This work was supported by the clinical research special fund from Zhongshan Hospital, Fudan University (2016ZSLC17). The authors are very grateful to Dr. Xianglin Hu in Zhongshan Hospital of Fudan University for his very professional suggestions to English writing.

This single-center retrospective study was approved by the local Institutional Review Board of Zhongshan Hospital, Fudan University.
1. Obtaining informed consent
<ol>
	<li>Before the TRA interventions, have interventional radiologists (IRs) explain the benefits and potential complications of TRA to the patients.</li>
</ol>
2. Patient evaluation
<ol>
	<li>After obtaining informed consent, evaluate the RA for the feasibility of puncture and cannulation.</li>
	<li>Perform a comprehensive review of the patient&#39;s medical history. Confirm if patients had severe vascular tortuosity, severe peripheral vascular disease, a fistula for dialysis, or preparation for RA dialysis operation. These are relative contraindications for patients receiving TRA interventions.</li>
	<li>Evaluate the visibility of the RA.
	<ol>
		<li>Perform a Barbeau test with the use of pulse oximetry to evaluate how visible the hand collateral arteries are before intervention11. The Barbeau D waveform is considered an absolute contraindication for RA cannulation.</li>
		<li>For patients tested as Barbeau C waveform, apply a Doppler ultrasound examination to provide more reliable information about the amount of collateral circulation in the forearm and hand. An inner diameter smaller than 2 mm is considered a contraindication. 
		NOTE: After medical history evaluation and the RA evaluation, patients with contraindications should abstain from a puncture via the ipsilateral RA. The contralateral RA might serve as an ideal supply if it is found to be patent through Barbeau test evaluation. The left RA is initially chosen as a preferred access route. The right RA might serve as an alternative choice if the left RA was found unsuitable.</li>
	</ol>
	</li>
</ol>
3. Radial artery access
<ol>
	<li>Place the patient in a supine position on the angiography table. Then, place the left arm parallel to the patient&#8217;s body and close to the left waist, allowing easy placement of the catheter and wire and enabling operator positioning comparable to that with the TFA.</li>
	<li>Mark the distal RA pulse by palpation. Clean the skin surface with 10% povidone-iodine surgical scrub solution and allow the solution to air dry. Cover the left arm with a surgical drape.
	<ol>
		<li>In case of potential left RA puncture failure, prepare an alternative access route by sterilizing and draping the right arm or right inguinal region.</li>
	</ol>
	</li>
	<li>Apply local anesthesia (i.e., 1 mL of lidocaine 2%) proximal to the styloid process along the axis of the most powerful pulsation of the left RA.</li>
	<li>Extend the wrist, and puncture the RA with a 20 G needle using the modified Seldinger technique. When pulsatile arterial blood return isobserved , introduce a 0.025 inch hydrophilic guidewire.
	<ol>
		<li>Retract the guidewire and readjust the needle if resistance is encountered. Do not force the insertion of the guidewire. With the assistance of of digital subtraction angiography (DSA), inject about 1 to 2 mL of contrast to highlight the RA and help insert the hydrophilic guidewire.</li>
	</ol>
	</li>
	<li>Once access is obtained, remove the needle and introduce a 4-French hydrophilic sheath with the guidewire. After sheath insertion, gently pump back a small amount of arterial blood with a syringe to confirm that the sheath tip is within the vessel.</li>
</ol>
4. Anticoagulation and vascular dilation
<ol>
	<li>Prepare 10 mL of a vasodilation cocktail solution (3,000 IU of unfractionated heparin, 0.1 mg of nitroglycerin, and 20 mg of lidocaine).</li>
	<li>Administer 8 mL of the vasodilation cocktail solution through the sheath at a speed of 0.5 mL/s (Figure 1). 
	NOTE: Reduce or stop the dose of heparin for patients with moderate or high bleeding risk.</li>
</ol>
5. Catheter selection
<ol>
	<li>Use a 4-French, 125 cm common catheter and a standard 0.035 inch x 180 cm hydrophilic wire to traverse the subclavian artery and engage the descending aorta. Use DSA fluoroscopy to visualize the proximal axillary artery during navigation within the arm to avoid potential lesions to an artery loop or vascular tortuosity. 
	NOTE: The subclavian artery has many arterial branches. Angiographic guidance prevents guidewire catheters from entering collateral vessels during retrograde catheterization. A few cases have an artery loop in the radial artery. If the standard wire cannot pass the loop, use of a microcatheter and angled 0.016 inch or 0.018 inch microwire is recommended.</li>
	<li>Use the 4-French, 125 cm common catheter in combination with a standard 0.035-inch wire to negotiate the transverse arch to direct the guidewire toward the descending aorta. 
	NOTE: If the angle between the aorta and left subclavian artery is very acute, a Cobra 2-shaped catheter (e.g., Simmons I or Simmons II catheter) is recommended to accomplish this turn.</li>
	<li>After catheterization of the descending aorta, replace the common catheter via a coaxial technique. Once the common catheter is inserted into the descending aorta, steer the catheter tip ventrally for catheterization of the celiac trunk under the guidance of DSA fluoroscopy. In most cases, it is easy to catheterize and perform angiography of the celiac trunk, the hepatic artery, and superior mesenteric artery. 
	NOTE: If the angle between the celiac artery and the descending aorta is very acute, use a Cobra catheter to complete the procedure.</li>
	<li>For hepatic embolization procedures, perform super-selective catheterization and chemoembolization using a coaxial technique and place a 2.8-French 150 cm microcatheter into the targeted branch of the hepatic artery feeding the tumors (Figure 2). Perform TACE according to the burden of disease and patient preference.</li>
	<li>Perform an angiogram through the common catheter using a high-pressure injector to confirm adequate embolization. The catheter tip is usually located in the common hepatic artery. Inject 9&#8211;12 mL of the contrast agent at a rate of 3&#8211;4 mL per s, with a fluoroscopy time of ~15 s. Then, remove the catheter over a guidewire to avoid damage to the RA.&#160;</li>
</ol>
6. Radial artery hemostasis
NOTE: Nonocclusive hemostasis is performed using a special tourniquet to maintain RA patency (Figure 3).
<ol>
	<li>Administer the remaining 2 mL of vasodilation cocktail solutions (section 4) through the RA sheath. Immediately after, retrieve the sheath about 5 cm.</li>
	<li>Place a tourniquet over the radial access site on the left wrist, and adequately inflate the tourniquet air bag of with air using the accompanying syringe. Then completely remove the sheath, and slowly deflate the air bag. When leaking is observed at the access site, add 1 mL of air back to the cuff. Typically, 10&#8211;15 mL of air is added to the air bag to keep hemostasis.</li>
	<li>Confirm that there is no bleeding or leaking. At the same time, ensure that the distal radial artery pulse is palpable during hemostasis. Use the pulse oximeter waveform to confirm the arterial waveform on the left thumb.</li>
	<li>Slowly inflate the air sac at ~2 mL every 2 h for no longer than 6 h. Reconfirm that hemostasis is accomplished once the tourniquet is removed 6 h after operation. 
	NOTE: If bleeding or leaking from the puncture site is observed during deflation, air is added back to the air sac for 30 min and the process is repeated.</li>
	<li>Before discharge, conduct Barbeau test to confirm the patency of the RA and record patients with radial artery occlusion and closely follow up.</li>
</ol>
7. Follow up
<ol>
	<li>About 1 month after intervention, give TRA patients a thorough physical examination, including inspection of the left wrist and pulse examination. For patients with potentially occluded RAs, perform subsequent evaluations of hand blood supply using forearm Doppler ultrasound or pulse oximetry.</li>
	<li>Closely follow up all patients after TACE. If new tumor nodules were evident on CT scans and the initial lesions seemed to revascularize, perform another TACE treatment.</li>
</ol>

