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Hepatic artery embolization


Medical editor Eric Dorenberg MD
Radiologist
Oslo University Hospital

General

The cells of the liver receive blood partly from the hepatic artery and partly from the hepatic portal vein. The cancer cells receive blood mainly from the hepatic artery. By embolizing the arteries to the tumor with small particles, it is possible to stop blood supply to the tumor tissue. By doing this, all or parts of the tumor becomes necrotic  . The normal cells in the area survive since they also receive blood from the hepatic portal vein. This treatment is appropriate if there are many large metastases in the liver. Generally, only one liver flap is embolized at a time. 

Liver embolization is also used for patients without serious symptomology since the procedure can be repeated, but the effect diminishes with repeated embolizations of the same lobe. This is mainly due colateral formation of arteries making effective embolization of arterial supply difficult for later procedures. 

The procedure is carried out by an interventional radiologist.

The treatment may be appropriate at an early stage to reduce tumor size, or later when liver metastases increase in size despite treatment. The treatment often relieves symptoms, especially for those with hormonal symptoms such as flushing and diarrhea. A life-prolonging effect can also be attained with this treatment.


Indications

  • Multiple liver metastases
  • Symptom-causing disease despite other treatment

Contraindications

Absolute:

  • Central port vein thrombosis

Relative:

  • Poor general health status
  • Enterobiliar anastomosis (increased risk for infection)
  • Little remaining liver parenchyme (risk of hepatic failure)

Goal

  • Relieve symptoms
  • Reduce amount of tumor tissue in the liver

Equipment

  • Angiography equipment (equipment for X-ray)
  • Selective catheters, microcatheters
  • Embolization materials

Preparation

  • Hepatic work-up with CT scan or MRI
  • Premedication (Sandostatin®)

Implementation

  • The catheter is inserted into the hepatic artery via the femoral artery.
  • Local anesthesia is placed.
  • The femoral artery is punctured using Seldinger's technique: the artery is punctured at the level of the head of the humerus. A leader probe is inserted through the needle and the needle is removed. An introducer casing is inserted into the artery over the leader probe.
  • A catheter is inserted in over the guidewire and up to the liver using X-ray.
  • Contrast fluid is used to visualize the hepatic artery. 
  • An angiograph with intra-arterial contrast is used to obtain more exact visualization and overview.
  • A microcatheter is inserted into the catheter. The embolization substance is placed through this. Polyvinyl alcohol particles are used (150-200 microns) and mixed in the contrast fluid before the injection. 
  • The particles are injected using X-ray. The microcatheter is gradually removed as the arteries block.
  • Finally, the result is checked with an overview angiography. The catheter and casing are removed and the puncture wound in the groin is closed. 
  • Embolization takes from 30 minutes to multiple hours.

Follow-up

The patient is checked with a CT scan or MRI usually 6 months after the procedure

Complications

In the days following the procedure, the patient may be very sick with a high fever, abdominal pain, and nausea due to edema in the liver and significant release of necrotic material from the destroyed metastasis. Hospitalization of 1-2 weeks is normal.

Incidental embolization of the cystic artery can lead to necrosis of the gall bladder and peritonitis. Both dissection and thrombosis of the common hepatic artery can occur. 


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