Transradial Access Chemoembolization for Hepatocellular Carcinoma Patients

Summary

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.

Abstract

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.

Introduction

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 decades^5,6. TRA PCI has several advantages: increased procedure comfort, decreased access site-related bleeding, decreased major vascular complications, and decreased mortality^7,8. 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.

Protocol

This single-center retrospective study was approved by the local Institutional Review Board of Zhongshan Hospital, Fudan University.

1. Obtaining informed consent

1. Before the TRA interventions, have interventional radiologists (IRs) explain the benefits and potential complications of TRA to the patients.

2. Patient evaluation

1. After obtaining informed consent, evaluate the RA for the feasibility of puncture and cannulation.
2. Perform a comprehensive review of the patient's medical history. Confirm if patients had severe vascular tortuosity, severe peripheral vascular disease, a fistula for dialysis, or preparation for RA dialysis operation. These are relative contraindications for patients receiving TRA interventions.
3. Evaluate the visibility of the RA.
   1. Perform a Barbeau test with the use of pulse oximetry to evaluate how visible the hand collateral arteries are before intervention¹¹. The Barbeau D waveform is considered an absolute contraindication for RA cannulation.
   2. For patients tested as Barbeau C waveform, apply a Doppler ultrasound examination to provide more reliable information about the amount of collateral circulation in the forearm and hand. An inner diameter smaller than 2 mm is considered a contraindication.
      NOTE: After medical history evaluation and the RA evaluation, patients with contraindications should abstain from a puncture via the ipsilateral RA. The contralateral RA might serve as an ideal supply if it is found to be patent through Barbeau test evaluation. The left RA is initially chosen as a preferred access route. The right RA might serve as an alternative choice if the left RA was found unsuitable.

3. Radial artery access

1. Place the patient in a supine position on the angiography table. Then, place the left arm parallel to the patient’s body and close to the left waist, allowing easy placement of the catheter and wire and enabling operator positioning comparable to that with the TFA.
2. Mark the distal RA pulse by palpation. Clean the skin surface with 10% povidone-iodine surgical scrub solution and allow the solution to air dry. Cover the left arm with a surgical drape.
   1. In case of potential left RA puncture failure, prepare an alternative access route by sterilizing and draping the right arm or right inguinal region.
3. Apply local anesthesia (i.e., 1 mL of lidocaine 2%) proximal to the styloid process along the axis of the most powerful pulsation of the left RA.
4. Extend the wrist, and puncture the RA with a 20 G needle using the modified Seldinger technique. When pulsatile arterial blood return isobserved , introduce a 0.025 inch hydrophilic guidewire.
   1. Retract the guidewire and readjust the needle if resistance is encountered. Do not force the insertion of the guidewire. With the assistance of of digital subtraction angiography (DSA), inject about 1 to 2 mL of contrast to highlight the RA and help insert the hydrophilic guidewire.
5. Once access is obtained, remove the needle and introduce a 4-French hydrophilic sheath with the guidewire. After sheath insertion, gently pump back a small amount of arterial blood with a syringe to confirm that the sheath tip is within the vessel.

4. Anticoagulation and vascular dilation

1. Prepare 10 mL of a vasodilation cocktail solution (3,000 IU of unfractionated heparin, 0.1 mg of nitroglycerin, and 20 mg of lidocaine).
2. Administer 8 mL of the vasodilation cocktail solution through the sheath at a speed of 0.5 mL/s (Figure 1).
   NOTE: Reduce or stop the dose of heparin for patients with moderate or high bleeding risk.

5. Catheter selection

1. Use a 4-French, 125 cm common catheter and a standard 0.035 inch x 180 cm hydrophilic wire to traverse the subclavian artery and engage the descending aorta. Use DSA fluoroscopy to visualize the proximal axillary artery during navigation within the arm to avoid potential lesions to an artery loop or vascular tortuosity.
   NOTE: The subclavian artery has many arterial branches. Angiographic guidance prevents guidewire catheters from entering collateral vessels during retrograde catheterization. A few cases have an artery loop in the radial artery. If the standard wire cannot pass the loop, use of a microcatheter and angled 0.016 inch or 0.018 inch microwire is recommended.
2. Use the 4-French, 125 cm common catheter in combination with a standard 0.035-inch wire to negotiate the transverse arch to direct the guidewire toward the descending aorta.
   NOTE: If the angle between the aorta and left subclavian artery is very acute, a Cobra 2-shaped catheter (e.g., Simmons I or Simmons II catheter) is recommended to accomplish this turn.
3. After catheterization of the descending aorta, replace the common catheter via a coaxial technique. Once the common catheter is inserted into the descending aorta, steer the catheter tip ventrally for catheterization of the celiac trunk under the guidance of DSA fluoroscopy. In most cases, it is easy to catheterize and perform angiography of the celiac trunk, the hepatic artery, and superior mesenteric artery.
   NOTE: If the angle between the celiac artery and the descending aorta is very acute, use a Cobra catheter to complete the procedure.
4. For hepatic embolization procedures, perform super-selective catheterization and chemoembolization using a coaxial technique and place a 2.8-French 150 cm microcatheter into the targeted branch of the hepatic artery feeding the tumors (Figure 2). Perform TACE according to the burden of disease and patient preference.
5. Perform an angiogram through the common catheter using a high-pressure injector to confirm adequate embolization. The catheter tip is usually located in the common hepatic artery. Inject 9–12 mL of the contrast agent at a rate of 3–4 mL per s, with a fluoroscopy time of ~15 s. Then, remove the catheter over a guidewire to avoid damage to the RA. 

6. Radial artery hemostasis

NOTE: Nonocclusive hemostasis is performed using a special tourniquet to maintain RA patency (Figure 3).

1. Administer the remaining 2 mL of vasodilation cocktail solutions (section 4) through the RA sheath. Immediately after, retrieve the sheath about 5 cm.
2. Place a tourniquet over the radial access site on the left wrist, and adequately inflate the tourniquet air bag of with air using the accompanying syringe. Then completely remove the sheath, and slowly deflate the air bag. When leaking is observed at the access site, add 1 mL of air back to the cuff. Typically, 10–15 mL of air is added to the air bag to keep hemostasis.
3. Confirm that there is no bleeding or leaking. At the same time, ensure that the distal radial artery pulse is palpable during hemostasis. Use the pulse oximeter waveform to confirm the arterial waveform on the left thumb.
4. Slowly inflate the air sac at ~2 mL every 2 h for no longer than 6 h. Reconfirm that hemostasis is accomplished once the tourniquet is removed 6 h after operation.
   NOTE: If bleeding or leaking from the puncture site is observed during deflation, air is added back to the air sac for 30 min and the process is repeated.
5. Before discharge, conduct Barbeau test to confirm the patency of the RA and record patients with radial artery occlusion and closely follow up.

7. Follow up

1. About 1 month after intervention, give TRA patients a thorough physical examination, including inspection of the left wrist and pulse examination. For patients with potentially occluded RAs, perform subsequent evaluations of hand blood supply using forearm Doppler ultrasound or pulse oximetry.
2. Closely follow up all patients after TACE. If new tumor nodules were evident on CT scans and the initial lesions seemed to revascularize, perform another TACE treatment.

Results

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 si...

Discussion

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 TFA^13,14. Compared with TFA, TRA is superior...

Materials

Name	Company	Catalog Number	Comments
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