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Study concept and design by WZ and ZPY; acquisition of data by ND, ZHZ and MJY; obtained funding by ZPY. The authors have no relevant financial disclosures.

TRA interventional therapy has grown significantly worldwide in recent years, especially in diagnostic and Interventional cardiology procedures12. Moreover, there has been increasing attention to peripheral vascular disease intervention. Without compromising procedural success rates, TRA to cardiac intervention can effectively reduce the rates of bleeding and vascular complications compared with TFA13,14. Compared with TFA, TRA is superior in several capacities, including monitoring time after the procedure, time of ambulation, and greater overall patient satisfaction15,16,17.
Despite these advantages recognized in coronary intervention, TRA is rarely applied by IRs. The apparent reluctance of IRs to utilize TRA may be explained by TRA&#39;s longer procedural time and a steep learning curve18. Potentially increased total fluoroscopic time and radiation dose also limit TRA to interventional procedures below the diaphragm, such as hepatic embolization and uterine artery embolization. At our institution, TRA intervention was introduced about 3 years ago and rapidly adopted as a preferred approach. As expected, expertise and institution-wide adoption are required before the benefits and efficiencies of TRA become clear19. Moreover, it is possible for IRs to increasingly learn more about TRA and improve their ability to use the method, which can rapidly increase adequate proficiency in TRA18.
This protocol usually uses the same standard technique with dedicated radial devices, such as a slender vascular introducer sheath (typically 4-Fr) and a single-catheter technique with no need for catheter exchange. It is obvious that TRA procedure failure was associated with an increased number of catheter utility (P &#60; 0.001). The rate of single catheter use in all cases is 85.6% and would further increase by the accumulated experience of the IRs and decreased rate of technical failure, which may somewhat decrease the cost during hospitalization. Due to the rarity of RAO, no significant correlation was found between the increased rate of RAO and a number of TRA procedures. A previous study demonstrated that the diameter of the RA decreased following TRA procedures20 because it is an important parameter to consider, which may preclude its future use as a conduit or develop to RAO. Even 8.0% of patients in this study received more than 3x TACE procedures via RA access without the occurrence of RAO; the total rate of RAO was only 2.7%. It is apparent that, with a low rate of RAO, repeated TRA for hepatic embolization is clinically feasible.
TRA has several obvious advantages when compared with TFA. First, RA is more superficial than FA, and there are no surrounding critical structures that are susceptible to injury during artery access. Hence, it is easy to compress and achieve hemostasis after intervention, which significantly decreases the incidence of postprocedural bleeding complications compared with TFA9. Furthermore, the potential difficulty in locating the common femoral artery and the difficulty in detecting and controlling postprocedural hemorrhage in obese patients makes TRA an ideal treatment option21. Due to the superficial location and easy hemostasis of RA, TRA may be advantageous for patients who are deemed high risk for bleeding complications, such as those with thrombocytopenia, coagulation disorders, or liver dysfunction, those receiving anticoagulation, and elderly patients22,23. Second, TRA can enable patients to ambulate immediately after intervention, which is of paramount important to improve patient satisfaction. Previous studies demonstrated a strong patient preference and procedure satisfaction for TRA over TFA during hepatic embolization3,24. Because patients are susceptible to postprocedural nausea, vomiting, or potential dysuria, immediate ambulation is important for them to keep a comfortable position and relieve the adverse reaction. TRA is especially significant for elderly patients and those with back pain. Third, compared with TFA, it is possible for TRA to decrease the cost of hospitalization and to decrease the time of hospitalization17,25.
Of course, complications for TRA also exist. Periprocedural stroke is a rare but serious complication associated with high mortality and impaired quality of life26. The potential reason for TRA&#39;s association with the risk of periprocedural stroke is that the guiding catheter is introduced through the subclavian artery, which is adjacent to the common carotid artery and vertebral artery, both of which directly supply the brain27. To date, no TRA-related stroke was reported, except a case of seizure recorded in a case series report28, which was hypothetically contributed to the intraarterial administration of verapamil. RAO is a common complication for repeated TRA intervention, which is often asymptomatic. Few patients have experienced symptomatic complication of RAO, such as pain, numbness, or discoloration of the arm6, making TRA an ideal alternative to TFA intervention. Typically, postprocedural mild pain at the access site is a common complication in the tested center&#39;s practice, which is often self-limited or treated with nonsteroidal anti-inflammatory drugs if necessary. Also, failure of TRA-related crossover to FA access, an unsatisfactory result for both patients and IRs, potential increases operation time, radiation exposure, or the time of hospitalization29. Furthermore, elderly patients are technically more challenging due to anatomical issues such as vascular tortuosity and atherosclerosis. All in all, the advantages of TRA must be balanced against these shortcomings. In general, a successful TRA entails a comprehensive evaluation of the access route for each patient before each therapy.
Critical steps of the protocol are given here. First, considering the convenience in operation and risk for cerebrovascular complications, the left RA could be the default choice for the procedure. Second, the Barbeau test must be performed for patients considered for TRA interventions. Third, ultrasound guidance is key to help RA puncture, especially for a new care provider. At last, use of a hydrophilic sheath, vasodilation cocktail solution, and nonocclusive hemostasis of the RA are essential precautions to reduce the occurrence of RAO.
In conclusion, this study demonstrates the safety and applicability of TRA hepatic embolization. Importantly, TRA can reduce postprocedural access site-related bleeding complications. TRA interventions can provide more convenience and comfort for HCC patients. TRA interventions can especially benefit patients with advanced age, obesity, or high risk for bleeding complications.

