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Puppala. Hepatoma Res 2019;5:44 I http://dx.doi.org/10.20517/2394-5079.2019.28 Page 3 of 10

Table 1. Indications for transcatheter arterial chemoembolization
Intermediate stage patients, BCLC-B (asymptomatic, multinodular tumors without vascular invasion or extrahepatic spread)
Patients tumor suitable for curative treatment but not eligible due to performance status
Disease recurrence after curative treatment by surgery or ablation
Bridging or downstaging while patient fulfills criteria for liver transplantation or donor becomes available
Downsizing tumor or reducing circulation to meet criteria for ablation

BCLC: barcelona clinic liver cancer

A B C

Figure 2. A: an oblique axial CTA multiple intensity projections reformat, showing the vascular path from the coeliac axis to the left
lobe tumor; B, C: intraprocedural images pre- and post-embolization. Given the prior delineation of vascular anatomy, only two arterial
angiograms were done, reducing contrast load and radiation exposure

contraindication are absolute contraindications. HCC size above 10 cm, portal hypertension with or
without untreated varices, portal vein thrombosis, and biliary involvement are relative contraindications.
The more infiltrative the tumor is into the vessels and bile ducts, the higher is the risk of complications.
Cardiac failure is a contraindication for cTACE but not for DEM-TACE.

TACE and liver transplantation
Unlike TACE, liver transplantation is curative in a select group of patients with HCC. TACE can be used
as a bridging treatment to inhibit tumor progression in patients who are candidates for transplant while
awaiting a suitable donor or fulfillment of transplant criteria [13,14] .

TACE as an adjunct to other therapies
Increasingly, TACE is being used as an adjunct to reduce tumor size and vascularity to facilitate ablation
techniques, such as radiofrequency, microwave, and cryotherapy. These ablation techniques can also be
used after TACE for residual disease even if a patient was originally deemed suitable only for TACE [15-17] .

PRE-PROCEDURE PATIENT MANAGEMENT
The preparation of a patient for TACE includes high-quality triple-phase post-contrast CT or magnetic
resonance imaging to delineate the arterial anatomy and circulation to the tumor [Figure 2]. Besides, 4D
CT can help reduce intra procedural volume of contrast and risk of nephrotoxicity. CIN (contrast-induced
nephrotoxicity) is more common in larger tumors measuring above 5 cm in size [18-20] .

A review of the patient by the operator ahead of the procedure ensures the patient is being informed of
the palliative, curative, or bridging nature of the procedure and its complications. For example, accidental
damage to the main hepatic artery during TACE is a rare risk, which can make transplant challenging and
rarely impossible.