Transarterial chemoembolization (TACE) is the standard therapy for patients in the intermediate stage of hepatocellular carcinoma and is typically performed through femoral artery access. Compared with transfemoral access, transradial access (TRA) can decrease the rate of bleeding complications and improve patient tolerance. A method is presented here to perform transarterial chemoembolization via radial artery access.
Transarterial chemoembolization (TACE) is the most common modality for treatment of hepatocellular carcinoma (HCC) at the intermediate stage. TACE is typically performed via transfemoral access (TFA). However, transradial access (TRA) is preferred in coronary artery interventions due to decreased complications and mortality. Whether the advantages of TRA can be applied to TACE required investigation.
Patients receiving TRA TACE at a single center were retrospectively enrolled for study. Procedural details, technical success, radial artery occlusion (RAO) rate, and access site-related bleeding complications were evaluated. From October 2017 to October 2018, 112 patients underwent 160 TRA TACE procedures. The overall technical success rate was 95.0% (152/160). The rate of crossover from TRA to TFA was 1.9%. No access site-related bleeding complications were found in any cases. Asymptomatic RA occlusion occurred in three patients (2.7%). Compared with TFA, TRA can increase safety and patient satisfaction while decreasing access site-related bleeding complications. Moreover, TRA interventions can benefit patients with advanced age, obesity, or a high risk of bleeding complications.
Hepatocellular carcinoma (HCC) is a very common malignancy, with the sixth highest incidence rate worldwide. It is also the second leading cause of cancer mortality around the world1. Because only 5%–20% of patients can receive curative therapy, transarterial chemoembolization (TACE) is the most popular palliative treatment for patients with unresectable HCC2. TACE has been recognized as the most commonly used and effective treatment approach for HCC patients at the intermediate stage3. Transfemoral access (TFA) chemoembolization is the most common approach for TACE4. However, there are risks associated with TFA intervention, including bleeding at the access site and major vascular complications5. These complications lead to prolonged hospitalization and increased costs. Moreover, TFA requires immobilization for at least 6 h, which increases discomfort and dissatisfaction for the patients.
Transradial access (TRA) is an alternative approach that has been used in percutaneous coronary intervention (PCI) for more than two decades5,6. TRA PCI has several advantages: increased procedure comfort, decreased access site-related bleeding, decreased major vascular complications, and decreased mortality7,8. The radial artery (RA) is easy to access and puncture because of its superficial location7. Hemostasis is easy to conduct after intervention and there is no strict immoblization9. Despite encouraging evidence for TRA intervention in cardiac catheterization, to date only a few studies used TRA in peripheral disease intervention. TRA interventions for malignant liver tumors are even rarer. Here, the clinical feasibility and safety of TRA hepatic embolization is analyzed. One institution’s experience with the step-by-step TRA protocol provided is also described.
This single-center retrospective study was approved by the local Institutional Review Board of Zhongshan Hospital, Fudan University.
1. Obtaining informed consent
2. Patient evaluation
3. Radial artery access
4. Anticoagulation and vascular dilation
5. Catheter selection
6. Radial artery hemostasis
NOTE: Nonocclusive hemostasis is performed using a special tourniquet to maintain RA patency (Figure 3).
7. Follow up
From October 2017 to October 2018, 112 patients underwent 160 TRA TACE procedures, and the overall technical success rate was 95.0% (152/160). Eight cases were met with technical failure. Of these, five cases were caused by left RA puncture failure and subsequently underwent successful TACE with right RA access. The other three cases were caused by cannulation failure, and underwent subsequent successful intervention by crossover to right FA access. The crossover rate of RA access to FA access was only 1.9%. No access site-related bleeding complications were found in any of the cases.
The baseline clinical data of cases with technical success or technical failure were compared (Table 1). Compared with patients that previously received TACE, patients undergoing first-time TACE via RA access were more likely to suffer technical failure (P = 0.016). No significant correlations were found between technical success or failure and patient characteristics, including age, sex, or combined medical comorbidities. Three patients suffered asymptomatic RA occlusion.
The numbers of TRA TACE procedures were compared (Table 2). Owing to the low frequency of radial artery occlusion (RAO), no significant correlation was found between the increased rate of RAO and the number of TRA procedures. No cases required urethral catheterization for postoperative dysuria. Also, no neurologic complications or contrast medium-induced nephropathy were found in any cases during follow-up.
Figure 1: Vasodilation cocktail solution. (A, B) 8 mL of vasodilation solution was given through the sheath immediately after access was obtained to prevent RA spasm and blood thrombosis. (C) Transradial artery insertion of a 4-Fr 125 cm common catheter. (D) The location of the left hand near the right inguinal region offered greater accessibility for intervention procedure. Please click here to view a larger version of this figure.
Figure 2: A patient receiving a third TRA-TACE. (A) The common hepatic arteriogram pictured shows that a tumor stain remains. (B) Superselective angiography with a microcatheter shows the tumor's feeding artery. (C, D) The tumor stain disappeared after embolization with epirubicin-lipiodol emulsion. Please click here to view a larger version of this figure.