Hepatocellular carcinoma (HCC) is a very common malignancy, with the sixth highest incidence rate worldwide. It is also the second leading cause of cancer mortality around the world1. Because only 5%&#8211;20% of patients can receive curative therapy, transarterial chemoembolization (TACE) is the most popular palliative treatment for patients with unresectable HCC2. TACE has been recognized as the most commonly used and effective treatment approach for HCC patients at the intermediate stage3. Transfemoral access (TFA) chemoembolization is the most common approach for TACE4. However, there are risks associated with TFA intervention, including bleeding at the access site and major vascular complications5. These complications lead to prolonged hospitalization and increased costs. Moreover, TFA requires immobilization for at least 6 h, which increases discomfort and dissatisfaction for the patients.&#160;
Transradial access (TRA) is an alternative approach that has been used in percutaneous coronary intervention (PCI) for more than two decades5,6. TRA PCI has several advantages: increased procedure comfort, decreased access site-related bleeding, decreased major vascular complications, and decreased mortality7,8. The radial artery (RA) is easy to access and puncture because of its superficial location7. Hemostasis is easy to conduct after intervention and there is no strict immoblization9. Despite encouraging evidence for TRA intervention in cardiac catheterization, to date only a few studies used TRA in peripheral disease intervention. TRA interventions for malignant liver tumors are even rarer. Here, the clinical feasibility and safety of TRA hepatic embolization is analyzed. One institution&#8217;s experience with the step-by-step TRA protocol provided is also described.

<table><tbody><tr><td>&lt;strong&gt;Reagents&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Embosphere</td><td>Merit</td><td>20173776165</td><td></td></tr><tr><td>Gelfoam</td><td>Alicon</td><td>20143771056</td><td></td></tr><tr><td>Heparin</td><td>Hepatunn</td><td>H51021209</td><td></td></tr><tr><td>Injection syringe</td><td>KDL</td><td>20163150518</td><td></td></tr><tr><td>Iodinated oil</td><td>Yantai Luyin Pharmaceutical Co.Ltd</td><td>H37022398</td><td></td></tr><tr><td>Lidocaine</td><td>Shandong Hualu Pharmaceutical Co.Ltd</td><td>H37022147</td><td></td></tr><tr><td>Lobaplatin</td><td>Hainan Changan International Pharmaceutical Co.Ltd</td><td>H20050308</td><td></td></tr><tr><td>Nitroglycerin</td><td>Brijing Yimin Pharmaceutical Co.Ltd</td><td>H11020289</td><td></td></tr><tr><td>Normal saline</td><td>Anhui Shuanghe Pharmaceutical Co.Ltd</td><td>H34023609</td><td></td></tr><tr><td>Pharmorubicin</td><td>Pfizer</td><td>H20000496</td><td></td></tr><tr><td>Ultravist 370</td><td>Bayer</td><td>H20171333</td><td></td></tr><tr><td>&lt;strong&gt;Material&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Hydrophilic Guide Wire</td><td>Merit</td><td>LWSTDA38180</td><td></td></tr><tr><td>Injection syringe</td><td>KDL</td><td>20163150518</td><td></td></tr><tr><td>Maestro Microcatheter</td><td>Merit</td><td>28MC24150SN</td><td></td></tr><tr><td>MPA1 (I) catheter</td><td>Cordis</td><td>451-406P0</td><td></td></tr><tr><td>Sheath Introducer</td><td>Merit</td><td>PSI-4F-11-035</td><td></td></tr><tr><td>Steerable Guidewire</td><td>Merit</td><td>TNR2411</td><td></td></tr><tr><td>TR Band</td><td>Terumo</td><td>XX*RF06</td><td></td></tr><tr><td>&lt;strong&gt;Equipment&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>DSA</td><td>Toshiba</td><td>INFX-9000V</td><td></td></tr><tr><td>Ultrasonic machine</td><td>SonoScape</td><td>20172231180</td><td></td></tr></tbody></table>

