Transarterial chemoembolization for hepatocellular carcinoma with vascular invasion

Although the global guidelines only recommend systemic therapy for hepatocellular carcinoma with vascular invasion, various treatments are performed for it. Among them, transarterial chemoembolization (TACE) is the most frequent option; however, standard techniques have not been established. Conventional TACE (cTACE) has also been frequently performed for tumors invading the portal vein (PVTT), hepatic vein (HVTT), and bile duct (BDTT). In cTACE for PVTT, selective catheterization into the tumor-feeder is essential to avoid adverse effects. However, if it is unsuccessful, injection of embolic agents under balloon occlusion of the hepatic artery can improve the therapeutic effects and avoid hepatic infarction. When marked arterioportal shunts are demonstrated, embolization with gelatin sponge particles soaked with a chemotherapeutic solution is another option. Arteriovenous shunts accompanied by HVTT may cause systemic embolization due to migration of embolic agents, and occlusion of a shunt-draining hepatic vein using a balloon catheter can reduce the risk. BDTT is often accompanied by obstructive jaundice; therefore, endoscopic or percutaneous biliary drainage is required when the serum total bilirubin concentration is ≥3 mg dl^-1. TACE should be performed as selectively as possible and attention should also be paid to the risk of obstructive jaundice and/or pancreatitis caused by sloughing of necrotized BDTT.