterial embolization for renal angiomyolipoma using a 1.8-French tip microballoon catheter and a mixture of ethanol and Lipiodol.

Methods

Seven consecutive patients with total of eight angiomyolipomas underwent this procedure between June 2014 and June 2017. A 1.8-French tip microballoon catheter was advanced to the feeding artery of the angiomyolipoma, and transcatheter arterial embolization was performed with a mixture of ethanol and Lipiodol under microballoon inflation. We retrospectively evaluated the characteristics of angiomyolipomas, technical success rate, clinical success rate, renal function, and adverse events. Technical success and clinical success were defined as complete embolization of all feeding arteries and reduction of tumor size, respectively.

Results

The median size of the angiomyolipomas was 46 mm (range, 40–64 mm). Transcatheter arterial embolization was successful in all eight angiomyolipomas. The median volume of the mixture of ethanol and Lipiodol was 6.0 ml (range, 2.0–14 ml). The median ratio of ethanol to Lipiodol was 71% (range, 71–75%). All eight angiomyolipomas shrank with a median shrinkage rate of 34% in diameter (range, 9–63%) and 77% in volume (range, 48–94%). The median follow-up period was 13 months (range, 9–54 months). Clinical success was achieved in all cases. Serum creatinine concentrations and the pre- and post-procedural estimated glomerular filtration rates did not change notably, and there were no major complications.

Conclusion

Transcatheter arterial embolization for renal angiomyolipoma using a 1.8-French tip microballoon catheter with a mixture of ethanol and Lipiodol is effective and safe.

Balloon-Occluded Transarterial Chemoembolization for the Treatment of Hepatocellular Carcinoma: A Single-Center US Preliminary Experience

This report describes a single-center experience with balloon-occluded transarterial chemoembolization for liver-directed therapy. A total of 26 patients (11 male, 4 female; mean age, 65 y ± 7) with 28 tumors (mean diameter, 2.7 cm; range, 1.1-5.9 cm) were treated. Technical success rate was 100% (28 of 28 cases), with 1 minor complication of left portal vein thrombosis and small liver infarct. Of the 15 tumors analyzed for response, 60% (9 of 15) exhibited complete response, 33.3% (5 of 15) exhibited partial response, and 6.6% (1 of 15) had stable disease on follow-up. Eight patients exhibited overall progression with a new hepatic lesion and a median time to progression of 7.9 months (range, 5-11 mo).

The Beauty and Bane of Pressure-Directed Embolotherapy: Hemodynamic Principles and Preliminary Clinical Evidence

OBJECTIVE

Particulate emboli are passive agents that follow blood flow. Deployed antireflux devices obstruct blood flow.

CONCLUSION

The aim of this review is to describe the complex hemodynamic alterations to blood flow caused by the deployment of antireflux devices and the resulting changes to embolic distribution. The therapeutic goal is optimization of embolization safety and efficacy.

A methodology for numerically analysing the hepatic artery haemodynamics during B-TACE: a proof of concept

Balloon-occluded transarterial chemoembolisation (B-TACE) is an intraarterial transcatheter treatment for liver cancer. In B-TACE, an artery-occluding microballoon catheter occludes an artery and promotes collateral circulation for drug delivery to tumours. This paper presents a methodology for analysing the haemodynamics during B-TACE, by combining zero-dimensional and three-dimensional modelling tools. As a proof of concept, we apply the methodology to a patient-specific hepatic artery geometry and analyse two catheter locations. Results show that the blood flow redistribution can be predicted in this proof-of-concept study, suggesting that this approach could potentially be used to optimise catheter location.

Balloon-occluded transcatheter arterial chemoembolization for hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) is widely accepted as a treatment for patients with hepatocellular carcinoma (HCC) in the intermediate stage according to the Barcelona Clinic Liver Cancer (BCLC) guidelines. Recently, balloon-occluded TACE (B-TACE) was developed in Japan. Despite the lack of a clear definition, B-TACE is generally defined as the infusion of emulsion of chemotherapeutic agents with lipiodol followed by gelatin particles under the occlusion of feeding arteries by a microballoon catheter, which leads to the dense lipiodol emulsion (LE) accumulation in HCC nodules. This phenomenon cannot be explained only by the prevention of proximal migration and leakage of embolization materials; it further involves causing local changes in the hemodynamics of the surrounding occlusion artery and targeted HCC nodules. Balloon-occluded arterial stump pressure plays an important role in the dense LE accumulation in targeted HCC nodules. Although randomized controlled trials comparing the therapeutic effect and the prognosis of B-TACE to those of the other TACE procedures, such as conventional-TACE and drug-eluting beads TACE, are still lacking, B-TACE is thought to be a promising treatment. The purpose of this review is to summarize the mechanism, therapeutic effect, indication, prognosis and complications of B-TACE.

Transvascular therapy of Hepatocellular Carcinoma (HCC), status and developments

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Only 30-40% of patients diagnosed with HCC are candidates for curative treatment options. The remaining majority of patients undergo local, regional or systemic palliative therapies. Transvascular therapy of HCC takes advantage of the fact that hypervascularized HCCs receive their main perfusion from the hepatic artery. In this context transvascular therapy describes different therapies: bland embolization (transarterial embolization, TAE), cTACE (conventional transarterial chemoembolization), DEB-TACE (TACE with drug-eluting beads, DEB) and SIRT (selective internal radiation therapy, radioembolization). cTACE is the most common type of transvascular treatment and represents a combination of the intra-arterial use of a chemotherapeutic agent and embolization. There is no standardized regimen for cTACE. It remains unclear whether the intra-arterial application of a chemotherapeutic agent is definitely required, because bland embolization alone using very small spherical particles shows tumor necrosis comparable to cTACE. For DEB-TACE microparticles loaded with a chemotherapeutic drug combine the advantages of cTACE and bland embolization.

Change in Imaging Findings on Angiography-Assisted CT During Balloon-Occluded Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma

PURPOSE

To evaluate changes in imaging findings on CT during hepatic arteriography (CTHA) and CT during arterial portography (CTAP) by balloon occlusion of the treated artery and their relationship with iodized oil accumulation in the tumor during balloon-occluded transcatheter arterial chemoembolization (B-TACE).

METHODS

Both B-TACE and angiography-assisted CT were performed for 27 hepatocellular carcinomas. Tumor enhancement on selective CTHA with/without balloon occlusion and iodized oil accumulation after B-TACE were evaluated. Tumorous portal perfusion defect size on CTAP was compared with/without balloon occlusion. Factors influencing discrepancies between selective CTHA with/without balloon occlusion and the degree of iodized oil accumulation were investigated.

RESULTS

Among 27 tumors, tumor enhancement on selective CTHA changed after balloon occlusion in 14 (decreased, 11; increased, 3). In 18 tumors, there was a discrepancy between tumor enhancement on selective CTHA with balloon occlusion and the degree of accumulated iodized oil, which was higher than the tumor enhancement grade in all 18. The tumorous portal perfusion defect on CTAP significantly decreased after balloon occlusion in 18 of 20 tumors (mean decrease from 21.9 to 19.1 mm in diameter; p = 0.0001). No significant factors influenced discrepancies between selective CTHA with/without balloon occlusion. Central area tumor location, poor tumor enhancement on selective CTHA with balloon occlusion, and no decrease in the tumorous portal perfusion defect area on CTAP after balloon occlusion significantly influenced poor iodized oil accumulation in the tumor.

CONCLUSIONS

Tumor enhancement on selective CTHA frequently changed after balloon occlusion, which did not correspond to accumulated iodized oil in most cases.