transradial access chemoembolization for hepatocellular carcinoma patients

Transarterial chemoembolization (TACE) is the most common modality for treatment of hepatocellular carcinoma (HCC) at the intermediate stage. TACE is typically performed via transfemoral access (TFA). However, transradial access (TRA) is preferred in coronary artery interventions due to decreased complications and mortality. Whether the advantages of TRA can be applied to TACE required investigation.
Patients receiving TRA TACE at a single center were retrospectively enrolled for study. Procedural details, technical success, radial artery occlusion (RAO) rate, and access site-related bleeding complications were evaluated. From October 2017 to October 2018, 112 patients underwent 160 TRA TACE procedures. The overall technical success rate was 95.0% (152/160). The rate of crossover from TRA to TFA was 1.9%. No access site-related bleeding complications were found in any cases. Asymptomatic RA occlusion occurred in three patients (2.7%). Compared with TFA, TRA can increase safety and patient satisfaction while decreasing access site-related bleeding complications. Moreover, TRA interventions can benefit patients with advanced age, obesity, or a high risk of bleeding complications.

From October 2017 to October 2018, 112 patients underwent 160 TRA TACE procedures, and the overall technical success rate was 95.0% (152/160). Eight cases were met with technical failure. Of these, five cases were caused by left RA puncture failure and subsequently underwent successful TACE with right RA access. The other three cases were caused by cannulation failure, and underwent subsequent successful intervention by crossover to right FA access. The crossover rate of RA access to FA access was only 1.9%. No access site-related bleeding complications were found in any of the cases.
The baseline clinical data of cases with technical success or technical failure were compared (Table 1). Compared with patients that previously received TACE, patients undergoing first-time TACE via RA access were more likely to suffer technical failure (P = 0.016).&#160; No significant correlations were found between technical success or failure and patient characteristics, including age, sex, or combined medical comorbidities. Three patients suffered asymptomatic RA occlusion.
The numbers of TRA TACE procedures were compared (Table 2). Owing to the low frequency of radial artery occlusion (RAO), no significant correlation was found between the increased rate of RAO and the number of TRA procedures. No cases required urethral catheterization for postoperative dysuria. Also, no neurologic complications or contrast medium-induced nephropathy were found in any cases during follow-up.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/61109/61109fig1.jpg" /> 
Figure 1: Vasodilation cocktail solution. (A, B) 8 mL of vasodilation solution was given through the sheath immediately after access was obtained to prevent RA spasm and blood thrombosis. (C) Transradial artery insertion of a 4-Fr 125 cm common catheter. (D) The location of the left hand near the right inguinal region offered greater accessibility for intervention procedure. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/61109/61109fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/61109/61109fig2.jpg" /> 
Figure 2: A patient receiving a third TRA-TACE. (A) The common hepatic arteriogram pictured shows that a tumor stain remains. (B) Superselective angiography with a microcatheter shows the tumor&#39;s feeding artery. (C, D) The tumor stain disappeared after embolization with epirubicin-lipiodol emulsion. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/61109/61109fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/61109/61109fig3.jpg" /> 
Figure 3: Hemostasis after intervention. (A) The tourniquet used for radial artery hemostasis in the department. (B) The remaining 2 mL of vasodilation solution was given through the sheath. (C) Before the sheath was removed, the air bag was inflated with 10 to 15 mL of air. (D) The pulse oximeter waveform was used to confirm the arterial waveform on the left thumb. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/61109/61109fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td>Case Characteristics</td>
			<td>Overall 
			(n=160)</td>
			<td>Successful case 
			(n=152)</td>
			<td>Failure case 
			(n=8)</td>
			<td>P Value</td>
		</tr>
		<tr>
			<td>Age, years</td>
			<td>58.7&#177;12.1</td>
			<td>58.6&#177;11.9</td>
			<td>60.0&#177;16.1</td>
			<td>0.754</td>
		</tr>
		<tr>
			<td>Sex, n (%)</td>
			<td></td>
			<td></td>
			<td></td>
			<td>0.893</td>
		</tr>
		<tr>
			<td>Male</td>
			<td>127(79.4)</td>
			<td>120(78.9)</td>
