Transarterial Chemoembolization (TACE)

Transarterial chemoembolization (TACE) is an interventional radiological procedure used for the selective treatment of hepatocellular carcinoma (HCC) and other hepatic malignancies (for example, secondary metastasis from colorectal cancer). This procedure involves the selective delivery of high concentrations of chemotherapeutic agents to the tumor bed, capitalizing on the preferential arterial supply of the tumor and limiting systemic exposure and associated adverse effects.

TACE can be performed as either cTACE (conventional TACE) where a chemotherapy drug such as Cisplatin is used, or as DEB-TACE (drug-eluting bead TACE) where microspheres coated with chemotherapy drug such as Doxorubicin is used for treatment.

Angiographically, the left and or hepatic arteries are injected with contrast media to demonstrate the vasculature of the tumours, which can be single or multiple in presentation, and can be either affecting one or both lobes of the liver. A follow-up study such as an MRI is usually performed post-TACE, around 6 months after, to check for the response of the tumour to the chemotherapy treatment.

A&I Protocol

The femoral approach for performing TACE is detailed here:

Femoral Approach:

Seldinger technique is used to gain access into the right common femoral artery.
A 5 French (F) sheath is inserted into the right common femoral artery over an 0.035" guidewire.
A 5 F Hockey-stick catheter is navigated up the abdominal towards the level of the celiac trunk, at approximately the twelfth thoracic vertebrae (T12).
Once positioned in the celiac trunk, a long DSA run is performed with patient expiration to see the arterial blood flow of hepatic system, as well as the portal venous system.
The right and/or left main hepatic arteries are catheterised and accessed with an 0.021" or 0.027' microcatheter.
If the tumours are present in the right lobe, the right hepatic artery is accessed. If the tumours are present in the left lobe, the left hepatic artery is accessed. If both lobes are affected with tumours, the right hepatic artery is accessed, and then a second femoral artery puncture is performed, then using a second catheter and microcatheter system, the left hepatic artery is accessed.
Once the microcatheters are positioned in the desired region of the artery that is supplying the tumours, DSA runs are performed. Further checks with an on-table cone-beam CT scan can also be performed to check for non-target vessels and to confirm catheter position for treatment. This can be done for both lobes of the liver.
When confirmed, the chemotherapy agent is prepared (using cytotoxic measures) and injected under fluoroscopic guidance and the use of contrast media into the hepatic arteries.
When completed, all devices are disposed of safely.
A vascular plug device or manual pressure is applied on the groin region post-procedure.

Arterial and portal venous DSA run to show blood supply to the liver and tumours. n.

[Left] Selective right hepatic artery angiogram showing supply to the tumours; and [Right] Final catheter position to embolize the tumour using drug-coated beads (DC-TACE) and visualised with contrast media.

References

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Vogl TJ, Gruber-Rouh T. HCC: Transarterial Therapies-What the Interventional Radiologist Can Offer. Dig Dis Sci. 2019 Apr;64(4):959–67.
Kouri BE. Interventional Oncology: Optimizing Transarterial Therapies for the Treatment of Hepatic Malignancy. Tech Vasc Interv Radiol. 2018 Dec;21(4):205–22.
Smith KA, Kim HS. Interventional radiology and image-guided medicine: interventional oncology. Semin Oncol. 2011 Feb;38(1):151–62.