1112020 1 TACE Transcatheter Arterial Chemoembolization 1112020 2

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TACE簡介 游宏祥 (Transcatheter Arterial Chemoembolization) 11/1/2020 2

Vascular Anatomy of liver Variations of hepatic artery A 0: Abdominal aorta C: Celiac trunk SM: Superior mesentery artery GD: Gastroduodenal artery S: Splenic artery LG: Left gastric artery RH: Right hepatic artery MH: Middle hepatic artery LH: Left hepatic artery Ac. RH: Accessory right hepatic artery Ac. LH: Accessory left hepatic artery 11/1/2020 7

Portal veins Vascular Anatomy of liver P: Portal trunk SV: Splenic vein A: Anterior branch P: Posterior branch L: Left branch 11/1/2020 8

Segmental Anatomy of liver n Couinaud’s classification – Main hepatic fissure • A line connecting the gallbladder and the left side of the IVC • Separating right and left lobe – Each lobe • 4 segments • Receiving a portal branch • Bordered by a hepatic vein 11/1/2020 9

Segmental Anatomy of liver 11/1/2020 10

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n A and B subtracted coleliac trunk arteriograms. n 1 Tip of catheter in coeliac trunk n 2 Splenic artery n 3 Left gastric artery n 4 Hepatic artery n 5 Gastroduodenal artery n 6 Superior pancreaticoduodenal artery n 7 Right � hepatic artery� n 8 Left n 9 Dorsal pancreatic artery n 10 Left � gastro-epiloic n 11 Right artery n 12 Phrenic artery n 13 Transverse pancreatic artery 11/1/2020 n 14 Pancreatica magna artery 14

Liver Circulation n Liver parenchyma – One third of normal hepatic flow from hepatic artery – Two third of hepatic flow from portal vein – One half oxygen required from hepatic artery n Several routes of arterio-portal communications 11/1/2020 – Peribiliary arterial plexus – The vasa vasorum – Direct arterio-portal connection in the sinusoid 15

Tumor Circulation n HCC – Almost from hepatic artery – After TACE • presence of AP communication to prevent complete ischemic change • Collateral blood supply to the HCC from portal vein 11/1/2020 16

Schema of blood supply of HCC Note: The hepatic arteries supplying tumor in the peripheral aspect of the HCC 11/1/2020 17

Indication n. Failure of transcatheter arterial embolization due to tumor extension or arterial occlusion n. Advanced HCC (hepatocellur carcinoma) n. HCC with portal vein thrombosis 11/1/2020 18

Contraindication n Bleeding tendency n prothrombin time>15 (25%) 11 -13 sec n active partial thromboplastin time >3 x 31. 3+ - 8 n international ratio >5 <2 n Poor renal function n BUN>50 n Cr>2 6 -21 0. 4 -1. 4 n Platelet count <50000 n Allergy to contrast medium n Bilirubin>2. 0 n Advanced liver cirrhosis (Child C) 11/1/2020 19

材料 n 設備 n TOSHIBA Digital subtraction 3 D Angiography Diagnostic equipment n PACS n 器械 n 血管攝影包 n sheath. catheter (RC 1. RH. YASHIRO). guide wire. 3 -way. Syringe. connect tube. 11/1/2020 20

材料 n 藥品 n contrast medium - Omnipaque. MD 76 2: 1 n Heparine. 1: 1000 2%Cylocaine. Demoral. NTG. n 急救車 n 栓塞物質 n Gelfoam n Liopidol n Adriamycin. Mitomycin C. (anticancer agents) 11/1/2020 21

Syringe. 血管攝影包 Micro catheter 3 -way. guide wire RC 1 n. Gelfoam n. Liopidol Syringe. connect tube sheath RH. catheter YASHIRO NS 11/1/2020 2%Cylocaine n. Heparine. n. Omnipaque. MD 76 22

Celiac Trunk 11/1/2020 25

n 超選擇血管攝影 (super-selective arteriography) n 如有實際需要，做完上述動脈攝影後，利用特殊金屬導線和 導管將導管放到common hepatic artery、proper hepatic artery、 left or right hepatic artery、seqmental artery，再依血管血流量 情況，決定使用對比劑之量和注射速度做血管攝影。 11/1/2020 27

Procedure of Chemoembolization n. The mixture of lipiodol and solution of anticancer agents. Lipiodol n. For TACE of the entire liver, lipiodol(A) kept a little larger than the size(S) of tumor A(ml) = S(cm) + ( =1~3) n. When the tumor not very large A(ml) < 0. 1 ml/Kg 11/1/2020 30

n. The mixture of lipiodol and solution of anticancer agents. Anticancer agents n. The amount of anticancer agents is decided based on liver function and the number of blood cells. n. The dose usually ranges from 10 – 70 mg. 11/1/2020 31

n Preparation of gelatine sponge – Gelatine sponge cut into particles – 0. 5 mm – 2. 0 mm according to the size of the vessels – Adding xylocaine (1 -2%, 1 -5 ml) to minimize the pain after TACE n Injection of the emulsion and gelatine sponge 11/1/2020 32

Pre TACE During TACE Post TACE 11/1/2020 33

Complications in TACE of HCC n n n n Technical complications Vascular complications Drug toxicity Hepatic injury Deterioration of hepatic function Hepatic infarction Liver abscess and tumor rupture 11/1/2020 35

Complications in TACE of HCC n n n Extrahepatic Complications GI bleeding Gallbladder infarction Splenic infarction Pulmonary oil embolization Spinal cord injury Systemic Complications Postembolization syndrome Septicemia Disseminated intravascular coagulopathy Mortality 11/1/2020 36