			<td>7(87.5)</td>
			<td></td>
		</tr>
		<tr>
			<td>Female</td>
			<td>33(20.6)</td>
			<td>32(21.1)</td>
			<td>1(12.5)</td>
			<td></td>
		</tr>
		<tr>
			<td>Height, meter</td>
			<td>1.68&#177;0.06</td>
			<td>1.68&#177;0.07</td>
			<td>1.70&#177;0.06</td>
			<td>0.389</td>
		</tr>
		<tr>
			<td>BMI, kg/m2</td>
			<td>22.41&#177;2.72</td>
			<td>22.37&#177;2.75</td>
			<td>22.32&#177;2.12</td>
			<td>0.338</td>
		</tr>
		<tr>
			<td>Hypertension, n (%)</td>
			<td></td>
			<td></td>
			<td></td>
			<td>1</td>
		</tr>
		<tr>
			<td>Yes</td>
			<td>53(33.1)</td>
			<td>50(32.9)</td>
			<td>3(37.5)</td>
			<td></td>
		</tr>
		<tr>
			<td>No</td>
			<td>107(66.9)</td>
			<td>103(67.1)</td>
			<td>5(62.5)</td>
			<td></td>
		</tr>
		<tr>
			<td>Diabetes mellitus, n (%)</td>
			<td></td>
			<td></td>
			<td></td>
			<td>0.543</td>
		</tr>
		<tr>
			<td>Yes</td>
			<td>36(22.5)</td>
			<td>33(21.7)</td>
			<td>3(37.5)</td>
			<td></td>
		</tr>
		<tr>
			<td>No</td>
			<td>124(77.5)</td>
			<td>119(78.3)</td>
			<td>5(62.5)</td>
			<td></td>
		</tr>
		<tr>
			<td>Previously TACE, n (%)</td>
			<td></td>
			<td></td>
			<td></td>
			<td>0.016*</td>
		</tr>
		<tr>
			<td>Na&#239;ve</td>
			<td>45(28.1)</td>
			<td>43(28.3)</td>
			<td>6(75.0)</td>
			<td></td>
		</tr>
		<tr>
			<td>Yes</td>
			<td>115(71.9)</td>
			<td>109(71.7)</td>
			<td>2(25.0)</td>
			<td></td>
		</tr>
		<tr>
			<td>HBV infection</td>
			<td></td>
			<td></td>
			<td></td>
			<td>1</td>
		</tr>
		<tr>
			<td>Yes</td>
			<td>103(64.4)</td>
			<td>98(64.5)</td>
			<td>5(62.5)</td>
			<td></td>
		</tr>
		<tr>
			<td>No</td>
			<td>57(35.6)</td>
			<td>54(35.5)</td>
			<td>3(37.5)</td>
			<td></td>
		</tr>
		<tr>
			<td>Catheter number (n)</td>
			<td></td>
			<td></td>
			<td></td>
			<td>&#60;0.001*</td>
		</tr>
		<tr>
			<td>1</td>
			<td>137(85.6)</td>
			<td>137(90.1)</td>
			<td>0(0)</td>
			<td></td>
		</tr>
		<tr>
			<td>&#8805;2</td>
			<td>23(14.4)</td>
			<td>15(9.9)</td>
			<td>8(100.0)</td>
			<td></td>
		</tr>
		<tr>
			<td>TACE: transarterial chemoembolization; BMI: body mass index. *P&#60;0.05</td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>
Table 1: Demographic and clinical differences between cases with technical success and technical failure. No significant difference was found between patient characteristics, including age, sex, or height, and successful TRA TACE or failure of RA access. TRA intervention failure may increase the number of catheters used.
<table border="1" fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td>Cases/patients</td>
			<td>None RAO 
			(n=109)</td>
			<td>RAO 
			(n=3)</td>
			<td>Total 
			(n=112)</td>
		</tr>
		<tr>
			<td>Numbers</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>1</td>
			<td>76(67.9)</td>
			<td>1(0.9)</td>
			<td>77(68.8)</td>
		</tr>
		<tr>
			<td>2</td>
			<td>24(21.4)</td>
			<td>1(0.9)</td>
			<td>25(22.3)</td>
		</tr>
		<tr>
			<td>&#8805;3</td>
			<td>9(8.0)</td>
			<td>1(0.9)</td>
			<td>10(8.9)</td>
		</tr>
		<tr>
			<td>RAO: radial artery occlusion; TACE: transarterial chemoembolization.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>
Table 2: The number of TRA TACE procedures patients underwent during the study. About 8% of patients had three or more TRA TACE procedures, no obvious increase of patients with post operational RAO.

Watch this Scientific Journal Video about Transradial Access Chemoembolization for Hepatocellular Carcinoma Patients at JoVE.com

Transradial Access Chemoembolization for Hepatocellular Carcinoma Patients

Transarterial chemoembolization (TACE) is the standard therapy for patients in the intermediate stage of hepatocellular carcinoma and is typically performed through femoral artery access. Compared with transfemoral access, transradial access (TRA) can decrease the rate of bleeding complications and improve patient tolerance. A method is presented here to perform transarterial chemoembolization via radial artery access.

Transarterial chemoembolization (TACE) is the most common modality for treatment of hepatocellular carcinoma (HCC) at the intermediate stage. TACE is ...

transradial-access-chemoembolization-for-hepatocellular-carcinoma

Nanyang Technological University

Research

JoVE Journal

Cancer Research

5.4K Views.  Fudan University. Transarterial chemoembolization (TACE) is the standard therapy for patients in the intermediate stage of hepatocellular carcinoma and is typically performed through femoral artery access. Compared with transfemoral access, transradial access (TRA) can decrease the rate of bleeding complications and improve patient tolerance. A method is presented here to perform transarterial chemoembolization via radial artery access.