Figure 3: Hemostasis after intervention. (A) The tourniquet used for radial artery hemostasis in the department. (B) The remaining 2 mL of vasodilation solution was given through the sheath. (C) Before the sheath was removed, the air bag was inflated with 10 to 15 mL of air. (D) The pulse oximeter waveform was used to confirm the arterial waveform on the left thumb. Please click here to view a larger version of this figure.
Case Characteristics | Overall (n=160) |
Successful case (n=152) |
Failure case (n=8) |
P Value |
Age, years | 58.7±12.1 | 58.6±11.9 | 60.0±16.1 | 0.754 |
Sex, n (%) | 0.893 | |||
Male | 127(79.4) | 120(78.9) | 7(87.5) | |
Female | 33(20.6) | 32(21.1) | 1(12.5) | |
Height, meter | 1.68±0.06 | 1.68±0.07 | 1.70±0.06 | 0.389 |
BMI, kg/m2 | 22.41±2.72 | 22.37±2.75 | 22.32±2.12 | 0.338 |
Hypertension, n (%) | 1 | |||
Yes | 53(33.1) | 50(32.9) | 3(37.5) | |
No | 107(66.9) | 103(67.1) | 5(62.5) | |
Diabetes mellitus, n (%) | 0.543 | |||
Yes | 36(22.5) | 33(21.7) | 3(37.5) | |
No | 124(77.5) | 119(78.3) | 5(62.5) | |
Previously TACE, n (%) | 0.016* | |||
Naïve | 45(28.1) | 43(28.3) | 6(75.0) | |
Yes | 115(71.9) | 109(71.7) | 2(25.0) | |
HBV infection | 1 | |||
Yes | 103(64.4) | 98(64.5) | 5(62.5) | |
No | 57(35.6) | 54(35.5) | 3(37.5) | |
Catheter number (n) | <0.001* | |||
1 | 137(85.6) | 137(90.1) | 0(0) | |
≥2 | 23(14.4) | 15(9.9) | 8(100.0) | |
TACE: transarterial chemoembolization; BMI: body mass index. *P<0.05 |
Table 1: Demographic and clinical differences between cases with technical success and technical failure. No significant difference was found between patient characteristics, including age, sex, or height, and successful TRA TACE or failure of RA access. TRA intervention failure may increase the number of catheters used.
Cases/patients | None RAO (n=109) |
RAO (n=3) |
Total (n=112) |
Numbers | |||
1 | 76(67.9) | 1(0.9) | 77(68.8) |
2 | 24(21.4) | 1(0.9) | 25(22.3) |
≥3 | 9(8.0) | 1(0.9) | 10(8.9) |
RAO: radial artery occlusion; TACE: transarterial chemoembolization. |
Table 2: The number of TRA TACE procedures patients underwent during the study. About 8% of patients had three or more TRA TACE procedures, no obvious increase of patients with post operational RAO.
TRA interventional therapy has grown significantly worldwide in recent years, especially in diagnostic and Interventional cardiology procedures12. Moreover, there has been increasing attention to peripheral vascular disease intervention. Without compromising procedural success rates, TRA to cardiac intervention can effectively reduce the rates of bleeding and vascular complications compared with TFA13,14. Compared with TFA, TRA is superior in several capacities, including monitoring time after the procedure, time of ambulation, and greater overall patient satisfaction15,16,17.
Despite these advantages recognized in coronary intervention, TRA is rarely applied by IRs. The apparent reluctance of IRs to utilize TRA may be explained by TRA's longer procedural time and a steep learning curve18. Potentially increased total fluoroscopic time and radiation dose also limit TRA to interventional procedures below the diaphragm, such as hepatic embolization and uterine artery embolization. At our institution, TRA intervention was introduced about 3 years ago and rapidly adopted as a preferred approach. As expected, expertise and institution-wide adoption are required before the benefits and efficiencies of TRA become clear19. Moreover, it is possible for IRs to increasingly learn more about TRA and improve their ability to use the method, which can rapidly increase adequate proficiency in TRA18.
This protocol usually uses the same standard technique with dedicated radial devices, such as a slender vascular introducer sheath (typically 4-Fr) and a single-catheter technique with no need for catheter exchange. It is obvious that TRA procedure failure was associated with an increased number of catheter utility (P < 0.001). The rate of single catheter use in all cases is 85.6% and would further increase by the accumulated experience of the IRs and decreased rate of technical failure, which may somewhat decrease the cost during hospitalization. Due to the rarity of RAO, no significant correlation was found between the increased rate of RAO and a number of TRA procedures. A previous study demonstrated that the diameter of the RA decreased following TRA procedures20 because it is an important parameter to consider, which may preclude its future use as a conduit or develop to RAO. Even 8.0% of patients in this study received more than 3x TACE procedures via RA access without the occurrence of RAO; the total rate of RAO was only 2.7%. It is apparent that, with a low rate of RAO, repeated TRA for hepatic embolization is clinically feasible.
