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Page 4 of 10 Puppala. Hepatoma Res 2019;5:44 I http://dx.doi.org/10.20517/2394-5079.2019.28

Figure 3. The top row shows the established spheres. The bottom row shows the newer spheres currently coming into clinical use. Image
courtesy of Biocompatibles UK Limited, Merit Medical USA and Terumo UK. Images of Embozene and Embocept obtained from free
brochures on the Internet

Before the procedure, patients should be well hydrated. This is to reduce the risk of nephrotoxicity from
iodinated contrast medium, tumor lysis syndrome, and dehydration due to a lack of fluid intake from
post-procedure nausea or vomiting [19,20] . Due to the risk of infection and abscess formation, antibiotics for
prophylaxis is a routine practice based on the local departmental or hospital rules [21,22] . Antibiotics, when
used, should cover both Gram-positive, Gram-negative and anaerobic organisms and are recommended
for all high-risk patient groups such as diabetics, immunosuppressed, etc. A mandatory up to date liver
function test should be performed within a week of the TACE given the risk of liver ischemia and failure
from the procedure. An echocardiogram of the heart is performed to assess the left ventricular function
and to facilitate both patient selection and assess the impact of cytotoxins on the myocardium, especially if
multiple episodes of treatment are being considered.

CHEMOTHERAPY AND EMBOLIC AGENTS UPDATE
Chemotherapy agents
Cisplatin and doxorubicin remain the routinely used chemotherapy agents for HCC. Other agents such as
epirubicin and combinations have been tried with limited advantage [23,24] .

Embolic agents
cTACE
Lipiodol is the agent used for cTACE. Lipiodol has a limited embolic property and causes transient
ischemia. Further bland embolization with gel foam or Polyvinyl alcohol (PVA) is used to bring arterial
flow to stasis. There has been no further development and a clinical alternative to lipiodol is not available.
Cisplatin and doxorubicin are the routine chemotherapy agents used with lipiodol.

DEM-TACE
DEM-TACE uses a drug-eluting microsphere as embolic agents. The various spheres available and their
advantages are listed in Table 2 and depicted in Figure 3. DC bead, HepaSphere, and Embozenes are
polyvinyl alcohol-based. Life pearl is polyethylene glycol-based.