Video: Transradial Access Chemoembolization for Hepatocellular Carcinoma Patients

Dual-phase Cone-beam Computed Tomography to See, Reach, and Treat Hepatocellular Carcinoma during Drug-eluting Beads Transarterial Chemo-embolization

The advent of cone-beam computed tomography (CBCT) in the angiography suite has been revolutionary in interventional radiology. CBCT offers 3 dimensional&#160;(3D) diagnostic imaging in the interventional suite and can enhance minimally-invasive therapy beyond the limitations of 2D angiography alone. The role of CBCT has been recognized in transarterial chemo-embolization (TACE) treatment of hepatocellular carcinoma (HCC). The recent introduction of a CBCT technique: dual-phase CBCT (DP-CBCT) improves intra-arterial HCC treatment with drug-eluting beads (DEB-TACE). DP-CBCT can be used to localize liver tumors with the diagnostic accuracy of multi-phasic multidetector computed tomography (M-MDCT) and contrast enhanced magnetic resonance imaging (CE-MRI) (See the tumor), to guide intra-arterially guidewire and microcatheter to the desired location for selective therapy (Reach the tumor), and to evaluate treatment success during the procedure (Treat the tumor). The purpose of this manuscript is to illustrate how DP-CBCT is used in DEB-TACE to see, reach, and treat HCC.

Dual-phase cone-beam computed tomography (DP-CBCT) is a useful intraprocedural imaging technique for transarterial chemo-embolization treatment with drug-eluting beads of hepatocellular carcinoma. DP-CBCT has been used to perform three major steps in oncologic interventional radiology: tumor localization (see), navigation and intraprocedural catheter guidance (reach), and intraprocedural evaluation of treatment success (treat).

The advent of cone-beam computed tomography (CBCT) in the angiography suite has been revolutionary in interventional radiology. CBCT offers 3 ...

Medicine

Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when there are tumors adjacent to the cystic bed, surgeons cannot palpate the surgical margins through the laparoscopic approach, which leads to uncertainty about R0 resection. Conventionally, the gallbladder is resected first, and the hepatic lobes or segments are resected second. However, tumor tissues can be disseminated in the above cases. To address this issue, based on the recognition of the porta hepatis and intrahepatic anatomy, we propose a unique approach to hepatectomy combined with gallbladder resection by en bloc anatomic resection in situ. Firstly, after dissecting the cystic duct, without cutting the gallbladder primarily, the porta hepatis is pre-occluded by the single lumen ureter; secondly, the left hepatic pedicle is made free by the gap of the Laennec membrane and Hilar plate; thirdly, the assistant is asked to drag the fundus of the gallbladder, and the liver parenchyma tissue is resected using a harmonic scalpel along the ischemia line on the liver surface and intraoperative ultrasound. The whole middle hepatic vein (MHV) and its tributaries appear completely; lastly, the left hepatic vein (LHV) is disconnected, and the specimen is taken out from the abdominal cavity. The tumor, gallbladder, and other surrounding tissues are resected en bloc, which meets the tumor-free criterion, and a wide incisal margin and R0 resection are achieved. Therefore, the laparoscopic hepatectomy with the combination of the en bloc concept and anatomic resection is a safe, effective, and radical method with low postoperative recurrence and metastasis.

Numerous studies have demonstrated the advantages of anatomic resection. Nonetheless, whether anatomic resection can increase R0 resection rates remains controversial. Consequently, the present study describes an innovative procedure involving the en bloc concept combined with anatomic resection in laparoscopic hepatectomy, which can reduce postoperative recurrence and metastasis.

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when ...

Right Hemihepatectomy by Suprahilar Intrahepatic Transection of the Right Hemipedicle using a Vascular Stapler

Successful hepatic resection requires profound anatomical knowledge and delicate surgical technique. Hemihepatectomies are mostly performed after preparing the extrahepatic hilar structures within the hepatoduodenal ligament, even in benign tumours or liver metastasis.1-5. Regional extrahepatic lymphadenectomy is an oncological standard in hilar cholangiocarcinoma, intrahepatic cholangio-cellular carcinoma and hepatocellular carcinoma, whereas lymph node metastases in the hepatic hilus in patients with liver metastasis are rarely occult. Major disadvantages of these procedures are the complex preparation of the hilus with the risk of injuring contralateral structures and the possibility of bleeding from portal vein side-branches or impaired perfusion of bile ducts. We developed a technique of right hemihepatectomy or resection of the left lateral segments with intrahepatic transection of the pedicle that leaves the hepatoduodenal ligament completely untouched. 6 However, if intraoperative visualization or palpation of the ligament is suspicious for tumor infiltration or lymph node metastasis, the hilus should be explored and a lymphadenectomy performed.

This video describes a right hemihepatectomy with intrahepatic transection of the right hemipedicle leaving the hepatoduodenal ligament completely untouched.

Successful hepatic resection requires profound anatomical knowledge and delicate surgical technique. Hemihepatectomies are mostly performed after ...

Biology

Transarterial Administration of Oncolytic Viruses for Locoregional Therapy of Orthotopic HCC in Rats

Hepatocellular carcinoma (HCC) is a disease with limited treatment options and poor prognosis. In recent years, oncolytic virotherapies have proven themselves to be potentially powerful tools to fight malignancy. Due to the unique dual blood supply in the liver, it is possible to apply therapies locally to orthotopic liver tumors, which are predominantly fed by arterial blood flow. We have previously demonstrated that hepatic arterial delivery of oncolytic viruses results in safe and efficient transduction efficiency of multifocal HCC lesions, resulting in significant prolongation of survival in immune competent rats. This procedure closely mimics the application of transarterial embolization in patients, which is the standard palliative care provided to many HCC patients. The ability to administer tumor therapies through the hepatic artery in rats allows for a highly sophisticated preclinical model for evaluating novel viral vectors under development. Here we describe the detailed protocol for microdissection of the hepatic artery for infusion of oncolytic virus vectors to treat orthotopic HCC.