TRA has several obvious advantages when compared with TFA. First, RA is more superficial than FA, and there are no surrounding critical structures that are susceptible to injury during artery access. Hence, it is easy to compress and achieve hemostasis after intervention, which significantly decreases the incidence of postprocedural bleeding complications compared with TFA9. Furthermore, the potential difficulty in locating the common femoral artery and the difficulty in detecting and controlling postprocedural hemorrhage in obese patients makes TRA an ideal treatment option21. Due to the superficial location and easy hemostasis of RA, TRA may be advantageous for patients who are deemed high risk for bleeding complications, such as those with thrombocytopenia, coagulation disorders, or liver dysfunction, those receiving anticoagulation, and elderly patients22,23. Second, TRA can enable patients to ambulate immediately after intervention, which is of paramount important to improve patient satisfaction. Previous studies demonstrated a strong patient preference and procedure satisfaction for TRA over TFA during hepatic embolization3,24. Because patients are susceptible to postprocedural nausea, vomiting, or potential dysuria, immediate ambulation is important for them to keep a comfortable position and relieve the adverse reaction. TRA is especially significant for elderly patients and those with back pain. Third, compared with TFA, it is possible for TRA to decrease the cost of hospitalization and to decrease the time of hospitalization17,25.
Of course, complications for TRA also exist. Periprocedural stroke is a rare but serious complication associated with high mortality and impaired quality of life26. The potential reason for TRA's association with the risk of periprocedural stroke is that the guiding catheter is introduced through the subclavian artery, which is adjacent to the common carotid artery and vertebral artery, both of which directly supply the brain27. To date, no TRA-related stroke was reported, except a case of seizure recorded in a case series report28, which was hypothetically contributed to the intraarterial administration of verapamil. RAO is a common complication for repeated TRA intervention, which is often asymptomatic. Few patients have experienced symptomatic complication of RAO, such as pain, numbness, or discoloration of the arm6, making TRA an ideal alternative to TFA intervention. Typically, postprocedural mild pain at the access site is a common complication in the tested center's practice, which is often self-limited or treated with nonsteroidal anti-inflammatory drugs if necessary. Also, failure of TRA-related crossover to FA access, an unsatisfactory result for both patients and IRs, potential increases operation time, radiation exposure, or the time of hospitalization29. Furthermore, elderly patients are technically more challenging due to anatomical issues such as vascular tortuosity and atherosclerosis. All in all, the advantages of TRA must be balanced against these shortcomings. In general, a successful TRA entails a comprehensive evaluation of the access route for each patient before each therapy.
Critical steps of the protocol are given here. First, considering the convenience in operation and risk for cerebrovascular complications, the left RA could be the default choice for the procedure. Second, the Barbeau test must be performed for patients considered for TRA interventions. Third, ultrasound guidance is key to help RA puncture, especially for a new care provider. At last, use of a hydrophilic sheath, vasodilation cocktail solution, and nonocclusive hemostasis of the RA are essential precautions to reduce the occurrence of RAO.
In conclusion, this study demonstrates the safety and applicability of TRA hepatic embolization. Importantly, TRA can reduce postprocedural access site-related bleeding complications. TRA interventions can provide more convenience and comfort for HCC patients. TRA interventions can especially benefit patients with advanced age, obesity, or high risk for bleeding complications.
The authors have nothing to disclose.
This work was supported by the clinical research special fund from Zhongshan Hospital, Fudan University (2016ZSLC17). The authors are very grateful to Dr. Xianglin Hu in Zhongshan Hospital of Fudan University for his very professional suggestions to English writing.
Reagents | |||
Embosphere | Merit | 20173776165 | |
Gelfoam | Alicon | 20143771056 | |
Heparin | Hepatunn | H51021209 | |
Injection syringe | KDL | 20163150518 | |
Iodinated oil | Yantai Luyin Pharmaceutical Co.Ltd | H37022398 | |
Lidocaine | Shandong Hualu Pharmaceutical Co.Ltd | H37022147 | |
Lobaplatin | Hainan Changan International Pharmaceutical Co.Ltd | H20050308 | |
Nitroglycerin | Brijing Yimin Pharmaceutical Co.Ltd | H11020289 | |
Normal saline | Anhui Shuanghe Pharmaceutical Co.Ltd | H34023609 | |
Pharmorubicin | Pfizer | H20000496 | |
Ultravist 370 | Bayer | H20171333 | |
Material | |||
Hydrophilic Guide Wire | Merit | LWSTDA38180 | |
Injection syringe | KDL | 20163150518 | |
Maestro Microcatheter | Merit | 28MC24150SN | |
MPA1 (I) catheter | Cordis | 451-406P0 | |
Sheath Introducer | Merit | PSI-4F-11-035 | |
Steerable Guidewire | Merit | TNR2411 | |
TR Band | Terumo | XX*RF06 | |
Equipment | |||
DSA | Toshiba | INFX-9000V | |
Ultrasonic machine | SonoScape | 20172231180 |