Oncolytic virotherapies are under development as novel therapeutics for the treatment of hepatocellular carcinoma (HCC). Here we describe a method for locoregional therapy of HCC via hepatic arterial administration of oncolytic virus.

Hepatocellular carcinoma (HCC) is a disease with limited treatment options and poor prognosis.  In recent years, oncolytic virotherapies have proven ...

Percutaneous Hepatic Perfusion (PHP) with Melphalan as a Treatment for Unresectable Metastases Confined to the Liver

Unresectable liver metastases of colorectal cancer can be treated with systemic chemotherapy, aiming to limit the disease, extend survival or turn unresectable metastases into resectable ones. Some patients however, suffer from side effects or progression under systemic treatment. For patients with metastasized uveal melanoma there are no standard systemic therapy options. For patients without extrahepatic disease, isolated liver perfusion (IHP) may enable local disease control with limited systemic side effects. Previously, this was performed during open surgery with satisfying results, but morbidity and mortality related to the open procedure, prohibited a widespread application. Therefore, percutaneous hepatic perfusion (PHP) with simultaneous chemofiltration was developed. Besides decreasing morbidity and mortality, this procedure can be repeated, hopefully leading to a higher response rate and improved survival (by local control of disease). During PHP, catheters are placed in the proper hepatic artery, to infuse the chemotherapeutic agent, and in the inferior caval vein to aspirate the chemosaturated blood returning through the hepatic veins. The caval vein catheter is a double balloon catheter that prohibits leakage into the systemic circulation. The blood returning from the hepatic veins is aspirated through the catheter fenestrations and then perfused through an extra-corporeal filtration system. After filtration, the blood is returned to the patient by a third catheter in the right internal jugular vein. During PHP a high dose of melphalan is infused into the liver, which is toxic and would lead to life threatening complications when administered systemically. Because of the significant hemodynamic instability resulting from the combination of caval vein occlusion and chemofiltration, hemodynamic monitoring and hemodynamic support is of paramount importance during this complex procedure.

Percutaneous Hepatic Perfusion PHP with Melphalan as a Treatment for Unresectable Metastases Confined to the Liver

In this manuscript, we describe percutaneous isolated hepatic perfusion with simultaneous chemofiltration as treatment for unresectable liver metastases. This procedure is performed under general anaesthesia in the angiosuite by an experienced team, consisting of an interventional radiologist, a clinical perfusionist and anaesthesiologist.

Unresectable liver metastases of colorectal cancer can be treated with systemic chemotherapy, aiming to limit the disease, extend survival or turn ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In this study, a 32-year-old male patient with Bismuth Type IVa hilar cholangiocarcinoma underwent radical robotic resection of hepatic S4b, S5, and S1 (Taj Mahal hepatectomy) combined with regional lymphadenectomy, hilar bile duct reconstruction, and hepaticojejunostomy by the robotic surgical system. Postoperative pathological examination showed moderately-differentiated adenocarcinoma of the hilar bile duct. The surgical margins of the liver and bile ducts were negative. Recovery was smooth and the patient was discharged on the 17th postoperative day. The robotic surgical system and associated multiple instruments along with flexible and precise movements is suitable for the local hepatectomy around the porta hepatis, and delicate reconstruction of the hilar bile duct with a smaller diameter. This first clinical application study found that robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma is safe and feasible and needs more experience for the evaluation of its long-term outcomes.

Robotic resection of hepatic S4b, S5, and S1 using the Taj Mahal procedure is feasible and safe for selected patients with hilar cholangiocarcinoma. The step-by-step details for this surgery are presented here.

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...

Y-90 TARE and PD-1 Inhibition as Bridging Therapy in Hepatocellular Carcinoma

Y-90 Radioembolization and PD-1 Inhibitor as Neoadjuvant Treatment in Hepatocellular Carcinoma

This study showcases a comprehensive treatment protocol for high-risk hepatocellular carcinoma (HCC) patients, focusing on the combined use of Y-90 transarterial radioembolization (TARE) and Programmed Cell Death-1 (PD-1) inhibitors as neoadjuvant therapy. Highlighted through a case report, it offers a step-by-step reference for similar therapeutic interventions. A retrospective analysis was conducted on a patient who underwent hepatectomy following Y-90 TARE and PD-1 inhibitor treatment. Key demographic and clinical details were recorded at admission to guide therapy selection. Y-90 TARE suitability and dosage calculation were based on Technetium-99m (Tc-99m) macroaggregated albumin (MAA) perfusion mapping tests. Lesion coverage by Y-90 microspheres was confirmed through single photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging, and adverse reactions and follow-up outcomes were meticulously documented. The patient, with a 7.2 cm HCC in the right hepatic lobe (T1bN0M0, BCLC A, CNLC Ib) and an initial alpha-fetoprotein (AFP) level of 66,840 ng/mL, opted for Y-90 TARE due to high recurrence risk and initial surgery refusal. The therapy's parameters, including the lung shunting fraction (LSF) and non-tumor ratio (TNR), were within therapeutic limits. A total of 1.36 GBq Y-90 was administered. At 1 month post-therapy, the tumor shrank to 6 cm with partial necrosis, and AFP levels dropped to 21,155 ng/mL, remaining stable for 3 months. After 3 months, PD-1 inhibitor treatment led to further tumor reduction to 4 cm and AFP decrease to 1.84 ng/mL. The patient then underwent hepatectomy; histopathology confirmed complete tumor necrosis. At 12 months post-surgery, no tumor recurrence or metastasis was observed in follow-up sessions. This protocol demonstrates the effective combination of Y-90 TARE and PD-1 inhibitor as a bridging strategy to surgery for HCC patients at high recurrence risk, providing a practical guide for implementing this approach.

This study illustrates the methodological potential of combining Yttrium-90 Trans-Arterial Radioembolization (Y-90 TARE) with an anti-PD-1 monoclonal antibody as an effective neoadjuvant strategy leading to hepatectomy in hepatocellular carcinoma (HCC) patients with a high initial recurrence risk. It emphasizes the safety, feasibility, and step-by-step procedural guidance of this approach.

This study showcases a comprehensive treatment protocol for high-risk hepatocellular carcinoma (HCC) patients, focusing on the combined use of Y-90 ...

Complete Laparoscopic Radical Resection of Perihilar Cholangiocarcinoma Type IIIb

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With continuous advancements in laparoscopic techniques and instruments, laparoscopic radical surgery for pCCA is now considered technically safe and feasible. However, due to the high complexity of the surgery and the lack of evidence-based clinical support, laparoscopic radical surgery for type IIIb pCCA is performed only in a few large hepatobiliary centers. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA. Therefore, in this article, we provide a detailed description of the surgical steps and technical points of complete laparoscopic left hemihepatectomy combined with total caudate lobectomy, regional lymphadenectomy, and right hepatic duct-jejunal Roux-en-Y anastomosis in patients with type IIIb pCCA, using fluorescence navigation technology to enhance surgical precision and safety. By adhering to standardized surgical procedures and precise intraoperative techniques, we offer an effective means to improve patient outcomes.

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With ...

Trans-Arterial Indocyanine Green Staining for Precise Anatomical Hepatectomy of Liver Segments VII and VIII

Anatomical hepatectomy for resectable hepatocellular carcinoma (HCC) is performed with precision using the Glissonean system, ultrasound imaging, and indocyanine green (ICG) fluorescence staining to define liver segments, enhancing surgical radicality and preserving liver volume. However, laparoscopic clamping and ultrasound-guided ICG staining for deep-seated tumors in liver segments VII and VIII pose challenges due to the depth of the Glissonean ducts and other technical limitations. This study aimed to overcome these obstacles by exploring a protocol using trans-arterial ICG staining, a technique specifically tailored for complex anatomical hepatectomy of liver segments VII and VIII. In this method, an interventionalist accessed the right femoral artery and advanced to the celiac trunk for arteriography, followed by strategic placement of a microcatheter into the tumor's blood supply vessel to facilitate surgical resection. During the operation, ICG was injected through the microcatheter to fluorescently label the tumor's liver segment, enabling precise anatomical resection under fluorescence guidance. This trans-arterial ICG staining approach allows for the accurate identification of tumor subsegments, facilitates complete resection, and optimizes liver function preservation, ultimately improving oncological outcomes without increasing surgical complication rates.

Laparoscopic anatomical hepatectomy has gained global recognition in liver surgery. However, delineating tumor boundaries in liver segments VII and VIII presents distinct technical challenges. This protocol utilizes trans-arterial indocyanine green (ICG) staining to accurately identify liver subsegments, facilitating complete tumor resection while preserving functional liver volume.

Anatomical hepatectomy for resectable hepatocellular carcinoma (HCC) is performed with precision using the Glissonean system, ultrasound imaging, and ...

Laparoscopic Left Hemihepatectomy Combined with Caudate Lobe Resection

Intrahepatic cholangiocarcinoma (ICC) is the common malignant tumor of the liver. Radical surgical resection is the mainstay of potentially curative treatment for ICC. Anatomical liver resection for ICC in the caudate lobe is one of the most difficult liver resections. Because the tumor is located deep and easily invades surrounding blood vessels, such as the left hepatic pedicle, right hepatic pedicle, and middle hepatic vein. Laparoscopic anatomic hepatectomy of the caudate lobe not only ensures a negative incision margin but also offers a more minimally invasive approach for patients. This technique is poised to become the preferred choice for radical surgery of the caudate lobe in the future. In this surgical protocol, a 65-year-old male patient with intrahepatic cholangiocarcinoma (sized about 3.2&#160;&#215; 1.9 cm2) located in the left caudal lobe underwent laparoscopic left hemihepatectomy combined with caudate lobe resection successfully without any postoperative complications. Postoperative pathological examination showed a cholangiocarcinoma with a tumor thrombus visible in the vasculature. The patient was discharged on the 14th postoperative day. Laparoscopic left hemihepatectomy combined with caudate lobectomy for the treatment of caudate lobe ICC can be performed safely and does not add significantly to the morbidity or mortality of the procedure.

Intrahepatic cholangiocarcinoma of the caudate lobe is a challenge for many surgeons due to its unique location. Here, we present a protocol to show the step-by-step details of laparoscopic left hemihepatectomy combined with caudate lobe resection for cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC) is the common malignant tumor of the liver. Radical surgical resection is the mainstay of potentially curative ...